Houseman Revision

OBSGYN ‼️Postpartum Haemorrhage‼️ Pic 1️⃣ : Classification & Causes Pic 2️⃣ : General risk factors, Management #n077

OBSGYN ‼️Shoulder Dystocia‼️ Pic 1⃣ : Diagnosis, Risk Factors & Complications Pic 2⃣ : Management #n076

DISCUSSION 1️⃣ Rate : Tachycardia. = 300/2.5 large boxes - 300/2 large boxes = 120 - 150 bpm 2️⃣ Rhythm : Irregular. RR interval varies, some are less than 2 boxes, some are 2 and half boxes 3️⃣ QRS : Broad complex because 120ms or more (3 small boxes or more) 4️⃣ Possible DDX for Broad Complex Tachycardia with Irregular Rhythm includes : - Ventricular Fibrillation - Polymorphic Ventricular Tachycardia - Torsades De Pointes - Supraventricular Tachycardia with Abberrant Conduction 5️⃣ Final Diagnosis : - Supraventricular Tachycardia with Abberrant Conduction. - In this case, the SVT could be Atrial Fibrillation or Atrial Flutter with Variable Block because the RR interval is irregular. Absence of characteristic flutter waves in V1 (resemble P wave) and II, III, AVF (saw tooth) and presence of undulating (smooth and wavy) baseline suggest that this could be Atrial Fibrillation. - Atrial Fibrillation and Atrial Flutter usually has narrow QRS complex but it could be broad if it is accompanied by abberant conduction, eg bundle branch block. Thus, we should check out V1/V2 and V5/V6 for the changes. RSR’ wave is seen in V5 while deep, wide S wave is seen in V2 (aka QS complex). These are features of left bundle branch block. - The final diagnosis is Atrial Fibrillation with LBBB. 6️⃣ Why other DDX is less likely : - Ventricular Fibrillation : P waves, QRS complexes, T waves should be absent. In this case, QRS complexes are present throughout. - Polymorphic Ventricular Tachycardia : The QRS complexes should have different morphology. In this case, it is monomorphic. - Torsades De Pointes : Requires polymorphic QRS + QT prolongation for diagnosis - Ventricular Tachycardia : The RR interval should be regular. Other features suggestive of VT is not present here eg concordance. The Brugada criteria is also not fulfilled, hence suggestive of SVT rather than VT. (See the notes for mnemonic ‘CAFECONA & CIA Brugada’) *For features not shown in the pic above, please refer to the previous notes given.

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INTERNAL MEDICINE ‼️ Case : Arrhythmia ‼️ See : ECG below Try to formulate your diagnosis based on the ddx that we have covered. Use this guide to help you : 1⃣ Tachy vs brady 2⃣ Regular vs Irregular RR interval 3⃣ Broad vs narrow QRS complex 4⃣ See the DDX available in the category (see notes) 5⃣ Choose your most probable diagnosis #c018

INTERNAL MEDICINE ‼️ Approach to Arrhythmias ‼️ Differential diagnosis for: 🔸 Tachycarrhythmias 🔸 Bradyarrhythmias Source : litfl.com #n075

INTERNAL MEDICINE ‼️ Management of Chronic Heart Failure ‼️ #m029 It can be divided into 4 components : pharmacological, education, device therapy & surgery. Mnemonic : LAMB SWEARS 1⃣ Pharmacological : LAMB 🔸 L - Loop Diuretics : for patient with fluid retention - Frusemide is the drug of choice, max weight reduction is 1kg/day - Bumetanide is 2nd generation loop diuretics (has more predictable absorption) - Thiazide (non loop) : may be preferred in pt with hypertensive HF and mild fluid retention - Combined tx (loop + thiazide) : severe HF/refractory oedema 🔸 A - ACE inhibitor : 1st line drug for all HF patient - improve QOL & survival - caution : can increase creatinine level and eGFR. maintain <30% increase from baseline, adjust dose if more 🔸 M - MRA (Spironolactone) : Addition reduces mortality & hospitalisation 🔸 B - Betablockers : only when lung is clear (pt no longer in overt HF) - reduce morbidity & mortality - contraindicated if : asthma, av block without pacemaker, symptomatic hypotension, if pt requires inotropic support 🔸 Other options : AID - ARNI : replacement for ACEi/ARB if patient remain symptomatic - Ivabradine : helps control rate (block SA node current) - Digoxin : If rate control not adequate with BB alone or BB is contraindicated 2⃣ Education : SWEARS 🔸 S - Stop smoking 🔸 W - Weight monitoring daily : - if >2kg in 3 days, adjust frusemide & restrict fluid intake 🔸 E - Exercise : - Aerobic eg walking. 30 mins, 5 days a week 🔸 A - Avoid alcohol : - Can cause acute decompensation 🔸 R - Restriction of fluid & salt : - Salt : avoid adding flavouring sauces or salt when cooking or at table - Fluid : individualised, generally 1-1.5L in patient with normal renal function - Dont restrict both too much : can cause intravascular volume depletion -> RAAS & symphatetic activation -> tachycardia 🔸 S - Sex & Pregnancy : - Defer sex if NYHA III or IV, modify to accommodate impaired effort tolerance - BB can cause erectile dysfunction : but it is important that pt remains compliant (weigh risk & benefit) - Pregnancy : advise termination if NYHA III or IV, or LVEF <30% 3⃣ Other Modalities : 🔸 Device therapy : considered when pt has good clinical fx and prognosis (life expectancy > 1 year) - Cardiac Resynchronisation Therapy : if pt symptomatic despite optimised medical therapy - Implantable Cardiac Defibrillator : to reduce sudden cardiac death from VT/VFib (common in HF) 🔸 Surgery : - Revascularisation : if CAD - Valve surgery : vulvular heart problem - LV aneurysmectomy : LV aneurysm *Source : CPG Heart Failure 2019 (new)