Pulsus Paradoxus: Cardiac Function and Assessment
PULSUS PARADOXUS
PATHOPHYSIOLOGY
In normal hemodynamic conditions, during inspiration, adequate cardiac, vascular function and adequate blood volume, certain changes in blood pressure occur. Keep in mind, when we measure blood pressure, we are assessing arterial pressures, not venous.
• Normally during inspiration, Cardiac Output (CO) decreases slightly, since the Left Ventricle (LV) does not have the adequate amount of space to expand for full capacity preload
•This drop in blood pressure is normally < 10mmHg
•The heart rate also increases, as a compensatory mechanism, in an attempt to maintain normal Oxygen Del...
Source: EMS 12-Lead - May 28, 2014 Category: Cardiology Authors: Ivan Rios Tags: patient-management Pulsus Paradoxus Training Assessment Cardiac Function Source Type: research
Pulsus Paradoxus: Cardiovascular Function and Assessment
Cardiovascular Assessment:
Pulsus Paradoxus
Assessing cardiac function, blood pressure and hemodynamic status play an important role during our overall patient assessment and treatment. Although 12 lead ECG evaluation is an essential part of patient assessment, especially cardiac etiology, understanding basic cardiac function plays a major role during treatment and overall patient status.
During normal hemodynamic conditions, during inspiration, adequate cardiac, vascular function and adequate blood volume, certain changes in blood pressure occur. Keep in mind, when we measure blood pressure, we are assessing arterial pr...
Source: EMS 12-Lead - May 28, 2014 Category: Cardiology Authors: Ivan Rios Tags: patient-management Pulsus Paradoxus Training Assessment Cardiac Function Source Type: research
Understanding Atropine
As requested, during our previous Adenosine discussion, we will briefly review, Parasympathetic stimulation and Atropine pharmacodynamics on the heart.
ACETYLCHOLINE (ACh) is one of the Neurotransmitters, a chemical signal, used by the Central Nervous System, which has many effects on the body, from stimulating muscle contraction, inducing peristalsis (digestion), Bile release by the liver, and as discussed here, decreasing Sinoatrial Node (SAN) and Atrioventricular Node (AVN) stimulation. When the later occurs, often we encounter its effect recorded on the ECG, seen as:
Sinus Bradycardia
SA Blocks
AV Blocks
The most co...
Source: EMS 12-Lead - May 24, 2014 Category: Cardiology Authors: Ivan Rios Tags: Pharmacology Training atropine bradycardia Source Type: research
Atropine Pharmacodymanics
As requested, during our previous Adenosine discussion, we will briefly review, Parasympathetic stimulation and Atropine pharmacodynamics on the heart.
ACETYLCHOLINE (ACh) is one of the Neurotransmitters, a chemical signal, used by the Central Nervous System, which has many effects on the body, from stimulating muscle contraction, inducing peristalsis (digestion), Bile release by the liver, and as discussed here, decreasing Sinoatrial Node (SAN) and Atrioventricular Node (AVN) stimulation. When the later occurs, often we encounter its effect recorded on the ECG, seen as:
Sinus Bradycardia
SA Blocks
AV Blocks
The most co...
Source: EMS 12-Lead - May 24, 2014 Category: Cardiology Authors: Ivan Rios Tags: Pharmacology Training atropine bradycardia Source Type: research
Masters Case #02: 60 Year Old Female – Chest Pain, Hx of Pericarditis
This is the second in our occasional series of Masters Cases. These are some of the toughest ECG’s we have seen and that is reflected in both the level of responses that are expected along with the depth of the discussions that will entail. For a taste of how these play out check out the conclusion to the Case #01.
As with the first case, this one was also submitted by Dr. Bojana Uzelac from Serbia. Her country, along with much of the Balkans, recently experienced flooding on a scale that has not been seen in anyone’s lifetime. In an email she described it to me as:
“For my 34 years I have seen war, bomb...
Source: EMS 12-Lead - May 23, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Masters Cases Bojana Uzelac Vince DiGiulio Source Type: research
Understanding Adenosine (Adenocard)
So, recently, I was involved in a conversation, where the topic of Adenosine administration came up. It seems like there is a misunderstanding regarding its use and mechanism of action. Although this is not our classic ECG interpretation topic, I believe its worth talking about for a bit.
Adenosine, a Class V antiarrhythmic from the Vaughan Williams Classification, is an Endogenous Neucloside, meaning, already present in the body. In the EMS system, Adenosine is known for the treatment of Supraventricular Tachycardias (SVT), however, the reality is that, Adenosine is responsible for many actions in the body at a cellular ...
Source: EMS 12-Lead - May 15, 2014 Category: Cardiology Authors: Ivan Rios Tags: Adenosine Pharmacodynamics Source Type: research
76 YOM with Chest Tightness… Peanut Allergy?
Conclusion:
Door to Balloon time was <35 min, revealing a 100% occluded Right Coronary Artery. (Source: EMS 12-Lead)
Source: EMS 12-Lead - May 9, 2014 Category: Cardiology Authors: Ivan Rios Tags: Uncategorized Source Type: research
Conclusion to Masters Case #01
Conclusion: 81 YOM with Chest Heaviness
Here’s a visual representation of the ST-vector here in comparison to what we usually see with run-of-the-mill diffuse subendocaridal ischemia and acute epicardial ischemia in the LAD distribution (aka STEMI).
Frontal ST-Vectors. Click to enlarge.
Transverse ST-Vectors. Click to enlarge.
I don’t think the wide-complex beats offer us any additional insight into the ST-changes as they sometimes can, though the morphology in V6 is a bit worrisome. What I mean by that is that the T-waves there are a bit large and feature a rather convex shape. While not diagnostic of anything itâ...
Source: EMS 12-Lead - May 8, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: ems-health-safety ems-topics Masters Cases patient-management Training training-development acute anterior STEMI aVR Bojana Uzelac conclusion STEMI Equivalents subendocardial ischemia Vince DiGiulio Source Type: research
Qrs axis determination
During ECG interpretation, cardiac Axis, or direction of electrical impulses, may be normal (physiologic) or abnormal (pathologic), suggesting abnormal cardiac conductivity. Although every deflection obtained on the ECG will have an axis, we will focus on the ventricular axis.
 When we think of our cardiac monitoring lead placement, we have to understand cardiac Vectors, which is the sum of all electrical impulses. These are recorded on each individual lead, because impulses travel underneath the electrodes in multiple directions, therefore, incorrect lead placement will give a false axis.
Here, we will disuss Fronta...
Source: EMS 12-Lead - May 6, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg axis determination hexaxial reference system vector Source Type: research
Revisiting Transcutaneous Cardiac Pacing
“Transcutaneous cardiac pacing is an effective procedure for patients experiencing unstable bradycardia.”
Or is it?
If you’ve read Tom’s introduction to the subject of false capture you’re already ahead of the game.
We’ve shown case after case of unstable bradycardia patients receiving ineffective transcutaneous pacing due to a lack of capture. In each case, phantom pacing impulses are interpreted by the paramedic as electrical capture. Typically, this is confirmed by an improvement in other vital signs, such as mental status or blood pressure.
If I was being shocked 70 to 80 times a ...
Source: EMS 12-Lead - May 2, 2014 Category: Cardiology Authors: Christopher Watford Tags: ems-topics patient-management appropriate T-wave discordance Christopher Watford data quality ECG education paced rhythm Paramedic phantom QRS complexes transcutaneous pacing Source Type: research
Qrs axis determination
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During ECG interpretation, cardiac Axis, or direction of electrical impulses, may be normal (physiologic) or abnormal (pathologic), suggesting abnormal cardiac conductivity. Although every deflection obtained on the ECG will have an axis, we will focus on the ventricular axis.
 When we think of our cardiac monitoring lead placement, we have to understand cardiac Vectors, which is the sum of all electrical impulses. These are recorded on each individual lead, because impulses travel underneath the electrodes in multiple directions, therefore, incorrect lead placement will give a false axis.
Here, we will disuss Fro...
Source: EMS 12-Lead - April 29, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg axis determination hexaxial reference system vector Source Type: research
59 year old male: chest pressure – Conclusion
This is the conclusion to 59 year old male: chest pressure, be sure to read the case study first!
When we left off, we’d loaded our 59 year old male patient with 10 of 10 chest pressure into the back of our unit with the help of a local volunteer EMT. The patient appeared acutely unwell and was hypotensive and bradycardic. We had the following initial ECG:
Before we discuss this ECG in depth, let’s show a serial 12-Lead the crew obtained shortly after leaving the scene:
The importance of serial ECG’s cannot be understated. Using only one prehospital ECG could miss nearly 20% of all STEMI patients!
At t...
Source: EMS 12-Lead - April 23, 2014 Category: Cardiology Authors: Christopher Watford Tags: ems-topics patient-management 12-Lead ECG acute inferior STEMI cardiac arrest case study Christopher Watford EMS 12-Lead hyperacute T-waves Paramedic RBBB right bundle branch block sudden cardiac arrest Source Type: research
Discussion for 70 Year Old Male: Short of Breath
This is the discussion for “70 Year Old Male: Short of Breath“.
Tough case. Â Lots of excellent comments and observations from our readers.
Right off the bat, the patient’s presentation offered a major distraction: the recent eye surgery resulting in the old “eye patch presentation”. Â Confounding the situation further was the lack of any cardiac history, and lack of chest pain.
Let’s review the 12 lead:
Sinus Tach, 115 bpm. Physiologic left axis deviation. Left Bundle Branch Block.
Clearly, the moderate dyspnea and basilar crackles were red flags, as was the sinus ...
Source: EMS 12-Lead - April 21, 2014 Category: Cardiology Authors: David Baumrind Tags: 12 lead ecg ems-health-safety ems-topics patient-management Training training-development 12-Lead ECG appropriate discordance appropriate T-wave discordance broad QRS tachycardia David Baumrind EMS 12-Lead ems12lead.com left bund Source Type: research
59 year old male: chest pressure
It’s a hot summer night in the suburbs, most of which you’ve spent on standby for a local baseball game. After clearing up you’re put on a chest pain call a few blocks from your quarters. The local volunteer fire department has a squad on scene which is advising you to, “continue on emergency.”
Upon your arrival you find the patient seated on the porch, on O2 via a non-rebreather, in moderate respiratory distress. The volunteer EMT relays that the patient, a 59 year old male, is having 10 of 10 chest pressure which started yesterday. He’s administered 324 mg of aspirin and withheld nitro...
Source: EMS 12-Lead - April 18, 2014 Category: Cardiology Authors: Christopher Watford Tags: ems-topics patient-management 12-Lead ECG case study Christopher Watford EMS 12-Lead Paramedic Source Type: research
Masters Case #01: 50 Year Old Male – Severe Chest Pain
Most of our cases here at EMS 12-Lead are designed to strike a balance between challenging experienced prehospital providers while also highlighting a couple of specific teaching points for those seeking to learn. It’s a difficult line to walk. We want to showcase EKG’s with specific findings that are apparent enough to make good teaching tools, but we also want them to be subtle enough to make our practiced readers work.
At this point I’m sure there are a few folks out there who have been following us (and related blogs) for long enough to be familiar with a lot of the major tropes we often discuss, so t...
Source: EMS 12-Lead - April 12, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: ems-health-safety ems-topics patient-management Training training-development Bojana Uzelac ems12lead.com Vince DiGiulio Source Type: research
