KCP: Palpitations and Syncope

Question 1

What is Syncope?

Answer 1

Loss of consciousness due to cerebral perfusion

Question 2

What is presyncope?

Answer 2

The lightheadedness experienced by someone who feels like they might be about to lose consciousness

Question 3

What do you call a fast heart rate?

Answer 3

Tachycardia

Question 4

What do you call a slow heart rate?

Answer 4

Bradycardia

Question 5

What do you call an irregular heart beat?

Answer 5

Arrhythmia

Question 6

Definition of tachycardia?

Answer 6

> 100 bpm

Question 7

Definition of bradycardia?

Answer 7

< 60 bpm

Question 8

How do you calculate heart rate from an ecg?

Does this patient have an irregular heart beat?

Answer 8

Count number of big squares between R waves

R-R=2.4 squares

Divide 300 by this number = 125 bpm

Patient is tachycardic

Question 9

How is time represented on an ecg?

Answer 9

Each square is 0.2s

Therefore there is 300 squares per minute

Therefore:

beats per minute = 300 / squares per beat

Question 10

Common arrhythmias for too fast, too slow and intermittent

Answer 10

Too fast
* Atrial fibrillation
* Ventricular tachycardia
* Supraventricular tachycardia

Too slow
* Heart block

Intermittent
* Paroxysmal supraventricular tachycardia
* Paroxysmal AF
* Ectopic beats

Question 11

What is Paroxysmal Supraventricular Tachycardia? (SVT)

Answer 11

Intermittent rapid tachycardia with abrupt onset and offset

Question 12

What is supraventricular tachycardia also known as?

Answer 12

It is a called a narrow complex tachycardia

Question 13

What does an ECG look like in SVT?

Answer 13

QRS complexes are of normal duration (< 3 small squares, < 120 ms)

So electrical impulse is following the normal ventricular conduction pathway, but at a fast rate

Question 14

SVT Presentation

Answer 14

• Palpitations
• Often had previous episodes that spontaneously reverted
• Light headedness
• Nausea
• Chest pain
• Breathlessness
• Usually haemodynamically stable

Question 15

Which nerve do you need to activate in order to treat SVT symptoms?

Answer 15

Vagus Nerve

Vagus nerve is involved in the parasympathetic nervous system, activation releases acetylcholine acting on the muscarinic receptors thus slowing down conduction on the atrioventricular node

Question 16

How can you activate the vagus nerve?

Answer 16

• Carotid sinus massage
• Valsalva manoeuvre
• Cold water on the face i.e. a diving response
• Modified Valsalva manoeuvre

Question 17

What is the valsalva manoeuvre

Answer 17

“Popping your nose”

Question 18

What is Ventricular Tachycardia?

Answer 18

It is a broad complex tachycardia

Question 19

What can Ventricular Tachycardia imply?

Answer 19

Patients normally have underlying heart disease

Question 20

What is going on in this ECG?

Answer 20

QRS complexes are of increased duration (>3 small squares, >120 ms)

So electrical impulse most likely originates in the ventricle and not following a normal conduction pathway.

It is fast and abnormal therefore is Ventricular Tachycardia

Question 21

VT-Presentation?

Answer 21

• Palpitations
• Chest pain
• Shortness of breath
• Loss of consciousness

Question 22

Briefly describe the ECGs of first, second and third degree heart block

Answer 22

Question 23

What’s going on with this ECG?

Answer 23

Complete heart block

Question 24

Presentation of complete block?

Answer 24

• Syncope and pre-syncope
• Fatigue
• Breathlessness
• Cardiac arrest
• Usually have underlying heart disease

Question 25

Complete heart block short term treatment?

Answer 25

We want to inhibit the vagus nerve which is a muscarinic cholinergic agonist. There fore we need a muscarinic cholinergic antagonist. This is Atropine

Question 26

Complete heart block long term treatment?

Answer 26

Pacemaker

Question 27

What is going on in this ECG?

Answer 27

Atrial Fibrillation

Question 28

Atrial Fibrillation Presentation

Answer 28

* Incidental finding * Palpitations * Breathlessness * Fatigue * Can be made worse by alcohol

Question 29

AF treatment?

Answer 29

Increase block at the AV node * Beta-adrenergic receptor blockers e.g. bisoprolol * Calcium channel antagonist e.g. diltiazem

Question 30

What other complication can AF lead to?

Answer 30

Stroke * Clot forms in fibrillating left atrium * Emboli can then pass to cerebral circulation leading to a stroke

Question 31

What is...

Answer 31

Is a metric used to assess the risk of osmeone having a stroke. If score is 1 consider anti-coagulant If score is > 2 anti-coagulant and anti-platelet

Question 32

Biggest risk from untreated atrial fibrillation

Answer 32

Stroke This rhythm can lead to systemic emboli. Patients are normall started on anticoagulation. It may also increase risk of heart failure.

Question 33

What would you use atropine for?

Answer 33

Short term treatment for complete heart block

Question 34

What would you use adenosine for?

Answer 34

A heart condition marked by episodes of rapid heart rate (paroxysmal supraventricular tachycardia)