Friday, September 12, 2008

Let the ECGs do the Blogging

Cardiology is one of my favorite aspects of this job. I find electrophysiology fascinating, and I relish every opportunity I get to look over an interesting ECG strip. I know some of my readers share some of the same interests, so I thought I'd post some strips from the past few weeks. I'll let the printouts do most of the talking:

80 year old male found seated in his recliner watching TV:




40 year old female feeling "weak" at Wal-Mart:



The nurses said this patient looked "restless." (This is the patient from Points of View):


12 comments:

Rach said...

I realise that one can't look at the ECG's interpretation of the rhythm for the dx, but how often is the lifepack's interpretation and your interpretation the same?

brendan said...

Jeezus. Do you feel the post-ROSC BP was accurate, or was that another classic output from the patented Physio-Control Random Number Generator (also known as the LP12 NIBP)?

fiznat said...

Nah we didn't believe the LP12 numbers either. A manual BP was something like 130/70 or so. We usually just leave the auto cuff on in those situations though just cause there's so much else to do at the same time.

DH(A HA)PD said...

Re the supposed a-flutter pt. (as the strip says...riiiiight), I don't buy it. The ventricular rate should be precisely 300 BPM (or 150) and it was off it enough that I don't believe it to be the case. Precordial concordance was present in this case which would indicate v-tach. It isn't a true RBBB which complicates diagnosis, as does the lack of path LAD. I would think if you don't get anywhere with 12mg of Adenosine then moving onto Amiodarone (150mg over 10 min.) makes sense. With a BP like that you were right to not cardiovert.

Great strips! I geek out on them too.

fiznat said...

DH(A HA)PD,

Yeah I had one or two people bring up the "150 or 300 bpm" bit about a-flutter, but I donno. The evidence for that seems relatively anecdotal although I suppose I could have missed that research. In the end I don't know if choosing Amio because the rate isn't exactly 300/150 is any better than paying attention to the marquette interpretation. ...Both are weak evidence and don't really stand on their own, but what else are you going to do I suppose.

I really don't think the rhythm is VT. There is the concordance but no E-RAD and I think the width looks a lot like RBBB. Also I think I can see p-waves but who knows.

Thanks for your comments, I enjoy arguing about this stuff...

Gertrude said...

Um that 2nd patient feeling weak at the wally world is in v-tach. That's why the adenocard and the cardiazem didn't work. jsut an observation. Speaking of cardiazem. Do you guys still carry it?? The powers that be in my region tooks our out sighting a shortage. I have needed it more since they took it than when I had it. Just curious if you heard the same story or if they were delusional.

fiznat said...

I donno, I didn't (and still dont) think its VT. The docs didn't think so either...

Never heard of any Cardizem shortage, we still carry it here...

DH(A HA)PD said...

Your reply had me do some research and according to AHA, it sounds like the 300 BPM appears in most patients, but as we all know, our patients don't read the textbooks! :)

http://www.americanheart.org/presenter.jhtml?identifier=52

So I guess it still could be. What did the rhythm look like as it was speeding back up after the brief Adenosine hiccup? Or did that never even happen?

fiznat said...

There was no adenosine hiccup. That drug didn't touch the rhythm at all. Actually, no drug that either I or the ED gave touched the rhythm, including amio and procanimide.

Cheating Death said...

rach--With my LP12 experience the monitor more often diagnoses wrong that right. We have it turned off now so somebody doesn't screw up and read it and think it is right.

Our NIBP will change 80mmHg in 5 seconds on a completely stable patient. I think we're moving on to zolls... though I doubt I'll be any more impressed.

Baby Medic--you've been blogrolled!

A said...

I was about to ask about the 8 year old watching Tv in fib... took a 2nd look and saw it was an 80 year old. Ha

Tom B said...

Before it's anything else, it's an undifferentiated wide complex tachycardia. Wide complex rhythms are ventricular until proven otherwise. If it's atrial flutter with 1:1 conduction, then you have to be concerned about the possibility of an accessory pathway. Regardless, calcium channel blockers and adenosine are contraindicated. If you're going to bother giving an antiarrhythmic, reach for the Amiodarone or Procainamide. But why bother? If it's hemodynamically unstable, cardiovert! If not, capture a 12 lead ECG, start an IV, place the patient on oxygen, and transport. Remember the wise words written all over the 2005 guidelines. "Consider expert consultation." There's no shame in it. Thanks for sharing! :)