Ministry of Health of Uzbekistan
TASHKENT MEDICAL ACADEMY
«Approved»
Vice Rector for Academic Affairs
Prof. ___________ Тешаев О.Р.
«____» ___________ 2012 г
Department: INTERNAL MEDICINE MEDICAL FACULTY
Item: GPs with an endocrinologist
TECHNOLOGY EDUCATION
on practical training on the topic:
«“THE SYNDROME OF AN ARRHYTHMIA OF HEART”»
SUBJECT: The syndrome of an arrhythmia of heart. Differential diagnostics
of arrhythmias: blinking and an atrial flutter (a constant, paroxysm), a
syndrome of premature excitation of ventricles - WPW. Tactics of GP.
Tashkent
1.Compiled by:
Nurillaeva NM - Candidate of Medical Sciences, Head of the department of
internal medicine for the preparation of a general practitioner and clinical
allergology
Abdumalikova FB - assistant of internal medicine for the training of general
practitioners and clinical allergology
Education technology approved:
At the faculty meeting minutes №
from «___ » ____________ 2012 y
Theme: The syndrome of an arrhythmia of heart. Differential diagnostics of
arrhythmias: blinking and an atrial flutter (a constant, paroxysm), a syndrome
of premature excitation of ventricles- WPW. Tactics of thr DGS.
1. Avenue and class equipment:
- Chair of internal illnesses on preparation of DGS with clinical allergology, a
thematic educational room, chamber in cardiology unit, cardioresuscitation
department, an electrocardiogram room and etc.
- Evident materials, tables, albums, slides; case histories, distributing materials: an
electrocardiogram, situational problems.
- Subjects of new information technology – electron presentation., banners
2. A chronological card of employment.
№
Stages of employment
Time
Duration of
employment
1
2
Morning conference
Discussion of a theme with use of
interactive game
8.30-9.15
9.20-10.00
45 min
40 min
3
4
Mastering by practical skills
Independent monitoring of patients
in the attached chambers, thematic
patients, participation in detours of
professors and senior lecturers
10.00-10.30
10.30-11.55
30 min
90 min
5
6
Break
Analysis in unit of the examined
thematic patients
11.55-12.40
12.40-13.15
45 min
35 min
7
Discussion of tests, cards problems
Comprehensibility check, the
announcement of estimations, the
task for the house
13.20-13.50
30 min
13.50-14.00
10 min
8
3. Duration of study subjects
- 6.9 hours
- Only 270 minutes - 45 = 235 - 15 = 220 minutes duration lessons
3. The employment purpose: According to algorithm to teach students to
questions of timely diagnostics, differential diagnostics, a choice of optimum
medical tactics and conducting tactics at blinking and an atrial flutter, a Bouveret's
disease, a syndrome of premature excitation of ventricles - Wolf- Parkinson-White
(WPW).
The student should know:
- An etiopathogenesis
- Risk factors
- Clinic and classification of arrhythmias
- Criteria of the diagnosis
- Treatment standards
- Indications for a direction on consultation
- Indications to hospitalization
- Rehabilitational actions.
The student should be able:
- Professional inquiry and survey of the patient
- Statement of the preliminary diagnosis
- Appointment of the plan of inspection
- Interpreting of the data of clinical, laboratory-tool methods of research (an
electrocardiogram, EchoCS)
- To carry out differential diagnostics
- To prove and make the clinical diagnosis
- To render the first medical assistance at urgent conditions
- To prescribe corresponding therapy
- To make references to the patient
4. Motivation. For today the arrhythmia is the most frequent reason of sudden
death and a progressing circulatory unefficiency, therefore knowledge of versions
of arrhythmias, their diagnostics, tactics of the emergency help and the further
therapy are obligatory for the DGS.
5. Intersubject and intrasubject interrelation – it is necessary to have
knowledge of bases of anatomy, physiology, pharmacology, propaedeutics of
internal illnesses, faculty and hospital therapy. Considering that the syndrome of "a
heart Arrhythmia” is a symptom of many diseases, for the DGS is necessary to
involve many experts – cardiologists, cardiosurgeons, arrhythmologists,
rheumatologists, endocrinologists. At analysis of the given theme the close
interrelation is traced by resuscitation and urgent conditions, functional
diagnostics.
6. The employment maintenance:
6.1. A theoretical part
Heart arrhythmias – any heart rhythm which is not a regular, sinoatrial rate of
normal rate, and also disturbance of conductivity of electric impulse to various
sites of spending system of heart
Bouveret's disease - disturbance of a heart rhythm in the form of attacks of
palpitation with frequency of reduction of heart 140-220 in a minute. The ciliary
arrhythmia - disturbance of a heart rhythm at which throughout all haert cycle is
observed frequent (from 350 to 600 in a minute) chaotic excitation and reductions
of separate groups of muscular fibers of auricles and is absent of their coordinative
reduction.
Syndromes of premature excitation of ventricles: Syndrome WPW - is caused by
presence of a way of carrying out between auricles and ventricles. Syndrome CLC
- truncated interval PQ - is caused by presence of an additional way of carrying out
between auricles and a ventriculonector.
Differential diagnostics of arrhythmias – ciliary arrhythmias, Bouveret's diseases,
syndrome WPW is spent by following criteria: on an etiopathogenesis, a clinical
picture, an electrocardiogram – to implications, treatment principles.
So, for example, at the heart of blinking and atrial flutter occurrence the
mechanism re-entry lies, and principal causes leading MA - is a stenosis of a mitral
orifice, a thyrotoxicosis, an atherosclerosis of coronal vessels, an ischemic heart
disease.
In a basis of occurrence WPW of a syndrome anomaly of development of heart, i.e.
presence of congenital additional communication – a fascicle of Kent lies.
The provoking factor paroxysme tachycardias can be an emotional or physical
overstrain, abusing alcohol, smoking. Arise these attacks can as at patients with a
myocardium crushing defeat (a myocardial infarction, an idiopathic hypertensia,
myocardites, a thyrotoxicosis, and at patients with a vegeto-vascular dystonia – a
supraventricular paroxysm, a tachycardia.
Differential diagnostics of SVPT and VPT.
Paroxysmal supraventricular
tachycardia
It can be observed at healthy people –
functional (70 %), an organic parentage
– 30 %
The reason are heart diseases,
myocardites, CMP
Often there are vegetative disorders (a
shiver, a sweating, a nausea, an
urination)
Effect from reflex assays
Paroxysmal ventricular tachycardia
At the healthy it is not observed, 90 %
of an organic parentage
The reason are heart diseases,
myocardites, CMP, an ischemic heart
disease. A myocardial infarction, a
digitalis intoxication
More expressed hemodynamic
disturbances (depressing a BP, an acute
left ventricular failure, disturbances of
coronary blood supply)
The effect from vagal assays isn't
present, reflex assays is contraindicative
CCR 140-250 in 1 minute, a correct
rhythm
Tooth Р deformed, before QRS,
diphasic, negative
QRS is invariable
Treatment to begin with vagal assays,
and then from antiarrhytmic
preparations; group – antagonists of
calcium, at an inefficiency lidocaine,
cordaronum, propranormum
to carry out
C C R 140-220 in 1 minute, a correct
rhythm
QRS is dilated more than 0,12 sec,
discordance of
А-В dissociation (Р with frequency
from the SA-knot, and QRS from the
ectopic center)
At an AMI – lidocaine intravenously,
cordaronum, propranormum
New pedagogical technologies used on employment:
«Cerebral storm»
Accessories to work:
1. Questions written on single sheets of paper.
2. Pens (red, dark blue)
Rules for carrying out the game:
1. The teacher costs at a board and asks a question.
2. Students start to list answers.
3. The teacher doesn't reject and doesn't make comments on each answer, all writes
down on a sheet of paper.
4. When all students will show the opinion, discussion of the arrived answers
begins with the first answer.
5 After discussion end, the teacher asks to underline the right answers on
sheet.
6. Students are estimated by quantity of the right answers.
7. Works spent on this game remain with the teacher
Questions for carrying out the game:
1. The most frequent reasons leading to blinking and an atrial flutter
2. The most frequent reasons leading to Bouveret's diseases.
3. Indications to carrying out of vagal assays and their transfer.
4. An acute management at a paroxysmal supraventricular tachycardia
5. An acute management at paroxusmal ventricular tachycardia
5. Ciliary arrhythmia electrocardiograms-signs
6. Electrocardiograms-signs of SVPT
7. Electrocardiograms-signs of VPT
8. The most frequent reasons leading to paroxysmal tachycardia.
6.2. An analytical part
Situational problems
1. The patient had a palpitation attack (160 beats/min), which doctor stopped by
the massage of a carotid sine. The palpitation attack most likely has been caused
by:
a) a sinus tachycardia
b) a paroxysm ciliary arrhythmia
c) a paroxysm atrial flutter
d) a paroxysm supraventricular tachycardia
e) a paroxysm ventricular tachycardia
The right answer is d.
2. Massage of a carotid sine at a tachycardia 184 in a minute with a correct rhythm
has led to become less rhythm to 80 in a minute. What most probable diagnosis?
a) a sinus tachycardia
b) Atrial flutter with the block 2:1
c) Bouveret's disease
d) a paroxysmal atrial tachycardia
e) Atrial fibrillation
The right answer is d.
3. At the patient the sinus bradycardia 45 beats/min against which periodically
there are ciliary arrhythmia attacks becomes perceptible. The equipment of a
pacemaker of the patient refuses flatly. What of the listed agents can be applied to
conservative treatment?
a) anaprilinum
b) cordaronum
c) Belloidum
d) Digoxinum
e) Verapamilum
The right answer is c.
4. The patient, 62 years. An acute infarct prescription of 10 hours. There was just
an atrial fibrillation with frequency of a ventricular rhythm nearby 130 in a minute.
A BP - 105/70 mm hg the small dyspnea in rest. Pains aren't present. With what it
is necessary to begin an acute management in the intensive care block?
a )Electric defibrillation
b) Lidocaine intravenously
c) Strophanthinum intravenously
d) Electrocardiostimulation
e) Nitroglycerinum i/v
The right answer is c.
6.3. A practical part. The student should have skills of propagation of a healthy
way of life, dialogue with patients, poll and survey, and also an estimation of the
received data, interpreting of an electrocardiogram, a substantiation of the clinical
diagnosis, inspection, treatment, filling of the medical documentation, consultation,
audit of the done work and skills of work with the medical literature. During the
class clinical analysis of patients with carrying out of differential diagnostics and
definition of tactics DGS is spent at Blinking and atrial flutter, a Bouveret's
disease, a syndrome of premature excitation of ventricles - Wolf-Parkinson - White
(WPW).
Monitoring of patients
ELECTROCARDIOGRAM
Holterovsky monitoring
EchoCS
Differential diagnostics
Diagnosis substantiation
Treatment
References
7. Forms of control of knowledge, skills, abilities:
Indicator
Not executed
Monitoring of patients
0
ELECTROCARDIOGRAM
0
Holterovsky monitoring
0
EchoCS
0
Differential diagnostics
0
Diagnosis substantiation
0
Treatment
0
References
0
Total:
Tests:
Completely executed
50
20
50
20
10
20
10
10
10
1. Name 3 reasons of a Bouveret's disease:
А. myocarditis
B. myocardial infarctis
C. reception of obsidanum
D. Syndrom of WPW
E. Verapamil overdosage
F. reception of heart glycosydes
2. Name 3 non-drug interventions at paroxysmal supraventricular tachycardia:
А. Massage ofthe bottom extremities
B. Pressing on an eyeball
C. Changing of body position
D. Assay of Valsalvy
E. Kick in a thorax
F. Massage of carotid knot
3. Name 3 reasons of a ciliary arrhythmia:
A. Mitral orifice stenosis
B. insufficiency of mitral valves
C. ISCHEMIC HEART DISEASE
D. Stenosis of an aorta mouth
E. Hypotireosis
F. Tireotoxicosis
4. Name 4 diseases at which often happens ciliary arrhythmia:
А. mitral insufficiency
B. tireotoxicosis
C. ischemic heart disease, cardiosclerosis
D. a cardiomyopathy
E. An aortal stenosis
F. Stenosis of a mitral orifice
G. a stenosis of the three-cuspidate valve
H. hypotireosis
5. Specify 4 signs of syndrome WPW:
A. a delta wave in complex QRS
B. elongation of ST interval
C. widening and deformation of complex QRS
D. discordance of segment ST
E. elongation of interval PQ
F. shortening of interval PQ
G. tooth Т is negative
H. high peaked tooth Т
6. Name 3 signs of a ventricular Bouveret's disease:
A. Presence of tooth Р
B. Deformation and уширение complex QRS
C. Discordance of interval ST and tooth T
D. CCR more than 140 in mines
E. Not changed complexes QRS
F. Wavy Р a tooth
7. Specify 3 electrocardiograms of a sign of an atrial fibrillation:
A. Chaotic of a wave f
B. Absense of tooth Р
C. Depression of interval ST
D. Wrong ventricular rhythm
E. SPreservation of a correct ventricular rhythm
F. Negative tooth Р
8. Specify 4 preparations for treatment of the constant form of ciliary arhythmias:
A. Digoksinum
B. Propranololum
C. Platyphyllinum
D. Kordaronum
E. Lidokainim
F. verapamilum
G. nifecard
H. corinfar
9. 3 electrocardiograms sign of an atrial flutter:
A. The CARDIAC CONTRACTIONS RATE to 200-400 in minute, regular,
identical waves F in abductions II, III, AVF, V1, V2
B. presence of Delta wave
C. not changed ventricular complex
D. Changed, deformed ventricular complex
E. Interval PQ - 0,22 sec.
F. Often a correct regular ventricular rhythm
8. Criteria of an estimation of the current control:
The characteristic of actions of students
Comprehensibility Estimation
The student is ready to employment on the basic 96-100
«5»
questions and questions of IWS, activly participates
in theme discussion, has deeply mastered a theme,
creatively thinks, completely owns practical skills,
accurately knows criteria of statement of the
diagnosis Ciliary arrhythmia, a Bouveret's disease
and syndrome of WPW, applying clinical, logic
thinking at bed of the patient (on the basis of the
data of inquiry, survey, interpreting of analyses and
the electrocardiogram) carries out differential
diagnostics. Defines tactics of DGS and
differentativly selects medicamental therapy, makes
preventive references to the patient. During watch
independently supervises patients, accurately
reports.
The student is ready to employment on the basic
91-95
questions and questions IWS, activly participates in
theme discussion, has deeply mastered a theme,
completely owns practical skills accurately knows
criteria of statement of the Ciliary arrhythmia, a
Bouveret's disease and syndrome of WPW, applying
clinical, logic thinking at bed of the patient (on the
basis of the data of inquiry, survey, interpreting of
analyses and the electrocardiogram) carries out
differential diagnostics. Defines tacticsof DGS and
differentativly selects medicamental therapy, makes
preventive references to the patient. During watch
independently supervises patients, accurately
reports.
The student is ready to employment on the basic 86-90
questions and questions of IWS, activly participates
in theme discussion, has mastered a theme, owns
practical skills, accurately knows criteria of
statement of the diagnosis Ciliary arrhythmia, a
Bouveret's disease and syndrome of WPW, applying
clinical, logic thinking at bed of the patient (on the
basis of the data of inquiry, survey, interpreting of
analyses and the electrocardiogram) carries out
differential diagnostics. Defines tactics of DGS and
selects medicamental therapy, makes preventive
references to the patient. During watch
independently supervises patients, reports.
The student is ready to employment on the basic 81-85
questions and questions of IWS,
Participates in theme discussion, has mastered a
theme, owns practical skills, knows criteria of
statement of the diagnosis Ciliary arrhythmia, a
Bouveret's disease and syndrome of WPW, at bed of
the patient (on the basis of the data of inquiry,
survey, interpreting of analyses and the
electrocardiogram)
carries
out
differential
diagnostics, but supposes some discrepancies.
Defines tactics of DGS and selects medicamental
therapy, makes preventive references to the patient.
During watch supervises patients, reports
indistinctly.
«5»
«5»
«4»
The student is ready to employment on the basic
questions and questions of IWS,
Participates in theme discussion, but inactively, has
mastered a theme, owns practical skills, can
diagnose a ciliary arrhythmia, a Bouveret's disease
and syndrome of WPW, at bed of the patient (on the
basis of the data of inquiry, survey, interpreting of
analyses and the electrocardiogram) carries out
differential diagnostics but supposes some
discrepancies. Defines tactics of DGS and
medicamental therapy, makes preventive references
to the patient. During watch supervises patients by
means of the doctor on duty, reports not accurately.
The student is ready to employment, has mastered a
theme, owns practical skills, can make the
preliminary diagnosis a ciliary arrhythmia, a
Bouveret's disease and syndrome of WPW, at bed of
the patient (on the basis of the data of inquiry,
survey, interpreting of analyses and the
electrocardiogram) hardly, carries out differential
diagnostics but supposes some discrepancies.
Defines tactics of DGS and medicamental therapy,
makes preventive references to the patient. During
watch supervises patients by means of the doctor on
duty, reports not accurately.
The student is ready to employment, has
insufficiently mastered a theme, is indistinctly owns
practical skills, can't independetly make the
preliminary diagnosis a ciliary arrhythmia, a
Bouveret's disease and syndrome of WPW, at bed of
the patient (on the basis of the data of inquiry,
survey, interpreting of analyses and an
electrocardiogram). Hardly defines tactics of DGS
and medicamental therapy, makes preventive
references to the patient not completely. During
watch supervises patients by means of the doctor on
duty, reports not accurately.
The student isn't completely ready to employment,
has insufficiently mastered a theme, is indistinctly
owns practical skills, can't independently make the
preliminary diagnosis of ciliary arrhythmia, a
Bouveret's disease and syndrome of WPW, at bed of
the patient (on the basis of the data of inquiry,
survey, interpreting of analyses and an
electrocardiogram. Hardly defines tactics of DGS
76-80
«4»
71-75
«4»
66-70
«3»
61-65
«3»
and medicamental therapy, makes preventive
references to the patient not completely. During
watch supervises patients only by means of the
doctor on duty, reports not accurately.
The student isn't completely ready to employment,
55-60
has insufficiently mastered a theme, is indistinctly
owns practical skills, can't independently make the
preliminary diagnosis of Ciliary arrhythmia, a
Bouveret's disease and syndrome of WPW, at bed of
the patient (on the basis of the data of inquiry,
survey, interpreting of analyses and an
electrocardiogram. Hardly defines tactics of DGS
and medicamental therapy, makes preventive
references to the patient not accurately and not
completely. During watch supervises patients by
means of the doctor on duty, isn't able to report.
The answer incorrect on all questions.
55 and down
«3»
«2»
10. Control questions:
- The basic diseases leading to disturbances of a rhythm in the form of a ciliary
arrhythmia, a Bouveret's disease, WPW syndrome
- Risk factors at the arrhythmias that has set forth above – similarities and
differences
- Criteria of the diagnosis at the arrhythmias that has set forth above, their early
diagnostics.
- Differential diagnostics of supraventricular and ventricular Bouveret's diseases
- Differential diagnostics at blinking and an atrial flutter
- An electrocardiogram picture at the kinds of arrhythmias that has set forth above
- A direction on inspection, consultation, hospitalization at the conditions that has
set forth above
- Rendering of the emergency help at Bouveret's diseases
- Rendering of the emergency help at blinking and an atrial flutter
- Indications for surgical treatment at a WPW-syndrome
11. The literature:
Textbooks,
monographies, lectures
1. V.I.Metelitsa. A
directory of the
cardiologist on clinical
pharmacology. М,
Basic literature
Additional literature
1. J. Merta. A directory of the
general practitioner. Moscow
1998.
2. Internal deseases,
1. Usmanov R. I, E.B.Zueva,
V.M.Kozhinsky Modern
recommended Rules of
treatment of therapeutic
2002
2. Chirkin. L.A.
Diagnostic directory
3. Flanks. Н.П.,
Nasonov. V.A.
Directory of the doctor
of the general practice.
– in 2 volumes-2000.
4. Stenford.
Antiarrhytmic therapy,
1998
5. Murashko V.V.,
Strutinsky. А.В. An
electrocardiogram.
1987
6. A clinical
echocardiography 1990
7. Komarov F.I..,
Kukes. V. Internal
illnesses. 1990
S.N.Bobodzhanov, 2004
3. Algorithms of diagnostics
and treatment of the basic
syndromes for preparation of
DGS, 2003
4. Algorithms of diagnostics
and treatment of diseases of a
therapeutic profile, 2003
5. Treatment of illnesses of an
internal in 4 volumes,
Gammons, А.Н., 2003
6. Diagnostics of illnesses of an
internal in 4 volumes,
Gammons, А.Н., 2003
7. Differential diagnostics of an
internal, Heglin, Р, 1997
8. Gadaev. A.G.Management
of DGS, 2006
9. A therapeutic directory of
the Washington university
under M.Vudli, transfer from
eng., М, 1995.
10. Michigan. Cardiology in
tables and schemes 1997
patients. A method.
References, Т, 1999
2. Demonstrative medicine.
Clinical references to
practising doctors, 2001
3. Kurbanov R. D, Yeliseyev
M.R. Ingibitory enzyme
angiotensin-transforming in
cardiologic practice.
Methodical references. Т,
2000.
4. Kurbanov. R.D. Modern
methods of diagnostics and
treatment of chronic
insufficiency, 2004
5. Usmanov R. I, E.B.Zueva
Cardiology problem in
schemes and tables. 2005
6. Zueva. E.B., Saidova. SH.A.
Modern principles and clinical
pharmacology of antiarrhytmic
medical products, 2003
7. Magazines - Therapeutic
archive
Cardiology
Medical sites on the Internet: www.medmir.ru, www.doctor.ru,
www.medbox.ru, www.medicum.ru, www.medline.ru