chbare

Cool, you found him in a CHB, then actually caught the conversion to a Mobitz II? How did he do en-route? Do we know the rest of the story? Take care, chbare.

What was done first? The XII lead clearly begins as a complete heart block. The LP 12 strip looks like a second degree heart block Mobitz II. Looks like this guys conduction system could not make up it's mind. Take care, chbare.

And if your wife is more than 10 years your senior? Take care, chbare.

This is curious, and a great strip. It looks like a complete heart block. Look closely, you have P waves all over the place. P waves in the T waves, and even a P wave that blends into the QRS on the first complex of the lead II continuous strip. I think what may throw some people is the fact the QRS morphology changes. First, you have wide QRS complexes, and I suspect a ventricular escape rhythm, then the QRS complexes become narrow as the junction takes over. EDIT: Review the continuous lead II strip. My assessment at least. Take care, chbare.

Actually, you do, because our education is typically derived from EBM. I did say "typically." Take care, chbare. Effective in preventing/reducing secondary injury or preventing additional injury from an unstable spinal injury. Take care, chbare.

I have seen sources quote 1-3 hours. However, there is more to consider than just skin breakdown. Concepts such as airway clearance issues, discomfort, and compliance issues could be problematic. In addition, since we are discussing EBM, is there any good peer reviewed evidence that says spinal immobilization with a LSB is even effective? Take care, chbare.

However, I did qualify my claim by stating "being placed and left." Unfortunately, many people are placed and left on the board for extended periods of time. While this may be more of a facility problem, EMS should take a proactive role in emphasizing the sequale of leaving patients on a LSB. This is especially true in my neck of the woods where people are taken to small facilities and left on the board until after they are eventually transferred to a trauma centre. The risk of iatrogenic injury is still a consideration. Take care, chbare.

What about all the people who develop iatrogenic injuries from being placed and left on a LSB? While I appreciate your anxiety, a practical evidence based approach that emphasizes education and experience of EMS providers regarding practices and techniques is critical. Unfortunately, doing something the same old way based on anecdotal evidence is just as silly as basing our practice on "feelings." However, you are not totally accurate when you say EBM is based on "feelings." EBM looks at the past and present evidence and makes theories and assumptions based on the said evidence. While far from perfect, it is a better method than simply saying I do not do something based on anecdotal evidence. In fact, the goal of good EBM is to take the "feelings" out of the practice and use the best and most accurate evidence possible. You are correct that some studies are suspect; however, the goal of good EBM is to look at the evidence and how it was collected. Remember, we need to use good evidence. Unfortunately, many of us are not all that good at recognizing good evidence from suspect evidence, or even identifying limitations of the evidence. Without EBM, we would still be back in the good old days cramming EOA's and placing MAST pants on every patient. Take care, chbare.

We are just talking about the flu? In essence, a bad cold. Last year, we would not bat an eyelash over a febrile patient, now "swine flu" has us loosing sleep. Take care, chbare.

There is a study in the works comparing NIBP to IBP. http://clinicaltrials.gov/ct2/show/NCT00739700 There are other studies through Springerlink that compare NIBP to Manual B/P in the ICU and PACU. Take care, chbare.

The basic pathophysiology is though to be related to the blockade of dopaminergic receptor sites. This action is sometimes thought to create a relative state of increased cholinergic activity. It is this so called increased cholinergic activity that appears to cause the manifestations of EPS. EPS can manifest with a myriad of signs and symptoms. The front line therapy can consist of giving an anticholinergic agent for obvious reasons. Cogentin falls into this category. Or, you can give an antihistamine with centrally acting anticholinergic properties. Non sedating antihistamines such as loratadine and cetirizine have limited central effects, and thus are not effective at treating EPS. Take care, chbare.

Word. Perhaps, both parties share some of the blame; however, some of the troopers actions were absolutely unacceptable. Take care, chbare.

I tend to agree with Dustdevil. This information should have clearly and thoroughly been covered in the first couple days of the class. If in fact it had been covered, attention to detail is paramount. Take care, chbare.

Scary stuff. This is a subject where many EMS providers lack even basic knowledge. A VAD (ventricular assist device) is a device implanted into the body that diverts blood from the ventricle into either the aorta or pulmonary artery depending on the device specifics. (LVAD left ventricular assist device, RVAD, right ventricular assist, or both BIVAD) Several types exist and many people are going home on destination therapy with these devices. Meaning that will live with the VAD for the rest of their life. In addition, the days of manual hand pumps and pump shut down for defibrillation and cardioversion are over. New devices such as the heart mate II have not manual back up. Additionally, these new devices create non-pulsatile blood flow as they tend to significantly dampen the underlying arterial waveform. Many concepts such as the patients underlying problems, medications such as anticoagulants, equipment, batteries, patient education, and the dynamics of the environment created by this device. In addition, these are not just for "old" people. Recently went to a workshop where a teenager with non-ischemic cardiomyopathy and a left ventricular ejection fraction of less than 10% is now at home in their community with a LVAD. It is likely this patient will be on destination therapy with this device. Take care, chbare.

I have seen a few patients with VAD's who walking around without a pulse. This is actually something that I consider. MVC, patient scrambled the noggin and unconscious, VAD in place, no pulse, EMS on scene, wonder what would happen? Take care, chbare.

It does not have right shoulder axis deviation. The QRS would need to be negative in lead I, II, & III. I stated RAD, not right shoulder deviation, or extreme RAD. Take care, chbare.

I would go with the left ventricle. We still have RAD suggestive of a possible inferior to superior movement. Going with the largest mass of tissue and most probable location for an ectopic focus (LV), and the axis, I would venture to say the left ventricle? Take care, chbare.

No worries, it's all good! Take care, chbare.

No it is not a definitive indicator for confirming a RBBB. However, it is not an uncommon finding in the presence of a BBB. However, the notching I see with this rhythm is significantly different from any rabbit ears pattern I have even seen. In fact, it does not even fit into any recognizable QRS pattern I know such as an RSR prime pattern. It looks somewhat like the dicrotic notch of an arterial waveform. (In V1 specifically.) With the notch on the descending slope of the waveform. This IMHO is more evidence to support the theory of ventricular tachycardia. Take care, chbare.

This is one case where you cannot rely solely on axis deviation to make the call. It looks like RAD using the three lead method; however, the criteria for right shoulder deviation does not exist. With that, I am still thinking we are dealing with ventricular tachycardia: 1) The rhythm is regular, and I do not think we have an underlying atrial fibrillation or flutter. 2) I cannot see any re-entry morphology such as Delta waves. 3) Looking at lead III, I think we have a couple of random P waves, this points to AV dissociation, a finding that pretty much rules out SVT. I would be willing to consider a good argument for SVT with aberrancy; however, too many things are pointing to ventricular tachycardia at this point. Take care, chbare.

I agree this is an educational discussion; however, people are going to disagree based on how they look at this XII lead. As I stated, I am not arguing against looking at this as ventricular until proven otherwise. However, I stated for the sake of mental masturbation, I am using axis as a tie breaker. We disagree on our assessments and go about our way without resorting to personal attacks, creating yet another hostile and pointless argument. In addition, where have I ever called my self "the great chbare?" Where have I sated that I cannot learn anything? Clearly, I am capabable of learning and have incorrect assessments, ideas, and concepts. Remember the paced rhythm strip tease? I initially missed that one. I am quite sure you can look at my other posts and find where I had the wrong idea or thought. I considered his stance and think it is a sound one. However, I continue to disagree. We disagree, not a big deal. Take care, chbare.

You asked, I gave a sound description of may stance, and you are free to disagree. Take care, chbare.

As ERDoc stated, debating the specific focus of the escape rhythm is academic when considering the pre-hospital treatment of a symptomatic patient. However, for the sake of mental masturbation, why not discuss the possible focus of the escape rhythm? Again, I point to the axis. Right shoulder axis deviation is still suggestive of a ventricular rhythm; however, this patient clearly does not demonstrate right shoulder axis deviation. As people have stated, the right shoulder finding is not always the case; however, it still provides evidence against a ventricular rhythm. As ERDoc stated, the rate is around 40, this is ~the upper limit for a ventricular escape (not including accelerated rhythms), and the ~ lower limit for a junctional rhythm. So, yes I would agree, it's a hard call when you have a wide complex escape rhythm with a rate that could go either way. In my case, I am using the axis as a tie breaker. Take care, chbare.

Unfortunately, by definition you cannot have a left anterior fascicular hemiblock with a left bundle branch block. Remember, we have three fascicles. Two on the left and one on the right. A left bundle branch block can only occur when both fascicles on the left side fail, thus causing a true block of the left bundle branch. Just to clarify the terminology because it is confusing: 1) A hemiblock refers to the block of a single fascicle on the left side. 2) A bifascicular block refers to the block of the right and the block of one of the left fascicles. 3) A trifascicular block refers to the block of the right, block of one of the left fascicles, and an incomplete or possibly intermittent block of the last remaining fascicle. Take care, chbare.

First, look at the irregularity of this rhythm. Ventricular tachycardia is typically fairly regular. This rhythm is quite irregular. Remember the characteristic finding of atrial fibrillation is an "irregularly irregular" rhythm. Also look at the axis. Right shoulder axis deviation is typically highly suggestive of a rhythm originating in the ventricles. Ventricular tachycardia, for example. For right shoulder axis deviation to exist, the QRS morphology in leads I, II, & III should demonstrate negative deflection. Lead I is clearly positive, so this rules out right shoulder axis deviation and most likely rules out a rhythm that originates from the ventricles. With this in mind, we need to look at causes. An underlying atrial fibrillation accounts for the irregularly irregular rhythm seen. In addition WPW accounts for the wide and strange shaped QRS complexes seen as you have conduction through an abnormal pathway known as the bundle of Kent. You essentially have a pathway that bypasses the AV node. Unfortunately, the conducted impulse is prone to re-enter the AV node and move back up the heart (retrograde movement) and back down again causing the nice "re-entry" tachycardia associated with WPW. Anther consideration, is the presence of Delta waves. The Delta wave is highly suggestive of WPW as conduction through the bundle of Kent (abnormal pathway) frequently causes this phenomenon. Look at the fifth QRS complex in V5. Note the strange ramp like slope at the beginning of the QRS. This is most likely a Delta wave. I have to agree with the initial assessment, atrial fibrillation with a rapid ventricular response and the presence of WPW. Take care, chbare.