Sudden Death Flashcards
What are the potential complications of grief following a sudden death
High risk of PTSD
Prolonged/complex grief
What is the definition of a sudden death
Death within 24hrs of the onset of symptoms
May have had the underlying illness for some time
Under what conditions does the procurator fiscal require an autopsy
Sudden and unexpected death Responsible clinician unable to certify death Death due to negligence Suspected suicide Suspected homicide Death due to drugs Death in custody Death at work Death due to medical or dental care Death of a child Death due to an industrial or notifiable disease Death due to an accident
Do you need familial consent for a hospital autopsy
Yes
Requires consent from the family or NOK
May be requested by clinician or family if unsure why patient died
What is a channelopathy
Heart conditions where there are arrhythmias related to the ion current imbalance and development of early/late depolarizations
Give examples of channelopathies
Congenital long QT syndrome
Brugada syndrome
CPVT
Short QT syndrome
What is a cardiomyopathy
Heart is dilated or thickened, and rhythm doesn’t work properly
Patients will be completely healthy until have a cardiac event
Which drugs can prolong the QT
Clarithromycin/ erythromycin
What is congenital long QT syndrome
Genetic heart condition which prolongs the QT segement of the heart rhythm
Can have Polymorphic VT (torsades de pointes) triggered by adrenergic stimulation
Autosomal dominant version is called romano-ward
Autosomal recessive is jervell and lange-nielsen syndrome
How do you diagnose congenital long QT syndrome
ECG - Repeated (3, 3 weeks apart) and stress testing
Corrected QT interval >480ms in repeated 12 lead ECGs
What are the ECG features of congenital long QT syndrome
Large T wave with long QT
Extra notch in middle of T wave with long QT
Delayed T wave
How do you manage congenital long QT syndrome
In some B-blockers can be effective
Most need an ICD
Avoid QT prolonging drugs
Avoid electrolyte abnormalities (hypokalaemia etc)
Avoid strenuous exertion (sprinting etc) in LQTS1
LQTS2; avoid loud noises
How does congenital long QT present
Syncope - 5%
Sudden cardiac death
Most are asymptomatic
Describe short QT syndrome
Genetic heart condition - very malignant
Causes a short QT
Don’t usually live very long - risk of SCD
Usually young children
What can trigger VF in those with Brugada syndrome
Usually rest or sleep
Fever
Excess alcohol or large meals
Can be provoked using certain drugs when testing -flecainide
What type of inheritance does Brugada syndrome show
Autosomal dominant
8x more common in men
How does Brugada syndrome present on an ECG
ST elevation and RBBB in V1-3
Can be triggered by flecainide
How does Brugada syndrome present
Blackouts Fits Palpitations May be intermittent and related to times of illness/fever Risk of SCD
How do you manage Brugada syndrome
Avoid certain drugs
Early paracetamol for fever (preventing fever)
ICD in some cases
Avoid drinking lots of alcohol
Describe Catecholaminergic Polymorphic Ventricular Tachycardia
CPVT is an arrhythmia disorder caused by an abnormal response to adrenaline
Triggered by emotional stress/physical activity
How do you manage Catecholaminergic Polymorphic Ventricular Tachycardia
High dose B-blocker
ICD
ICU admission
Avoid high intensity sport
How does Wolff-Parkinson White syndrome present on an ECG
Short PR interval
Delta wave
What causes Wolff-Parkinson White syndrome
Extra bit of conducting tissue (accessory pathway)
Can bypass AV node to cause VF as a result of AF
How do you diagnose Wolff-Parkinson White syndrome
Exercise ECG
If doing exercise with High HR do they sustain the rhythm problems
How do you manage Wolff-Parkinson White syndrome
Ablation of the accessory pathway
What causes hypertrophic cardiomyopathy
Genetic disorder
Mutation in sarcomeric genes
The heart wall muscle thickens which leads to rhythm and outflow tract problems
How do you manage hypertrophic cardiomyopathy
Avoid competitive sports
B-blockers, CCB etc
ICD for those who have had cardiac arrest
How can hypertrophic cardiomyopathy present
Palpitations Chest pain Dizziness and syncope Breathlessness Sudden cardiac death
Which sex is more likely to have dilated cardiomyopathy
Men
Describe the pathophysiology of dilated cardiomyopathy
Heart muscle slowly dilates and scars
Becomes ineffective heart tissue
Leads to arrhythmias
Describe the pathophysiology of Arrhythmogenic Right Ventricular Cardiomyopathy
Fibro-fatty replacement of cardiomyocytes
This can affect the electrical activity of the heart and causes arrhythmias.
How do you manage Arrhythmogenic Right Ventricular Cardiomyopathy
Usually ICD to protect from rhythm problems
Avoid competitive sports
What are the risks of using an ICD
- Infection
- Endocarditis
- Leads break
- Lead dislodgement
What is SUDI
Sudden unexpected death in infancy
All infant deaths which happen suddenly for no apparent reason (unexpected)
May be called cot death
Can SUDI be used as an official cause of death
Yes
If death is still unexplained after PM
What is SIDS
Sudden infant death
Diagnosis of exclusion - used if no pathology or risk factors present
Subset of SUDI
May be called cot death syndrome
What maternal factors can increase risk of SUDI/SIDS
There is an association with social deprivation
Symptomatic depression in mother or primary carer
Alcohol use by mother >2 unit
Substance misuse by the parent
Smoking by mum in pregnancy or postnatally
Domestic violence
What environmental factors can increase risk of SUDI/SIDS
Poor housing or overcrowding Sleeping on a pillow or other soft surface Co-sleeping Sleeping on tummy or side Overheating Head covering
What infant factors can increase risk of SUDI/SIDS
Acute illness (e.g. URTI Being preterm Congenital abnormality Small for gestational age Being male Multiple births
What is the safe sleep advice
Information about how to put a baby down to sleep to reduce risk of SIDS
Keep them away from smoke
Put baby in a cot, crib or moses to sleep
Never fall asleep with them on a sofa/chair
Never fall asleep with baby after drinking or taking drugs
Put baby to sleep on their back with their feet at the bottom of the cot
Ensure their face/head is uncovered and the do not overheat
Don’t let them sleep in your bed
If a baby dies of suspected SUDI/SIDS do they need a post mortem
YES
Most common cause is infection but need to rule out NAI etc
What is the definition of a stillbirth
When a baby dies after 24 weeks of pregnancy and before or during birth
What is the definition of a miscarriage
The loss of a baby before 24 weeks of pregnancy
What are some of the risk factors for stillbirth
Intrauterine Growth restriction Congenital abnormalities Maternal infection Extremes of age Medical complications in pregnancy Multiple pregnancy Obesity Placental issues - abruption, haemorrhage etc
How can mum reduce risk of stillbirth
Going to sleep on your side in the third trimester
Quitting smoking
Staying a healthy weight during your pregnancy
Avoid alcohol and drugs
Attend all antenatal appointments
Get flu vaccine
What is penetrance
The likelihood of having a disease if you have a gene mutation
100% penetrance means you will always get the disease if you have the mutation
How do you write down a mutation
Gene name
First AA name listed was the original one
The number is the position on the gene
The second AA name is the one that is there now
Stop codon can be denoted by an Asterix
How might familial hypercholesterolaemia present
Young MI may be the presenting problem Tendon xanthoma Corneal arcus – rare in a young person Family history of young MI High cholesterol
How can you manage familial hypercholesterolaemia
Recommendation is to treat everyone over the age of 10 with statins
What is the difference between clinical death and biological death
Clinical = the period of respiratory, circulatory and brain arrest during which initiation of resuscitation can lead to recovery (reversible)
Biological = an irreversible state of cellular destruction.
Occurs after around 6 mins
What are the shockable rhythms
VF
Pulseless VT
What are the non-shockable rhythms
Asystole
Pulseless electrical activity
How do you treat a non-shockable rhythm
CPR
Adrenaline 1 mg IV then every 3-5 min
Which drugs are given during resuscitation
Give adrenaline every 3-5 min
Give amiodarone after 3 shocks
How do you treat hyperkalaemia
calcium chloride - protects the heart
insulin/dextrose
What are the 5 main classes of shock
Hypovolaemic Cardiogenic Obstructive Distributive Cytotoxic
What causes hypovolaemic shock
Loss of circulating volume which leads to reduced preload and CO
Can be due to bleeding or dehydration
What causes cardiogenic shock
- Failure of the heart as a pump (myocardial dysfunction)
Leads to reduction in systolic function and CO
Can be due to acute MI, acute valve lesion
What causes obstructive shock
Physical obstruction to filling of the heart which leads to reduced preload and cardiac output
Can be due to tamponade, PE
What causes distributive shock
Significant reduction in SVR beyond the compensatory limits of increased cardiac output - circulation becomes larger
Can be caused by sepsis, anaphylaxis or neurogenic factors
What causes cytotoxic shock
Uncoupling of tissue oxygen delivery and mitochondrial oxygen uptake
Can be due to CO poisoning, CN- poisoning
How can the heart increase CO
It can increase HR
Increase stroke volume (although young children cannot do this)
Increase both
Which patients require a lower fluid dose
Those with heart failure
At risk of being overloaded
What is the aim of fluid resuscitation
To increase the end diastolic volume
Try to compensate for the lower SV
List the body’s compensatory mechanisms for hypovolaemia
Baroreceptor response
Sympathetic mediated neurohormonal response - release of vasoconstrictors etc
Capillary absorption of interstitial fluid
Hypothalamo-pituitary-adrenal response
What are the clinical signs of cardiogenic shock
Poor forward flow – Hypotension/shock, fatigue, syncope
Backpressure – Pulmonary oedema, elevated JVP, hepatic congestion
What is positive inotropy
An increase in force of cardiac contraction for any given preload
How can you increase cardiac contractility
Physiological achieved by sympathetic nervous system
Replicated pharmacological by β and dopaminergic stimulation - dobutamine, adrenaline, dopamine etc
How does an intra-aortic balloon pump work
It inflates during ventricular diastole to increase diastolic pressure which helps perfuse the coronary arteries
Deflates during systole = reduced afterload to reduce O2 demand and myocardial stress
Which part of the cardiac cycle is most affected by obstructive shock
Mainly affects cardiac filling rather than ejection
How do you manage obstructive shock
Treatment involves removing the underlying cause
- PE – anticoagulation +/- thrombolysis
- Cardiac tamponade – pericardial drainage
- Tension pneumothorax – decompression and a chest drain
What are the 3 subtypes of distributive shock
Septic – bacterial endotoxin causes capillary dysfunction
Anaphylactic – inappropriate release of vasodilators (histamine) from mast cells in response to allergen
Neurogenic – loss of thoracic sympathetic outflow after a spinal injury leading to massive vasodilatation
What is the early sign of hypoperfusion in septic shock
Rising lactate levels
How do you treat septic shock
Early use of vasopressors
Appropriate antibiotics
Sepsis 6
How do you treat anaphylactic shock
Give adrenaline as it acts as a vasoconstrictor and a mast cell stabiliser
How do you confirm a diagnosis of anaphylactic shock
Serum mast cell tryptase levels
How do you treat neurogenic shock
Dopamine alongside vasopressors are the mainstays
Why do patients with neurogenic shock have inappropriate bradycardia
There is stimulation of the vagus nerve (which cause brady) that is no longer opposed by the sympathetic system (as it has been lost)
What are the reversible causes of cardiac arrest
4H’s – hypovolemia, hypothermia, hypoxia, hypokalaemia
4T’s – tamponade, tension pneumothorax, thrombosis, toxins
What is the most common cause of pulseless electrical activity
Most commonly caused by hypovolemia
The heart is still pumping normally but there is no real output (therefore pulseless)
