mobey Posted May 10, 2009 Share Posted May 10, 2009 Hope I link these ECG's properly... sorry bout the quality, scanner quit. Called for a 62 y/o male, with chest pain and a headache On arrival: Patient found supine in bed in obvious distress. Patient is clutching chest and breathing rapidly. Patient reports sudden onset SOB, chest pain, palpitations while watching T.V.. Took 2 sprays of own nitro with no relief. Got dizzy, headache and layed down. Patient appears appropriate for age, history of NIDDM, and is a retired autobody worker. Non smoker, lives a healthy lifestyle in a well kept home. Angioplasty 2 mos ago, no angina pains since. No Hx of CVA, MI, or Resp illness. Patient presents pale & diaphorretic, Resps 26 non-laboured, BP 100/62 Pulse 68 irreg at radial. Patient sts irreg pulse is new. SpO2 95%. Meds: Beta blocker, calcium channel blocker recently removed from regimine, Nitro PRN, Lipitor, Metformin. (I think that was it) You are about 20 min from a rural hospital Any questions... Just ask! Link to comment Share on other sites More sharing options...
scott33 Posted May 10, 2009 Share Posted May 10, 2009 New onset AF. Management other than the usual ABCs is going to be rate control, while keeping an eye on the BP. Positioning, fluids, and slow IVP of your B-blocker / Ca++ channel blocker of choice is a start. Link to comment Share on other sites More sharing options...
celticcare Posted May 10, 2009 Share Posted May 10, 2009 New onset AF yes, icomplete left bundle branch. curious as to which vessels got plastied and with what sort of stent, BMS or DES. It was plastied right not just angiograph? Scotty Link to comment Share on other sites More sharing options...
mobey Posted May 10, 2009 Author Share Posted May 10, 2009 (edited) New onset AF yes, icomplete left bundle branch. curious as to which vessels got plastied and with what sort of stent, BMS or DES. It was plastied right not just angiograph? Scotty definatly plastied I dunno what the difference in the two are so I did not ask LOL He said the stent went in the Left side.... sorry that's all I got slow IVP of your B-blocker / Ca++ channel blocker of choice is a start. Hmmm.... B-Blocker and Ca blocker together? BTW: 1st year medic student, still learning. Edited May 10, 2009 by mobey Link to comment Share on other sites More sharing options...
scott33 Posted May 10, 2009 Share Posted May 10, 2009 (edited) Hmmm.... B-Blocker and Ca blocker together? Nope. Either one, depending on what you carry, hence the "/" (either, or) So, is this what you did? Edited May 10, 2009 by scott33 Link to comment Share on other sites More sharing options...
celticcare Posted May 10, 2009 Share Posted May 10, 2009 Sounds like an LAD stenting, wouldnt be surprised with some pain later on afterwards or even a stent moving. But it seems like new onset af which is causing the issues for him personally. Link to comment Share on other sites More sharing options...
mobey Posted May 10, 2009 Author Share Posted May 10, 2009 (edited) Nope. Either one, depending on what you carry, hence the "/" (either, or) So, is this what you did? Hahaha... sorry... a little computer illiterate! Naa, I am working BLS. I did O2, IV NaCl 250ml bolus, 160mg ASA. It slowed the rate down and the chest pain faded so I was satisfied. Although if I was working ALS I probably would have went down the Amiodarone route... maybe (student), Perhaps even considered a quick electrical cardioversion. Edited May 10, 2009 by mobey Link to comment Share on other sites More sharing options...
celticcare Posted May 10, 2009 Share Posted May 10, 2009 Hahaha... sorry... a little computer illiterate! Naa, I am working BLS. I did O2, IV NaCl 250ml bolus, 160mg ASA. It slowed the rate down and the chest pain faded so I was satisfied. Although if I was working ALS I probably would have went down the Amiodarone route... maybe (student), Perhaps even considered a quick electrical cardioversion. Its down to if he is symptomatic, I would have held fire on the DCCV route and gone with pharmaco first if he was unstable then yes the lunchbox of life would be great though. Good thinking on the whole though Mobey Link to comment Share on other sites More sharing options...
FL_Medic Posted May 11, 2009 Share Posted May 11, 2009 (edited) New onset AF yes, icomplete left bundle branch. curious as to which vessels got plastied and with what sort of stent, BMS or DES. It was plastied right not just angiograph? Scotty That's actually not an incomplete LBBB. Note that the axis is around 60 degrees*. If you have a normal axis, you lack a hemifasicular block. Since LBBB is a block of both the left fasicles, you should be able to identify at least a single fasicular block to call it incomplete LBBB. Normal vectors, and R wave progression. That width you are seeing is probably due to early repol. Note notched J point most visible in V5(looks similar to osborn wave). *You can figure this out by considering aVL to be perpendicular to axis of depolarization because it is the most equiphasic lead(not predominately positive or negative. Since lead 2 is perpendicular to aVL than your axis is almost in line to lead 2. Since lead 2 is positive, and the positive electrode for lead 2 lies at about 60 degrees....abracadabra. If you already knew this, disregard. Edited May 11, 2009 by FL_Medic Link to comment Share on other sites More sharing options...
celticcare Posted May 11, 2009 Share Posted May 11, 2009 That's actually not an incomplete LBBB. Note that the axis is around 60 degrees*. If you have a normal axis, you lack a hemifasicular block. Since LBBB is a block of both the left fasicles, you should be able to identify at least a single fasicular block to call it incomplete LBBB. Normal vectors, and R wave progression. That width you are seeing is probably due to early repol. Note notched J point most visible in V5(looks similar to osborn wave). *You can figure this out by considering aVL to be perpendicular to axis of depolarization because it is the most equiphasic lead(not predominately positive or negative. Since lead 2 is perpendicular to aVL than your axis is almost in line to lead 2. Since lead 2 is positive, and the positive electrode for lead 2 lies at about 60 degrees....abracadabra. If you already knew this, disregard. *Looks with a fresh set of eyes and more coffee on board* Thanks FL Link to comment Share on other sites More sharing options...
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