زكاة العلم الدكتور محمد البيضاني

Old age male with history of IHD on digoxin therapy and other medication presented with palpitations, nausea, vomited , headache and slight abdominal pain. ECG show AF with frequent ventricular ectopic beat . Keep in your mind there is suspicion of disease toxicity ( clinically and ECG findings) . As simple as that hold the digoxin, send for S electrolytes and follow the patient. Notes: remember signs of digoxin toxicity in previous posts - increase in the vagal tones - increase in the automaticity like ventricular ectopic beats

40 years old female presented with SOB, chest pain with sweating , confusion, restlessness and palpitations. During examination there is - tachycardia - tachypnea - bilateral good air entry - muffled heart sound - rise JVP - hypotension ECG show - tachycardia - slightly low voltage ECG - electrical alternans ( change in the hight of QRS) Echo study show - pericardial collection - diastolic collapse of right side History, examination, ECG and echo study pass with cardiac tamponade. The patient was passed before intervention. Notes: - pericardial space contain less than 50 mL of pericardial fluid - more than 50 mL is pericardial effusion - acute heart failure due to pericardial collection is cardiac tamponade - tamponade occurs regardless the amount as rapid collection of small amounts can causes tamponade. - avoid diuretics and give IV NS and prepare for pericardiocentecesis as some as possible.

ST elevation in the anterior leads and part of lateral leads with ST elevation in inferior lead ( leads II ,III and avF). This is due to occlusion of beginning of left anterior descending coronary artery which supply anterior and lateral and sometimes wraparound inferior wall as in this patient.

Ischeic insult will be better as the patient older as there is collateral supply. I see multiple case in the CCU with three vessel disease and patient had preserved Left ventricular systolic function. On the other had as the patient younger has worser prognosis and enter in complications with poor response to the treatment. That’s why some old people had multiple Ischmic insult but they are alive while younger people continues in deterioration until death

Old age male with history of DM and HTN. Echo study show sever LV systolic dysfunction ECG show - widespread ST depression - ST elevation in avR The causes of LV dysfunction is three vessel occlusion.

Something to remember

What is the history , examination and investigation for this ECG ?

- rSR pattern in V1 with narrow QRS this is incomplete RBBB - left axis deviation with ( small Q and large R in lead I and small R and deep S in avF) this is left anterior fascicular block. - RBBB and left anterior fascicular block = bifascicular block.

30, years old female with hyperthyroidism due to multinodular goitre undergo thyroidectomy befor one month . Now presented with generalised fatiguability, headache and myalgia. She also report muscle spasm in her arms . Anyhow ECG was done and show - sinus tachycardia - partial RBBB - prolonged QT due to prolonged ST segment which is specific for hypocalcemia. Conclusion; the patient had thyroidectomy and accidentally the parathyroid gland removed during the operation. That’s why the patient had fractures of low calcium and improved clinically with calcium therapy. Not : hypocalcemia causes prolonged ST segment and hypercalcemia causes short ST segment.

- ECG number 1 patient came with epigastric pain for 6 hour to the ED and remained become on serial ECG(I don’t know why serial ECG) 2- after 2-3 hours and 3 serial ECG she discharged on her responsibility and go to the private clinic The senior cardiologist admit her to the CCU as established MI. Discussion - time mean muscle mass n acute coronary syndrome - ST elevation MI as in the ECG (1) not required serial ECG and don’t required S troponine - don’t discharged the patient even on her responsibility ( if you know the case is MI 🌝) - ECG 1 is inferior Stemi within the golden perio - ECG 2 established Inferior MI passed the golden period -

First comment

Old age male with severe LV systolic dysfunction on digoxin therapy Presented with confusion and gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhoea and abdominal pain). ECG show - sinus rhythm - there is ventricular ectopic beats ( bigmeni) - at the sinus beat there is ST depression due to the effect of digoxin ECG ( ventricular ectopic beat) with clinical features pass with digoxin toxicity

Old age with history of IHD, heart failure and atrial fibrillation. Recently on routine follow up she note that bood urea start to elevate and reach 90 mg/dl . Anyhow He take digoxin daily . Nowadays she develop bradycardia, nause , vomiting and slight confusional state. ECG SHOW - regular R—R interval - narrow QRS - obvious fibrillation ease without P wave Conclusion: the patient develop complete heart block with junctional escape rhythm due to digoxin toxicity Note : regularisation of AF with fibrillation wave and patient on digoxin treatment is digoxin toxicity until prove otherwise.

Accelerated junctional rhythm (AJR) occurs when the rate of an AV junctional pacemaker exceeds that of the sinus node. This situation arises when there is increased automaticity in the AV node coupled with decreased automaticity in the sinus node. ECG Features of AJR • Narrow complex rhythm; QRS duration < 120ms (unless pre-existing bundle branch block or rate-related aberrant conduction) • Ventricular rate usually 60 – 100 bpm • Retrograde P waves may be present and can appear before, during or after the QRS complex. They are usually inverted in inferior leads (II, III, aVF), upright in aVR + V1 • AV dissociation may be present with the ventricular rate usually greater than the atrial rate • There may be associated ECG features of digoxin effect or digoxin toxicity NOTE: AJR with aberrant conduction may be difficult to distinguish from accelerated idioventricular rhythm. The presence of fusion or capture beats indicates a ventricular rather than junctional focus. #digoxin toxicity

Rate complication of digoxin toxicity is bidirectional tachycardia. There is alternation in QRS axis . It also very rarely can occur in MI , Myocarditis. The antidote not really available we can use phenytoin.

First comment

Old age with history of IHD , HF and atrial fibrillation. ECG was done accidentally without clinical complain. ECG show - irregular irregularity without apparent P wave - ST segment depression take shape of revered stick 🦯 or Salvador dial sagging - short QT interval give appearance of ST elevation This is features of digital effects as the patient on digoxin therapy and not digoxin toxicity

70 yeah old female with just of HTN , DM , renal failure and IHD. This ECG was take as the patient in the hospital to follow up he cardiac and renal problems. See the first comment

Keep in your mind in the pericarditis related to ischmia the only treatment option is aspirin as the other option ( ibuprofen, prediction and colchicine) impair healing of infarcted myocardial tissue and increase the risk of mechanical complications