Posted by Dan Crompton

This 31 year old female presented at 12:30 to a sub-tertiary emergency department. Brought in by ambulance complaining of feeling generally unwell with chest and abdominal pains. She had seen her GP a week prior and was diagnosed with influenza.

Further history revealed having fevers and sweats and she denied opening her bowels for 2 days and had pain in the RIF. She denied vomiting, previous PID and pregnancy.

​Her observations on arrival were:

P 140              BP123/70             RR 20               Sa O2 98% - room air
Temp 38.5              GCS 14 (V4)

PMH
IVDU - currently using - Ice and amphetamines
Renal Failure - undifferentiated
Pancreatitis
Cholecystectomy
Bipolar disorder
Personality disorder
Chronic chest pain following MVA 10 years ago

Triaged Category 3 and assigned to a cubicle. She was seen by a doctor 105 minutes after arriving.

On exam she had stigmata of recent IVDU. Abdomen was "soft" with tenderness in the right iliac fossa and hypochondrium.

​As part of her initial work-up she had an abdominal x-ray requested "tro SBO".

What is the utility of a plain abdominal film in a patient with sepsis?
What abnormality does the image show?

Answer next week.

Posted by Dan Crompton

This 72 year old man presented by ambulance, to a regional hospital at 4am, acutely short of breath. He complained of having had a cough and increasing dyspnoea for the last 3 days but suddenly worse at 2am. He had recently been diagnosed with COPD after a hospital admission for pneumonia and the paramedics had given him a total of 15mg salbutamol and 1.5mg ipratropium. His initial sats were 77% and he had widespread wheeze but no crackles. He hadn't improved much on the way.

PMH
COPD
- recently diagnosed following similar presentation
HT
recent ex-smoker
abdominal surgery - uncertain what

DH
Salbutamol
Tiotropium 
Atorvastatin
Bromhexine (bisolvon)

First set of Obs in ED
P   123     BP  160/110         RR   35       SaO2  86%         GCS  15     Temp 36.5

This is his ECG.

What are the major abnormalities on this ECG?
What additional assessment would you perform?

68 year old male presented to the Emergency Department after experiencing an episode of conscious collapse (felt lightheaded initially, sweaty, nausea, vomiting with associated chest discomfort). Was found to have a BBB by AV.

​PMHx:
IHD-CABG's previously
HTN, Hypercholesterolemia
Femoropopliteal bypass
Was stable hemodynamically on initial assessment and the initial ECG is as shown below: (No previous ECG's on records to compare to).

Initial troponin was elevated. Patient was being cardiac monitored when he was noticed to be tachycardic. ECG is as shown below. Systolic BP was 80/- with the patient conscious and conversing normally with minimal symptoms.

So what is the rhythm? How to work it out?

A few features suggesting VT:
==>AV disassociation(can be appreciated in V1)
==>Extreme axis
==>Lead V6: qS pattern
==>Left rabbit ear (Rsr')-V1
==>QRS narrower compared to initial ECG (QRS duration in initial ECG appears slightly greater)- Happens when the ventricular tachycardia arises close to the conducting system
==>Initial R wave in aVR  (terminal R wave is seen in TCA toxicity)

Other criteria for VT: Classical wellens criteria and Brugada criteria
 
 
 
While getting ready for sedation/cardioversion,patient became unresponsive with CPR being commenced. Was back to normal conscious state after 15-30 seconds. Repeat ECG was similar to the initial ECG.
 
A brief overview of management:

Non sustained VT( >/= 3 ventricular beats,rate >120/min, Duration <30 seconds)

Beta blockers
Calcium channel blockers
Antiarrhythmics

Sustained VT( Duration >/= 30 seconds)

All Unstable VT: SHOCK/DEFIBRILLATION

Monomorphic VT

Stable:   Synchronized cardioversion following appropriate sedation

In refractory or recurrent VT:  antiarrhythmics
Class I:  Procainamide(can slow down the rate even if it fails to revert),Lignocaine
Class III: Amiodarone

Polymorphic VT with prolonged QT(Torsades)

Stable: IV magnesium. Overdrive pacing if no response to IV magnesium

Polymorphic VT with normal QT


Polymorphic VT with normal QT

Beta blockers if BP tolerates
Amiodarone

Thanks to Sashi for the great case!

This man presented after two syncopal events at home. He describes sudden LOC and woke without any post ictal phase. He has had no episodes of chest pain.

1. What is the diagnosis?
2. How would you manage this man?

​Stem: 46 year old man presented by private vehicle following an episode of chest pain that has now resolved. No significant pmhx.
Describe the ECG
What is the diagnosis
What would you do with this patient?