Cardiovascular critical care viva- Wellington Course 2016. L Walker.

1/ A 22 year old woman G1PO 35/40 is brought into your emergency department by paramedics
after a collapse at home. Paramedics found her lying on the floor in her kitchen, conscious, HR 200
and ECG revealed VT with a blood pressure of 82/56. She was brought into your emergency
department with an IV line and 6L O2 via a hudson mask, O2 sats are 88%. There have been no
other interventions. She is agitated with laboured breathing. You are called down to the
emergency department to assist. How would you manage this situation?

2 patients. Life threatening for Mother and baby. Priority currently is the Mother. Early call for
help- Anaesthetics, Obstetrician, Neonatologist. Perform a rapid assessment and simultaneous
resuscitation. Brief history focusing on other presenting symptoms, past medical history, antenatal
care. Resuscitation based on A, B, C approach to exclude immediately life threatening pathology
such as tension pneumothorax etc with mention of urgency of situation, need for intubation, DC
cardioversion and urgent CTG and consideration of immediate delivery of baby by C-section in
theatre. (2 marks total- 1 for Initial resus, 1 for overall aims)

2/ What is your differential of the underlying pathology for this presentation?

Peri-partum cardiomyopathy, Pulmonary embolism, Inherited cardiac disorder (Long QT/Brugada

etc), Toxins/Drugs (TCA’s, QT prolonging drugs), Congenital cardiac disorder that is revealed in
pregnancy, Other idiopathic cardiomyopathy revealed in pregnancy, MI (thrombus/embolus), (Less
likely- eclampsia, tension pneumothorax, antepartum hemorrhage) (5 of these for 2 marks)

3/ She is successfully cardioverted with 200J and an ECHO in the ED by a cardiologist reveals a
dilated and severely impaired left ventricle (EF 15%) and a mildly dilated right ventricle and
moderately impaired systolic function. There is mild MR and no other valvular abnormalities.

What are the likely diagnoses now?

As above, focusing on primary chronic vs acute cardiac disorders. The most likely is peripartum
cardiomyopathy (1 mark)

4/ She is hypotensive 74/36 after cardioversion. What intravenous medication/s would you
recommend to support her cardiovascular system and explain why you choose this/these
medications.

Positive inotropes: Adrenaline, Milrinone, Dopamine, Dobutamine all ok answers but mention
anticipated hypotension if Dobuatmine/Milrinone used. Also mention arrythmogenic risks. (2
marks, 1 mark for 2 inotropes, 1 mark for reason). No marks given for pure vasopressors without
concomitant inotrope.

5/ She is admitted to your ICU straight from theatre. In the first 2 hours in your ICU she has
recurrent episodes of VT. With each episode she becomes hypotensive with MAPS down into the
low 50’s. What would you do to manage her recurrent VT and haemodynamic instability?

Chemical support: (Mg/K)Amiodarone, Lignocaine, Short acting B-Blocker (1 mark)

Electrical support: DC cardioversion, Catheter ablation by EP, ICD ( 1 mark)

Mechanical support: IABP, VA ECMO (LVAD/Transplant as a potential endpoint) (1 mark)

6/ What medications can be used to treat the underlying disease process involved in peripartum
cardiomyopathy? (bromocriptine).
 Cardiovascular critical care viva- Wellington Course 2016. L Walker.

1/ A 22 year old woman G1PO 35/40 is brought into your emergency department by paramedics
after a collapse at home. Paramedics found her lying on the floor in her kitchen, conscious, HR 200
and ECG revealed VT with a blood pressure of 82/56. She was brought into your emergency
department with an IV line and 6L O2 via a hudson mask, O2 sats are 88%. There have been no
other interventions. She is agitated with laboured breathing. You are called down to the
emergency department to assist. How would you manage this situation?

2/ What is your differential of the underlying pathology for this presentation?

3/ She is successfully cardioverted with 200J and an ECHO in the ED by a cardiologist reveals a
dilated and severely impaired left ventricle (EF 15%) and a mildly dilated right ventricle and
moderately impaired systolic function. There is mild MR and no other valvular abnormalities.

What are the likely diagnoses now?

4/ She is hypotensive 74/36 after cardioversion. What intravenous medication/s would you
recommend to support her cardiovascular system and explain why you choose this/these
medications.

5/ She is admitted to your ICU straight from theatre. In the first 2 hours in your ICU she has
recurrent episodes of VT. With each episode she becomes hypotensive with MAPS down into the
low 50’s. What would you do to manage her recurrent VT and haemodynamic instability?

6/ What medications can be used to treat the underlying disease process involved in peripartum
cardiomyopathy?