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Acute Pulmonary Edema
- Sushilkumar S Gupta.PGY2 Internal Medicine.Maimonides medical center.Brooklyn, NY, 11219.Ventricular Tachycardia and Management. Case Based approach.
Chief Complaint.77 y/o MaleChief complaint: Found on street, unconscious, brought in by EMS to the hospital.
Past Medical HistoryAtrial Fibrillation from past 15 years s/p Pacemaker in May 2014. Echo done in July 2015 -45% (outpatient).HypertensionHyperlipidemiaDiabetes MellitusBPH
HPIThe patient was brought in by EMS, while he was found unconscious on street, duration unknown. He had a rapid Heart rate 250beats per minute.On detailed evaluation later after he was conscious, patient states that while he was riding his bike he had chest pain, felt dizzy and had headache after which he became unconscious and when woke up was found to be in hospital.On baseline, Patient is ambulatory, ADL independent, AOO x 3.
Social HxNon smokerNon alcoholicNo illicit drug use describedMarried, lives with wife. Family HxNo family history of Arrhythmia or Cardiovascular disorder.Surgical HxPacemaker insertion in May 2014.
Review of SystemsGeneral: -fever, -chillsNeuro: +generalized weakness, -confusion, +dizziness, +loss of consciousnessSkin: -lesions, -rashNose, Mouth, Throat: -nasal discharge, -epistaxisRespiratory: -cough, +dyspnea, -hemoptysis, -pleuritic -wheezingCardiovascular: +chest pain, +palpitationsGI: -constipation, +abdominal pain, -diarrhea, -nausea, -vomiting, -hematochezia, -black stoolsExtremities: +bilateral LE swelling.GU No hematuria or dysuria.
Physical ExamVitals: Temp 100.7F, HR 285bpm, RR 26bpm, BP 92/65mmhg, O2 sat 100% on 2L NCGeneral: Lying in stretcher, unconsciousPsych: unable to assessNeuro: unconscious, Pupils bilateral equal size and reacting.Skin: No rashes observed, dry skinHEENT: NC/AT, dry oral mucosaRespiratory: Left side healed scar from pacemaker insertion, clear breath sounds bilaterally, no wheezing, rales or crackles auscultatedCardiac: tachycardia, normal S1/S2, no murmurs appreciatedAbdominal: Soft, non-distended, active BS, RUQ tenderness.Extremities: 2+ pitting edema, 1+ dorsalis pedis.
Medication ListWarfarin 3mg OD.Tamsulosin 0.4mg QHSSimvastatin 20mg QHS.Metformin 1gm BIDLosartan 25mg ODAtenolol 50mg BID
Initial Lab Workup16.512.237.83941354.310021190.9303PT 94.6INR 8.5Ca 8.5AG - 14BNP 488Mg -1.4
Cardiac Enzymes:Myoglobin 57, 58,39CKMB 3.1, 2.7Troponin I - 0.12sec
Rate > 100 (or 120) bpm
Origin: from one of the Ventricles i.e., distal to the bundle of His.
Three or more consecutive beats on a ECG.
Classification is based on:Duration of EpisodesMorphologySymptoms
1. Duration of EpisodesThree or More beats on an ECG at a rate >100bpm originating from VentriclesNon Sustained VT: If rhythm self-terminates spontaneously in less than 30secondsSustained VT : If rhythm lasts > 30seconds (Even if it self-terminates spontaneously after 30s)
2. MorphologyMonomorphic VT : same configuration beat to beat. This is the most common VT; and the most common reason is ischemia.Polymorphic VT : Continually changing QRS morphology. Causes Ischemia, electrolyte disturbance, drug toxicity and familial.Torsade de pointes (twisting of points)Waxing and waning QRS amplitude during tachycardia associated with prolonged QT interval
3. Sinusoidal VT :sinusoidal appearance of rhythm. Electrolyte dist.4. Accelerated idioventricular rhythm (AIVR) m/c cause - reperfusion arrythmia in first 12hrs after acute MI or during periods of elevated sympathetic tone. No treatment necessary, self terminates.
Prolonged QT intervalWhat is the difference between prolonged QT interval and Polymorphic VT??????
Acquired : K Channel blocking medication : Quinidine, Erythromycin, Clarithromycin, Haloperidol, Droperidol, Ondensetron.Type 1A antiarrhythmic : sotalol, Amiodarone,Congenital : Brugada syndrome Congenital long and short QT syndromes Catecholamingeric polymorphic VT
SymptomsChest PainLight headednessPalpitationsSyncopeSudden Cardiac Death (SCD) :Ambulatory ECG records at SCD have shown 50-60% at sustained monomorphic VT as the initial event.
DifferentialsSVT with aberrant intraventricular conductionPreexcited Tachycardia (associated with or mediated by accessory pathway)BBBVentricular paced rhythms
Treatment depends on hemodynamics: Stable Vs Unstable.
Amiodarone (Class 3)Large volume of distribution & long half lifeContraindicationsIodine sensitivitySinus bradycardiaHeart blockPrecautionsIncompatible with NS. Preferred with D5W.Preferable via CVC.Monitor TFT, PFT, LFTAdverse effectsShort term : Prolongation of QT interval, Skin reactions, Brady, hypotension, corneal micro-deposits.
Pioneers of ICD.
Martin MowerMichel Mirowski
The idea of the ICD came to Dr. Michel Mirowski when his friend died of SCDConcept: could a defibrillator be implanted in the body?Technological challenges: Could an implantable device deliver sufficient energy? Could leads be developed to carry that much energy? How would the device detect arrhythmias? How could defibrillation become automated?Dr. Harry Heller died of SCD in 1966. His friend, Dr. Michel Mirowski, knew that he might have lived had he received defibrillation immediatelyBy 1969, Dr. Mirowski was working on the first experimental models of what would later become the ICDBut it would be almost 20 years before the device was commercially available!Sinai Hospital of Baltimore recruited Dr. Mirowski and offered him opportunity to work on ICD idea At Sinai, Mirowski teamed up with Martin Mower in the research labIn 1969, experimental modelFirst transvenous defibrillation (1969)Canine implants (1970s)First human implant: 1980 (Johns Hopkins, Baltimore)
Primary and Secondary indications of AICD use.Primary Prevention - Patients at high risk for cardiac arrest due to a defined pre-existing disease state but without clinical expression of potentially fatal arrhythmias.
Secondary Prevention- Patients surviving cardiac arrests due to ventricular tachyarrhythmia's.