9 June 2021 - Environmental

Teaching this week will be over Zoom:

https://zoom.us/j/5981463478?pwd=RThaZzNkL2w5bldBMlNHeE1zZFFaZz09 

Meeting ID: 598 146 3478 

Passcode: 2021

Program

1000-1010: Recap

1010-1020: ECG of the Week — Jannet Chan

1020-1030: Image of the Week — Katherine Watson

1030-1130: Working with Interpreters — Karella de Jongh (SVHM Interpreter Services)

1130-1230: Hyperbaric Medicine — Dr Arun Ilancheran (FACEM & FCICM)

1230-1300: Lunch

1300-1330: Heat-related Illness — Ezra Limm

1330-1400: Cold Thermal Injuries — Sarah Simons

NOTE: 1330-1400: Fellowship Exam Groups — Written with Alex Handrinos & OSCE with Brendan Morrissey

Join Zoom Meeting: https://us02web.zoom.us/j/89545481615

Meeting ID: 895 4548 1615

Image of the Week

33F tripped and fell while intoxicated. She is unable to weight bear with severe left ankle pain.

ECG of the Week

82F presents with syncope.

1) Describe the ECG and diagnosis

• Atrial rate of 85bpm

• Ventricular rate of 38 bpm

• Complete AV dissociation with junctional bradycardia

• Normal axis

Diagnosis: Complete heart block with junctional bradycardia

Approach to bradycardic ECG:

• Atrial rate?

• Ventricular rate?

• p wave — conducting or non-conducting?

  • 2 consecutive non-conducting p waves = High-grade AV block

• PR interval — constant or variable?

  • Mobitz type 1 — Variable PR interval before and after the missed beat

  • Mobitz type 2 — Same PR interval before and after the missed beat

    • Consider AV block with 2:1 / 3:1 / 4:1 block with atrial and ventricular rate ratio

• QRS — narrow or wide

2) What may cause complete heart block?

• AV nodal blocking drugs, e.g. calcium channel blocker, beta blocker, digoxin

• AMI — especially inferior myocardial infarction

• Degenerative disease of the conduction system

• Metabolic, e.g. hyperkalaemia

3) The patient becomes hypotensive BP 70/50. Describe your stepwise management priorities.

• Atropine 600mcg IV, repeat every 5 mins, max of 3mg- likely unsuccessful

• IV saline bolus 500mL stat

• IV adrenaline infusion — starting at 5mcg/min and increasing every 2 minutes until systolic BP >90mmHg

• Transcutaneous pacing

  • Informed consent

  • Haemodynamically stable analgesia/sedation, e.g. ketamine 0.5mg/kg

  • Apply pads in the antero-posterior position

  • Set to demand mode, at rate of 70, output 70mA

  • Ensure both electrical and mechanical achieved

• Identify and treat reversible causes

• Transvenous pacing in cath lab +/- PPM insertion