zumjus

That's interesting. I will have to ask around about that.

If you get depression in the Septal leads (v1, v2), especially with a tall R waves, then that would be a reciprocal of a posterior MI. Elevation in Septal lead would indicate septal MI. My two cents: I agree that lead 2 is pretty much worthless in 3 lead unless you need to tell speed (or major obvious cardiac arrythmias, i.e. V-Fib/V-Tach/Asystole/etc. etc. etc.). We use 4 leads and 12 leads in my system and I prefer looking at leads 1 and AVF instead of lead 2 when using a 4 lead (it tells me more about their cardiac status then lead 2 does). Doing the "modified 12 lead" with a 3 lead, by moving the leads around, is still not very helpful. I know they used to do it, but luckily testing and research has revealed that it is not a very good indicator of MI. Hell we used to shock Asystole too, but we now know that isn't a very good idea anymore, or helpful either. The monitor needs to be in diagnostic mode (like a 12 lead does, not 3 lead). Just because you are moving around the leads, doesn't make it any more diagnostic if the monitor is in monitoring mode. I don't know how many times I have taken a person into the ER with elevation showing in leads 2/3, but the 12 lead showed nothing going on in the inferior leads. The nurses are quick to freak out, until I show them the 12 lead. Here is an idea, if the patient is having CP or a CP equivalent then treat them like they are having an MI regardless of whether or not the monitor shows elevation or not. If your service doesn't have a 12 lead monitor, then raise the money to get one. The are essential now and standard of care. Of course if I had to choose between a 12 lead and CPAP, I'd go with CPAP everyday of the week, and twice on Sundays.

Thank you!!

I agree with that, but most AMBULANCE services have CPAP, not BiPAP.

Thank You

BLEB

You can use CPAP for SOB on COPD pt's too. CPAP would be highly recommended. Rule of thumb is that is your interventions aren't working, then go for the CPAP.

I agree with flight-lp. V1-V2 show Septal. Now v1/v2 can give a suspicion of posterior MI if you have exaggerated/tall R waves with depression (assuming you don't have the RsR pattern associated with RBBB). This would be the reciprocal view of the posterior wall. You can do a quick "mirror" look by turning the EKG backwards and upside down to look, but a more conclusive view would be v7-v9. Unfortunately I don't know of a good link other than http://www.anaesthetist.com/icu/organs/heart/ecg/ You may find info there. Generally speaking leads II, III, and AvF are considered inferior leads. v1-v6, I, and AvL are considered anterior. More specifically it is as follows: II,III,AvF: Inferior v1-v2: Septal/Anterior v3-v4: Anterior (true) v5-v6: Lateral/Anterior (Low Angle) I, AvL: Lateral/Anterior (High Angle) AvR: Endocardial Rv4: Right Ventricular (can also utilize Rv3, Rv5, Rv6) Pv7, Pv8, Pv9: Posterior I believe this standard is pretty much universal with a little variance here and there. I hope this helps.

You all crack me up. 8)

I agree 100% with the diuresis and nitro. Intubation . . . yes in extreme cases. You are right CPAP is good for a starter (at the begining) but then BiPAP after that. The Docs around here have the thought, and I agree, that if we have to intubate these pts. then we have already gotten behind the game. Don't get me wrong, I do agree with intubation with PEEP, but only if the other less invasive strategies don't work, or the pt. is too far along. Of course if the pt. was too worn out for the CPAP, then we would intubate, but I've seen some pretty tired pts. get immediate relief from CPAP and get their "strength" back to breathe. Unfortunately the scenario presented was not that detailed as to how tired the pt. was or anything like that. "we have to treat the etiology of the problem.." of course we do. I would hope we ALWAYS try to do that. Unfortunately pre-hospital we are limited in what we can do. Sometimes you have to treat the s/s first before you can move onto the etiology. A lot of time we can only treat the results of the disease process so that the hospital doesn't have to worry about that and start with actually treating the core of the problem. But that's another discussion not relevant to this posting.

Ok we are getting away from the point and this will be a never ending argument. You are putting too much emphasis on the fluid, when you won't even need the fluid for this pt. That is his problem, too much fluid. He is in Pulmonary edema and needs CPAP, nitro, Lasix, MS, ASA, and obviously O2. The fluid thing was just a "what if" scenario in case his BP somehow dropped. If his problem is hypotension to where he needs fluid, then he most likely won't be in Pulmonary Edema. I got carried away with the admin of fluid because someone brought up RVI and that is synonymous with fluid. In any case, this pt. won't need fluid. He just needs to be able to breathe right now. Can we agree on this? Pulmonary edema Rx: O2, Nitro, CPAP/BiPAP, Lasix, ASA (if able to comply), and MS. *Remember this is Pre-Hospital.

The fluid is just in case the BP drops. You don't give him fluid until his BP drops below a manageable level. Let's pretend he IS having an RVI and his BP is high. His BP is say . . . 140/80. You give him a nitro and his BP drops to 110/50. Now here comes the balancing act where fluid is needed. Do we stop giving him nitro? No! He needs it. Do you just give him another one since his BP is above 90 systolic? No, again. He had a 30 point drop in systolic BP and you don't want to risk that again and bottom his BP out. You give him a small bolus, let's say 250 cc then give him another nitro and re-evaluate. Generally CHF'ers can handle small boluses of 1-200 cc as long as you are doing something with the fluid. Lasix, nitro, CPAP, etc. etc. etc. The point is that he NEEDS the nitrates so we need to aggressively treat these pts. Now if he is not having an RVI, then you don't have to treat with aggressive fluid treatment. You just give him nitro nitro nitro, MS, Lasix, etc. etc. etc. Of course you don't load up a CHFer with fluid if his BP is normal or stable. That would be crazy. I guess I assumed (i know I know) that people would just know that. I think people are misinterpreting my initial treatment. I should have been more clear.

I didn't kill him. The nitro, lasix, and CPAP are removing the fluid from his lungs so he can BREATHE!! The MS is lowering the O2 demand on his heart. The nitro is venous dilating to take pressure off of the pump and help with the fluid. The NS is just in case his BP drops. You don't give him boluses if his BP is doing good, ONLY if it drops too low for the nitro. I figured everyone would know that. When he gets to the ER they will put him on BiPAP and a nitro drip. You are right that I forgot to mention LASIX. Give him the LASIX. Have you never used CPAP? It's pretty instantaneous. If his lungs are full of fluid, then you want nitro, CPAP, lasix, and MS. He said the lowest BP was 138/80. I STILL don't buy the RVI. You are right not ALL RVIs are brady/hypotensive, but MOST of them are. You will find out after the first nitro you give. I have used this treatment several times, and have been VERY successful with it. Sacra and the education department don't seem to have a problem with it.

I know I'm late with this post, but here is MY interp. 1. It's not RVI. RVI's almost ALWAYS are bradycardic or Hypotensive. We don't know the rate here, but it wasn't significant enough to post which leads me to believe it was normal. 2. He had a (+) hepatojugular reflex which usually indicates RHF. 3. Hx of cardiac. Load him up with Nitro. O2 (CPAP preferred), IV, ASA, MS. Don't be afraid of the Nitro. Yeah yeah, if it's RVI you can bottom it, but those pt.s are usually hypotensive anyways. Load him with NS and give nitro nitro nitro. This pt. is not having an RVI so load him up til his BP cannot take it anymore, then give him fluid and load him up with nitro again. Don't forget the MS.

Ok, 1st of all QUIT calling it A-Fib!! Let's look at this in different parts. 1. At the beginning of the strip the QRS's plot out. = NOT A-FIB. 2. At the end of the strip the QRS's plot out. = NOT A-FIB !! 3. There are some ectopic beats. The smaller ones. Not ventricular (it doesn't appear) 4. Narrow complexes. = NOT V-TACH !! 5. So what is it? It's a conversion rhythm. Whoever said that was ABSOLUTELY right. You "convert" from a Tachy 150 bpm to a slower rhythm with some ectopic premature beats. The "fluff" in the middle is probably just the heart reacting from the conversion. You are all forgetting that this is a 98 y.o. heart. It probably does this a lot. I think we've beat this horse long enough. By the way, did someone say that ST was an SVT rhythm? Hmmm?