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Sinus Tachycardia in the asymptomatic patient may seem benign, but.............. A 28 yo woman presents to the Emergency Department following an ankle injury. She has a past medical history of diabetes. Her blood sugar on the day is 24 mmol/L and it's obvious, by the fact that she has just eaten a chocolate bar in the waiting room, that she may have issues with her glycaemic control. She is found to be tachycardic, however has no symptoms of palpitations or chest pain or shortness of breath. The ankle injury is not causing significant pain at rest, but the tachycardia continues. She is managed for her ankle injury and discharged. This same patient had been in the emergency department the day before for initial treatment and was also tachycardic at that time. Her ECG is shown below (this is not the actual patient's ECG but one similar). What do you think?  Please note that this is not the actual patient's ECG, but a similar ECG with Source: Wikipedia. This is a straightforward sinus tachycardia.
Why would I have called the patient back when I saw the history? Persistent sinus tachycardia is worrying. Simple sinus tachycardia may be caused by responses to pain, drinking coffee or even eating some chocolate, We need to separate the benign from the pathological causes of sinus tachycardia. These include: Cardiac:
There are many causes of sinus tachycardia. Inappropriate sinus tachycardia is usually associated with symptoms such as palpitations, dyspnoea and dizziness. No cause is found. Trying to control the heart rate in these patients doesn't always control the symptoms and the usual approach involves decreasing stimulants taking up exercise and controlling fluid and salt intake. In our patient's case of an asymptomatic tachycardia at rest and on the background history of diabetes, cardiac autonomic neuropathy is the most probable diagnosis. What are the subclinical and Clinical Manifestations of cardiac autonomic neuropathy How do we diagnose it? What do we have to be on the lookout for?
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A 62 yo woman presents to the emergency department with palpitations. She has a past medical history of hypertension. Her examination is normal. Vitals on arrival are: Afebrile, heart rate 70bpm, BP 90/42 An ecg is done and is shown below. What is the diagnosis?  This is atrial flutter. It is the second most common tachy-arrhythmia after atrial fibrillation It is a macroreentrant atrial tachycardia with the loop above the AV node in the right atrium.
It can conduct as
How do we best manage the STABLE patient?
How to best manage the UNSTABLE patient? Who would you anticoagulate? Remember that this arrhythmia will typically not revert with vagal manoeuvres. This year at the Cardiac Bootcamp face to face course in Sydney we had a fantastic turnout and we went over a huge amount of content in Acute Cardiology and reading ECGs. There were some ECGs that we looked at, as part of the ECG Quiz. Here is one of those ECGs, to test your memory and to reinforce some of the most important things we learnt about this case. A 68 yo woman presented with worsening SOB over the previous 24 Hours. She now also had chest pain and was speaking in very short phrases. She was a smoker, with a past medical history of COPD and hypertension. Her vitals were:
Her blood pressure dropped to 65/32 before peripheral inotropes were commenced. Her ECG and Chest Xray are shown below. What is your diagnosis?   There is a pericardia effusion diagnosed on LOW VOLTAGE CRITERIA. Small complexes and tachycardia = pericardial effusion. The are Sensitive Criteria and Specific criteria for picking low voltage on an ECG. This was all part of the 'SHOCKED' A mnemonic on Cardiac Bootcamp Course, to minimise missed cases.  A 50 yo male presents with chest pain. His ECG is shown below. What does it show?  Rate: 66
Rhythm: Irregularly irregular, not many P waves, so atrial fibrillation. QRS: Narrow ST-T: The obvious abnormality here is the STE in II, III and aVF with reciprocal changes in aVL. There is also some ST depression in V2-V4. The diagnosis here is an inferior infarction. We need to beware of potential Right Ventricular infarction as well. How do patients with Right Ventricular Infarction present? What does the ECG show? What are the differentials? What is the management of these patients? Isolated right ventricular infarction is rare, but it does occur in 30-50% of cases of inferior infarction. We need to think of the possibility of right ventricular infarction, or we can miss it. The right ventricle is thin walled and is perfused throughout the cardiac cycle, explaining why it is less likely to infarct....... |
AuthorDr Peter Kas 
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