chbare

Several places as this has been an ongoing process. This site, NREMT.org,JEMS, among several others have articles and discussions about the national SOP transition. Take care, chbare.

A paper that argues against some of the long held concepts considered "EMS dogma" when in fact have little to no evidence exists to back up these long held and taught beliefs. The emphasis of placing high flow oxygen on every patient for example. Or you could even take a specific concept such as high flow oxygen for ACS patients. I will be waiting for Vent to correct my misuse of the term "high flow." Take care, chbare.

Viagra and nitro? Lungs clear? A little fluid may be in order. I am not much into the old "shock position." Take care, chbare.

If the patient had no significant hemodynamic changes or indications of being in distress, and the only finding was an ECG with peaked T waves, I would not take active measures to treat the suspected hyperkalemia in the pre-hospital environment. Obviously, I would have calcium chloride ready to administer if needed and would emphasize the patient history and ECG findings in my radio report. Take care, chbare.

Treating for hyperkalemia based solely on peaked T waves is not really indicated. Immediate pre-hospital treatment should be based on a high suspicion of having a condition causing severe hyperkalemia, hemodynamic compromise, and marked ECG changes such as wide QRS complex and presence of a sinusoidal rhythm. Unfortunately, you can also have a relatively normal ECG in the presence of severe hyperkalemia as well. Also remember life threatening cardiac complications can also occur with mild elevations in potassium. Also, medication effect and potassium imbalance can be quite problematic. Digoxin for example. In addition, I do not think we have ruled out other causes linked to what we see on this XII lead. Take care, chbare.

Absolutely, look for history of renal failure, non-compliance, missed dialysis, and other causes of hyperkalemia. Take care, chbare.

Sounds good. Take care, chbare.

Why three years before paramedic? If the program in question cannot produce good entry level providers, it stinks IMHO. I never had to work as a LPN for three years prior to entry into a RN program. I do not know of any doctors who were forced to work as PA's prior to acceptance into medical school. The list goes on. Why is EMS still among the few fields where people think working as a lower level provider is mandatory? Not trying to bust you down; however, my question is serious. Take care, chbare.

I think the OP was not looking for a DDX so much as being retrospective and asking about how best to handle a situation. We all most likely have difficult patients that we frequently take care of, so I understand. Not to say I disagree with Fiznat's point however. Take care, chbare.

Look at V4 & V5, a little imagination, and you can see what could be pacing spikes. I passed them off as artifact; however, still a consideration. Take care, chbare.

It could be a paced rhythm, at this time I will assume non-paced because I can do a little more brain picking. Without a better image, I am hard pressed to definitively say it's a paced rhythm. Take care, chbare.

Do you mean a hemorrhage of the pons? Also known as a pontine hemorrhage. Take care, chbare.

Do you honsetly use hemostatic agents? Even overseas, it seems many people use hemostatic agents on every casualty. My non-peer reviewed anecdotal experience is, they often do not work, and most bleeding can be controlled with direct pressure. Cost versus benefit in the civilian world, leads me to believe the money would be better spent elsewhere. Take care, chbare.

True, however, do we actually have a paced patient? Cannot definitively ID this with the strip available. As stated, a paced patient with capture is in no mans land regarding XII lead findings. With the exception of pacemaker related concepts. (sensing, capture, and such) Take care, chbare.

You are looking at V4 & V5? Take care, chbare.

No worries, cheers mate. ECG changes status post transplant can vary from AV blocks to ventricular conduction problems. Obviously, complications such as pericarditis can also cause changes. Some of the more interesting changes include two P waves and two different QRS complex morphologies. This is especially common in "piggyback" transplants. Take care, chbare.

This actually explains axis with the needed pictures and diagrams: http://www.nursce.com/x_courses/1071/1071.htm Axis is essentially, the average direction all of the electrical activity in our heart moves. (measured in degrees) Deviate significantly from a normal axis, and you have electrical vectors moving left or right. Many causes of axis deviation such as MI, BBB, COPD, old age, normal physiological variant, and many other causes. Look at the diagrams and numbers for normal, LAD, RAD, and the extremes such as right shoulder and pathological deviation. The limb lead diagrams for assessing are helpful. In addition, you can always look at the QRS axis on top of the XII lead and not the number. Then compare that number to the norms and find axis. Take care, chbare.

Do not listen to people who tell you rabbit ears is a definitive finding for right bundle branch block. The ECG in this scenario proves you can have RBBB without the characteristic rabbit ears finding (AKA RSR Prime). A bundle branch block is simply a delay or block in conduction through the bundle branch network of the cardiac conduction system. If you recall your A&P class, the conduction system essentially diverges into to bundle branches below the AV note. If you think about bundle branch blocks, you essentially have delayed ventricular conduction as the wave of depolarization has to take alternative routes through the heart. This is manifested as a widened QRS complex. Generally, a QRS wider than 0.12 seconds (3 small boxes) indicates BBB. Many methods exist to differentiate a RBBB for LBBB. I typically utilize what is called the turn signal criteria. If you look at V1, find the J point at the ST segment and draw a line back through the QRS. If you note a positive wave, you have a RBBB. Hence, you are turning right and your turn signal know would be pulled up. A LBBB will have negative deflection. Look at V1 in this ECG and you should be able to easily identify the upward deflection signifying RBBB. In addition, I talked about a bifascicular block. You see, the left bundle branch actually splits into two fascicles. The left anterior fascicle and the left posterior fascicle. Named for their respective locations. These guys are tricky to spot when blocked, because you may not develop significant QRS changes, so typically, you will have axis changes with fascicular blocks. We will talk about axis in a bit. The exception being, the presence of a LBBB. If you identify a LBBB, then both of the fascicles are blocked. People talk about hemiblocks. This means only one of the left fascicles are present. However, always remember a hemiblock cannot occur with a LBBB because both fascicles are already blocked. When I spot a RBBB, I follow this flow guideline to identify a block of one of the left fascicles: -Is RBBB present? In this case, yes. If a RBBB is not present you cannot have a bifascicular block, because the definition of a bifascicular block is a RBBB and a block of one of the two fascicles. (Hence, bifascicular or a blockage on the right and left side, with one remaining fascicle.) -Is lead I negative? In this case no; however, if the answer was yes, you have a bifascicular block. -If lead one is positive, are leads II & III negative? In this case, yes, therefore we have a bifascicular block. Why is this stuff important? Obviously, many people argue against advanced education and for skills without the background. However, think about somebody with a bifascicular block? What would occur if they loose the last remaining fascicle? What interventions should you anticipate looking at this ECG? I will address axis in a second post, as this one is already quite long. Take care, chbare.

A few considerations: 1) You will have a difficult time definitively identifying ST segment elevation in the presence of bundle branch blocks. Definitively calling this a STEMI may be difficult. If these changes are new, you would have more information to base your decision. If this ECG is unchanged from a prior XII lead, you are going to have difficulty making any conclusions on ECG criteria alone. 2) In addition to a right bundle branch block, I can identify pathologic left axis deviation. 3) In addition to pathological left axis deviation, I can identify a bifascicular block. So, we have additional information. We can research the causes of these findings and possibly correlate to our patient's clinical presentation. Without knowing the history, having an old ECG, and knowing the patient's signs and symptoms, we are just shooting in the dark at possibilities. These could be new changes or changes from years ago. Take care, chbare.

You also want to choose your battles wisely. You may find your self in a position where you feel very strongly about making a point, and may consider making an off topic post. Your prior actions could come back and cause you grief. Not every discussion goes the way I want; however, it is a big community. Personal attacks, no; however, disagreement and discussion is going to occur. Take care, chbare.

Sums it up quite nicely. Take care, chbare.

Agreed, a few off topic posts and some disagreement; however, ALS versus BLS? In the world outside of EMS, this whole concept of ALS and BLS really does not exist. Take care, chbare.

Way off topic; however, you are absolutely wrong. We taxpaying Americans are being hit up to bail out banks, companies, and major organizations. We are talking billions upon billions of dollars. In fact, we are starting to hit countries like China up for money as well. We are pumping money into failing companies like that money is raining down from a giant manna storm of the century. However, people still argue that we cannot have paid EMS, they argue there is no money? Take care, chbare.

Only problem. is the damn flip cover breaks off if you even sneeze on it. Otherwise, I am a fan of the syringe drivers. Still not as small as the Minimed three channel IV pump; however, much easier to use IMHO. Take care, chbare.

Or, think twice about taking American hostages, as killing the Americans would be easier. I doubt three dead pirates are going to stop the thousands of pirates willing to take the risk for easy money. Not that I disagree with how the US navy acted, or the outcome of this specific situation. Take care, chbare.