The 12 Rhythms of Christmas: Type II AV-Block
This article is the sixth in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It’s a continuation of the theme behind last year’s 12 Leads of Christmas.
Type II AV-Block
Except for first degree, type II is probably the simplest of the AV-blocks to identify. There’s really only two major criteria:
A P-wave suddenly and unexpectedly fails to conduct to the ventricles.
The PR-intervals of the P-waves that do conduct are fixed and equal.
Let’s examine the ECG below, which exhibits both of those findings. The computer, however, disagrees and suggests and altern...
Source: EMS 12-Lead - January 4, 2016 Category: Cardiology Authors: Vince DiGiulio Tags: 12 Rhythms of Christmas Vince DiGiulio Source Type: research
The 12 Rhythms of Christmas: Type I AV-Block
This article is the fifth in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It’s a continuation of the theme behind last year’s 12 Leads of Christmas.
Before we delve into today’s particular rhythm I’d like to discuss a bit of terminology. My first ECG textbook was the 8th edition of Marriott’s “Practical Electrocardiography,” which I chased with a couple more of Dr. Marriott’s books. As a result, I tend to describe arrhythmias using the same language he used in his texts.
We should all be aware that there are four main types of...
Source: EMS 12-Lead - December 30, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: 12 Rhythms of Christmas Vince DiGiulio Source Type: research
The 12 Rhythms of Christmas: First Degree AV-Block
This article is the fourth in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It is a continuation of the theme behind last year’s 12 Leads of Christmas.
An 84 year old male presents with a chief complaint of abdominal pain. The ECG below is performed:
Figure 1. What is the rhythm?
What is the rhythm?
You may think the title of this article gives the answer away but, as we learned in the series’ first post on sinus tachycardia, the obvious can fool you when we’re dealing with ECG’s. Let’s walk through it step by step.
There are regular P-waves of n...
Source: EMS 12-Lead - December 29, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: 12 Rhythms of Christmas Vince DiGiulio Source Type: research
The 12 Rhythms of Christmas: Atrial Flutter
This article is the third in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It is a continuation of the theme behind last year’s 12 Leads of Christmas.
This is a new edit of the first article I ever published on my personal blog, so it may seem familiar to some readers.
Finally, if you were curious about the mystery rhythm in Fig. 16 of the first post on sinus tachycardia, you might be surprised to know that it shows atrial flutter with 2:1 conduction. The same tracing pops up in Fig. 23 of this article.
Atrial Flutter
Have you slammed adenosine to cure a patient̵...
Source: EMS 12-Lead - December 28, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: 12 Rhythms of Christmas Vince DiGiulio Source Type: research
The 12 Rhythms of Christmas: Sinus Bradycardia
This article is the second in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It is a continuation of the theme behind of last year’s 12 Leads of Christmas.
We were almost day behind kicking off the series (a peril of posting around the holidays), so I’m going to interrupt my planned order with an easy post to get things back on schedule. The arrhythmia hinted at near the end of the first post will instead be revealed tomorrow.
Last year I posted a nearly identical article titled Don’t let your bradycardic patient D.I.E., but this is an update focused on sinus ...
Source: EMS 12-Lead - December 27, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: 12 Rhythms of Christmas Vince DiGiulio Source Type: research
The 12 Rhythms of Christmas: Sinus Tachycardia
This article is the first in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It is a continuation of the theme behind of last year’s 12 Leads of Christmas.
Sinus Tachycardia
It’s one of the first arrhythmias we all learn and it seems so simple. Sinus tachycardia is a regular rhythm faster than 100 bpm with a sinus P-wave before each QRS, right?
Well, let’s examine some of the finer points of sinus tachycardia.
Figure 1. This is not sinus tachycardia.
I’m going to tell you that the ECG above does not show sinus tachycardia.
It’s from an 85 year o...
Source: EMS 12-Lead - December 26, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: 12 Rhythms of Christmas Vince DiGiulio Source Type: research
AMS, hypotensive with HR > 150: Cardiovert?
EMS was called for middle-aged man, found slumped over a table at restaurant. He had quite a poor mental status and could not offer any medical history. Per the staff he had just arrived, and not eaten or drank anything.
Although he is carrying a home glucometer, his blood sugar is 160. He has a new-ish looking hospital wrist band on, but no shoes.
Systolic BP in the 80s, and HR around 160. Dry, hot skin, and the rest of the exam isn’t revealing. IVs are started, and a rhythm strip obtained:
And a 12-lead:So, what do we have so far? And what do we do with the ECG findings?
What does the ECG show?
Yes,...
Source: EMS 12-Lead - December 17, 2015 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
Transcutaneous pacing: “Put it up to eleven!”
What. The. Heck.
Dramatic ECG! But there is a short answer, actually just a number. And as the title suggests, the answers to this case are (both literally and figuratively) 11.
But what are the questions?
The Case
EMS brought in a middle-aged male with altered mental status and an ill appearance.Over the past 3-4 days he had become increasingly weak, and now seemed “out of it” to his family.
He had a recent admission to the hospital for atrial fibrillation, and was discharged on an ACE inhibitor, as well as both a beta-blocker and a calcium-channel blocker. (No digoxin.)
The paramedic found his heart rate to b...
Source: EMS 12-Lead - November 30, 2015 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
Is this a STEMI-equivalent?
EMS was called for a young adult male who had collapsed at home.
He had been walking through the kitchen when he complained of some chest discomfort, appeared to perhaps have trouble breathing, and then had a syncopal episode.
He had a PMHx history of trisomy 21, sleep apnea, DM type 2, and right-sided CHF due to his sleep apnea. His family also told medics that he had some congenital heart problems: A ventricular septal defect had been repaired in childhood, but he currently had an unrepaired bicuspid aortic valve, with aortic stenosis.
He was conscious by the time EMS arrived. Vital signs and exam were unremarkable.
EMS ...
Source: EMS 12-Lead - November 12, 2015 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
Heroin Withdrawal: QT Prolongation & Torsade de Pointes
This is the case of a 61 year old male who presented to the emergency department with a chief complaint of nausea and vomiting. The patient was alert and oriented, reporting intermittent chest pressure for the last 12 hours that he rated as a 9/10 pain level. He also reported multiple syncopal episodes within the last 24 hrs.
Previous Medical History:
Hypertension
Previous MI
Coronary artery disease
2 coronary stents
No known allergies
Medications:
Lisinopril
Plavix
Pravachol
Depakote
Methadone
Initial Vital Signs:
Heart Rate: 72 beats/min
Respiratory Rate: 22 breaths/min
Non-invasive Blood Pressure: 142/78...
Source: EMS 12-Lead - October 29, 2015 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg Torsade de Pointes Source Type: research
Spot the STEMI #1
Discussion
Patient A is experiencing a subtle lateral STEMI while Patient B has a normal ECG.
Both tracings exhibit slight J-point elevation in V2 with a tall T-wave. In fact, Patient B shows an even taller T-wave than Patient A and also has a similar morphology in V3 that Patient A lacks. Taken in isolation these findings are mildly concerning for a subtle “hyperacute” T-wave morphology indicative of ischemia.
Given only the precordial leads I’d actually be more worried about Patient B.
But there’s a reason we look at all twelve leads—and in this case the limb leads are absolutely key to the dia...
Source: EMS 12-Lead - September 19, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Spot the STEMI Vince DiGiulio Source Type: research
Conclusion to 43 Year Old Female – Chest Discomfort After Eating
Conclusion
Going back to our initial case; the patient first stopped in the emergency department where she had some labs drawn and a chest X-ray performed.
Her initial troponin-I on a current-generation assay (in the U.S.; not high-sensitivity) came back undetectable at < 0.01 ng/mL (ref <= 0.04 ng/mL). Thankfully an astute emergency physician recognized the significance of the patient’s ECG and activated the cath lab before that value returned. Had they waited for the troponin they would have been falsely re-assured as it was still very early in the patient’s MI and the level simply had not had time to a...
Source: EMS 12-Lead - September 12, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Vince DiGiulio Source Type: research
“You Make the Call” — 86 Year old Female: Dizzy
It is a beautiful September morning when the tones go off for a 91 year old female, “altered mental status”.
“Guess breakfast will have to wait”, as you and your partner head towards the residence.
As you enter the one level home, you are directed to a back bedroom where you find your patient lying in bed.
She is alert and oriented, but her color seems pale. She seems uncomfortable. Her radial pulse is strong, and she is breathing normally.
You ask what happened…
” I was sitting at the kitchen table having some tea when I got really dizzy. My friend helped me to bed, but it hasn&#...
Source: EMS 12-Lead - September 10, 2015 Category: Cardiology Authors: David Baumrind Tags: 12 lead ecg Cases ems-health-safety ems-topics patient-management 12-Lead ECG case study David Baumrind ems12lead.com Paramedic Source Type: research
43 Year Old Female – Chest Discomfort After Eating
You respond to an office workplace for a 43-year-old female with a chief complaint of chest discomfort.
On arrival you are greeted by the patient who is pleasant and well-appearing. Her skin is warm, pink, and dry and pulse strong at the radials. Respiratory effort is normal with clear lung sounds bilaterally and she does not seem to be in any distress aside from some mild anxiety about having the ambulance pick her up at work.
She had just finished eating lunch (soup and a sandwich) when she began to experience retrosternal chest pain that she describes as “like a cramp—as if there’s something stuck in there...
Source: EMS 12-Lead - September 5, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Vince DiGiulio Source Type: research
I “over-diagnosed” an ECG. Maybe you should too.
It’s important to be wrong now and then. Not just for the usual blather about being humble, understanding cognitive biases, or even nailing the Kobayashi-Maru test.
Don’t do it Saavik…
No, it’s important to be wrong in the right sort of way, a willingness to be humble in the interest of patient care. Let me explain!
Case #1: I was sooo right.
EMS brought in a middle-aged male who was “found on the floor,” having been their for an unknown period of time. Their medical history and medications were also unknown, and his altered mental status didn’t help. Vital signs were okay, although the heart ra...
Source: EMS 12-Lead - August 10, 2015 Category: Cardiology Authors: Brooks Walsh MD Tags: 12 lead ecg Source Type: research
