p3medic Posted February 9, 2008 Posted February 9, 2008 Spontaneous resp effort? can I get that in 12lds? What is his BP?
chbare Posted February 9, 2008 Author Posted February 9, 2008 No spontaneous resp effort noted. Systolic pressure of 80 by palpation noted. XII Lead: Take care, chbare.
Niftymedi911 Posted February 10, 2008 Posted February 10, 2008 For your reading pleasure: Pedro Brugada and Josep brugada of Barcelona publish a series of 8 cases of sudden death, Right Bundle Branch Block pattern and ST elevation in V1 - V3 in apparently healthy individuals. This 'Brugada Syndrome' may account for 4-12% of unexpected sudden deaths and is the commonest cause of sudden cardiac death in individuals aged under 50 years. Brugada P, Brugada J. Right Bundle Branch Block, Persistent ST Segment Elevation and Sudden Cardiac Death: A Distinct Clinical and Electrocardiographic Syndrome. J Am Coll Cardiol 1992;20:1391-6. Poor dude was having the big one. Getting back to the senario. For one thing, what's the FD like in this part of town?? Is it podunk North Fort Myers or upper crust Estero?? I wouldn't cancel FD. I'll already have a King tube in place. Just revaluate the need for intubation. I will take 1 more regular 12 lead and do a V3R and V4R just to make sure. Call for orders to call STEMI alert and any medications the MD might want me to ultilize, due to the post-arrest. Large bore IV's bi-laterally and possibly an EJ. Bolus 150mg Amio for the time being and hang a Amio drip in the truck enroute. I'll also bring his B/P up a little bit more with some Dopamine 5 mcg/min ( I guessing apporx 70 kg patient so 13 or 14 qtts/min) to help the brain re-perfuse and circulation where it needs to be. Grab a FF to take with me for an extra pair of hands and tell my partner to drive fast but do not kill me.
chbare Posted February 10, 2008 Author Posted February 10, 2008 What other findings and or information would support your diagnosis? If this is Brugada, what is occurring physiologically? If this is Brugada, what type is presenting? If this is Brugada, what is the common treatment modality for the diagnosis in question? Take care, chbare.
Kaisu Posted February 10, 2008 Posted February 10, 2008 I don't see a right bundle branch or even a wide QRS. I do see a septal STEMI. I agree with amiodarone 150mg over 8 - 10 minutes, but the drip can wait till the hospital. How many ambulances carry 900mg of amiodarone to make up the drip and with the half life of oral amiodarone at 280 days, there is no hurry to get the drip going. I wouldn't tube the guy if ventilations are adequate and there is no distended belly. If I have any doubt about ventilations, he would get the ET tube - At the hospital, the guy will get heparin and possibly fibrionolytics but it's cath lab HO! The rest of the ischemia protocol (MONA) has been superceded by the VF and the arrest. It's time for the cardology experts to take over.
chbare Posted February 10, 2008 Author Posted February 10, 2008 Unfortunately, you are ordered to continue driving around the block until you can nail the diagnosis. With all of the ER crowding, your state adopted a new protocol where the EMS crew cannot deliver the patient without a diagnosis and direct admit orders. Oh yeah, the ICD-9 code needs to be correct as well. But, I am in a good mood, so I will let that one slide. :wink: Ventilations are adequate with your airway device of choice. Take care, chbare.
p3medic Posted February 10, 2008 Posted February 10, 2008 This is NOT a STEMI. This IS Brugada syndrome. There is abnormal repolarization, its type 1 and the tx is ICD. This patient in the mean time would get an antiarrythmic, fluid, and have a brief neuro exam, hopefully he will wake up in the next minute or two, and all the other heroics won't need to take place.
Niftymedi911 Posted February 10, 2008 Posted February 10, 2008 CHbare, here ya go.... Cases occurring during physical activity are rare. HOWEVER there is a possibility because regular physical activity may increase the vagal tone, sport may eventually enhance the propensity of athletes with Brugada syndrome to have ventricular fibrillation and sudden cardiac death at rest or during recovery after exercise. Therefore, patients with a definite diagnosis of Brugada syndrome should be restricted from competitive sports It is untreated unaware Type I Brugada syndrome. The only true definitive care or treatment is placement of a ICD. More for your Reading pleasure: Brugada syndrome is a disorder characterized by coved or saddle-shaped ST-segment elevation in leads V1 through V3 on ECG. It is associated with complete or incomplete right bundle-branch block and T-wave inversion. In its initial description, the heart was reported to be structurally normal, but this has recently been challenged (Frustaci, 2005). Moreover, subtle structural abnormalities in the right ventricular outflow tract can also be observed. The ECG abnormality may not be evident until it is unmasked by infusion of flecainide or procainamide, or is augmented by a beta-blocker. When such premature shortening of the action potential heterogeneously occurs in the myocardium, it may generate phase 2 reentries that can cause ventricular tachycardia and ventricular fibrillation. The large transmural voltage gradients generated by the short action potentials in the right ventricular outflow epicardium are thought to be the basis of the ECG patterns of Brugada syndrome. These specific alterations in cardiac electrical activity, which mainly affect the right ventricle, manifest at ST-segment elevation in precordial leads V1 through V3, with a QRS morphology resembling that of a right bundle-branch block (RBBB). Such a pattern may also be due to a J point elevation. This pattern is called coved-type when ST elevation is the most prominent feature, and it is called saddleback-type when J point elevation occurs without ST elevation. Brugada syndrome is 8-10 times more prevalent in men than in women, although the probability of having a mutated gene does not differ by sex. The penetrance of the mutation appears to be much higher in men than in women. Brugada syndrome most commonly affects otherwise healthy men aged 30-50 years, but affected patients aged 0-84 years have been reported. The mean age of patients who die suddenly is 41 years. Patients with Brugada syndrome are prone to develop ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest, or sudden cardiac death (Martini, 1989; Brugada, 1992; Brugada, 2001). Brugada syndrome is genetically determined and has an autosomal dominant pattern of transmission in about 50% of familial cases. About 5% of survivors of cardiac arrest have no clinically identified cardiac abnormality; about half of these cases are thought to be due to Brugada syndrome (Alings, 1999).
chbare Posted February 10, 2008 Author Posted February 10, 2008 So, if I was a betting man, what race would I bed on? (Ethnic race that is.) In addition, if his wife told you he had a history of "bad nightmares", would that provide evidence for or against your diagnosis? Take care, chbare.
Niftymedi911 Posted February 10, 2008 Posted February 10, 2008 Young 50 y/o male of Asian decent. The history of bad nightmares would provide better understanding of undiagnosed Burgada's syndrome. It just confirms the diagnosis. I would scehdule a cardiology consult and schedule for ICD placement.
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