Bi- and Trifascicular Block

Bifascicular block or one-and-a-half block = Left Anterior Fascicular Block (LAFB)/ Left Posterior Fascicular Block (LPFB) + Right Bundle Branch Block (RBBB)

Trifascicular block = LAFB/LPFB + RBBB + First degree AV block

Wolff-Parkinson-White (WPW) Syndrome

Had practical lesson in Arrhythmia-ICU today. Dr. Valek kicked off the session with some ECGs for us to interpret. I am quite satisfied with myself for not knowing 'only' 4 of them, LOL. I must really thank Dr. Thaller :)

I was quite amazed by the multiple ECGs of a same patient with WPW syndrome.

Something I read about WPW syndrome but did not realised its importance:

-if there is short PR interval, wide ORS with delta wave but patient doesn't have paroxysmal tachycardia, the patient has only preexcitation and this is called WPW pattern.

-if there is WPW pattern(as mentioned above) and patient has history of paroxysmal tachycardia, it is then only called WPW syndrome

-the most common arrhythmia in WPW syndrome is Atrioventricular Reentrant Tachycardia(AVRT)

-there are two forms of AVRT: orhtodromic AVRT and antidromic AVRT (depending on how the impulse goes in the reentrant circuit)

-Vagal maneuvre can be used to terminate AVRT as it transiently blocks AVN

-Atrial Fibrillation and Atrial Flutter can occur too

-Rx: antiarrhythmics

-Do not use calcium channel blocker, digoxin or beta blocker!!

-iv procainamide for AF and AFL in patient with bypass tract. Electrical cardioversion can be considered

-radiofrequency cathether ablation (95% success rate)

*Study Lown-Ganong-Levine Syndrome too!

Abdominal Aorta Aneurysm (AAA)

Lucky to see a case of abdominal aorta aneurysm(AAA)on Thursday but maybe not so lucky for that patient because in case of aneurysm rupture, the mortality is quite high. Managed to see and feel what is written on textbook--- pulsatile abdominal mass above the umbilicus. It amazed me! We saw the CT angiography with 3D reconstruction too. Wow, it is just so unbelievable that such a big aneurysm has developed in his abdomen and produces so many 'bends' or 'kinks'. The patient is going to have endovascular treatment---a stent graft will be placed into his abdominal aorta to prevent the rupture.



Risk factors:
smoking, hypertension, age over 70 years old, family history of AAA

Symptoms:
75% asymptomatic
in case of acute expansion or disruption of wall: pain(abdominal, back, flank pain), hypotension, pulsatile abdominal mass rarely partila intestinal obstruction, ureteric obstruction and hydronephrosis, GI bleeding(duodenal mucosal hemorrhage, aortoduodenal fistula), aortocaval fistula, distal embolisation(blue toe)

Diagnosis:
pulsatile abdominal mass, bruits on auscultation, abdominal USG, CT, MRI, Doppler

Treatment:
smoking cessation, HTN control, DM control, hyperlipidemia control
surgery or endovascular options(stent graft)