83 Year Old Male: Shortness of Breath
You are called to the residence of an 83 year old male with a chief complaint of shortness of breath.
On arrival you find a sick-appearing gentleman working hard to breath. He states that he woke up feeling a bit weak this morning with dyspnea-on-exertion that it has gotten progressively worse over past 12 hours—to the point where his is experiencing respiratory distress at rest. He has also had a productive cough. Noticing that he didn’t sound great on the phone his son came to visit, found him in this state, and called 911.
The patient is in moderate respiratory distress (4-5 word sentences) with a respiratory ra...
Source: EMS 12-Lead - October 29, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Cases 12-Lead ECG aVR Vince DiGiulio Source Type: research
Understanding Amiodarone
Recently, I was part of a short discussion between fellow healthcare providers of different levels of care, about Amiodarone and its expected effects on the heart during Ventricular Tachycardia (VT). I figured, I could break it down and write a short summary of how it works.
Most healthcare providers are familiar, or at least have heard of AMIODARONE. We also know that it is one of the leading antiarrhythmics used for treating ventricular dysrhythmias. But the reality is that, it can be used for more than just ventricular tachyarrhythmias.
Amiodarone is a Class III antiarrhythmic of the Vaughan-Williams Classification ...
Source: EMS 12-Lead - October 28, 2014 Category: Cardiology Authors: Ivan Rios Tags: Uncategorized Source Type: research
Calcium and Hyperkalemia
“Calcium Chloride/Gluconate are used during Hyperkalemia induced ECG changes to reduce Serum Potassium.”
The answer is: False!
The majority of Potassium in our body is found intracellular. Only a very small percentage (about 2%) is found extracellular, ranging between 3.5- 5.5 mEq/L.
As extracellular Potassium levels increase, the action potential threshold decreases, for example, instead of -90mV, now its -80mV. Remember, the Sodium-Potassium ATPase pump controls these ions, so as Hyperkalemia worsens, the amount of Sodium influx also decreases. All of these factors lead to decreased ventricular conduction, cau...
Source: EMS 12-Lead - October 27, 2014 Category: Cardiology Authors: Ivan Rios Tags: Hyperkalemia Pharmacology Source Type: research
The 360 Degree Heart – Part II
The first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane (limb) leads relate to one another. We also introduced the concept of “negative leads,” which are just the standard leads flipped upside down. If you didn’t read that post it would probably be helpful to start there.
This week we’re going to review another cases that emphasize how the simple concepts behind the “360 Degree Heart” can improve your EKG reading.
As luck would have it, I stumbled upon the perfect addition to this series soon after writing up Part I. Many thanks...
Source: EMS 12-Lead - October 21, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: 360 Degree Heart Series 12-Lead ECG axis determination cardiac axis case study Vince DiGiulio why learn axis determination? why learn axis? Source Type: research
68 y.o. male w/ weakness: conclusion – “Treat the monitor.”
But perhaps not the computer…
Recap of the case:
A patient with CHF, COPD, and diabetes called after falling, apparently due to weakness. Their ECG was recorded by the paramedic:
Interpretation:
The underlying rhythm is unclear, due to artifact, but there are very wide QRS complexes. The computer measures the QRS as 158 ms, which is clearly wrong. A conservative measurement in V1-V3 suggests a width of at least 200 ms.
Such a wide QRS would be unusual for a bundle-branch block, as Dr Stephen Smith has pointed out. Of course, this could be a ventricular rhythm, but the classic sine-wave pattern (best seen in V1, and...
Source: EMS 12-Lead - October 2, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
Conclusion: Rate Related VS Primary ST-T Changes
This is the conclusion to our previous case, “RATE RELATED VS PRIMARY ST-T CHANGES“. Check it out before you read the final portion.
This was the initial 12 lead ECG obtained by EMS prior ED arrival:
There is an irregularly irregular tachycardia with no signs of P waves, which the Lifepak 15 determined to be Atrial Fibrillation with Rapid Ventricular Response (RVR), however, V1 also appears to have the presence of Flutter waves, so the possibility of A-flutter is present. There is evidence of subendocardial ischemia, seen as generalized ST segment depression and slight ST segment elevation in aVR...
Source: EMS 12-Lead - September 29, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg Arrhythmias Digoxin Source Type: research
68 y.o. male with weakness: “Treat the monitor, not the patient?”
Discussion:
The nearest 24/7 PCI center is 20 minutes away, while a smaller community hospital (fibrinolysis only, but has an ICU, etc.) is “just around the corner.” What is your transport destination? (Source: EMS 12-Lead)
Source: EMS 12-Lead - September 28, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: 12 lead ecg Uncategorized Source Type: research
Rate Related VS. Primary ST-T Changes:
A 56 year old black male presents to the Emergency Department via EMS, complaining of Chest Pressure, 10/10 pain scale. Pain started suddenly following sudden onset of palpitations, while mowing his lawn. All approximately 5 minutes prior calling EMS. Keep in mind, it was a hot and sunny day with temperature in the 90′s. He advised of prior episodes of chest pressure but never as severe as today’s episode. The pressure is generalized throughout his chest, and nothing seems to make it better.
PRIMARY ASSESSMENT:
Patent airway
Adequate ventilation with regular and equal chest expansion
Strong, irregular ...
Source: EMS 12-Lead - September 19, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg Arrhythmias patient-management Source Type: research
The 360 Degree Heart – Part I
The hexaxial reference system.
If I asked you to imagine how the limb leads “look” at the heart, you would probably picture something like the image below.
Heart drawing courtesy of Dawn Altman from the ECG Guru website: http://ecgguru.com/
Notice those gaps in the limb leads? They don’t really exist. They’re an illusion.
This isn’t something that is commonly emphasized when the cardiac axis is being taught, but it’s absolutely vital to realize that in addition to each “positive” lead seen above, there is a corresponding “negative” lead in the opposite direction. ...
Source: EMS 12-Lead - September 11, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Uncategorized 12-Lead ECG axis axis determination cardiac axis Vince DiGiulio why learn axis determination? why learn axis? Source Type: research
Conclusion: “And then I gave her a NTG…”
Recap:
From Part 1: A 64 y.o. woman with typical symptoms of ACS was given nitroglycerin by the paramedic. Her ECG:
ECG Interpretation:
As noted by many of our astute readers, there is obvious ST-segment elevation (STE) in leads III and aVF. Lead II doesn’t show much STE, but relative to the small R wave it is striking. Reciprocal ST-segment depression (STD) is seen in leads I and aVL. This all points to an inferior-wall STEMI.
Because the STE in lead III >> STE in lead II, and given the prominent STD in lead I, the RCA is the most likely infarct-related artery. The T-wave inversion and STD in V2 suggest tha...
Source: EMS 12-Lead - September 8, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
64 y.o. Female with CP – “And then I gave her a NTG…”
My apologies for the faded ECGs. Turns out the medic (a recent grad from our hospital’s program) had been carrying them in his work pants for over a week, waiting to catch me in the ED. The patient had been brought to another hospital, but he wanted to review the ECGs with me.
They had been called for a 64 year-old woman at a gym, who had been getting ready for her Zumba class. She described an abrupt onset of precordial chest pressure, 8/10, that radiated to the jaw and left arm. Of note, the Zumba instructor insisted “We hadn’t even started the class!”
PMHx: HTN, but no CAD.
Meds: ASA daily, P...
Source: EMS 12-Lead - September 4, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
Conclusion to 80 Year Old Male: Fall
Conclusion
In this case the patient received IV hydromorphone for his pain, was admitted for pacemaker placement the next day, and received his new hip soon after that. He experienced no lingering complications from his stay except for slightly decreased renal function and was discharged to rehab in good condition.
(Source: EMS 12-Lead)
Source: EMS 12-Lead - August 25, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Arrhythmia Cases Conclusion arrhythmias AV Block bifascicular block LAFB left atrial abnormality Mobitz II RBBB Syncope type II Vince DiGiulio Source Type: research
“Bad heartburn” – Conclusion
Recap
In “Bad Heartburn” – 82 y.o. female without chest pain, the paramedic had obtained an ECG on an elderly woman who only complained of mild “heartburn.” An initial ECG was obtained:
STE in II, III, aVF, STD in aVL and V2-V4. Also, the T wave is fully inverted in V2 and V3.
ECG interpretation :
The degree of ST elevation is significantly higher in lead II than lead II, which usually supports an RCA occlusion. Furthermore, there is mild ST depression in lead I, also typical for RCA occlusion. There is apparent sinus arrest, with a junctional escape rhythm, which suggests that the SA nodal ar...
Source: EMS 12-Lead - August 22, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
“Bad heartburn” – 82 y.o. male without chest pain.
Discussion Points:
Do you believe that this patient requires PCI for acute coronary occlusion?
If so, what was the likely site of the occlusion?
Are there any other management concerns, given this ECG pattern?
Should you routinely obtain ECGs in patients who complain of GI symptoms, but who deny any chest pain, pressure, or discomfort?
Lastly, although the local protocols do not require that the computer interpretation display ***MEETS ST ELEVATION MI CRITERIA *** in order to activate the cath lab, they limit activation to patients with “active chest pain and/or dyspnea.” In that context, how should the param...
Source: EMS 12-Lead - August 20, 2014 Category: Cardiology Authors: brooksw Tags: Uncategorized Source Type: research
“Bad heartburn” – 82 y.o. female without chest pain.
Discussion Points:
Do you believe that this patient requires PCI for acute coronary occlusion?
If so, what was the likely site of the occlusion?
Are there any other management concerns, given this ECG pattern?
Should you routinely obtain ECGs in patients who complain of GI symptoms, but who deny any chest pain, pressure, or discomfort?
Lastly, although the local protocols do not require that the computer interpretation display ***MEETS ST ELEVATION MI CRITERIA *** in order to activate the cath lab, they limit activation to patients with “active chest pain and/or dyspnea.” In that context, how should the param...
Source: EMS 12-Lead - August 20, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
