People often remark to me, 'Wah working in emergency department must be very exciting! I bet you gets to see lots of gory injuries and things people 'accidentally' stick up their various orifices!'

Don't worry, you won't be seeing any of those. :)

What you WILL see, however, are interesting photos, ECGs, Xrays etc. which serve to remind us of the vast variety of cases that may come our way, and some of the learning points behind them.

Enjoy. :)


Tuesday, February 1, 2011

Case 1


80 year old female

Past medical hx : hyperlipidemia, diabetes
Chief complaint : giddiness and breathless for 2 days
BP 100/60, HR 40

(1) What is the diagnosis?
(2) How would you manage this patient?


Answer : Complete (Third Degree) Heart Block


  • Complete dissociation of P waves with QRS complexes
  • P-P interval regular; R-R interval also regular
Causes
  • Myocardial infarction - in 10% of inferior MI (usually benign); more serious if associated with anterior MI
  • Cardiomyopathy (e.g. Lyme disease), acute rheumatic fever
  • Overdose of meds (e.g. calcium-channel blocker; beta-blockers)
Approach
  • Manage as P1 case
  • Immediate support of ABC and cardiac monitoring
  1. High-flow oxygen
  2. IV access - take blood for FBC/ UE/ cardiac enzymes & troponin
  • Atropine - 0.6 mg IV every 5 mins up to total of 3 mg
  • Consider dopamine
  • Transcutaneous pacing if medications ineffective (with analgesia/ sedation)
  • Transvenous pacing (by cardiologist) if transcutaneous pacing unsuccessful, or as a definitive procedure after stabilized with transcutaneous pacing
  • Treat underlying cause (e.g. MI, overdose) and complications (heart failure, shock)

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