Day 6 A&E Flashcards
What is a bone tectinium scan for to look for?
bone mets
HLA-A3 is associated with which condition?
haemochromatosis
HLA-B51 is associated with which condition?
Behcet’s disease
HLA-B27 is associated with which conditions?
ankylosing spondylitis
reactive arthritis
acute anterior uveitis
HLA-DQ2/DQ8 are associated with which condition?
coeliac disease
HLA-DR2 is associated with which conditions?
narcolepsy
Goodpasture’s
HLA-DR3 is associated with which conditions?
dermatitis herpetiformis
Sjogren’s syndrome
primary biliary cirrhosis
HLA-DR4 is associated with which conditions?
type 1 diabetes mellitus*
rheumatoid arthritis - in particular the DRB1 gene (DRB1*04:01 and DRB1*04:04 hence the association with DR4)
Which conditions are associated with a raised creatinine?
(4)
If you have high creatinine levels, symptoms may include:
- nausea.
- vomiting.
- high blood pressure.
- muscle cramps
Which conditions are associated with a low creatinine?
(4)
reduced muscle bulk
liver disease
significant fluid overload
poor nutritional status
Hypocapnia can be caused by
(5)
pneumonia
asthma
pulmonary edema
pulmonary embolism
pneumothorax
A 45 year old woman has presented with symptoms consistent with COVID-19 infection.
Her observations show:
- temperature 37.9°C
- Pulse 87 bpm
- BP 120/70 mmHg
- RR 18
- SpO2 93% in air
An ABG in air has been performed and is shown below.
What does this show?
This is an ABG taken in air.
The FiO2 is therefore 0.21.
The pH is normal.
There is a type 1 respiratory failure- the expected PaO2 in air (FiO2 of 0.21) would be at least 11KPa.
The PaCO2 and the HCO3 are normal.
The other values of the ABG are also normal.
Addison’s disease: investigations
(2)
Plasma cortisol is measured before and 30 minutes after giving Synacthen (ACTH) 250ug IM.
Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated.
A 55 year old man has presented with symptoms consistent with COVID-19 infection.
His observations show:
- temperature 37.9°C, P 87 bpm
- BP 120/70 mmHg
- RR 18
- SpO2 93% in air
An ABG in air has been performed and is shown below.
What does this ABG show?
This is an ABG taken in air. The FiO2 is therefore 0.21.
- There is acidaemia caused by metabolic acidosis.
- There is also evidence of respiratory alkalosis.
- The lactate is elevated - the cause of this is likely to be anaerobic respiration because the patient is hypoxaemic.
There is a type 1 respiratory failure- the expected PaO2 in air (FiO2 of 0.21) would be at least 11KPa.
The PaCO2 is low because the patient is hyperventilating to increase oxygen delivery.
The consequence of this is that the CO2 is ‘blown off’, causing a low CO2 and a respiratory alkalosis.
This respiratory alkalosis is also compensation for the high lactate.
Overall, the degree of acidosis has outweighed the degree of alkalosis, causing an acidaemia.
The other values of the ABG are normal.
A 19-year-old man has presented with abdominal pain and vomiting.
He has no relevant past medical history.
He looks very dehydrated and is obviously unwell.
His observations show:
- temperature 36.9°C, P 130 bpm
- BP 90/50 mmHg
- RR 23,
- SpO2 98% in 15L NRBM
What does his ABG show?
There is a profound acidaemia caused by a metabolic acidosis (the pH and the bicarbonate are very low).
When considering the causes of an acidosis it is helpful to consider the anion gap. In this case it is elevated.
The common causes of a raised anion gap acidosis are elevated lactate, urea or ketones.
There is evidence of respiratory alkalosis (low PaCO2)- this was already evident clinically by the high respiratory rate.
The PaCO2 is low because the patient is hyperventilating to ‘blow off’ CO2, leading to a respiratory alkalosis.
This respiratory alkalosis is an attempt to compensate for the very low pH.
Compensation such as this is an indicator of untreated critical illness. Overall, the degree of acidosis has outweighed the degree of alkalosis, causing an acidaemia.
We already know the patient is volume depleted (the history and the observations), and this is supported by the high Hb.
The Na, K+ and Cl- are all normal.
The lactate is surprisingly normal (considering the hypotension). Finally, the glucose level is very high
What is a normal anion gap?
8-16 mmol/L
How is anion gap calculated from an ABG?
Sodium - Chloride - Bicarbonate = Anion gap
Metabolic acidosis causes of an increased anion gap (normo-chloraemia)
(7)
Metabolic acidosis causes of an increased anion gap (normo-chloraemia)
- Diabetes mellitus (ketones)
- Lactic acidosis (lactate)
- Chronic renal failure (urea)
- Aspirin (acetylsalicylic acid)
- Methanol poisoning
- Ethylene glycol poisoning
- Starvation
Causes of metabolic acidosis with normal ion gap (hyper-chloraemia)
(4)
Diarrhoea
Renal tubular acidosis
Carbonic anhydrase inhibitors
Addison’s disease
What is a normal osmolar gap?
What does an increased osmolar gap indicate?
What is a normal osmolar gap?
10-15
What does an increased osmolar gap indicate?
Metabolic acidosis with elevated osmolal gap indicates methanol and ethylene glycol ingestions.
A 69 year old man has presented with a history of shivering, abdominal pain and vomiting.
He is known to have hypertension, for which he takes ramipril.
Currently, he is clammy and is obviously unwell. His observations show: temperature 38.9°C, P 130 bpm, BP 90/50 mmHg, RR 23, SpO2 98% in 15L NRBM.
An ABG on oxygen has been performed and is shown below.
There is acidaemia caused by a metabolic acidosis (the pH and the bicarbonate are low). When considering the causes of an acidosis it is helpful to consider the anion gap. In this case it is elevated. The common causes of a raised anion gap acidosis are elevated lactate, urea or ketones.
In this case, we would not be suspecting a ketoacidosis. He may have an acute kidney injury but given that the potassium is not grossly elevated this is unlikely to be the sole cause of the acidaemia. The lactate is elevated which is not a surprise considering the hypotension and the clinical scenario (which is consistent with a severe sepsis).
There is evidence of respiratory alkalosis (low PaCO2)- this was already evident clinically by the high respiratory rate.
The PaCO2 is low because the patient is hyperventilating to increase oxygen delivery and to try to ‘blow off’ the CO2, as an attempt to compensate for the very low pH. Compensation such as this is an indicator of untreated critical illness. Overall, the degree of acidosis has outweighed the degree of alkalosis, causing an acidaemia.
We already suspect that the patient is volume depleted (the history and the observations), and this is supported by the high Hb (indicating haemoconcentration). The Na, K+ and Cl- are all normal although the potassium is at the higher of end of normal and, in the clinical context and his medications, an acute kidney injury should be expected.
A 89 year old woman has presented with a history of abdominal pain and vomiting. She is known to have ischaemic heart disease, for which she takes ramipril, atorvastatin and asprin.
Currently, she is in pain, her abdomen is distended and is obviously unwell.
Her observations show:
- temperature 35.4°C
- P 130 bpm
- BP 80/50 mmHg
- RR 19
- SpO2 98% in 15L NRBM
What does her ABG show?
There is acidaemia caused by a metabolic acidosis (the pH and the bicarbonate are low). When considering the causes of an acidosis it is helpful to consider the anion gap. In this case it is elevated. The common causes of a raised anion gap acidosis are elevated lactate, urea or ketones.
In this case, we would not be suspecting a ketoacidosis. She may have an acute kidney injury but given that the potassium is not grossly elevated this is unlikely to be the sole cause of the acidaemia. The lactate is elevated which is not a surprise considering the hypotension and the clinical scenario (which is consistent with ischaemic bowel).
There is no evidence of respiratory alkalosis. Her abdominal distension may be splinting her diaphragm meaning that she cannot increase her tidal volume sufficiently to hyperventilate to ‘blown off’ the CO2 (usually seen as compensation for a metabolic acidosis).
We already suspect that the patient is volume depleted (the history and the observations), and this is supported by the high Hb (indicating haemoconcentration). The Na, K+ and Cl- are all normal although the potassium is at the higher of end of normal and, in the clinical context and her medications, an acute kidney injury should be expected.
A 68 year old woman has presented with symptoms consistent with an exacerbation of her COPD. Her observations show:
- temperature 36.9°C
- P 110 bpm
- BP 110/65 mmHg
- RR 23
- SpO2 84% in air
- 95% on 6L oxygen
An ABG in 6L oxygen has been performed and is shown below.
What does his ABG show?
This is an ABG taken in 6L of oxygen.
There is an acidaemia caused by a respiratory acidosis (high PaCO2).
The PaCO2 is high (hypercapnia) because the patient is having an exacerbation of her COPD which has caused a lower airway obstruction that is impeding gas exchange. The high CO2 defines type 2 respiratory failure.
There is hyperoxaemia as the patient’s oxygen target range is 88-92%. However, it can also be seen that there is an A-a gradient abnormality as the PaO2 is actually slightly lower than would be expected on 6L of oxygen, evidencing a problem with gas diffusion.
The other values of the ABG are normal. However, a ‘normal’ HCO3 is probably abnormal for this patient (her levels are likely to be chronically elevated to compensate for the chronically high PaCO2). The fact the HCO3 is not high shows that there has been an acute increase in circulating acid (in this case CO2) which has been buffered by the HCO3. This shows us that she is decompensating because of her COPD exacerbation.
A 28 year old woman has presented with symptoms consistent with an exacerbation of her asthma.
She is clearly unwell.
Her observations show:
- temperature 36.9°C, P 130 bpm
- BP 100/65 mmHg
- RR 27
- SpO2 90% on 6L oxygen
An ABG in 6L oxygen has been performed and is shown below.
What does the ABG show?
This is an ABG taken in 6L of oxygen.
There is an acidaemia. This is a mixed picture caused by a respiratory acidosis (high PaCO2) and a metabolic acidosis (high lactate).
Her respiratory rate was very high to try to improve oxygen delivery- usually this would cause a low CO2. However, we see on the ABG that the PaCO2 is high (hypercapnia). This is because the patient is having an exacerbation of her asthma which has caused a lower airway obstruction that is impeding gas exchange. The high CO2 defines type 2 respiratory failure and in the context of asthma, this defines a near-fatal exacerbation and is very serious.
There is hypoxaemia as the patient’s oxygen target range is 94-98%. It can also be seen that there is an A-a gradient abnormality as the PaO2 is lower than would be expected on 6L of oxygen (PaO2 would be approximately 35KPa), further evidencing a problem with gas diffusion.
The HCO3 is low indicating an acute acid-base problem. This shows us that is rapidly decompensating because of her asthma exacerbation and that she is critically ill.
The lactate is high.
This is likely to be a mixed cause- the hypoxia leading to anaerobic respiration and the increased work of breathing.
A 25-year-old man has presented with symptoms consistent with a panic attack.
His observations show:
- temperature 36.9°C,
- P 120 bpm,
- BP 120/70 mmHg,
- RR 30,
- SpO2 99% in 5L of oxygen.
An ABG in 5L of oxygen has been performed and is shown below.
What does his ABG show?
This is an ABG taken in oxygen.
The pH shows an alkalaemia. This is caused by a respiratory alkalosis (low PaCO2). There is no evidence of a metabolic alkalosis as there is a normal HCO3.
There is hyperoxaemia.
The calcium is low, as is the potassium. This is because of the acute metabolic changes result from intracellular shifts and increased protein binding of various electrolytes during respiratory alkalosis.
Acute secondary hypocalcaemia can result in carpopedal spasm, muscle twitching, a prolonged QT interval, and positive Chvostek and Trousseau signs.
Hypokalaemia tends to be less pronounced than hypocalcaemia but can produce generalized weakness. Acute secondary hypophosphataemia is common and may contribute to paraesthesias and generalized weakness.
Acute secondary hypocalcaemia can result in: (3)
Acute secondary hypocalcaemia can result in
- carpopedal spasm
- muscle twitching
- a prolonged QT interval
What is Chvostek sign?
What is Trousseau sign?
Chvostek’s sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve.
Trousseau’s sign is carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes.
A 52 year old man has presented with symptoms consistent with a chest infection.
His observations show:
temperature 37.9°C
P 87 bpm
BP 120/70 mmHg
RR 18
SpO2 95% in air.
An CXR has been performed and is shown.
What does the CXR show?
What is the diagnosis?
Details: Patient name, DOB, film type, date image taken
Technical: Rotation, Inspiration, Position, Penetration (exposure)
Interpretation:
- S: Soft tissues
- B: Bones
- T: Trachea
- M: Mediastinum
- P: Pleura
- D: Diaphragm
- L: Lung fields
This chest X-ray shows a right upper lobe opacity and air bronchograms.
Consolidation abuts the minor fissure.
(Consolidation refers to the alveolar airspaces being filled with fluid (exudate/transudate/blood), cells (inflammatory), tissue, or other material.)
These findings are consistent with RUL pneumonia.
Lobar pneumonias are usually bacterial.
A 22 year old woman has presented with breathlessness.
She has been a cigarette smoker since the age of 16.
Her observations show:
- temperature 36.9°C,
- P 87 bpm
- BP 120/70 mmHg
- RR 18
- SpO2 95% in air.
An CXR has been performed and is shown.
What does the CXR show?
What is the diagnosis?
Details: Patient name, DOB, film type, date image taken
Technical: Rotation, Inspiration, Position, Penetration (exposure)
Interpretation:
S: Soft tissues
B: Bones
T: Trachea
M: Mediastinum
P: Pleura
D: Diaphragm
L: Lung fields
This chest X-ray shows air in the left pleural cavity (ie, interspersed between the lung and the chest wall), consistent with a moderately sized pneumothorax.
Pneumothoraces are considered as:
primary spontaneous: no underlying lung disease
secondary spontaneous: underlying lung disease is present
traumatic
Presentation is variable and may range from no symptoms to severe dyspnoea with tachycardia and hypotension.
An 82 year old woman has been referred to hospital by her GP with breathlessness.
She reports waking at night and gasping for breath for the past week, and being breathless when walking about in her flat.
A CXR has already been requested by a senior doctor at assessment.
What does the x-ray show?
What is the diagnosis?
Details: Patient name, DOB, film type, date image taken
Technical: Rotation, Inspiration, Position, Penetration (exposure)
Interpretation:
S: Soft tissues
B: Bones
T: Trachea
M: Mediastinum
P: Pleura
D: Diaphragm
L: Lung fields
This chest X-ray shows a moderate, unilateral pleural effusion.
There is also displacement of the heart laterally.
It appears that the right breast tissue is absent but this is difficult to identify due to the density of the right sided effusion.
An 80 year old woman has been referred to hospital by her GP with progressive breathless over the last few months, worse in the last week.
The referral letter tells you she used to love getting ‘out and about’ but recently has been limited by progressive breathless on exertion.
A CXR has been taken and is shown below.
What is the diagnosis?
Interpretation of chest X-rays needs to have a consistent approach.
SBTMPDL or ABCDE are recognised approaches to chest X-ray interpretation (amongst others). Irrespective of your chosen structure, the following details should be included:
Details: Patient name, DOB, film type, date image taken
Technical: Rotation, Inspiration, Position, Penetration (exposure)
Interpretation:
S: Soft tissues
B: Bones
T: Trachea
M: Mediastinum
P: Pleura
D: Diaphragm
L: Lung fields
This chest X-ray shows cardiomegaly, which may explain the patient’s symptoms.
This would warrant further testing of cardiac function with an ECHO.
An 80 year old man has presented to hospital with progressive breathless over the last few months, worse in the few days.
A CXR has been taken and is shown below.
What is the diagnosis?
Details: Patient name, DOB, film type, date image taken
Technical: Rotation, Inspiration, Position, Penetration (exposure)
Interpretation:
S: Soft tissues
B: Bones
T: Trachea
M: Mediastinum
P: Pleura
D: Diaphragm
L: Lung fields
This chest X-ray shows
- symmetrical area shadowing in the central region of both lungs,
- left heart enlargement
- with congestion in the pulmonary veins
- and bilateral small pleural effusions
Features useful for broadly assessing pulmonary oedema on a plain chest radiograph include:
* upper lobe pulmonary venous diversion
* increased cardiothoracic ratio/cardiac silhouette size
* features of pulmonary interstitial oedema: peribronchial cuffing and perihilar haze; septal (Kerley) lines; thickening of interlobar fissures
* features of pulmonary alveolar oedema: air space opacification (classically in a batwing distribution); air bronchograms
* pleural effusions and fluid in interlobar fissures
An 81 year old man has been referred to ED by his GP after a worsening of his chronic cough.
It has changed from being dry to being productive of a red, frothy sputum.
He looks pale on examination and has reduced air entry to the left side of his chest.
A chest X-ray has been requested and is shown below:
Details: Patient name, DOB, film type, date image taken
Technical: Rotation, Inspiration, Position, Penetration (exposure)
Interpretation:
S: Soft tissues
B: Bones
T: Trachea
M: Mediastinum
P: Pleura
D: Diaphragm
L: Lung fields
This chest X-ray shows:
- Large hyper-density in the left mid-zone, adjacent to the hilum.
- No evidence of air-fluid level or cavitation.
This large, parahilar mass on the left is suspicious for a lung cancer. Patients with lung cancer may be asymptomatic in up to 50% of cases.
Cough and dyspnoea are rather non-specific symptoms that are common among those with lung cancer.
A 30 year old woman is brought to ED by a paramedic crew.
She is homeless and an IV drug user.
She reports that she has been coughing up sputum (green and red) for the last few weeks.
She is fatigued and “feels rough”.
A CXR is obtained and is shown below:
What is the diagnosis?
Details: Patient name, DOB, film type, date image taken
Technical: Rotation, Inspiration, Position, Penetration (exposure)
Interpretation:
S: Soft tissues
B: Bones
T: Trachea
M: Mediastinum
P: Pleura
D: Diaphragm
L: Lung fields
This xray shows a large right upper lobe, cavitating lung mass with a thick wall and air-fluid level.
This is likely to represent a lung abscess as these typically occur in the immunosuppressed and/or those with background lung disease.
Large lesions can erode into pulmonary vessels causing haemoptysis, which can be catastrophic.
Differentials for pulmonary cavitations range from malignancy to infection. The mnemonic CAVITY is useful to remember the causes:
C: cancer - bronchogenic carcinoma: most frequently squamous cell carcinoma (SCC), cavitary pulmonary metastasis(es): most frequently SCC
A: autoimmune;
granulomas from granulomatosis with polyangiitis
rheumatoid arthritis (rheumatoid nodules) etc.
V: vascular
(both bland and septic pulmonary emboli)
I: infection (bacterial/fungal)
pulmonary abscess
pulmonary tuberculosis
T: trauma -
pneumatoceles
Y: youth
A 70 year old man was fishing when he suddenly developed central chest pain and vomiting.
He normally takes medication for hypertension.
His observations show:
temperature 35.5 °C
P 60bpm
BP 95/60 mmHg
RR 18
SpO2 96% in air.
An ECG has been performed and is shown below.
What does the ECG show?
Details:
Patient name, DOB, time and date the ECG performed
Technical:
calibrated correctly?
Interpretation:
Rate, rhythm, axis
P wave, PR interval, QRS complex, ST-segment, T wave, QT interval
Abnormalities most commonly will be consistent with four types of pathology:
ischaemia (arterial problems)
conduction abnormalities
electrolyte disturbances
poisonings (causing channelopathies)
- Hyperacute T waves in II, III and aVF.
- Early ST elevation and loss of R wave height in II, III and aVF.
- Reciprocal change in aVL and lead I.
These features are consistent with an inferior ST-elevation myocardial infarction. aVL is the only lead truly reciprocal to the inferior wall, as it is the only lead facing the superior part of the ventricle.
It is thus a sensitive marker for inferior infarction.
Inferior myocardial infarction (MI) accounts for 40-50% of all MIs. It generally has a more favourable prognosis than anterior myocardial infarction (in-hospital mortality only 2-9%).
A 72 year old man was golfing when he suddenly developed central chest pain.
He felt nauseated and sweaty.
He normally takes medication for hypertension.
His observations show:
- temperature 35.5 °C
- P 75bpm
- BP 130/70 mmHg
- RR 18,
- SpO2 96% in air
What does his ECG show?
This ECG shows:
- ST elevation and early Q wave formation in V2-5
- ST elevation is also present in I and aVL.
- There is some reciprocal ST depression in lead III.
These features are consistent with a large anterior ST-elevation myocardial infarction in the anterior vessels
Anterior myocardial infarction carries the worst prognosis of all infarct locations, mostly due to larger infarct size.
The different infarct patterns are named according to the leads with maximal ST elevation:
Septal = V1-2
Anterior = V2-5
Anteroseptal = V1-4
Anterolateral = V3-6, I + aVL
Extensive anterior / anterolateral = V1-6, I + aVL
A 71 year old man was shovelling snow on his driveway when he suddenly developed a severe pain in his upper back.
He felt very light-headed and nauseated.
A neighbour saw him looking pale and unwell so phoned an ambulance.
Driving conditions and the weather contributed to delays in arriving so it has now been about two hours since the episode of pain.
The pain has resolved after some morphine with YAS and he is feeling much better.
He has a past medical history of hypertension but nil else.
Interpret his ECG
This is a normal ECG!
This means:
- Regular rhythm at a rate of 60-100 bpm (or age-appropriate rate in children).
- Each QRS complex is preceded by a normal P wave.
- Normal P wave axis: P waves should be upright in leads I and II, inverted in aVR.
- The PR interval remains constant.
- QRS complexes are < 120 ms wide.
However, this story is very concerning clinically for an acute aortic dissection (probably a Type B): older age, male, history of hypertension, sudden onset severe pain with associated visceral pain features.
Other plausible suggestions include musculoskeletal pain, ACS or PE.
Best case scenario is that this is something musculoskeletal but that’s very unlikely with the story.
ECGs are completely normal in about 30% of aortic dissection cases.
To make the diagnosis, patients need to go for a CT aortogram urgently.
A 25 year old woman has had palpitations for the past 60 minutes.
She states she can feel her heart racing and also feels breathless.
She has had previous episodes over the past 6 months which have resolved after a few minutes, so has never sought medical attention.
What does her ECG show?
- The ECG shows a regular, narrow QRS -complex tachycardia without evidence of P-wave activity.
- There is also ST-segment depression (which is seen commonly in AVNRT and can occur with or without underlying coronary artery disease).
This patient has an AVNRT (also known as ‘SVT’).
‘SVT’ is used synonymously to describe an AVNRT but actually ‘SVT’ can be used to refer to any tachydysrhythmia arising from above the level of the Bundle of His.
Different types of SVT arise from, or are propagated by, the atria or AV node. They typically produce a narrow-complex tachycardia (unless aberrant conduction is present). Examples include: AF, atria flutter, sinus tachycardia etc.
AV Nodal Re-entry Tachycardia (AVNRT) are the commonest cause of palpitations in patients with structurally normal hearts (except for appropriate sinus tachycardia) . AVNRT is typically paroxysmal and may occur spontaneously or upon provocation with exertion, caffeine, alcohol, beta-agonists (e.g. salbutamol) or sympathomimetics (e.g. amphetamines).
Which Rhythms are shockable?
(3)
A 45 year old woman has been advised to attend ED with palpitations.
She has a history of hypertension for which she takes amlodipine.
An ECG has been performed and you have been asked to ‘sign this ECG’.
What does the ECG show?
- This ECG shows an irregularly-irregular, narrow QRS-complex tachycardia.
- There are no observable P-waves.
- There are no ischaemic changes.
This patient has Atrial Fibrillation (AF)- the most common sustained arrhythmia.
It is characterised by disorganised atrial electrical activity and contraction.
The patient’s potassium and magnesium levels should also be checked and levels corrected if they are low.
The incidence and prevalence of AF is increasing. Lifetime risk over the age of 40 years is ~25%.
Complications of AF include haemodynamic instability, cardiomyopathy, cardiac failure, and embolic events such as stroke.
The causes of AF can be remembered by the mnemonic Dehydrated PIRATES.
Can you list the causes of AF?
Causes of AF
(6)
A 75 year old man has arrived at the ED with palpitations. He has a history of ischaemic heart disease and has coronary stents.
He is feeling lightheaded.
An ECG has been performed and you have been asked to ‘sign this ECG’.
What does the ECG show?
- This ECG shows a tachycardia of approximately 160 bpm with uniform, very broad QRS complexes.
- Notching near the S wave is also noted.
- The axis is indeterminate.
This patient has an ECG and presentation consistent with pulsed, sustained, monomorphic VT.
This needs to be treated as an emergency!
- Unstable patients with monomorphic VT should be immediately treated with synchronized direct current (DC) cardioversion
A 79 year old man was found collapsed in the bathroom of the ward.
The nurse who found him couldn’t feel a pulse and started cardiac compressions.
The ‘crash trolley’ has now arrived and the patient is attached to the defibrillator.
What does the ECG show?
- This ECG shows a fast tachycardia with chaotic irregular deflections of varying amplitude.
- There are no identifiable P waves, QRS complexes, or T waves.
- This patient has an ECG and presentation consistent with ventricular fibrillation.
This needs to be treated as an emergency and he needs to be defibrillated.
The patient’s potassium and magnesium levels should also be checked and levels corrected if they are abnormal
A 78 year old man has become unwell.
He is unable to get out of bed and when he tries to stand up he develops significant pre-syncopal symptoms.
His observations show:
- temperature 35.5 °C,
- P 28bpm,
- BP 80/50 mmHg
- RR 16
- SpO2 96% in air
What does the ECG show?
- This ECG shows a profound bradycardia.
- There is evidence of p-wave activity at a rate of approximately 60 bpm.
- The QRS complexes are broad, with a ventricular rate of 28 bpm.
- None of the atrial impulses appear to be conducted to the ventricles.
- There are no obvious ischaemic changes.
This patient has an ECG and presentation consistent with a 3rd degree AV nodal block (“complete heart block”).
Patients with this block are at high risk of ventricular standstill and sudden cardiac death.
They require urgent admission for temporary pacing, cardiac monitoring and usually insertion of a permanent pacemaker.
An 81 year old man has presented to the ED following a vasovagal collapse at home.
He has had diarrhoea and vomiting for the past 3 days.
He is known to have ischaemic heart disease, type 2 diabetes and osteoarthritis.
He currently looks dehydrated and frail.
His observations show: BP 90/60mmHg, P 102 bpm, RR 19, SpO2 97%.
What does his ECG show? (4)
This ECG displays many of the features of hyperkalaemia:
- Prolonged PR interval.
- Broad, bizarre QRS complexes (these merge with both the preceding P wave and subsequent T wave).
- Peaked T waves.
- Additionally, there is tachycardia.
An 18 year old woman has presented to the ED at the request of her community mental health team.
She is known to have bulimia nervosa and is suffering with a significant relapse.
She looks dehydrated and frail.
Her observations show: BP 90/60mmHg, P 102 bpm, RR 19, SpO2 97%.
What does her ECG show?
- rate, rhythm and axis are all normal.
- subtle ST depression (non-territorial)
- global T wave inversion.
- prominent U waves.
- long QU interval.
These features and the story are consistent with severe hypokalaemia.
Hypokalaemia can lead to a wide variety of arrhythmia including frequent supraventricular and ventricular ectopics supraventricular tachyarrhythmias: AF, atrial flutter, atrial tachycardia
life-threatening ventricular arrhythmias, e.g. VT, VF and Torsades de Pointes
She needs an urgent VBG and lab potassium (and magnesium) level checking. Potassium replacement needs to be safely initiated and requires cardiac monitoring.
An 30 year old woman has presented to the ED with breathlessness on exertion.
She looks well and bedside examination is entirely normal.
Her observations show: BP 115/60mmHg, P 84 bpm, RR 12, SpO2 97%.
What does her ECG show?
What is the likely diagnosis?
- This ECG shows normal rate, rhythm and axis.
- The ventricular rhythm is regular and the rate is 84 bpm.
- There is normal P wave morphology (upright in I and II, inverted in aVR).
- The QRS complexes are narrow(< 100 ms wide).
- Each P wave is followed by a QRS complex.
- The PR interval is constant.
This patient needs a thorough clinical evaluation including assessment for her risk of VTE.
The most common ECG finding in PE is normal sinus rhythm so a normal ECG doesn’t exclude the diagnosis.
Bernard is a 55 year old bookshop owner.
He was brought into the ED after he had a collapse in his shop.
He regained consciousness spontaneously and has recovered well but is complaining of palpitations.
He is relatively fit and well despite drinking alcohol excessively and smoking 40 cigarettes/day.
What does his ECG show?
How should he be manged?
This ECG shows narrow QRS complex and a classical “saw-tooth” pattern.
- This is Atrial Flutter
- with a 4:1 block
- and a ventricular rate of 75bpm
ED management goals include:
- Control of ventricular rate
- Restoration of sinus rhythm
You are asked to see Helen Brandy, a 63 year old woman who has presented to ED following an episode of collapse.
She was hanging her Christmas wreath on the front door when she suddenly became lightheaded and collapsed.
She had a brief loss of consciousness from which she recovered but still feels lightheaded.
What does her ECG show?
- This ECG shows a 2nd degree AV heart block,
- with a fixed 2:1 block - there are 2 P waves for every QRS complex.
- The ventricular rate is 42 bpm (bradycardia).
You can also get 3:1 or 4:1 fixed AV blocks.
For patients with symptoms (such as this case) then long term treatment like a pacemaker should be considered.
A 65 year old man had been enjoying a fun night at the opera when he developed heavy pain in the front of his chest unlike any he had suffered from previously.
At his wife’s request, an ambulance was phoned and he has been brought to the ED.
What does his ECG show?
This ECG shows widespread ST depression ( aka signs of ischaemia) in leads in I, II, v3-v6. there is also ST elevation aVR.
The concern with this ECG is that this represents left main coronary occlusion or a proximal LAD occlusion.
Differentials of an appearance of global ischaemia such as this would include aortic dissection, severe hypo/hyperkalemia, early post-cardiac arrest, massive PE and LBBB.
When looking for signs of ischaemia, look for dynamic ST segment and T wave changes (i.e. different from baseline ECG or changing over time); then make sure to correlate these to the appropriate region of the heart (which don’t forget have different coronary arteries supplying them).
A 59 year old woman has presented to the ED with breathlessness without associated symptoms.
She is overtly breathless at rest.
Her observations show:
BP 105/60mmHg
P 130 bpm
RR 22
SpO2 93%
What does her ECG show?
- This ECG shows sinus tachycardia with RBBB.
- There is also T-wave inversion in precordial leads V1-3 plus inferior leads III and aVF.
The ECG changes and the presentation are consistent with a massive PE. The patient needs an urgent CTPA.
What does this x-ray show?
This chest X-ray shows air in the left pleural cavity (ie, interspersed between the lung and the chest wall), consistent with a small pneumothorax. It is most evident at the left apex.
What does this chest x-ray show?
This chest X-ray shows lobar consolidation of the right middle lobe.
Arthur is a 74 year old man. He has attended the Emergency Department with a cough and marked increased shortness of breath.
He has a background of COPD for which he is on inhalers and nebulisers at home.
Inspection shows he has increased respiratory effort and is speaking partial sentences.
Initial observations show P 123 bpm, BP 135/80mmHg, RR 24, SpO2 84% on room air and a temperature of 36.4℃.
What is the best oxygen management for him?
Start on 24% venturi mask and titrate up
Harriet Friday is an 80 year old woman who has been referred to hospital by her GP with progressive breathless over the last few months, worse in the last week.
Harriet tells you she used to love getting ‘out and about’ in the Yorkshire Dales, but recently she’s become more and more breathless on exertion.
What does her x-ray show?
Congestive heart failure
A - alveolar oedema (bat wing opacities)
B - Kerley B lines (subpleural interlobar septal thickening indicating
interstitial oedema. Seen at the bases in the posterior tissue)
C - cardiomegaly and cephalization
D - dilated upper lobe vessels
E - pleural effusion
What does the ECG show?
The man is stable.
What is the first-line treatment?
The ECG shows a regular, narrow QRS -complex tachycardia without evidence of P-wave activity. There is also ST-segment depression.
This patient has an AVNRT (also known as ‘SVT’). ‘SVT’ is used synonymously to describe an AVNRT but actually ‘SVT’ can be used to refer to any tachydysrhythmia arising from above the level of the Bundle of His.
Different types of SVT arise from, or are propagated by, the atria or AV node. They typically produce a narrow-complex tachycardia (unless aberrant conduction is present). Examples include: AF, atria flutter, sinus tachycardia etc.
AV Nodal Re-entry Tachycardia (AVNRT) are the commonest cause of palpitations in patients with structurally normal hearts (except for appropriate sinus tachycardia) . AVNRT is typically paroxysmal and may occur spontaneously or upon provocation with exertion, caffeine, alcohol, beta-agonists (e.g. salbutamol) or sympathomimetics (e.g. amphetamines).
His treatment should therefore begin with vagal manoeuvres.
If these do not revert him to sinus rhythm, adenosine should be given.
John is a 67 year old man.
Yesterday afternoon, when he was playing golf, he developed chest pain.
It lasted for about 5 minutes and then resolved.
Today the pain has started again whilst he was eating lunch.
He describes having central pain which radiates into his right shoulder.
He feels clammy and looks pale.
He is usually well and takes no medications.
Initial observations show P 85 bpm, BP 135/80mmHg, RR 16, SpO2 97% on room air and a temperature of 36.4℃.
Which investigation should be done first?
What does the ECG show?
What is the likely diagnosis?
Which investigation should be done first?
- ECG
What does the ECG show?
- This ECG shows clear ST elevation and hyperacute T waves in V2-4 with
- ST elevation in I and aVL.
- There is reciprocal ST depression in lead III
- Q waves are present in the septal leads V1-2
What is the likely diagnosis?
- From the sounds of things, John is experiencing ischaemic cardiac pain. Currently, this may be a STEMI, NSTEMI, or unstable angina.
A 70 year old man was busy shovelling snow on his driveway when he suddenly developed a severe pain in his upper back.
He felt very light-headed and nauseated.
The pain resolved after some morphine with YAS and he is feeling much better. He has a past medical history of hypertension but nil else.
- P 75 bpm
- BP 170/80mmHg
- RR 18, SpO2 96% in air
An ECG has been performed at assessment.
What’s your working diagnosis for this patient?
Which is the most appropriate immediate investigation to request for this man?
What’s your working diagnosis for this patient?
This story is very concerning for an acute aortic dissection (probably a Type B): older age, male, history of hypertension, sudden onset severe pain with associated visceral pain features.
- inferior ST elevation (right coronary dissection) but can be any STEMI (0.1% of STEMIs are dissections)
Which is the most appropriate immediate investigation to request for this man?
CT aortogram
What does this ECG show?
What is the diagnosis?
electrical alternans
cardiac tamponade
An 83 year old man has been brought to the ED following an episode of collapse.
He was trying to get to a toilet when he collapsed to the floor and was unconscious for a few seconds.
His carers phoned an ambulance.
He is currently feeling lightheaded and says he feels “washed out”.
He has had no further blackouts and appears to have no injuries.
An ECG has been taken which is as shown.
What is the diagnosis?
This ECG shows a profound bradycardia.
There is evidence of p-wave activity at a rate of approximately 60 bpm.
The QRS complexes are broad, with a ventricular rate of 28 bpm.
None of the atrial impulses appear to be conducted to the ventricles. There are no obvious ischaemic changes.
This patient has an ECG and presentation consistent with a 3rd degree AV nodal block (“complete heart block”).
Patients with this block are at high risk of ventricular standstill and sudden cardiac death.
Complete heart block usually arises from one of three pathologies:
- Inferior myocardial infarction
- AV-nodal blocking drugs (e.g. calcium-channel blockers, beta-blockers, digoxin)
- Degeneration of the conducting system
A 24 year old man attends the ED with pain, one day after being assaulted in the city centre.
He doesn’t recall the specifics of the attack but he has been told that someone stamped on his head.
On examination you notice the injuries shown.
What is the name of this sign?
What type of injury is this sign suggestive of?*
What is the name of this sign?
“Battle’s sign”.
This sign was described by WH Battle, an English surgeon in 1890, who deemed battle sign: “a most important indication that the posterior fossa of the skull is the seat of the fracture” and concluded “that it appears, in the first place, in front of the apex of the mastoid process. That it often spreads upwards over the mastoid in a line, slightly curved, and with the convexity backwards, its direction being approximately that of the outline of the external ear, from which it is distant half to three-quarters of an inch”
What type of injury is this sign suggestive of?*
- basal skull fracture
- basilar skull fracture
A 34 year old man attends the ED with facial injuries.
He has fallen 3 hours ago whilst intoxicated and has little recall of events since his injury.
He has vomited once.
Observations show P 110 bpm, BP 140/70mmHg, RR 17. His GCS is 14 (E4V4M6).
Which feature in the history would make you concerned for a clinically significant head injury (according to NICE guidance)?
Which feature in the history would make you concerned for a clinically significant head injury (according to NICE guidance)?
- This man has a GCS less than 15 more than two hours after his injury.
- This means he needs a CT within one hour.
A 50 year old man has been brought into the ED following a sudden collapse which has left him with with ‘confusion’ and unilateral weakness.
His GCS is assessed as E2V3M4.
His airway was supported and an urgent CT head scan was undertaken to determine the cause of his symptoms.
Which intracerebral pathology is demonstrated on the scan?
What are the immediate priorities when managing a patient with signs of raised intracranial pressure?
Which intracerebral pathology is demonstrated on the scan?
Subarachnoid haemorrhage (SAH) is a type of extra-axial intracranial haemorrhage and denotes the presence of blood within the subarachnoid space.
What are the immediate priorities when managing a patient with signs of raised intracranial pressure?
- A: The airway must be adequately protected. If the patient has a GCS <8 they may need intubation
- B: Keep SpO2 in normal range.
- C: Ensure euvolaemia (to maintain cerebral perfusion pressure)
- D: Maintain normoglycaemia and nurse at 20-30 degrees head up.
What does this head CT show?
venous sinus thrombosis
