Morning Report 04/22/09

Jad Skaf

87 y.o. F. admitted for Change of Mental Status

HPI• History obtained from EMS, patient lives

alone, called 911 claiming that there were people walking through her walls. Vitals stable during transportation.

• Patient knows it’s cooper and obama is president but thinks it’s 1996

PMH

• CKD (Baseline 1.4)• HTN• OA• Gout

MEDS• Aricept• Allopurinol• celebrex• Catapres• asa• pentoxifylline• Tylenol-Codeine#3• Metoprolol

96.6 44 139/67 16 97

• Drowsy, opens eyes to verbal stimuli• No ecchymosis or evidence of trauma• R eye cataract• Decr. BS bibasilar• HS reg, no murmurs• Abd Soft NTNDBS+• LE: trace edema• AA, Ox1 (persons). Non focal exam

“Oh and by the way she dropped her HR to the low 30’s once…”

HR

0

20

40

60

80

100

14:30 15:00 15:30 16:00 16:30 17:00 17:30 18:00 18:30 19:00

HR

155/68 175/72

SpO2>98%

Bradycardia

• SSS• Increased Vagal Activity• Myocardial Ischemia• Increased Intracranial Pressure• Athletes• OSA• Meds (BB, CCB, Digoxin, AA)• Idiopathic Degeneration (Aging)• Others: Hypothy, hypothº, K, CVD, Amyloidosis,

Sarc…

CCU day#1:

• Atropine 80

• Glucagon 60

• Cutaneous Patches

• No indication for PPM at this time

• Hallucinations resolved

CCU day#2:

HR reversed off metoprolol/clonidine/Aricept

Will continue to observe

May not need a PPM

UTI: E coli susc. to levaquin

Stable for Tx to PCU

PCU day # 1:

BP 138/96 HR 200 RR 22 97.6

Metoprolol 5 IVP HR 120

PCU day # 2:

Pt. is transferred to Medicine with EP consult

Med day # 1:

Atrial Chamber PM implant via L cephalic vein cut down without complication. Converted to sinus during procedure, suggest Sotalol to maintain in sinus.

Discharge Meds

• Sotalol 40 BID• Metoprolol 25 BID• …

SSS – Lown (1967)

SSSPatients with symptomatic SSS are primarily older, with frequent co morbid diseases and a high mortality rate. In three major trials of pacing in this disorder, the median or mean age was 73 to 76 years.

Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. Lamas GA; Lee KL; Sweeney MO; Silverman R; Leon A; Yee R; Marinchak RA; Flaker G; Schron E; Orav EJ; Hellkamp AS; Greer S; McAnulty J; Ellenbogen K; Ehlert F; Freedman RA; Estes NA 3rd; Greenspon A; Goldman. N Engl J Med 2002 Jun 13;346(24):1854-62.

• Chronic, inappropriate, and often severe bradycardia • Sinus pauses, arrest, and exit block with and often

without, appropriate atrial and junctional escape rhythms.

• AV conduction disturbances in over 50 percent of patients

• Alternating bradycardia and atrial tachyarrhythmias in over 50 percent of cases. AF is most common, but atrial flutter and paroxysmal supraventricular tachycardias may also occur.

SSS - ETIOLOGY

• Tachy-Brady Syndrome (50%)• Sinus Node Fibrosis• Disease of SA Nodal artery• Familial disease (rare – SCN5A, HCN4 mutations)• Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria,

Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies…

• Drugs: Parasympathomimeticssympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB)CimetidineDigoxinCCBAmiodarone

…

SSS - ETIOLOGY

• Tachy-Brady Syndrome (50%)• Sinus Node Fibrosis• Disease of SA Nodal artery• Familial disease (rare – SCN5A, HCN4 mutations)• Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria,

Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies…

• Drugs: Parasympathomimeticssympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB)CimetidineDigoxinCCBAmiodarone

…

SSS - ETIOLOGY

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