EMS_Cadet

http://www.medicine.nevada.edu/dept/IMNort...SKulick_001.pdf Page 5, third point. "Almost always located infranodal (the bundle branches), which means that the QRS duration is wide." I do see your point and it is quite valid. I suppose you could have either. The AHA also makes several interesting points on their website.. "This type of block [Type II second-degree AV block] most often occurs at the level of the bundle branches." "Conducted P waves may display a normal QRS complex if the site of block is within the bundle of His, or a bundle branch block pattern if it is more distal, as in the bundle branches, which is more common."

You could approach this from two perspectives... First off, I need to see a 12-lead from this pt for further evaluation. My two cents...

http://www.wakegov.com/NR/rdonlyres/2F6EC7...0/2007Adult.pdf Protocols are above. This is our breakdown: 10gtt/set and a 250mL bag of NS. Inject 12mL of epi 1:1000 into the bag of NS. You can choose either 1mg/3min or 1mg/5 mins. Also, if you look in the protocol, we also use epi drips in symptomatic adult bradycardia. Let me know if you need any further.

We currently have epi drips in our cardiac arrest protocol as a standing order.

We can use the orange button (see post above) or we can say "Signal 25".

Your 12 lead is above.

No toxic exposure or overdose. He remembers running around trying to catch his friend when pain started in his left arm and started moving down into his chest.

Respirations @ 28 and labored.

He is tachypneic with shallow respirations. Lung sounds are C/E bilat. At this time, he is A/O.

S - Nausea/vomiting (new symptoms), "pain all over", dizziness, "faint feeling" A - NKDA M - Insulin P - IDDM L - Lunch (it's now 4pm) E - See original post. Vitals: Pulse @ 62, BP 92/68, Pulse ox @ 89%, Temp @ 98.7F. His skin is very pale, cool, and somewhat diaphoretic.

You are dispatched to an upscale neighborhood for a "DIABETIC EMERGENCY". Dispatch advises that your patient is a 15 year old male, known IDDM, with a chief complaint of "dizziness". You arrive on scene. Scene is secure. The mother lets you in the house and directs you upstairs to her child's bedroom. As you climb the stairs, you obtain that the child was fine this morning (it's about 1pm now), but was playing in the backyard with friends when he came in and started complaining of "pain all over his body". Mom assumed this was some type of neurological disturbance due to the diabetes. She checked his BS and it came back @ 156. She gave him some Motrin and sent him to bed. About 4pm, she went in and checked on him. He is now pale and cool. He is unable to move to due being extremely lethargic. Go for it.

I said it a while ago...Honestly, I wasn't thinking a valvular issue, but it did cross my mind.

Hmmm...Very interesting scenario! I'm very tempted to think that this is acute pulmonary edema. I am, however, reminded that no patient is "normal" or "textbook". As an EMT (and EKG guru) waiting to state test, this is my line of thinking: More than likely, this patient has suffered a previous anteroseptal MI, causing acute heart failure. The presence of the Q waves in the septal and anteroseptal leads leads me to believe there was an old infarction. Also, since the bundle branches are contained in the septal area, an old infarction could possibly damage the LBBB. The septal damage is probably causing LV dysfunction, resulting in acute pulmonary edema. As for the presentation, it sounds like a classic CHF case with the exception of the BP. However, this patient could be one of those "odd" people that has a fairly normal BP even during a major cardiac event. Also, does the patient have any edema, JVD, or abnormal cardiac tones? I also would LOVE to get a BGL on this man. I don't think anyone has asked for one, despite his NIDDM.

Alright...Well, I'm gonna admit that I'm sorta lost. Possibly a seizure (his mental status might be from being postictal)? CVA is still in my list.

Please forgive me, but I'm gonna have to start my assessment from the beginning. It's too confusing for me to "skip" over certain parts that have already been answered. Alright, let's give this a go. -Scene Questions Any exposure to toxic gases/hazardous materials? Any possible ingestion of unknown substances/medications? Any known falls? Last time patient was seen? Has the patient complained of anything recently? Does the patient take his medications or does the nursing staff administer them? Any recent visitors? Any recent surgery? Has nursing staff or fellow patients noticed the pt. acting out of the normal? - Mental Status? -Airway- -Breathing? -Adequate? -Any signs of poor oxygenation? -Circulation? -Any obvious bleeding? -I'm assuming a (-) radial pulse? -Skin color/temp/condition? -Rapid medical exam. -HEENT - Any edema? Pupils? Nasal flaring? JVD? Tracheal deviation? Hives? Cyanosis? -Chest - Equal chest rise and fall? Any paradoxical movement? Breath sounds? Heart tones? Hives? -Abdomen - Any tenderness, ecchymosis, guarding or masses? Hives? -Pelvis - Stable? Incontinence? -Lower extremities - (+) PMS in both? Any edema? Hives? -Upper extremities - (+) PMS in both? Hives? -Any signs of trauma? -Vitals BP, HR, RR, Temp, BGL, Pulse ox, Co2. Orthostatic? -Monitor: 12 lead. -Cincinnati Prehospital Stroke Scale? -SAMPLE history. -Is the patient complaining of anything himself? Alright...This could be anything, but my differentials include (but are not limited to): -MI. -Shock -Cardiogenic. -Anaphylactic -Septic. -Neurological. -Hypovolemic. -Neurogenic orthostatic hypotension -CVA (rare, but maybe). -Post-ganglionic sympathetic denervation (I came up with this after some research on Parkinson's and hypotension). -Pulmonary embolus -Medication effect /overdose