Aussieaid

I apologize for oversimplifying the explanation. I was simply trying to answer the OP's original question about Cushing's Triad and instead of getting sidetracked into all the different types of herniation I mentioned the type I have seen most commonly. The Cushing's triad can occur in the late phases of both the Central and Uncal herniation syndromes as well as other types of herniation so the point is kind of moot. Sorry I am too tired to think clearly to explain my thought so will check back tomorrow! Good night and keep safe!

Oops! I changed it. I had just never really changed it from the default settings in my profile. I am female.

I haven't had a chance to do the research but the first thing I thought of with this case was inhalant abuse. It is really a big problem with the preteen and early adolescent age group. Most of the parents have no idea their kids are doing it unless something bad happens. The same as they have no idea when their kids are playing the choking game. There are often few obvious signs unless you have a really strong suspicion and actually know what to look for. A lot of the mood alterations/moodiness associated with the abuse is probably put down to the phase of preteens and teenagers which is why it is really hard to monitor and prevent it. There is a very high risk of encephalitis and brain damage from "huffing". I don't have the profile of abusers in front of me but the fact that he is a loner and doesn't have many friends puts him at risk of depression and inhalant abuse. You don't need friends or company to do it and it seems to be a less social form of abuse although they do do it with friends as well.

I will be happy to meet up sometime. I am just not 100% sure I am going to make it yet. I've booked a room at the Red Roof Inn if anyone (female please- I am a little shy like that!) would like to share. I will wait until I get back from my vacation to book my flight. Hopefully something cheaper (flight) turns up or else I may have to bow out. PM me if you want to arrange anything. Cheers,

LOL. I had to sit and reread your post a few times to follow it! Still not sure if I understand exactly what you were trying to say so forgive me if I have misunderstood something. I think the reasoning behind giving atropine pre-RSI is that it is better to prevent the bradycardia than try and get a kid back from bradycardia although we never used it with our intubations in the PICU. We would have it ready on infants but I rarely ever gave it. In my flight program it is protocol to give it for under 6 years of age (and no I don't agree with it!) The increase in the SBP by widening the pulse pressure in herniation is an autoregulatory mechanism to increase cerebral perfusion pressure to a brain that has decreased blood flow due to increased ICP. The bradycardia and irregular and slowing respirations is from pressure on the brainstem with ensuing ischemia as the brain herniates downward through the foramen magnum. The brainstem is the where the vital cardiovascular and respiratory centers are. It's funny you bring up "coning" because when I first came to the States people had no idea what I was talking about when I would say someone is "coning". As a tidbit that term comes from the way the brain is pushed down through the foramen magnum like down an ice-cream cone. I was not referring to neonatal head bleeds when I talked about herniation in pediatrics. We used to see a lot of TBI, shaken baby syndrome, near-drowners and cerebral edema from any other variety of insults to the brain (including mismanaged DKAs). I have certainly seen my share of herniations and taken care of way too many pediatric organ donors. The child I was talking about was not a regular preemie with apnea/brady spells. This pt had multiple congenital heart defects (coarctation was not one of them) as well as a number of other defects and was on a rate on the ventilator. His episodes were related to the tracheal sling not necessarily hypoxia. We managed the plain old apnea/brady babies with stimulation, O2, bagging and usually caffeine or maybe stronger meds as needed. CPR was rarely needed on these infants as they usually respond before you get to that point. I am a little confused as to what you agree to disagree on and exactly what relevance to my post your links were (interesting though they were!) Have a great weekend and feel free to disagree or agree as much as you like. I am always open for good discussions and learning new things. I just reread your post and I think you misunderstood what I meant about compressions being first line treatment in peds versus adults. I am not talking about the apnea/brady spells in neonates where you don't do compressions first. I was responding to the OP's thoughts about compressions being used earlier for bradycardia in pediatrics in general (i.e. PALS guidelines) and more as a last resort in adults (per ACLS guidelines). Cheers!!

The more I learn the more I find inconsistencies in everything to do with medicine. I guess that is why it is rare to find two doctors, nurses, paramedics, emts etc who will agree on everything. I usually end up researching as much as I can and then go with what makes the most sense/logic to me. I just agree to disagree and as long as someone has a good rationale behind why they are doing something I don't try to change their opinion to agree with mine. I think part of the thinking behind the not suctioning the mouth if there is meconium staining present is, as someone said, that it actually stimulates the baby to breathe when you want to avoid that and intubate them before they start breathing if possible. The Cushing's Triad is more the widening pulse pressure being manifested by a sudden increase in the SBP along with the bradycardia and the irregular respirations leading to apnea. The interesting thing I have found in kids who are actively herniating is that they actually become suddenly tachycardic followed by bradycardia and they often like to code at the time of herniation. With a more gradual increase in ICP I see more of the bradycardia (usually a junctional rhythm). We had a baby who lived the first year of his life in the PICU and we had to do chest compressions on him at least once a shift for a while because of bradycardia. He would go bradycardic, you'd do a few compressions and he was fine again. Didn't even have to use epi or atropine every time. If I remember correctly they found out that he had a pulmonary artery sling around the trachea along with his 101 other congenital defects. He was totally FUBAR! I also think that compressions are more of a first line in peds with bradycardia because it is usually related to hypoxia or a more immediately reversible cause other than a cardiac arrhythmia or heart block like it is in adults.

I sent out the info to folks at work as well so may talk someone else into going and splitting costs as well. Big thing for me is the airfare. I am going on vacation next month so will be really poor in December!

Ok, I caved and signed up for both days. Hopefully can talk someone into letting us do a cric. Mrsbull I am interested in sharing a room. I was going to look into Dust's suggestion of the Red Roof Inn near the lab. Have you booked anything yet?

How about a section for general educational/informational powerpoints? Would be nice to get feedback from the city before having to present one.

I will just agree to disagree. (It is after all a free country ). I understand the point you are trying to make but it seems that you are coming up with a hypothetical scenario that is not supported by any of the limited information given. The conclusion I reached was based off the information we did get. The Doctor was given the opportunity to give a medical history and did not give any other information except that the baby was 2 months premature and had been in the hospital for a week with pneumonia for which he had not been treated. I can't imagine a Dr not telling a paramedic that the pt is on palliative care or is a DNR no matter how little information they give. It seems to me that SA was attempting to find out more information on the pt but was not receiving it from the Dr not that he was "overriding any points of reason". I don't know how it works in Africa but in the States a parent still has to give consent (unless there is a court order) to not escalate care or make the baby DNR status. It does not sound like the parents changed their mind but were unhappy with the lack of care altogether which is why they wanted him transferred. (Based on what SA has given us although it is hard to know since they had a language barrier). The infant's weight is definitely concerning and there absolutely could be some underlying health problems especially as it was 2 months premature. There are any number of non-lethal conditions that can cause a baby to be in the lower growth percentiles and some could have been from the pregnancy and possibly even a cause of the prematurity. But the baby has also been sick for over a week and is severelydehydrated and starving. A baby can lose >10-15% body weight with dehydration in less than 24 hours so if this baby was on the small side to start with and now has not been able to eat or drink with no IV fluids for over a week he has most likely lost a way larger percentage of his body weight. In this case I am willing to give SA the benefit of the doubt over the Dr who does not even know what a normal infant HR should be. SA has been polite, professional and does not come across as unknowledgable in this thread. The Dr does come across as ignorant even though I admit that we only have one side of the story. I am not disagreeing with your thoughts on lack of quality of life and babies/people being saved who should be let go. I understand that whole concept very well after many years in PICU's. I am just not seeing that that is the scenario in this case rather that it is a case of blatant neglect. I have seen any number of medically mismanaged cases (by all walks of health care) and am under no illusion that Dr's are perfect (or paramedics). A jury can only make judgements based on the evidence given no matter what other hypothetical scenarios there could be and that is all I am doing in this case. SA, it would be interesting to hear if you have any further information or follow-up on this case.

Vent medic, I understand what you are saying about quality of life and allowing nature to take it's course especially when a baby has defects incompatible with any kind of quality of life. I also understand how families don't get that sometimes there is nothing you can do and how they have a hard time letting go. I worked in a PICU for quite a few years and was frequently frustrated and heartbroken watching unnecessary suffering. From everything SA has posted this is a completely different scenario. 1) The unit with babies on it was freezing cold requiring SA to zip up his jacket. First rule of infants is maintaining a euthermic environment. 2) The Dr did not even know normal infant vital signs (HR in the 50-60's and he calls it a "normal sleeping baby rate"!) 3) Why have a saline lock in if the baby is just there for palliative care? Also why have the baby on CPAP at all especially as his hypoxia proved to be easily resolved with proper treatment. 4) The Dr mentioned nothing about any other medical conditions other than the prematurity and pneumonia. These are indications of lack of even basic care or knowledge. Sounds like all the babies are there for "palliative" care! Pneumonia and even basic ventilation are often available in larger hospitals even in third world countries. Obviously these are available where SA was as it was at the private hospital 5 minutes away. If your hospital doesn't have the capability then send them on don't hold on to them for a week and do absolutely nothing for them. From what SA has told us (and I am basing all my opinions just on what he has said the same as everyone else) this baby had a treatable medical condition which was not treated and even worse was caused harm. Everything he has said has led me to believe that this is a case of severe malpractice over palliative care. Also the parents wanted the baby transferred because they weren't happy with care. If they are willing to pay the cost of taking the baby to a private hospital and perhaps get a second opinion there then the Dr has no right to refuse to allow the kid to be transferred. Wouldn't you be happy to let them go and not have to be troubled with a "difficult" family? The receiving hospital had obviously accepted the baby and they had more resources and at least a PICU where the baby needed to be. I get the impression he refused because he knew his ignorance and neglect would be found out. Obviously there was a discussion with the Dr but the parents wishes were simply ignored and nothing leads me to believe what was being done or not done was in the best interests of the baby. I am all for allowing a child to die a peaceful death if it has a poor prognosis but I don't believe in letting a baby die from treatable conditions because of ignorance and neglect. Pneumonia, dehydration, starvation, hypoxia, bradycardia were all treatable in this baby. Yes some babies die from pneumonia but you won't know if it was curable if you don't at least treat it. Disclaimer: All my opinions have been formed based solely on the information provided. If we are given further information that negates my conclusions I am more than happy to recant my opinion.

SA Medic I commend you on giving this baby a chance at survival. If it survives it is only because you saved it. I am appalled at the neglect and care that this baby received even allowing for the lack of resources you have to deal with over there. I have cared for kids in third world countries with some medically ignorant people but what you describe is beyond ignorant. I have also been amazed at what some people can do with very limited resources and just a decent level of medical knowledge. Correct me if I am wrong but from what you have told us this was a preterm baby who is now at a term newborn corrected age. The only medical condition that you have described is the current pneumonia and possibly a PDA. You have given no other indications that this baby is a special needs baby outside the fact of it's prematurity. The more premature the baby the higher the risk of the PDA not closing and it just may have to be treated either medically or surgically to close it. No big deal if that is the only cardiac anomaly. A premature baby is also at higher risk than term babies for lung problems and infections. The baby had been doing well enough prior to the current PNA (pneumonia) to survive almost 2 months at home. If there was no other medical conditions then there is absolutely no reason that this baby could not have survived PNA especially if it was correctly and promptly treated. This baby was literally about to die when you got to it SA and the fact that you were able to keep it alive and improve it's sats to the mid 90's leads me to believe that it was simply dying from neglect. I simply cannot commend you enough! This baby needed to start with: 1) IV maintenance fluids with dextrose. (The baby was life-threateningly dehydrated and literally starving and that can happen in less than 24 hrs in an infant this young let alone having been on a saline lock for a week!) Did you do a glucose test on the baby? I'm sure it was probably almost non-existent if you had done one. I bet it was severely hypoglycemic as well as acidotic. 2) To be intubated. The baby was lethargic (practically comatose) and would not have been able to maintain it's own airway. 3) Mechanical ventilation. The CPAP was totally not even working and was not helping the baby at all (severe retractions, hypoxia, cyanosis). This baby was moments away from coding as evidenced by the severe bradycardia. 4) This baby should have been on empiric antibiotics to start with (considering it is more commonly caused by bacteria than pneumonia). Neonates and even more, premature babies are highly susceptible to infection and they become septic if you even look at them funny. In the NICU's babies are started on antibiotics at the slightest sign of an infection and they don't wait for the lab results to come back before they start them - it could be too late by then). Easier to stop unnecessary antibiotics than to try and stop a rampant infection. 5) Fluid boluses. See number 1. 6) Baby should have been on an infant warming table at least or if not available should have been kept warm with warm room and wrapped warmly in blankets at least. Babies cannot regulate their temperature and they have even less control when they are ill. Septic babies become hypothermic very quickly and that contributes significantly to their downward spiral. 7) Transferred to a higher level of care. Obviously they had no clue of how to treat this baby (or any babies for that matter). These are just to start with! I am totally in empathy with you SA and find my blood is boiling at the neglect and lack of care that this helpless baby received to the point that it was literally about to die. There is no excuse for this total lack of basic medical care. I don't know what channels you have to be able to address this but I agree that it warrants further investigation and follow up. How many other babies have died because of this abhorrent lack of regard for basic medical care and unbelievable ignorance? I am sorry for the rant but I cannot give SA enough kudos for saving this baby's life (even if it dies most likely as a direct result of the neglect) and giving it a tiny chance of survival after the horrors that it has managed to live through. Because of how sick this baby was allowed to become before it got help it has that much less chance of surviving now. My heart goes out to the parents who had to watch their baby dying before their eyes and feeling powerless to help it. I think I would have walked out of the hospital with it and directly to the private hospital myself. Yes, I don't have all the details but everything you have said points to neglect and ignorance. Nothing you mentioned leads me to believe that this was a baby with a condition that is incompatible with life. There was also no kind of care let alone end-of-life comfort care. In my books you are a true hero SA.

Doc, what are the chances of actually being able to do a surgical cric on a cadaver with this course? It is in our protocols and I hope to never have to do one but I would like to do one on a cadaver in case I ever have to do one on a live person. I have been looking for courses with labs or cadavers but have never been lucky enough to be able to do one in either an animal lab or cadaver lab. It looks like an excellent course but it is a long way for me to go (and considering my finances at the moment) so would like to know exactly how beneficial the course would be for me. Thanks.

Studies have shown that there is actually more instances of broken ribs (~30%) than fractured sternum (~14%). The risk of breaking anything depends totally on the patient and also on the person performing CPR a lot more than the technique. Although poor technique is going to increase the risk. A strong male doing the correct technique on a frail old lady is more than likely going to break something. The older the person the more likely they are going to end up with fractures. It seem females also receive more rib fractures than males as well. If a person is in poor health or has underlying problems they are also going to be at high risk. Think of the older people with osteoarthritis. Hard to not break something or else you are really probably doing ineffective CPR. I am used to doing CPR on children more and they have very elastic rib cages but you can still break them occasionally. I have noticed that children often receive over enthusiastic CPR so it is lucky that they generally are more compliant. (I have seen 2 handed CPR used on a child less than 2 years old by a large male - adrenaline overcoming training). The last person I did CPR on was a 60 something year old homeless male in very poor health and I could feel the ribs breaking and the bones crunching Not an experience I am going to forget easily. I don't have very strong arms so I will get on the gurney if we are moving or up on the side of the bed to be able to do more effective CPR. What position you use depends on the individual but it is more important to recognize what works best for you. For an adult (pt) the 2 handed technique is going to be much more effective. If you think about it they are switching out people at the 2 minute mark because of decreased effectiveness and tiring so using one arm is going to tire you and decrease the effectiveness faster. Logistically wise it is probably easier for a large person to walk beside the gurney than climb on it though. Usually it is only for a short distance at least so something is better than nothing. The breaking or "cracking", "popping" can occur at any stage as it depends on all the aforementioned factors. The longer you do it though the more risk of breaking as you are repeatedly causing stress and trauma to the area. This is a link to one of the studies I mentioned.

It's certainly encouraging to see so many people advocating for adequate pain management in the prehospital setting. Rarely in our QA process are we "dinged" for giving too much pain medication but we are quickly informed if we haven't given enough. It is also encouraged to give it IM if you are having trouble obtaining an IV or it is taking a while to get one. I like to give a dose before we even transport the patient to the helicopter and I will usually give a dose or encourage the patient to accept pain medication just before we unload them out of the aircraft and into the ER. I know that there are going to be bumps with the multiple movements involved and then when they turn the pt and are completing their assessments in the ER. The only time I am really cautious about giving narcotics is if the patient is in extremis and I know their BP won't tolerate even a small dose. It helps to think that at least if they are at that point they probably aren't feeling a lot of the pain anyway. Better alive and in some pain then totally losing their BP. In these circumstances sometimes the few catecholamines they have floating around are all that is keeping them alive and if you take them away with narcotics they just crump and die. As has already been mentioned, Dr's should not be basing treatments on their physical assessments alone and this includes abdominal pain and head injuries (the diagnoses most often undertreated for fear of interfering with accurate diagnosis). If they are suspecting a fracture or an injury they are going to do additional x-rays, scans and lab tests anyway. And a patient's perception of pain is totally individual and quite often not that reliable to diagnose major injuries. I have had pt's with multiple fractures/major injuries who look atraumatic say that they have no pain or very little pain. Then you get the patients with 10/10 pain who end up having nothing at all wrong with them except minor aches and pains. I always take into consideration the verbal and the non-verbal cues and always take at face value what the pt states the pain is. We had a lady with a pelvic fracture among other injuries who said her pain was severe but she didn't receive much pain meds because the provider thought she was too calm (lying there quietly with her eyes closed) and didn't think she was really in pain. Here is an article written by a nurse on the physiological response of pain. One main point I think is that pain causes increased oxygen consumption and in sick and traumatized pts we really need to be minimizing this. I enjoyed all the other articles posted and found the Dr BledsoeJEMS one very useful for teaching purposes. Thank you all for a great discussion.

I am not sure where the idea of hanging D5W comes from when giving D50 boluses. I understand the theory of wanting to maintain the glucose level after giving a bolus but in the hospital they rarely run a straight D5W drip as it becomes hypotonic as someone said. They would usually change it to a dextrose/saline combination drip in the hospital anyway if they want to continue giving dextrose (and this is usually placed on a pump where you have strict control over how much they are getting). It is better to just give repeat dextrose boluses in the prehospital environment. D5W is only really used to dilute drugs that are incompatible with saline and where glucose control isn't an issue (like potential head bleeds as was also mentioned). The reason you give fluids with the D50 is to dilute it so it isn't as caustic on the veins. Adding more dextrose to the mix is actually defeating the purpose as it will make the solution even more hypertonic (adding more dextrose). For EMS purposes the best thing is to use saline with which there is no problem giving boluses when you need it and it is more often compatible with any other medications you want to give. D5W should not be used in place of saline/LR as regular IV fluids. In the case of glucose control more is not always better. Yes, you want to maintain a decent blood level but it is really easy to overshoot and that comes with a whole new set of problems. That is why they have very strict glucose level parameters in the critically ill patients especially those with head bleeds, sepsis, pediatrics, neonates etc. They often start insulin drips to control the levels in the ICUs even on non-diabetics and the desirable range is pretty narrow. Just my opinion for what it's worth. (Hopefully at least a penny )

I totally encourage your pursuit of either RN or RRT degree. Either will open up many possibilities and avenues. I would discourage you from thinking about trying to get a job in the flight arena per diem. I don't know of any flight program that would hire someone without previous flight experience for a per diem position. If they did I would be looking at a different program. People who have already worked full-time in flight are ok to go to per diem but it is not a position that you should be starting and learning about in a per diem position. You will also need 3-5 years of critical care experience as either an RN or RRT or good 911 ground experience as a paramedic before you should even consider a flight position. When you say you are looking at retiring at age 55 is that just the fire service or working altogether?

I have to agree with the check pulse first group. I've worked in a PICU for 8 years and can't tell you the number of times I've had a perfectly calibrated, previously beautiful art. line waveform go suddenly flat or dampened due to arterial spasms or positioning and because you aren't sure of the cause you always check the patient first. The first thing you learn in an ICU is look at your patient and not the monitor because equipment can always fail. Unfortunately especially in the ICU environment people rely too much on the machines and forget the basics. I've seen people fiddling around trying to trouble shoot a machine instead of treating the patient and actually assessing the patient themselves. I've also had patients where the monitor numbers and waveforms look good but the patient is definitely not ok. A lot of scenarios can be misleading because sometimes they are trying to get you to go back to basics when people want to go straight to ALS. This scenario wasn't very well presented by AHA either. The child would definitely already be on a monitor and PICUs don't carry AED's. In this scenario asystole would probably not be the presenting rhythm either so I think they could have written a better scenario to start with that wouldn't be so confusing. Having said all that I appreciate what you were trying to do WANTYNU. The information is a good review of some of the changes in thinking in regards to PALS. Cheers all

Ventmedic, I agree with a lot of the things you have said and I do understand that budgets are a real issue. Definitely agree that technology should not replace good assessment skills and education but that it enhances these. I know many departments would rather have more hands than equipment but the sad reality is that most departments are short staffed and this is where having good equipment comes in. If you are not able to be in the room with the patient all the time at least a nurse can let you know what is happening with your ETCO2 and frequently assist the RT with suctioning the pt when they are too busy or let the RT know they need suctioning or vent adjustments when the nurse is unable to. Technology will not make a better clinician but it certainly enhances a good clinician and can be beneficial with a less than good clinician.

I work in a large hospital that has probably 100 ventilators or more and practically every ventilated pt (except for the long term rehab pts) has an ETCO2 monitor on. Occasionally they won't run it on a pt but that is the exception rather than the rule. A lot of the ventilators have it built in so it is just cheap of the hospital to not be paying for it to be used. It is the safest thing to have the pt on continuous ETCO2 monitoring but not all the "budget minded" individuals put the pt safety over the $$$. I have been in a lot of hospitals that don't have it on, especially in the ER's but I think it is a substandard level of care. (Talking about the hospitals here not in pre-hospital environment). Why would you check the waveform and not the numbers? If the number is where you want it then you have a good idea where to start with your vent settings. Checking with the EZCAP is just redundant really but I guess people should do whatever makes them feel comfortable. The EZCAP is really a less ideal alternative if you don't have capnography available. We do use it after initial intubation if our ETCO2 monitor hasn't been plugged in or is warming up. Some people use it anyway. But once you have a good waveform on the monitor the EZCAP is redundant. How did they ever run codes before defibrillators, or treat arrhythmias without EKG's...scientific advances mostly result in improved pt care and outcomes. People do their job to the best of their ability with the tools and science that is available to them at the time. Morbidity and mortality rates improve generally with advances so just because you used to do something "such and such a way" in the good old days doesn't mean that improvements can't be made. I say if the technology is available and it improves pt's safety and morbidity/mortality then you should be using it. Anyway this is not a rant more of a thinking out loud. I don't have strong feelings on the subject and the ER people who have done it have really done it out of a real lack of understanding of what they were doing. Cheers

I have to say I couldn't believe it either the first time they took off my ETCO2 monitor with a perfect waveform and put on an Ezycap in the ER. Hmmm I guess you can't trust our equipment because it is prehospital equipment? :roll:

My bad.. :roll: I apologise for misunderstanding. I thought he was referring to the ACLS 2005 guidelines and was trying to be diplomatic. (obviously failed). There has been a lot of confusion at a two of the places I work about how exactly the algorithms go. Seems to be a few ways to interpret some of the steps. I also apologise if my post came across patronizing as that certainly wasn't the intent. Anyway cheers and fingers crossed for ROSC :wink: Aussie

Etfink, It sounds like you guys did a fantastic job!!! Pt survival is what it is all about (hopefully with minimal deficits) and you achieved that end. Just to clarify the new guidelines as there seems to be some confusion....(surprise, surprise!!! the new guidelines are confusing.) :shock: For an unwitnessed arrest (generally VF) it is recommended to do 5 cycles of compressions/ventilations with a ratio of 30:2 (which is about 2 minutes with compressions at a rate of 100/min) before defibrillating as was said to "prime the pump". You are meant to pause for the breath but the compressions are of a higher priority and are meant to have as minimal interruptions as possible. The breath is given faster than previously taught with an inspiratory time of no longer than 1 second and just enough to see visible chest rise. "To minimize the potential for gastric inflation and its complications, deliver each breath to patients with or without an advanced airway over 1 second and deliver a tidal volume that is sufficient to produce a visible chest rise. But do not deliver more volume or use more force than is needed to produce visible chest rise." (AHA guidelines) If someone is requiring CPR they actually don't need as much oxygen and ventilation as is normally required and the emphasis is on not OVERVENTILATING as worse outcomes have been associated with that. Once the person is intubated you give breaths at a rate of 8 - 10/min or about every 6-8 seconds without pauses in compressions. Hope this helps with the confusion. If you want the full guidelines with the rationales behind it all check it out on the American Heart Association website. Congrats and all the best for your medic school etfink :thumbright: Aussie

[/font:7e62c56bd1] This is a tough one. This could be V-Tach but I'm wondering if it might be multifocal atrial tachycardia with a huge right bundle branch block just to throw you off. You can see about 3 different P wave morphologies and the rate is greater than 100. (Some of the p-waves seem to be buried in the preceding T-wave and the rhythm is slightly irregular.) This rhythm is usually significant in decompensating chronic lung disease, (i.e. COPD) or CHF, sepsis, MI or pneumonia. If he is having a lateral wall infarct that could be the cause. If they are hemodynamically stable I would treat them with O2, monitor, pulse ox, IV and transport without delay. Adding nitro and morphine if complaining of pain and an aspirin sure won't hurt him. Thanks for sharing this interesting strip. (By the way before anyone takes my head off......peace.. )

Hi all, I usually just read these forums but figured it wouldn't kill me to post for once :lurk: [/font:11babba7ee] (I figure someone here might be kind enough to help me when I get beaten into the ground - if I put my foot in my mouth!!!) Sounds like Bass did all the troubleshooting.. I would be in agreement with AZCEP. This guy is probably extremely acidotic by this stage and that really increases your pacemaker capture threshold. The guy has a history or hypertension and presents in the first place with a SBP in the 90's hours prior to you being called. Compound that with the fact that it only takes 40 minutes of renal hypoperfusion to go into renal failure and it adds to the acidosis and the risk of hyperkalemia which can also increase the capture threshold......whew, take a deep breath. Other causes of increased capture threshold include hypoxia, hyperglycemia, certain antiarrhymic drugs, verapamil, beta-blockers and alkalosis. So take your pick. By the way could they do any kinds of gases or labs at the infirmary, like maybe an I-stat. That would have been a big help for you. Also agree that the heart was probably just a little "pooped" by this stage and just didn't have enough "ZAP" left to respond. :mrgreen: Thanks for letting me play in the sandbox.. :smilebox: