Just say no to drugs... and this rhythm

[crotchitymedic1986]

Damn guys, I hate it when I might be wrong, but I may have to change my diagnosis after further study:

1. I would still like to stick with my original diagnosis, calling that little lump in the T-segment a retrograde P-wave (hense the junctional diagnosis).

2. But in the "larger-non sinus rhythm", is that a delta wave I see before the sloping QRS, possibly indicating WPW ?

Wished i had the strip in my hand.

Any other opinions, now that you can see the strip through my rose-colored glasses ?

PS -- Nope, never mind, there is no delta in ECG 2---- the retrograde P does measure out, this is Junctional.

[KSEMT122]

woke up with it 7 hours ago then drove 4 hours before calling 911 (he was driving from texas to california on a big rig)

With the symptoms you are describing (SOB, Chest Pain, Nausea, vomiting) and this quote above that he is driving a big rig from TX to CA I would suspect a PE. More than likely you are not going to notice a big change in lung sounds although you may. Just because the lungs sound clear doesn't mean he still couldn't have a PE. Once he got to the hospital hopefully somebody ran a D-Dimer just to rule it out. The signs and symptoms of PE's can be short lived and easily missed especially in the field.

As far as the ECG goes. I was thinking short runs of V-Tach. Now what part that would play into a PE I have no clue. I've never associated V-Tach or ventricular rhythms with PE's. ST depression and/or tachycardia usually present right along with a PE. Only 13% of people with a PE have a normal ECG. I would call this one abnormal, I think we could all agree with that. I won't argue with the Doc on the interpretation of this rhythm since he's at one end of the spectrum and I'm at the total other end. That was just my first inclination when I saw it.

[p3medic]

A normal D-Dimer doesn't rule out PE, nor does an elevated D-Dimer rule it in.

[crotchitymedic1986]

Sing along to the tune of "there's a tear in my beer"

Theres a "P" in my "t"

Which makes Junctional hard to see

But you could mistakenly call it AIVRRRRRRRRRRRRRRRRRRRRRRRRR

[KSEMT122]

A normal D-Dimer doesn't rule out PE, nor does an elevated D-Dimer rule it in.

I'm well aware of this. It's a place to start. There is a formula regarding D-Dimers that takes into consideration risk factors plus the level of the D-Dimer test. A PE can in fact be ruled out to a certain percentage that is quite high if the correct formula is followed. It can also be ruled in to a percentage as well using that formula. I would have to defer to Doc on the ins and outs of that formula. I've tried to find the link and I have been unsuccessful. The point being in using the D-Dimer, it's a place to start. There are many more false positives than false negatives.

[KSEMT122]

D-dimer has utility in the assessment of deep vein thrombosis (DVT) and pulmonary embolism (PE).10 The automated method employed by LabCorp is quantitative and has the analytic sensitivity required for this clinical application.6 D-dimer levels can be elevated in many clinical circumstances, especially in hospitalized patients.11 While increased levels are not specific for DVT or PE, low D-dimer levels may be used to rule out these conditions. The negative predictive values for DVT and PE are >90% using the sensitive D-dimer assay with a cutoff <0.5 FEU.6,9,11 The negative predictive value is further enhanced through the use of a clinical probability model along with D-dimer in the decision process.7,8 Values <0.5 FEU in an individual with a low clinical risk of venous thrombosis can serve as the basis for not performing more expensive diagnostic tests for DVT and PE. Patients with results greater than this cutoff require further diagnostic testing to establish the diagnosis.

https://www.labcorp.com/datasets/labcorp/ht...no/cf002900.htm

This isn't the complete formula I was thinking of that I think you can find in the PDR book, but it articulates my point in using the D-Dimer in this patient better than I could.