I was checking out the old LIFENET Receiving Station and this case caught my eye.
What do you think?
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Found on the LIFENET – October 2008
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Here’s a really interesting case submission from David Baumrind.
EMS is called out in a rain storm to evaluate a 60 year old male with a chief complaint of shortness of breath.
The patient was released from the rehab center 8 days prior after having experienced a stroke while having his “carotids done”.
He suffers from persistent left-sided hemiparesis.
For approximately 36 hours prior to contacting 9-1-1 the patient experienced increasing shortness of breath made worse by lying flat or with physical activity (paroxysmal nocturnal dyspnea and new exertional dyspnea).
The patient is found sitting in a living room chair. He is in no acute distress at the time of evaluation.
Skin is slightly “dusky” but warm and dry.
The patient denies chest discomfort. He admits to some nausea but has not vomited. He denies light-headedness and palpitations.
Past medical history: NIDDM, CABG x 4 years ago, myocardial infarction, left bundle branch block, ICD placement
Medications: Numerous but unavailable at the time of evaluation
Vital signs
RR: 22
Pulse: 96 and irregular
BP: 142/82
SpO2: 92 on RA
The cardiac monitor is attached.
A 12-lead ECG is captured.
Here is the computerized interpretive statement.
What do you think is going on with this patient?
Are you concerned about his 12-lead ECG?
You are 15 minutes from the local non-PCI hospital and the STEMI Receiving Center is 45 minutes in the opposite direction.
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While the drivers and owners may get most of the credit a good "pit crew" is essential for team success in NASCAR.
So what makes a good pit crew?
Leadership
A good pit manager will ensure that the pit crew is ready and that all the necessary resources are in place. That includes ensuring that the appropriate number of people have been assigned to critical tasks, and that equipment is organized in a logical manner.
Skills and Competencies
Individual team members should possess all of the skills and competencies to perform their functions quickly, efficiently, and accurately. For example, the tire replacement crew should know when the tires need to be replaced, where the tires are kept, and whether wet or dry tires are required. Similar skills are required of the team members responsible for refueling and repairing mechanical breakdowns.
Teamwork and Communication
Fluency in communication can make the difference between winning and losing. This is where precious seconds can be lost or gained. Good communication is what leads to coordination and problem solving. Lack of communication leads to errors and loss of situational awareness.
Best Practices
Doing something because "that's the way it's always been done" or because "that's how a real pit crew operates" is short-sighted if the end result is losing the race. A good pit crew learns from its mistakes (and the mistakes of others) and will not hesitate to amend its procedures when another pit crew demonstrates a way to do it better. The outcome drives the process. Not tradition. Not ego.
Rehearsal
A good pit crew doesn't "make it up the day of the race" and neither does any other high-performance team (Navy SEALs, surgical team at Johns Hopkins, NFL football team). It takes practice. Lots of practice. It also takes a commitment to excellence which is the motivation. It has to start with the desire to win and be the best.
Applying these lessons
Firefighters with Hilton Head Island Fire & Rescue discuss
the "lessons learned" from a recent cardaic arrest.
Are you familiar with the latest evidence based guidelines for the care of cardiac arrest patients?
Have you bothered to find out how the top EMS systems in the country are doing it?
When's the last time you practiced working a cardiac arrest with a fully clothed 175 pound mannequin found face-down between a toilet and a bathtub?
When's the last time you practiced using your own real equipment (as opposed to the equipment laid out on the table at your last ACLS class)?
When's the last time you sat down with your crew and choreographed exactly who would do what during a cardiac arrest?
Are you like a "pit crew" when you arrive on scene? Or do you "do the best you can" and hope for the best?
Who would you want showing up to save a member of your family?
Photo credit: Wake County EMS blog
See also:
Why you need to strengthen your community's chain-of-survival
Tom Bouthillet and Jamie Davis discuss cardiac arrest and the chain-of-survival
Cardiac arrest – Anatomy of a System Failure
Cardiac arrest – Are you ready to save one of our own?
This is the conclusion to “The Bait and Switch“.
Let’s take another look at the 12-lead ECG.
This patient was experiencing an acute inferior STEMI and reperfusion was delayed.
Those of you who predicted that the white and red electrodes were switched were exactly right. The frontal plane axis is in the right superior quadrant (no man’s land) which is unusual and should tip you off that there’s an error with lead placement.
What’s really unfortunate about this case is that physical inspection of the leads would have shown them to be placed properly. That’s because the leads themselves weren’t misplaced.
The leads were “plugged in” to the machine backwards.
The result was the transposition of the white and red electrodes.
In reality, you can still see the STEMI if you know what to look for. One of the “tricks” I teach students to help them identify acute posterior STEMI is to ignore the limb leads for acute inferior STEMIs and look only at the right precordial leads (V1-V3).
This helps “train the eye” to see subtle signs of acute posterior STEMI and this case demonstrates why having a “trained eye” could be potentially life-saving.
In this case, there is a slight downsloping of the ST-segment in lead V2.
Throw in the “classic” appearance of lead aVL (reciprocal change) and this 12-lead ECG is highly suspicious for acute inferio-posterior STEMI.
So, when trouble-shooting a 12-lead ECG remember to check both the leads and the connections!
See also:
Imagine you are an emergency physician working in a medium-sized community hospital.
It’s a busy day in the emergency department. You are the only physician on duty.
One of the nurses has called in sick, there is no tech, and the weakest unit secretary is on duty.
All the rooms are full, the waiting room is packed, the ambulance bay is jammed, and there are overflow patients waiting to be admitted.
There is a policy in the emergency department that the emergency physician shall review the 12-lead ECG of chest pain patients within 10 minutes of the patient’s arrival.
You are suturing a large laceration in a patient’s leg when a nurse walks in, holds up an ECG and says, “We have a walk-in chest pain patient in bed 4.”
It’s going to take you another 20 minutes to suture up the patient’s laceration.
What are your orders?
See also:
Here’s the conclusion to the January 2011 EMS 12-Lead column “Not So Fast…” at EMS1.com.
Congratulations to Vince DiGiulio for submitting the winning diagnosis!
Image credit: heartfailure.org
via The Huffington Post (transcribing the NBC interview)
JAMIE GANGEL:
Let’s start in the obvious place. For those who have not seen you recently, you look a little different. You lost some weight. This past summer your doctors told you that after five heart attacks you had to make a decision. And you had major surgery. And you had a heart pump put in. Can you tell me a little bit about what they did?
DICK CHENEY:
Sure. Well, there’s a system called the LVAD, Left Ventricular Assist Device. And it in effect takes blood from the ventricle chamber of your heart and moves it into your aorta. And it significantly increases the amount of blood flow you’ve got going, which is vital when you get to end stage heart failure.
It significantly improves the function in the kidneys and your liver because they get an adequate supply of blood. And I’d reached the point after 30 years and five heart attacks where I really needed to do something. And so that’s what we did. It’s a pump that runs at about 9,000 RPMs. It’s battery powered from the outside. But it’s a wondrous device. It’s really a miracle of modern technology. And now I’m here today because we have that kind of technology. And because the doctors were able to adapt it to my situation.
…
JAMIE GANGEL:
More and more people are using these instead of heart transplants, but usually they use them for a year or two. Are you thinking about a heart transplant?
DICK CHENEY:
I haven’t made a decision yet. The technology was originally developed to provide a transition. To take somebody who’s reached the point where they needed a transplant but a transplant wouldn’t immediately be available, so they put this in as a temporary measure.
What’s happened over time is the technology’s gotten better and better and we’ve gotten more and more experience with people living with this technology. So I’ll have to make a decision at some point whether or not I want to go for a transplant. But we haven’t addressed that yet.
Editor’s note: If only all of our patients were this educated about their health care.
Episode #3 of the EMS Research podcast is now available.
Keith Wesley, M.D. leads a discussion about how to read and interpret medical research and contextualize it for your EMS system.
Episode #3 of the EMS Research Podcast – Reading EMS Research
To become a fan of the EMS Research podcast on Facebook click HERE.
To follow the EMS Research podcast on Twitter click HERE.
To find the EMS Research podcast on iTunes click HERE.
Here’s the conclusion to 81 year old male CC: Palpitations.
Let’s take another look at the 12-lead ECG.
Some of you expressed concerns about the possibility of the ECG abnormality we sometimes refer to as left ventricular aneurysm (persistent ST-elevation after previous MI).
To put it another way, some of you think this STEMI looks “old”.
Stephen Smith, M.D. of Dr. Smith’s ECG Blog has a decision rule to help distinguish LVA from acute anterior STEMI by looking at the T/QRS ratio in leads V1-V4. T/QRS ratio best distinguishes ventricular aneurysm from anterior myocardial infarction. Am J of Emerg Med 2005 May; 23(3):279-287.
A high T/QRS ratio indicates acute STEMI. A low T/QRS ratio indicates LVA.
To come up with the T/QRS ratio you measure the amplitude of the T wave and divide by the depth of the S-wave.
If there is one lead in V1-V4 with a T/QRS ratio > 0.36, then STEMI is likely.
Or, if the sum of the T-waves in V1-V4 divided by the sum of the S-waves in V1-V4 > 0.22, then STEMI is likely.
Let’s look at the current case.
Lead V4 shows a T/QRS ratio of 0.38 which is suggestive of acute STEMI.
Let’s try the more complicated calculation (TV1+TV2+TV3+TV4 divided by SV1+SV2+SV3+SV4).
1+1.5+6+5 = 13.5
11+13+18+13 = 55
13.5/55 = 0.24 (T/QRS ratio)
Remember, the cut-off is 0.22 so this is very close but favors acute STEMI.
Finally, let’s consider another of Dr. Smith’s ECG interpretation tips: the rule of proportionality.
Lead V5 in this case shows a little bit of ST-elevation but the QRS complex is small. Let’s consider the ST/QRS ratio in this lead.
Here we use PowerPoint to “stretch” the QRS complex while preserving the ST/QRS ratio.
Looks pretty impressive to me!
Another finding that supports acute STEMI is the well formed R-waves in leads V3 and V4.
Typically LVA shows QS-complexes in leads V1-V4.
Diagnosis: Acute anterior STEMI (confirmed with angiography)
See also:
ECG mimics of acute STEM (left ventricular aneurysm)
Excessive discordance as a marker of acute STEMI in LBBB
76 year old female CC: Chest pain – Tako-Tsubo Cardiomyopathy
Wolff-Parkinson-White (WPW) – STEMI Mimic
EMS is called to a local medical clinic to transport an 81 year old male to the emergency department.
The patient had experienced an episode of chest discomfort the day prior that was accompanied by palpitations and tachycardia.
He described the pain as a “pressure” in the center of his chest without radiation that resolved on its own after he sat down in a chair.
His primary care physician is concerned about “changes on his ECG.”
Past medical history: HTN, asthma, atrial fibrillation, cardiac stents
Medications: Albuterol, aspirin, warfarin, loratadine, avodart, furosemide, diltiazem, flunisolide
Vital signs
RR: 20
Pulse: 130 Irregular
NIBP: 142/80
SpO2: 97 on oxygen via NC @ 2 LPM
Skin: Pink, warm and dry
Breath sounds: clear bilaterally
At the time of EMS evaluation he has no complaints.
The cardiac monitor is attached.
A 12-lead ECG is captured (which is similar to the 12-lead ECG taken at the doctor’s office).
What do you think of this patient’s 12-lead ECG?
See also:
Conclusion to 81 year old male CC: Palpitations – Left ventricular aneurysm vs. acute anterior STEMI
Here is the conclusion to 63 year old male CC: Chest pain.
Let’s take another look at the patient’s heart rhythm.
I can see why some of you thought this was Torsades de Pointes but the cycle rate is over 300 and the underlying rhythm showed a normal QTc. In my experience it’s not unusual for the onset of VF to be relatively slow and then accelerate (sometimes with a cyclic rate over 700).
I feel confident this is course VF. Either way, it was pulseless.
The paramedic in charge of the call shocked the patient at 200 J.
Here is a 12-lead ECG of the post-shock rhythm.
I find it interesting that the limb leads become non-diagnostic during accelerated idioventricular rhythm (AIVR).
Several minutes and later the rhythm had stabilized.
The patient was delivered to a PCI-hospital where the interventional cardiologist was waiting.
Here is the 12-lead ECG captured prior to the procedure.
Here is the post-cath 12-lead ECG taken after successful stenting of the LCX.
These are the days that make it all worth while! Thanks for sharing the case, Phil!
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