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Job13_5

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Job13_5 last won the day on March 1 2013

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    Boise ID, USA

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  1. Being bold, I'd not call it AF because it appears regularly irregular. The R-Rs appear consistent for every other beat...ie two different foci working as the pacemaker. So it wouldn't be electrical alternans either. Edit: I should add the caveat that I'm only using a piece of paper to mark the R-Rs from the pic in the phone (no calipers)...but it appears to march out consistently on the running strip.
  2. I've used the Lewis lead quite a bit prehospitally. It's been very useful. For example, the other day I had a patient with a narrow irregularly irregular rhythm in the 150's. A standard set of leads was unhelpful in determining if it was sinus with frequent PACs, MAT, or AF. A Lewis lead helped amplify atrial activity, showing associated p-waves of only two morphologies. I can't think of an instance when it's changed my treatment plan, but by using it, I have been able to be more definitive about rhythms, and I can only imagine that that will eventually lead to a change in course.
  3. The reason for the difference in the two 12-leads appears to be due to a shift in the pacemaker from a supraventricular (or high ventricular) pacemaker, to a lower ventricular one. In the rhythm strip you have a slow, wide, possibly supraventricular focus (maybe high ventricular) pacing the heart at about 60 bpm. This is interrupted by a pause, then an apparent ventricular beat. Afer which the original pacemaker takes over again. In the first 12-lead, the predominant pacemaker is the one we see the most of in the rhythm strip (the supra or high ventricular beat at about 60 bpm). In the
  4. Great information here! Just a quick question, for the potentially spine injured patient that is nauseous and vomiting, in what position are they to be placed/immobilized and how is that patient secured? I admit that though I really like the new evidence based approach to this topic, and the general change in the way we should be thinking about the use of LBBs, I still have it so ingrained in me that it is the best thing for these patients, that there are certain notions that are hard to let go of. With that caveat, I am picturing a retching and vomiting patient not on a LBB (that warran
  5. Point taken. I think some of these instructions are unnecessary because the morphologies described are necessary to even measure a Vi and Vt per the simple criteria. But, I'm going to read the article a few times to make sure I get it...which proves your point.
  6. Now you guys have got me worried that I'm miss understanding the AVR criteria...I thought it was pretty straight forward (except for the last test, but even that one's pretty simple once you get it...unless I've missed something). Are there more intricacies than I know about? For instance, it was posted above that you have to pick the correct QRS when evaluating excursion. I hadn't heard that before.
  7. As for vagaling, I said no because she wasn't bearing down with a BM. That doesn't rule out vagal nerve issues, of course. The doctor worked her as a myxedema coma (spot on DartmouthDave!): hypothyroidism, hypothermic, hypotension, recent infection, waxy skin. From what I read, she fits the bill.
  8. I'll try to answer your questions... I think you misread the first bits. The pt did not have an initial bp per fire, but I felt a weak radial pulse at a rate of 70. Moved the pt to the cot, couldn't get a bp or radial pulse. Meds: vigamox, PCN, phenergan, levothyroxine, maxzide, zestril, flexeril, fioricet, asa, premerin, zocor. Respirations were 14 regular and shallow. GCS was 14 -- opens eyes to voice -- throughout transport GCS was 11 when pt started to decrease in LOC (2,5,4) GCS was 3 when unresponsive. She did not have a vagal episode 2nd to BM because she never made
  9. I fail to see your point. Isn't this an exercise in examining the 12-lead? The question posted by the OP is "Aberrancy or VT?" My answer is VT. If I'm wrong, I would sure like to know about it so I don't make the mistake when it matters.
  10. No one has mentioned the AVR criteria here yet. According to such this 12-lead would be positive for VT because of the initial R-wave in AVR. Here's a quick article that describes AVR criteria in brief: WCT Algorithms In the article it reports the accuracy of the AVR criteria being at 90.3% with a P of 0.006 vs 84.8% overall for Brugada's. I would feel very confident calling this VT for several of the reasons stated previously, with the addition of the positive AVR criteria.
  11. Can you explain this a little more? I.e. the "proarrhythmic state of the hypothermic heart."
  12. Had a patient yesterday that brought me back to the books and thought I might share. For those that are more learned than me, this will be ridiculously simple, but I had to get the diagnosis from the doc. Called for a 56 YOF "in and out of consciousness." Arrive to find a female on the bathroom floor, average body type for her age in a clean and well taken care of home. Patient is lying left lateral recumbant, breathing quietly about 24 x/min, very pale with "waxy" appearing skin, barely palpable radial pulse at ~70bpm, very cold to the touch, slightly clammy, oriented but responsive on
  13. It works, I've done it. Although, I found that more force needed to be applied than the prescribed "let your fist drop onto pt's chest," making it more of a precordial thump, but aimed just left of the lower end of the sternum. I'd say I used moderate force with my hand 6-8" above pt chest, and it definitely produced perfusing pacing beats. Attached is a snippet of the strip. The difference in beats, seemed to be related to the force used. With percussion pacing, though, I imagine you would have to worry about R on T phenomenon, or commotio cordis...
  14. In the protocols I'm working under right now, these pts would meet inclusionary criteria (meaning there's a higher likelihood of them having a spinal injury), but it doesn't mean we can't still clear c-spine with more assessment. Not being argumentative here, just chiming in with more protocol examples.
  15. Job13_5

    Oh Poop

    Had a pt the other day who was covered head to toe in her own poop ask "do I have time to put my makeup on before we go to the hospital?" She was a sweet old lady with dementia; obviously didn't know she had been laying in her own filth for two days. It was sad, but her makeup comment sure made the call a little more fun! Ignorance is bliss.
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