SUPRAVENTRICULAR TACHYCARDIA

DAY1 -04.04.2013 AT 15 30
Female 82 yrs came with the
following complaints
Palpitation on and off since today
morning
Dizziness on and off since today
morning
No other complaints- no chest pain
no
shortness of breath
no syncope

 Past medical history

DM
HBP
Pulmonary hypertension(2011)
Bronchial asthma?? COPD(since 5 years)
Atrial fibrillation(2011)
Renal impairment(2009)
Anaemia
She has been admitted in cardiac ICU jeetoo hospital.
She came to AN E on 14.01.13 with same complaints.
She was diagnosed as SVT.. She missed COPD

 Drug history
T digoxin 0.125 mg od
T verapamil SR120 mg od
T cloprez 75 mg od
T metformin 500 mg od
Inhaler ventolin 2 puffs qid prn
Inhaler beclotide 2 puffs bd

 Past surgical history : nil significance

Allergic history: nil significance
Personal history
Non veg
Occupation: labourer in the past
Widow since 30 years. Stays with son
7 children-(three died)
Smoking-nil
Alcohol-nil

On examination

Not dyspneic
No pallor/cyanosis/jaundice
Hydration good
No pedal edema
BP:110/60
RBS:11.3 mmol/l
Pulse150/min

 CVS: S1 S2 heard
HR 150/min
regular
systolic murmur grade 2/6 over mitral area
RS: Bilateral and equal air entry. No added sounds
P/A: soft not distended.
non tender.
No hepatomegaly.BS+
CNS:well orientated with time place and person

 ECG
HR 150/MIN
T inversion in I II avF v2-v6
Supraventricular tachycardia
no acute ST T changes

DIAGNOSIS
Supraventricular tachycardia k/c/o
DM
HBP
Pulmonary hypertension
Bronchial asthma?? COPD
Atrial fibrillation
Renal impairment
Anaemia

Management in casualty

Connect to cardiac monitor

Iv access
Iv verapamil 5 mg was given
Patient reverted back
Then after 15 min patient started
feeling weak
Cardiac monitor showed SVT
Iv verapamil 5 mg was repeated

Post verapamil

Advice
Admit in ward
Drip kvo
T digoxin 0.25 mg od
T verapamil SR 120 mg od
T cloprez 75 mg od
S.c actrapid 8u tds if a/c > 10.0
mmol/l

Investigations sent
FBC
U&E/Cr
CPK

DAY 2
CARDIAC
No chest pain
No shortness of breath

BP 116/46mmhg
PULSE 66/min
Temp:36.7c
Fbs:4.9 mmol/ l

No pedal edema
CVS S1S2 heard
RS- b/l and equal air entry
P/A-non tender . Bs+
CNS: well orientated to
t/p/p

Urea: 23.0
Potassium: 5.4
Creatinine:157
CPK:100U/L
WBC: 8.74X 10e9/l
Hb: 12.6 g/dl
Platelet:295.10e9/l

D2

 ECG: AF
Ventricular rate:80/min

cardiac

medical

Advice
T digoxin 0.0625 mg
od
T lasix 20 mg bd
T verapamil SR 120
mg od
T cloprez 75 mg od

Advice
Neb with atrovent 500
microgram 6 hourly/
PRN
S.c actrapid 6u qid if
a/c > 10.0 mmol/l

DAY 3
CARDIAC

C/O: epigastric pain

BP:123/73
P:62/MIN
T:36.7
A/C:4.9MMOL/L

CVS: S1 S2 regular
RS: bll chest clear
Per abdomen: soft
tender
epigastrium. BS+
CNS: well orientated with
t/p/p

ECG:AF
VR: 80/min
Advice
Cap omeprazole 20 mg
bd
T digoxin 0.0625 mg od
T lasix 20 mg bd
T verapamil SR 120 mg
od
T cloprez 75 mg od

d3

medical

Neb with atrovent 0.5

mg 6 hourly
S.c actraphane -6
units

4
units

DAY 4
CARDIAC
C/O: dizziness
constipation
no SOB/ no
palpitation
BP: 118/45
P:69/MIN
FBS:4.7 MMOL/L
T:36.7C

CVS: s1s2 heard

RS: b/l and equal air
entry
P/A: soft , tender
epigastric region. Bs+
CNS:well orientated
with t/p/p
ECG: HR OF 60/MIN
Advice
Withold verapamil
IV tagamet 200 mg stat
Shift to recover room

D4

DAY 5
CARDIAC
C/0: weakness
dizziness
no SOB/No
palpitation
BP: 110/80 mmhg
P:73/MIN
T:36.7C
FBS:4.9MMOL/L

ECG: sinus rhythm

occasional
ventricular ectopics
Advice:
D/s I pint 8 hourly and I
pair parentrovite od

DAY 6
CARDIAC

MEDICAL

Neb with atrovent 0.5

mg 6 hourly
S.c actraphane -6
units

4
units

No complaints
BP 142/38
P:63/MIN
T 36.7C
FBS:5.2 MMOL/L

ECG: HR : 55-75/MIN

CARDIAC
Advice
T digoxin 0.0625 mg
od
T lasix 20 mg bd
T verapamil SR 120
mg od
T cloprez 75 mg od

Day 7
cardiac
Dizziness

BP128/45
P 86/MIN
T36.7
FBS: 4.9 MMOL/L

ECG: sinus rhythm

HR 60/min

ADVICE
Discharge CARDIAC on
T digoxin 0.0625 mg
od
T lasix 20 mg bd
T verapamil SR 120
mg od
T cloprez 75 mg od

 CASE 2

07.04.2013 AT 2030
DAY1

Male 68 came to A&E unit with

Palpitation since 1/52
Shortness of breath since 1/52
h/o of fever since 5 days
Productive cough and yellow sputun
since 5/7
No chest pain
No peripheral edema

PAST MEDICAL HISTORY

AF (since 2011)
COPD
Drug history
T verapamil SR120 mg od
T lasix 20 mg od
T cloprez 75 mg od
T atv 20 mg nocte
Inhaler ventolin 2 puffs qid
Inhaler beclotide 2 puffs bd
Theophylline 150 microgram

Past surgical history: nil

Personal history
Married
4 children
Non veg
Occupation: vegetable seller
Smoking: has been smoking 1 pack/day since
age of 12 years. Has stopped since 6/12
Alcohol- nil

On examination

Not dyspneic
BP: 130/80mmhg
P:140/min
T36.7C
RBS:6.5mmol/l
Spo2 in air: 96%

No pallor /no cyanosis/no jaundice

Hydration good
No pedal edema

CVS: S1S2 irregular

RS: bilateral basal creps and expiratory rhonchi
Per abdomen:soft non tender ,BS+
CNS: well orientated with t/p/p

ECG:
AF
Runs of SVT
Ventricular rate 160/min
No acute ST T changes
Occasional premature ventricular ectopics

MANAGEMENT IN A&E
Connect to cardiac monitor
Iv access
IV amiodarone 150mg diluted in 5 ml
D5% given
Patient not relieved
Iv verapamil 5 mg given slowly
Chest xray

Advice
Admit
Connect on monitor
T clopidogrel 75 mg od
T atv 40 mg od
Iv lasix 40 mg stat then tab lasix 20 mg od
T verapamil SR 120 mg od
Neb with atrovent 500microgram 6 hourly

DAY 2
No chest pain
No SOB
o/E
No pedal edema
BP 110/60mmhg
P61/MIN
T36.6C

CVS: S1S2 heard

RS: bilateral basal creps
Per abdomen:soft non tender ,BS+
CNS: well orientated with t/p/p

ECG: sinus rhythm

HR 65/min
occasional premature ventricular ectopics
no acute ST T changes
ADVICE
T clopidogrel 75 mg od
T atv 40 mg od
Tab lasix 20 mg od
T verapamil SR 120 mg od

DAY 3
No chest pain
no palpitation
No SOB
BP 100/70mmhg
P58/MIN
T36.7C

CVS: S1S2 heard

RS: bilateral basal creps
Per abdomen:soft non tender ,BS+
CNS: well orientated with t/p/p

 ECG: normal sinus rhythm

HR 60 min
no acute ST T changes
Advice
T clopidogrel 75 mg od
T atv 40 mg od
Tab lasix 20 mg od
T verapamil 40 mg tds

D3(09/04/13)

Day 4
c/o: productive cough with yellow sputum
CVS: S1S2 regular
RS:B/l expiratory rhonchi
Per abdomen: soft nontender. Bs+
CNS: well orientated with t/p/p
ECG: HR 60/min
no acute ST T changes

d4

Echocardiography
Normal valve
Normal dimension of cardiac chamber
No wall motion abnormality
Trivial MR, TR,AR
Good LV function
No intra cardiac thrombus
EF60%

 ADVICE
Discharged on
T lasix 20 mg od
T verapamil 40 mg tds
T clopidogrel 75 mg od
T atv 20 mg od
Syr cough exp 10 ml tds
Cap augmentin 750 mg tds

An 81 yr old white female with

multiple medical problems presents
to the ED complaining only of
syncope and weakness; the routine
12-lead EKG is pictured below.

HYPERKALEMIA
It is defined as serum potassium
more than 5.5 mmol/l

CAUSES
Acute or chronic renal failure, especially in patients who are on dialysis
Trauma, including crush injuries (rhabdomyolysis), or burns
Ingestion of foods high in potassium (eg, bananas, oranges, highprotein diets, tomatoes, salt substitutes). it is often a contributing factor
to an acute potassium elevation.
Medications - Potassium supplements, potassium-sparing diuretics,
nonsteroidal anti-inflammatory drugs (NSAIDs), beta-blockers, digoxin,
succinylcholine, and digitalis glycoside
Medication combinations (ie, spironolactone, ACE inhibitors)
Redistribution - Metabolic acidosis (diabetic ketoacidosis [DKA]),
catabolic states

SYMPTOMS
Patients may be asymptomatic or
report the following:
Generalized fatigue
Weakness
Paresthesias
Paralysis
Palpitations

A&E
Urgent u&E
ECG
ECG show flattened p wave,
increased PR interval ,widened QRS
complex and peaked T waves

 Complications
Ventricular fibrilation
Bundle branch block

TREATMENT
IV access established
Cardiac monitoring
10 ml 10%calcium gluconate given over 2 min
slowly
50 ml D50% with 20 units actrapid given over
30 min
Neb with ventolin 5 mg
Calcium resonium 30g stat then 15 g tds
Stop any drugs(ACE Inhibitors, NSAIDs)
hemodialysis

SIDE EFFECTS OF
CORTICOSTEROIDS

EFFECTS
Increased
gluconeogene
sis
Increased
lipolysis

Impair
immunologica
l competence

steroi
ds

Increases
excretion of
calcium and
decrease
absorption of
calcium

Increased
sodium and
water
absorption

EARLY SIDE EFFECTS

If steroids are used for a short period
increased appetite that often leads to
weight gain
acne
mood changes
rapid mood swings
Gastro intestinal side effectsdyspepsia, abdominal distension

Late side effects

Hypertension
Diabetes mellitus
Osteoporosis
Avascular necrosis
Muscle wasting(proximal myopathy)
Peptic ulceration and perforation
Cushings syndrome(moon face striae acne)
Endocrine effects like menstrual irregularities
and amenorrhea
Hirsutism
Weight gain
Sodium and water retention

 Increased susceptibility to infection(measles, varicella)

Neuropsychiatric effects-psychological dependance,
insomnia , aggravation of schizophrenia , aggravation of
epilepsy
Ophthalmic-glaucoma, posterior subscapsular cataracts
Impaired healing, petechiae, ecchymoses, hyperhidrosis
Leucocytosis
Growth retardation in children

CONDITIONS IN WHICH STEROIDS SHOULD

BE CAUTIOUSLY USED
Peptic ulcer
DM and hypertension
Viral and fungal infection
Tuberculosis and other infections
Osteoporosis
Epilepsy and psychosis
CHF and renal failure

 THANK YOU