Conclusion: 38 Year Old Male – Chest Pain and Leg Paralysis.
Recap
In the post yesterday , the paramedic crew was evaluating a 38 y.o. male who had sudden, severe chest pain, as well as leg numbness and paralysis, and whose vital signs showed a mild bradycardia and pronounced hypertension.
The ECG obtained by EMS appears to be junctional, with an unclear contribution from the SA node. More concerning, however, is the ST segment elevation in V2-V5, with modest ST depression in aVF and perhaps in III. This would usually define an anterior wall acute coronary occlusion (i.e. STEMI). However, the depth of the S wave in V2 and V3, combined with the high R wave in V5 and V6, strongly sug...
Source: EMS 12-Lead - July 31, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
38 Year Old Male – Chest Pain and Leg Paralysis.
You are called for severe chest pain.
The patient is a 38 year old male who describes the abrupt onset of a severe pain in his chest about 30 minutes before his wife called EMS. While sweat streams off his face, he tells you that he has never felt pain this intense. He isn’t sure if it’s pleuritic, and he endorses some shortness of breath. The pain radiates to his shoulders, back, and epigastrium. Despite the severity of the pain, he is actually far more worried that his left lower extremity is numb, and that he can’t move it – he repeatedly tells you in a loud voice that “Something’s wr...
Source: EMS 12-Lead - July 30, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
57 Year Old Male–Chest Discomfort
It is a bright Sunday morning when you and your partner are dispatched for an “adult male-chest pain”.
You arrive at a well kept residence, noting a ladder and paint cans as you enter.
You find your patient, a 57 year old male, sitting on the sofa in mild distress.
“I was doing some painting, and about 20 minutes ago I felt some pressure here (points to central chest just left of sternum), and my arm started hurting too (rubs left bicep area).”
He rates the discomfort at 7/10. He also says he became very sweaty and nauseous at the time of onset. Oh, and just for good measure, he tells you he ...
Source: EMS 12-Lead - July 27, 2014 Category: Cardiology Authors: David Baumrind Tags: 12 lead ecg ems-topics patient-management Training training-development 12-Lead ECG case study David Baumrind ems12lead.com Paramedic Source Type: research
80 Year Old Male: Fall
A previously well 80-year-old experienced a fall at his home where he lives alone. He was walking from the living room to the kitchen when suddenly he found himself on the ground, which he attributes to tripping on the runner rug in the hallway.
“My son has been telling me to get rid of that thing for years but I don’t like getting the carpet dirty.”
Unfortunately he injured his hip in the process and wasn’t able to get to the phone to call for assistance, spending two days on the floor until the Meals on Wheels volunteer came by. Skin is cool and dry and his mucous membranes are dry. He has severe ...
Source: EMS 12-Lead - July 22, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: 12 lead ecg Arrhythmias Cases AV Block bifascicular block bradycardia Heart Block LAFB Mobitz II RBBB Syncope type II Source Type: research
Dont let your bradycardic patient D.I.E.
At the risk of plagiarizing myself, I’d like to revisit a topic that I discussed on my personal blog a couple of years ago. The story goes that I am not very good with mnemonics. For me they are almost never useful in clinical practice, and as the patient gets sicker my chances of properly recalling the applicable mnemonic decreases exponentially.
There is, however, one mnemonic that I never forget, and it’s the DIE mnemonic for bradycardia. I developed this memory aid based off a talk on bradycardia given by the great Dr. Mel Herbert, where he discusses the above differential but in a different order and with ...
Source: EMS 12-Lead - July 15, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: 12 lead ecg Training 12-Lead ECG bradycardia hyperkalema ischemia mnemonic overdose STEMI Vince DiGiulio Source Type: research
36 YOM with Chest Pressure: Reperfusion AIVR
Conclusion:
AIVR is one of the most common rhythms post reperfusion, and although we can’t fully compare QRS morphology and ST segments from AIVR and LBBB, primary ST-T changes can still be found in both ECG patterns with proper ECG evaluation.
(Source: EMS 12-Lead)
Source: EMS 12-Lead - July 2, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg AIVR LBBB Sgarbossa's Criteria Source Type: research
45 year old male with “numb hands” – Discussion
Go back to 45 year old male with “numb hands” to read about the presentation, and see the ECGs.
The culprit artery?
After arriving at the hospital, the patient bypassed the ED, going directly to the cardiac catheterization lab. The patient was found to have a total occlusion of the proximal RCA, and the cardiologist was able to deploy a stent without problem.
Excellent D2B, but …
Despite prompt activation of the 911 system, excellent EMS care, field activation of the cath lab, and an uncomplicated percutaneous coronary intervention, he was left with moderate ventricular dysfunction. The system “di...
Source: EMS 12-Lead - July 1, 2014 Category: Cardiology Authors: brooksw Tags: Uncategorized Source Type: research
45 year old male with “numb hands”
This case illustrates both how good modern EMS can be at expediting emergency cardiac care, but also the challenges that still confront us. Yes, there is a “twist,” but only a small one.
Note: I never saw this patient, but the ECGs and outcome were brought to my attention by a colleague, Dr K. Thrace, who moonlights at a number of EDs in the region. Paramedic Tim Y. also generously shared his recollections of the patient.
The Case
EMS was called for a 45 year-old man with chest pain. The patient was initially reluctant to talk with the paramedic, Tim, since “my girlfriend called for you guys, not me.” He was even...
Source: EMS 12-Lead - June 30, 2014 Category: Cardiology Authors: brooksw Tags: 12 lead ecg MI patient-management Uncategorized Source Type: research
Pediatric Pit Crew CPR
A reader asks, “Does your Pit Crew CPR process work for pediatrics?”
See also: Pit Crew CPR – The Explicit Details
The answer is, “Yes!” with some minor modifications. We are developing a class for Pediatric Pit Crew CPR. It has not yet been implemented so consider this a beta version. I hate to give a disclaimer but you should have your Medical Director review this Pediatric Pit Crew CPR concept and the accuracy of our airway chart before using it.
Some things to keep in mind:
Pediatric cardiac arrest is more likely to be respiratory / asphyxial so there is less emphasis on “patient&#...
Source: EMS 12-Lead - June 26, 2014 Category: Cardiology Authors: Tom Bouthillet Tags: ems-topics patient-management pediatrics Pediatric Pit Crew CPR Source Type: research
Conclusion: 53 YOF with AMS: STEMI or Secondary ST-T changes?
This is the conclusion to the previous case:
53 YOF with AMS: STEMI or Secondary ST-T changes?
This female presented to the ED with Altered Mental Status (AMS), via ambulance, as STEMI ALERT, after completing approximately 3 hours of her usual dialysis.
This was the 12 lead ECG provided by EMS…
We have a sinus rhythm with Bi-atrial Enlargement or Abnormality and Left Ventricular Hypertrophy with Secondary ST-T changes.
We can categorize ST-T changes as Primary or Secondary.
Primary ST-T changes refer to changes due ischemia
Secondary ST-T changes refer to non-ischemic repolarization abnormalities (i.e. LVH, ...
Source: EMS 12-Lead - June 25, 2014 Category: Cardiology Authors: Ivan Rios Tags: Uncategorized Source Type: research
53 YOF with AMS: STEMI or Secondary ST-T Changes?
This is the case of a 53 year old female who presented to the Emergency Department (ED) via EMS, with Altered Mental Status (AMS).
EMS was called to a local dialysis center due to the patient being unresponsive after approximately 3 hours of dialysis.
Upon arrival to the ED, the patient was unable to answer questions, with a Glasgow Coma Scale (GCS) of 8 and the following baseline vital sings:
Heart Rate: 74 beats/min, strong and regular
Respiratory Rate: 15 breaths/min, adequate tidal volume and regular, with clear sounds
Non-invasive Blood Pressure: 202/76 mmHg
SpO2: 99% on 15 LPM via Non-rebreather
Pupils: 3 m...
Source: EMS 12-Lead - June 24, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg Training Source Type: research
The most awesome STEMI test on the internet!
Senior Editor Christopher Watford created an online STEMI test based on McCabe JM, et al. Physician Accuracy in Interpreting Potential ST-Segment Elevation Myocardial Infarction Electrocardiograms. J Am Heart Assoc. 2013; 2:e000268.
It was in beta testing for a while (see this thread at EMTLife.com) but apparently it is now ready for prime time!
I say that because the test was featured at the AmboFOAM blog by Robert Simpson (@AmboFOAM) and was so well received by the #FOAMed community on Twitter that it almost broke the internet.
The test also received The Most Fair Dinkum Ripper Beaut of the Week recognition at Life in ...
Source: EMS 12-Lead - June 23, 2014 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized Source Type: research
Pit Crew CPR – The Explicit Details
I’ve given an overview of my department’s Pit Crew CPR process many times at ems12lead.com, our Facebook page, the Resuscitation group, and various conferences around the country.
(See also: Why do we send so many people to a cardiac arrest?)
Even so, I’m frequently asked for specific details. People want to know exactly how we do it. Here is a very simple description of HHIFR’s Pit Crew CPR process in bullet point form (recently updated). It helps to think of it as a 4-phase process.
Phase 1: Patient’s side to first shock
Confirm pulselessness and announce “at patient, code blue”
Start CPR ...
Source: EMS 12-Lead - June 20, 2014 Category: Cardiology Authors: Tom Bouthillet Tags: administration-leadership ems-topics patient-management Pit Crew CPR resuscitation Source Type: research
Conclusion to Masters Case #02
This is the conclusion to Masters Case #02: 60 Year Old Female – Chest Pain, Hx of Pericarditis. If you haven’t already done so, check out the original post there.
Your patient was a 60yo F who experienced significant 8/10 chest pain that was now down to a 1 or 2 and presented with this EKG:
What to do?
This is a really though ECG to sort out (hence it being a “Masters Case”) and will be labelled “non-specific” by most folks who see it, even experts. Indeed, that would be my official interpretation without any further investigations or follow-up to confirm my hunches. Still, b...
Source: EMS 12-Lead - June 11, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Conclusion Masters Cases Bojana Uzelac posterior reperfusion waves STEMI Vince DiGiulio Source Type: research
Just a paced rhythm… Or is it?
Ok, so I posted a 12 Lead ECG on Facebook this past Monday, June 2nd, 2014, which generated some interesting comments and thoughts…
https://www.facebook.com/photo.php?fbid=10152417488161049&set=a.436337931048.217588.216914116048&type=1&theater
This ECG was obtained from a 67 year old male, complaining of difficulty breathing for the past 2 hours, and presented diaphoretic, with no other signs of hypoperfusion.
Past medical history:
Hypertension
Congestive Heart Failure (CHF)
Hypothyroidism
Vital signs:
Blood Pressure: 110/88 mmHg
Heart Rate: Between 80 -94 beats/min and regular
Respiratory Rate: 1...
Source: EMS 12-Lead - June 4, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg MI Paced Rhythm Sgarbossa's Criteria Source Type: research
