FL_Medic

My point is that if someone appears unresponsive, treat them as such. Ammonia inhalants are useless!! Unless you want a way to adequately display your ignorance. You will not harm your patient if you treat the symptoms they present with. You are no cooler for determining that someone is "faking". AVPU does not include ammonia inhalants or racial slurs. Be professional, don't just do what you've seen the old timers do. If the paramedic position is ever to be respected, we have to raise the bar on ourselves.

I hope that's just a joke. Please explain if not...

We only took the ammonia inhalants off last year. Tell me, what harm is there in treating a patient that is faking an unconscious state like they are truly unconscious?

The following article explains this topic well. Better than I could. Beyond the Basics: Interpreting Altered Mental Status Assessment Findings EMS providers frequently encounter patients who are not alert and present with an altered mental status, meaning their level of brain function is in question. Various physical examination techniques are employed during the assessment to determine the level of cerebral function and integrity of the brainstem. It is important to understand the limitations of these techniques, as well as potential findings that may cause you to erroneously interpret, report and document the level of brain function. This information is often used to identify trends to determine if the patient's condition is deteriorating, remaining the same or improving. ANATOMY OF A CONSCIOUS STATE Two structures are responsible for a conscious state: the ascending reticular activating system (ARAS) and the cerebral hemispheres. The ascending reticular activating system is not truly a single tangible anatomic structure; however, it is a network of nerve cells and fibers that extend from the spinal cord through the lower brainstem and continue upward toward the mesencephalon and thalamus. The impulses are then distributed throughout the cerebral cortex. The ARAS continuously receives sensory input that allows the body to remain in a wake or sleep state, remain aware of surroundings and respond appropriately while awake. The ARAS has an effect on both the autonomic nervous and motor systems, which in turn control the body's cardiovascular, respiratory and motor response to external stimuli. Consciousness requires the patient to have an intact ARAS and at least one cerebral hemisphere. If either the ARAS or both cerebral hemispheres are affected by a particular condition and not functioning properly, the patient will not remain in a wake or alert state. Head injuries, severe cerebral hypoxia or anoxia, central nervous system-depressant drugs and electrolyte disturbances are only a few of the possible factors that would disrupt the function of the ARAS or both cerebral hemispheres and render the patient unconscious. Several assessment techniques may be used during the physical exam to determine the brain's ability to receive, transmit, interpret and respond appropriately to an external stimulus applied to the body. One of the most common techniques is a painful stimulus applied to a patient who is not alert or not responding to verbal stimuli. The patient's response assists the examiner in determining the extent or level at which the brain is able to function. Continuous reassessment provides valuable input when considering a differential diagnosis; making a decision on providing more advanced emergency medical care; and determining whether your treatment is improving the patient's condition, if the patient is remaining stable or if the condition is deteriorating. AVPU The mnemonic AVPU is universally used by EMS personnel at all levels to determine a patient's mental status. Historically, AVPU was used only to assess eye-opening to various stimuli; however, it has evolved to a more general interpretation of patient responses. A refers to alert. An alert patient opens his eyes spontaneously upon your arrival at his side. If the patient is alert, there is no reason to continue with the AVPU assessment. It would be prudent to determine if the patient was oriented to person, place and time. If the patient does not have spontaneous eye-opening, V is the next step in the AVPU process, which is achieved by using a verbal stimulus in an attempt to get the patient to respond. Historically, the patient was asked specifically to "open your eyes" when applying the verbal stimulus. If eye-opening was attained, the patient was said to have responded to a verbal stimulus. Today, many emergency services providers ask the patient to "squeeze my fingers" or "wiggle your fingers" in place of the traditional eye-opening command. Again, if the patient responds to a verbal stimulus, there is no need to continue. P refers to painful stimulus applied if the patient did not respond to a verbal stimulus. Originally, this test was used to determine if the patient opened his eyes when a painful stimulus was applied. When emergency medical services personnel utilize a painful stimulus, they are watching for any indication of a response, whether it is flexion, extension, withdrawal of an extremity or localization of the pain by attempting to remove it. As evidenced by the numeric rating on the Glasgow Coma Scale (GCS), a higher score is awarded for a more specific response. For example, if the patient wiggles his fingers upon command, he is awarded a 6the highest score possible. Five points are awarded if he localizes the pain; 4 points are given if he withdraws to a painful stimulus. A higher score on the GCS correlates with better brain function. If there is no response to a painful stimulus, the patient is said to be unresponsive, which represents the U in AVPU. A patient who does not respond to noxious stimuli is considered comatose. MISINTERPRETING NO RESPONSE TO A STERNAL RUB Sternal rub is one of the primary methods used by EMS for applying a painful stimulus. This technique is performed by rubbing the knuckles of a closed fist firmly and vigorously on the patient's sternum. Because the stimulus is applied to the core of the body, it is referred to as a central painful stimulus. The intent is to determine the type of response to pain, which will provide an indication of the patient's level of brain function. As previously mentioned, a more specific response, such as reaching up and removing the knuckles from the chest, correlates with a higher level of brain function. If no response is elicited, the examiner would assume the brain function is extremely poor. Anecdotal reports from neurology nurses and physicians have noted that it may take up to 30 seconds of sternal rub to get a response from the patient. Most emergency service personnel only apply hard knuckle pressure to the sternum for a few seconds. If no response is achieved in this brief period of time, brain function is thought to be poor and mental status is noted as being unresponsive. However, if the sternal rub was applied for 30 seconds, the patient may have actually responded. Thus, no response to a sternal rub that is applied for less than 30 seconds may provide an inaccurate finding in the mental status. Keep in mind that the sternal rub only needs to be applied until a response is elicited. In the prehospital environment, it is not realistic or desirable to apply a sternal rub for 30 seconds during the initial assessment. On the scene of an emergency, the entire initial assessment should be performed in less than 60 seconds! Consider an alternative central painful stimulus technique like the trapezius pinch or supraorbital pressure to ensure a more accurate finding during the physical examination. The trapezius pinch is applied by grasping approximately two inches of the trapezius muscle at the base of the neck between your thumb and index finger. Simultaneously twist and squeeze the muscle firmly and watch the patient's face for a grimace, eye-opening or some other response. Listen for a groan, moan or other incomprehensible sounds or comprehensible words. Watch the extremities for any movement that includes an attempt to remove the stimulus. To apply supraorbital pressure, it is necessary to locate the bony ridge along the superior border of the orbit that contains the eyeball. Pain and severe discomfort are achieved by applying a straight upward pressure with the tip of the thumb to the midline of the supraorbital bony ridge. Be sure your thumb is on the bony ridge and no pressure is being applied to the eyeball, which can damage the globe or promote a vagal response. While pressure is being applied, watch the patient's face and extremities for a response, or listen for a comprehensible or incomprehensible response. MISINTERPRETATION OF A PERIPHERAL RESPONSE TO PAINFUL STIMULUS EMS personnel may elect to apply a painful stimulus to an extremity, which is referred to as a peripheral painful stimulus. The fingernail bed is compressed between the examiner's downward thumbnail pressure and the index finger, or the skin or web of soft tissue between the patient's thumb and index finger is pinched. The response to a painful stimulus applied to an extremity may also provide a finding that can be easily misinterpreted due to a spinal reflex arc. If a painful stimulus is applied to the extremity and the patient does not respond, one would interpret this as an indication of poor cerebral function. However, if the patient withdrew his arm or leg when the painful stimulus was applied, it would be interpreted, reported and documented as withdrawal to pain. This may be an indication of a higher level of cerebral function and the patient would be awarded a 4 on the Glasgow Coma Scale for best motor response. If the patient responded, the examiner would assume the impulse traveled via an afferent (sensory) nerve fiber to the spinal cord, up a spinothalamic tract to the brain, where the pain impulse was interpreted and an appropriate response was sent down the spinal cord via a corticospinal tract and out to the muscle by an efferent (motor) fiber, causing the patient to withdraw from the pain. Thus, it is assumed from the withdrawal response to painful stimulus that the patient's brain received the impulse, interpreted it correctly and sent down an appropriate response. The spinal cord has the ability to produce a reflex response when pain is applied to cutaneous sensory receptors in the extremities. When pain is applied to the extremity, the impulse travels via an afferent nerve fiber to the spinal cord, where it triggers a pool of interneurons. These neurons then return the impulse immediately via an efferent (motor) nerve fiber to flexor muscles in the extremity. The result is withdrawal of the extremity from the painful stimulus. This is often referred to as a spinal reflex arc. Interestingly, the reason for applying a painful stimulus to the extremity is to assess the integrity of brain function; however, in the case of a spinal flexor reflex response, the impulse creating withdrawal of the extremity never traveled to the brain. In this patient, the examiner misinterprets withdrawal of the extremity that was produced by the spinal flexor reflex as being a good sign of cerebral function when the brain never received or invoked the response. If a spinal flexor reflex is triggered by applying pain to an extremity, the examiner would interpret, report and document the flexion of muscles as an appropriate withdrawal response to pain and award the patient a 4 on the GCS, even though the brain was not involved in the response. Thus, be careful in your interpretation of withdrawal when pain is applied to an extremity. This is contrary to misinterpretation of a lack of response to a briefly applied sternal rub. BLINK TEST Some patients encountered in the prehospital setting may fake an unresponsive state for a variety of reasons. Various techniques are used by the emergency personnel to distinguish between a patient faking a coma and one who is truly comatose. A common practice is to drop the patient's hand onto his face. If the hand slips to the side of the patient's face, it is commonly interpreted as a purposeful movement with the intent to not strike the patient directly in the face, which would indicate he is not truly comatose. A patient is thought to be comatose if the hand is dropped directly onto his face with no attempt by him to redirect it. Be cautious when interpreting this response, because there are patients who are intent on making the examiner believe they are unresponsive. An examination that may be applied to a patient who appears to be unresponsive but is thought to be faking is the blink test. This is performed by snapping your fingers in front of the open eyelid or making a motion with your fingers as if you are going to poke the patient in the eye. If the patient blinks, you may interpret this as a sign that the patient is faking the unresponsive state. The patient who truly is unresponsive cannot see the snapped fingers or fingers coming in to poke his eye; however, he may blink his eyes when these techniques are performed due to a corneal reflex. When air passes over the cornea, the corneal reflex causes the eyelid to blink, even though the patient may not be able to respond to other stimuli. In the blink test, snapping the fingers or movement of the finger toward the eye may cause air to pass over the cornea, eliciting a blink. The examiner may misinterpret this blink as being an indication that the patient can see the fingers and is faking the coma. PALMAR GRASP REFLEX The palmar grasp is a primitive reflex that appears at birth and is present until the infant is 5 to 6 months of age. When the palm of the hand is stroked, the infant will close his fingers and grasp the object in his hand. When the back of the hand is stroked, the infant will open his fingers. An adult patient who is not alert and is being assessed for responsiveness to verbal stimuli might be asked by the examiner to "squeeze my fingers" to determine if he is able to obey the command. If the patient squeezes or grasps the examiner's fingers, it would be interpreted as a finding that the patient is able to obey commandsa good indication of a higher level of cerebral function. If an adult patient suffers an injury to the frontal lobe, the primitive palmar grasp reflex may become active once again. If the examiner happens to stroke the palm of the patient's hand as he is asking the patient to "squeeze my fingers," he may trigger the palmar grasp reflex, which might result in the patient unconsciously and lightly grasping the examiner's fingers. This finding would then be misinterpreted as an appropriate response to a verbal stimulus when the patient may truly be unresponsive. It is important to understand the limitations of certain techniques used in determining the level of responsiveness. The assessment findings can be misinterpreted and provide an erroneous interpretation of brain function. This may impact the differential diagnosis and possibly the emergency care provided to the patient. CEU Review Form Beyond the Basics: INTERPRETING Altered Mental Status ASSESSMENT Findings (PDF) Valid until October 6, 2008 Bibliography alton AL, Limmer D, Mistovich JJ, Werman HA. Advanced Medical Life Support: A Practical Approach to Adult Medical Emergencies, 3rd edition. Upper Saddle River, NJ: Prentice Hall, 2007. Guyton AC, Hall JE. Textbook of Medical Physiology, 10th edition. Philadelphia, PA: W.B. Saunders, 2001. Marieb EN. Anatomy and Physiology, 2nd edition. San Francisco, CA: Pearson Education, 2005. ;Martini FH. Anatomy and Physiology. San Francisco, CA: Pearson Education, 2005. Marx JA, Hockberger, RS, Walls RM. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition. St. Louis, MO: Mosby, Inc., 2002. Joseph J. Mistovich, Med, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University. William S. Krost, MBA, NREMT-P, is director of Emergency Services & Health System Access for Blanchard Valley Health System in Findlay, OH. Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME.

It's funny how it becomes the crime scene even when it's not the scene of the crime and wasn't present at the time of the crime. I understand that they don't want us to move the deceased any more than we have to.

GSW TO HEAD: To save or not to save First let me explain why I even got this call. My lieutenant was having me meet him at our dispatch center, way out of our zone, so he could fix my key ring. Our narc keys are on a special ring which was damaged, and they have a special tool to fix it. So I was subject to calls out of our zone while on the way. Dispatch Medic 8 respond to possible suicide attempt. Dispatch Notes 65 y/o male unconscious, breathing. GSW(gunshot wound) to the head. We wait for the scene to be secured by law enforcement and head in. Of coarse the address we have is a little off, but we eventually locate the patient indicator lights (cop cars). Scene Size Up The patient is located supine, on the ground, just outside the driver-side door of his pickup truck. The police officer stated that he found a 0.22 caliber rifle about 5 feet away from the patient. The patient was found by a friend of his, and by our arrival the patient's adult son and daughter were both on scene. This road is on the patient's property. Assessment Obvious hemorrhaging from the patient's head; unsure exactly where from. The patient was breathing about 8 to 10 times per minute with blood in his oropharynx. My first impression was to control the patient's airway. I have heard of the calls where the bullet misses the brain somehow. I do, however inspect for brain matter. The patient had an obvious skull fracture indicated by bilateral periorbital ecchymosis. The patient had a good radial pulse and HR of about 70. I called trauma alert. Plan Control the bleeding, get the patient packaged and into the ambulance. We needed room to work, and I didn't want to work this patient right in front of his family. As we are placing the patient on to a backboard I notice it, the wound was proximal to his frontal lobe, dead center of the forehead. We were assisting ventilations at the time via bag-valve mask. I noticed what appeared to be brain matter oozing from the wound. I had never seen brain matter before, and always thought it to be grey, but this was yellow. It was like slime, what else could it be? At this point I had made the decision that this patient was obviously not going to make it. Our protocol states that if a patient has injuries incompatible with life, resuscitation is unnecessary. In addition, as we were rolling the stretcher towards our truck, the daughter stated that the patient has a DNR. I told her to get it, because we were going to need it. This patient subsided rather quickly, leaving me with an uneasy feeling as I watched him die. I know the patient's outcome wasn't going to change. I took into consideration that the patient obviously didn't want to live, and this helped me cope with my decision. Postmortem By moving the patient to my ambulance, I successfully turned my rig into a crime scene. We had to await the medical examiner's arrival. Once there, he did in fact confirm the presence of brain matter. Here's the unusual part. He identified the wound on the forehead as an entrance wound. I presumed that the blood in the mouth possibly indicated an entrance wound with the exit wound on the forehead. His finding meant possible homicide. Fortunately, with further examination, this was a confirmed suicide. When the ME checked the patient's wallet, he identified the label "organ donor" on the patient's driver's license. This thought never entered my head. He was an old guy, and I didn't think anything would be viable. The ME explained how his kidneys and liver could have been used. I will never forget this call. I think I did the right thing. I believe this is what the patient wanted, and I don't feel organ harvesting would have been appropriate. Guess that is a matter of opinion. What do you think?

Ok, Fred is correct. This is an anteriolateral STEMI. The patient appears to have a normal QRS-axis probably around 60 degrees considering AVL is equiphasic, and lead 2 has the largest positive deflection. Leads 1, 2, & 3 are all positive. I am not great at reading angiography so I am going to make an educated guess. V3, V4 elevation indicates LAD occlusion while V5, & V6 indicate circumflex occlusion. This could be a proximal Left artery occlusion but judging by the degree of elevation I doubt it. Unless of coarse there is still a little bit of oxygen saturated blood passing by. Since the damage seems to be worse in the anterior leads (more ST elevation), I think it is probable that this is a proximal LAD occlusion with a large area of infarct stretching towards the lateral wall. This is hard to swallow because the angio looks more like a lateral artery similar to the circumflex. I think that if that is the circumflex it would explain anterior infarct, but the lateral infarct would be more prominent. It is possible that the LAD is feeding some of the low lateral wall causing this relatively diffuse pattern of STE. If someone out there is better at reading these, please analyze. This was caught by one of our EMS crews and the door-to-balloon time was 77min. The left is pre-cath lab, the right is post. *****Message to Moderators***** Would it be possible to get an entire thread aimed towards ECGs/Cardio?? EMS village has something similar to this and I think it would be appreciated by many on here. Considering the widespread need for more education on this topic. If you do this, please move my strip teases for me. I have a lot more to add!! *****End Message****

also check out my strip teases on here.

I think the joke was that all human beings are "preload dependant". It's very understood what preload reduction will due to these patients. The are preload needy & on afterload overload. There's a new catch phrase for you. I was the same way when I first found that blog.

Remember, the right ventricle is only responsible for pulmonary circulation (lower pressure) where as the left ventricle (higher pressure) has to pump blood to the entire body and back. In the setting of right ventricular infarction, the right ventricle can become "stunned" and fail to pump blood effectively. It essentially becomes a conduit through which blood flows. When this occurs, the patient becomes highly dependent on central venous pressure to maintain adequate cardiac output. Sometimes, this is referred to as being "pre-load dependent" which is a term that I find amusing. In the first place, it's become a catch phrase, but more importantly, raise your hand if you're not pre-load dependent! Because patients with a stunned right ventricle are dependent on central venous pressure to maintain cardiac output, it can be dangerous to give these patients nitroglycerin, which is a potent vasodilator. Morphine can cause problems for the same reason. Patients with right ventricular infarction (almost always associated with inferior wall MI) tend to start out with borderline blood pressures. This is due in part to right ventricular stunning, but also because inferior MI often stimulates the Bezold-Jarisch reflex, which leads to a state of hypervagotonia. It's no accident that sinus bradycardia is the most common arrhythmia associated with inferior MI! - EMS12lead.blogspot.com Just though this was a good statement.

Well I meant with this EKG specifically. I'm not against checking the posterior leads, I just had already diagnosed STEMI on this patient with RV involvement. I was more concerned with Tx at that point. You are correct though, had I not had obvious changes indicating STEMI in other leads a posterior check would be more than indicated.

Would make sense. Morbidity and mortality associated with AMI has two do mostly with one of the two following reasons: - Time - Where the clot is located Of coarse there are other factors like age, and medical Hx, but these are the biggest. Time is what you are talking about. If the area of infarction is in a sense growing from the inferior wall, and reaches the RV and posterior wall you would, in turn, have greater morbidity. The clot location is a pretty big one as well, we've all heard about the "widow-maker" (LAD) occlusions.

Anyone disagree or have any other take on this?? You're welcome Fred.

What's the point? With v1 & v2 the way they are, you already know there is posterior involvement. I guess, if time allowed, changing up the leads wouldn't hurt.

This is a RVI from a call I ran personally. Try clicking it to zoom.

Fred, First, read this, you'll appreciate it: http://www.viamedica.pl/gazety/gazeta1/dar...indeks_art=1310 I'm with you on checking v6 for ST/T ratio (even though some heart docs preach V4), and I commend you on your effort to exclude early repolarization (one of the most common causes of STEMI mis-Dx). Without changing your assessment strategy entirely, because it is a good one, I would like to add something. In the acute setting of rapid 12-lead interpretation when we are looking to exclude STEMI mimickers like early repol, make it easy on yourself. Reciprocal changes is a big one. S-T depression isn't the only possibility, what do you see in lead 3? While early repol may cause ST-elevation (or J-point elevation) by dragging that J point up, not sure it would account for the discordant (inverted) T wave. Early repol was an initial consideration for me as well with the notched J points which some have called osborn or J waves. You have correctly ruled out early repol as a cause of this ST elevation. Now lets talk about acute pericarditis: A good Hx would help with your differential Dx. What would you ask? The T wave inversion could be a clinical finding of CHRONIC pericarditis. ST-segment elevation in more than one coronary vascular territory makes the diagnosis of acute myocardial infarction highly unlikely. This is why the finding of diffuse ST-elevation coupled with PR depression is important. This 12-lead does not show "diffuse" patterns of ST-elevation. The PR interval is not depressed. Use your TP segment, or bottom of your 1mv calibration line to determine true isoelectric line. The PR interval maintains it's position on that line (excluding some artifact). I believe the Hx would follow this pattern, and r/o acute pericarditis. Remember Fred, sometimes it is what it is. This might just be an easier strip than you were hoping for. I find myself looking for the same things when Corey sends out a simple BBB. We are always expecting more. Once again, I am very impressed with your analysis. So knowing this, wanna retry?

Anymore questions? We have talked a lot about hyperkalemia. Here is a guess, potassium is not the acute problem here. I have a good follow up on this. Anyone want to diagnose and treat?

Sounds like a good future strip tease. Move V3 or V4 to opposite side of chest. (or both, or entire 12-lead). Don't expect to see tombstones, RVMI usually displays with 1-2mm of elevation. Avoid nitrates or other preload reducers, and administer fluids as needed.

Wasn't my call. I agree on the fluids, positioning doesn't hurt though.

Ready for more? PT STATES HE WAS ASLEEP AND WAS WOKE OUT OF A SLEEP BY SEVERE SUBSTERNAL CHEST PAIN, 10/10 ON PAIN SCALE. PT STATES HE TOOK THREE OF HIS OWN NITROGLYCERIN AND CALLED 911. PT STATES AT TIME OF INITIAL EMS ASSESSMENT PATIENT'S PAIN WAS A 2/10 ON PAIN SCALE. PT DENIES NAUSEA, DIAPHORESIS, VOMITING, OR SHORTNESS OF BREATH. PT IS ALERT AND ORIENTATED. PT ADMITS TO DRINKING APPROX 5 ALCOHOLIC DRINKS THIS EVENING, AND STATES HE DID TAKE A VIAGRA THIS EVENING SEVERAL HOURS BEFORE BEDTIME. DURING INITIAL ASSESSMENT PATIENT STATES PAIN DID RE-OCCUR AND WAS NOW A 10/10, WITH RADIATION TO THE NECK AND JAW. PT IS STILL DENYING NAUSEA OR SHORTNESS OF BREATH. Medical assessment: Mental Status: Normal Mental Status for Patient, Oriented-Person, Oriented-Place, Oriented-Time, Oriented-Events, ; Neuro: Normal, ; Eyes: R: Reactive,; L: Reactive, ; Skin: Normal, ; Head/Face: Normal, ; Neck: Normal, ; LUQ: Normal (Soft, Non-Tender), ; LLQ: Normal (Soft, Non-Tender), ; RUQ: Normal (Soft, Non-Tender), ; RLQ: Normal (Soft, Non-Tender), ; GU: Normal, ; Cervical: Normal (No Pain or Deformities), ; Thoracic(back): Normal (No Pain or Deformities), ; Lumbar: Normal (No Pain or Deformities), ; Extremities: Upper R: Normal, ; Upper L: Normal, ; Lower R: Normal, ; Lower L: Normal, ; Chest/Lungs: Chest Pain/Pressure (Non-reproducable), SEVERE PAIN 10/10 RADIATING TO NECK, AND JAW; Vitals: 01:02 92/60 80 RR 20 Normal 97 Low O2 2/10 Right Arm (Supine) 01:12 88/60 78 RR 20 Normal 100 High O2 10/10 Right Arm (Semi-Fowlers) 01:24 86/56 72 RR 22 Normal 100 High O2 10/10 Right Arm (Supine) 01:31 118/63 72 RR 20 Normal 100 High O2 10/10 Right Arm (Trendelenburg) 01:38 108/60 68 RR 20 Normal 100 High O2 8/10 Right Arm (Trendelenburg) Wouldn't the osborn waves be apparent on every complex within a single lead. I see them on maybe one or 2 complexes on the entire 12-lead. They could also be early-repol notches.

I think this one may be a little easier. I have the story and a follow up on this one. Instructions for larger viewing from FireEMT: If you enlarge the image when you click on the part where it says to click to enlarge and it opens a new window click and hold the control key on your keyboard and then hit the + key. It will enlarge the image even larger as many times as your click it. If you do the same, but use the - key, it will make it smaller. This also works for normal web page viewing. It works in firefox, and internet explorer.

Thanks to all that replied with their impressions. The next strip tease will be on the way shortly!!

I was wondering about the Temp, O2 saturation and ETCO2. This would help to determine the patient's oxygenation and ventilation status. It would also help determine if the tachycardia was due to dehydration from infection. The urine output could also be causing dehydration. I would hold off on the Lasix, seeing how research is showing less and less of a need for this med prehospital. Like Vent said a BNP( brain-type natruetic peptide) and chest x-ray are needed to truly Dx CHF. CPAP may be a little much, but as stated O2 sat, and ETCO2 would help determine this. Consider the patient's Hx, emphysema. This could lead to pulmonary HTN, then RVF via cor pulmonale, then consequently LVF (or BVF if you may). But as stated the crackles could be lung infection. I don't see a problem with an updraft to open them up. The tachycardia is most likely from the increased effort, or dehydration. I pretty much agree with Vent's take on this. An updraft is commonly given in the hospital with CPAP/BIPAP to patient's with pulmonary edema, or as you put it, secretions. "Cranking up" the O2 on an Emphysema patient isn't always the best treatment if low-flow O2 is improving the patient's condition. You're right about the respiratory drive, depending on what there current effort is. Where are you in the pulmonary toilet at this point though? This patient would probably benefit from some broncho-dilation with the supplemental O2. Of coarse, there are some questions still unasnwered, and I wasn't there.

ATRIAL SYNCHRONOUS PACEMAKER: SA node firing is sensed by pacemaker and using an AV interval the pacemaker generates ventricular contraction via intrinsic SA nodal firing. As with normal conduction, the SA node determines the rate, not the pacemaker. I believe this type of pacemaker is used when the SA node is still functional, but there is interference with the communication to the ventricles. So a pacer is used to bypass that problem. So the rate may seem atypical for a pacer, but it would be functioning normally.

The ANSWER This is a Sinus Rhythm with synchronous ventricular pacer.