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 pain and external rotation of his left hip. You cannot assess shortening because the knee and hip are both flexed, in a position of relative comfort.

Vitals upon your arrival are:

  • Heart rate: 45-65 bpm, irregular
  • Respiratory rate: 14 /min
  • SpO2, room air: 97%
  • NIBP: 179/93 mmHg
  • Temp, oral: 36.3 C (97.3 F)

While you are drawing up an initial dose of morphine your partner captures the following 12-lead.

What does it show? How will this affect your management?

80yo M - Fall

28 Comments

  • Gusepperm says:

    RBBB+LAFB, II dgree AV block Mobitz II type, positive T wave in V1-V3(could be due to ischaemia or reperfusion). I would not focus on her hip. This type of rhythm can change to CHB or can get worse. 2x IV line, ASA, O2, fast transport to hospotal. I suggest to be prepare to transcutaneous stimulation in case of CHB or asystole with P waves.

  • Mikey Johnson says:

    2nd degree Mobitz 2 AV block. Right bundle branch block. Lateral ischemia, V5-V6. Stabilize the hip fracture, O2, IV, 324 mg ASA. Hold off on the morphine due to the heart block. Monitor cardiac activity with serial 12 leads.

  • Kevin says:

    I agree with all of the above, only to add hypothermia (Osborn waves) right precordials…

  • Dustin says:

    I would start by giving warm IV fluids since his membranes are dry and he is hypothermic. I would obvioulsy monitor his lung sounds with the fluid administration. There are osbornes waves present in the precrodial leads which leads me to think his bradycaria is related to his hypothermia. Serial 12 leads to look for changes and a transport to the hospital is indicated. Also I would give Fentanyl (fewer side effects than morphine, only personnal preference).
    I would venture to say his ECG improves with increasing his body temp.

    • Gusepperm says:

      Im affraid that this is not hypothermia. She’s quite hot. It’s seems to be not Osbourn waves. They appear rather in all leads. V1-V3 is rather thypical QRS morphology for RBBB

  • ltc says:

    I’m thinking the ecg is an incidental finding. Treat the patients complaint, hip injury. Splint well to avoid vascular damage. Fluids for two days lost nutrition and blankets, reassess after ten min and see if we need to treat hr further. Obly , avb is a dramatic finding .but right now its asymptomatic brady. I always do a second interview , hx of present illness, after I alleviate pain or handle the cc. Its amazing the things u find out.

  • Trish says:

    pt is hypovolemic and probably has rhabdomyolsis. Needs lots of fluids, while monitoring lung sounds. definitely fentanyl for pain management.

  • Don Ruppert says:

    This EKG strip indicates a 2nd degree type 2 block and calls for immediate pacing. With capture and pacing, you will see a definite improvement in your patient.

    • Trevor says:

      Why the heck would you pace this patient? That’s completely uncalled for.

    • Audrie says:

      Wat.

      No. What makes you think this patient is a candidate for pacing?

      Treat the patient, not the machine. If the patient is perfusing, has no change in level of consciousness, and is in no immediate distress, pacing will likely do more harm than good. You don’t want to increase the demand on a patient who is likely ischemic.

  • PittsburghParamedic says:

    I can’t believe people are putting hypothermia as the temperature is given to us at 97.3 F. Not to mention the EKG shows a textbook RBBB pattern, NOT osbourne waves. The rhythm is Mobitz I. Also, if the patient is in significant pain from the hip fx, there is NO reason not to treat his pain with MS, Fentanyl or whatever you carry. He has a blood pressure that should allow you to treat his hip pain effectively.

  • Trevor says:

    At that temperature, I’d agree that those are not osborn waves.

  • Tristane says:

    I agree with the mobitz and LAFB. But, QT is quite prolonged. I would attribute the rate and non-conduction to an electrolyte deficiency. A Lytes draw would be helpful but, looking just at the morphology I would lean towards hypocalcemia. I see nothing in the ECG or Hx that leads me to believe there are any ischemic changes.

    I would manage pain with cardiovascular suppression, ideally ketamine. If I had an iStat I would draw lytes and patch for orders for calcium.

  • Bob the legend says:

    10mg IM morphine, and yell at him to “Get up and walk your a** to the ambulance soldier!” Problem solved. – Jim the legend.

    -Honest answer : Don’t looking at the ECG and look at the patient first, understand the history. Trifasicular block but the morphology of V2+V3 aren’t typical ischemia are they. The guys been lying on the floor for days with a potential compartment syndrome / rhabdomyolysis building up. No one mentioned the QTC being massive, which again is indicative of electrolyte imbalance due to muscle and cellar destruction. It’s even printed right there for you, but can be easily missed given the type II block. -No worries folks. *Hi 5’s. And he’s not hypodermic.

  • PANAYIOTIS ARVANITIS says:

    Mobitz II 2:1,L.A.H.,R.B.B.B.

  • Mark says:

    The more I look at this, the more it looks like a Sick Sinus Syndrome. I think I see more than one P wave morphology. This is best seen in the first 2 conducted QRS complex’s on the V5 strip at the bottom. I think the first QRS is an escape beat, from lower in the atria, as it follows the pause of a non-conducted p wave, that I think is sinus, and is flatter than the non conducted beat. Then, everytime one of these ?sinus beats is non conducted, we see the flatter p wave morphology, and it is conducted. This would also explain the inverted P wave in AVL, that lines up with what I would call an escape beat.

    I agree with other people that rhabdomylosis is likely, with the long QT interval suggesting hypocalcaemia (causing the very long ST segment, best seen in II). This gentleman is high risk for developing very dangerous arrythmias. I would advise IVI, catheterise if possible (urine colour will help with rhabdo confirmation) and prepare to pace externally if needed. He is also likely to have a derranged K+ level, which could be explaining much of this, but it is far from typical hyperkalcaemia (although, it wouldn’t be in isolation, so could be hidden amongst other abnormalities).

    Treat his pain, stabalise the hip, and transfer him has quickly as possible.

  • tyson says:

    the patient is in a heart block obliviously; however, the patient is hemodynamically stable, there is no known loc, the patient is alert and unfortunately severe pain.. Stabilization of the hip, and admin of MS is indicated and totally valid. From this standpoint what block, and how to proceed treatment (longterm) wise is up to the ER doc, and the cardiologist on his case not the transport medic. All you people need to stop trying to play Dr and get a life

  • acika says:

    Av blok 1. Level. It’s prolonged PQ interval. Agree also with other.

  • CC says:

    You know.. the story says “suddenly he found himself on the ground, which he attributes to tripping on the runner rug in the hallway.” If you want to look at the patient first… an unwitnessed fall with that kind of EKG (long qt in particular) in an 80 year old male who has been on the ground for 2 days would lead me to believe he may have likely gone into a rhythm to make him pass out (v tach?)… does he really know how he ended up on the ground or is he just guessing? I agree with Gusepperm’s initial post and would be ready for v tach when it comes en route. I don’t think giving morphine would be an issue to help with the pain. But those pads would be on for sure.

1 Trackback

Leave a Reply

Your email address will not be published. Required fields are marked *