12 lead and oxygen

[tniuqs]

Well finally a 12 Lead!

Yea as a matter of fact bedside Trop is done and less than 1.5 ng/ml. (negative)

Pain described as discomfort only now until the EMR says .. thats weird are the leads on right ?

Pt. refuses IV ... will see the MD when the $300,000.00 per day is complete.

( a hydrocarbon Frac for those in the oilpatch)

Closest Thromolytics in rural facility as stated 1.5 hours travel on mountain ice roads.

http://content.onlinejacc.org/cgi/content/full/46/1/39

[kevkei]

Stand correct, LBBB

[Kiwiology]

Our patient has some sass, I like him already

I'd say LBBB w/ anterior infarct so ..... oxygen, IV, ASA, withhold the GTN for now, if pain becomes severe I'd consider milligram increments of morphine.

My impression is we should try to transport him to the hospital, or if he insists, call him a cab, its cheaper!

[kevkei]

Our patient has some sass, I like him already

I'd say LBBB w/ anterior infarct so .....

How can you say anterior STEMI in the presence of LBBB?

[tniuqs]

'kiwimedic'

Our patient has some sass, I like him already

I'd say LBBB w/ anterior infarct so ..... oxygen, IV, ASA, withhold the GTN for now, if pain becomes severe I'd consider milligram increments of morphine.

My impression is we should try to transport him to the hospital, or if he insists, call him a cab, its cheaper!

<late info sorry NKA>

No cab available (oilfield) winter roads, no HEMS, stated prior pt refuses immediate transport, IV, O2.

Put into perspetive your now 1.5 hours return to base/ ER anyway.

Patient will go in to ER as Paramedic explains this is not a NORMAL 12 lead.

Question would you still not give NTG (or in kiwi speak GTN) just c/o mild SOB and mild discomfort ?

EMR finds batteries for Pulse Ox: what is expected SPO2 ? Refer to altitude (hint)...

Anything else you would like as far as History ?

kevkei

How can you say anterior STEMI in the presence of LBBB?

Ah appears the treat the monitor vs patient has an interesting twist

TBC.

Edited December 3, 2009 by tniuqs

[kevkei]

Ah appears the treat the monitor vs patient has an interesting twist

TBC.

Sorry to you, can't stir the pot with me I've said repeatedly you need to treat both, with respect.

ACLS Principles and Practice - "When a LBBB is present, the delayed LV repolarization of LBBB distorts interpretation of the ST segment, preventing accurate identification of ST elevation." 2003, pp 407.

[tniuqs]

Sorry to you, can't stir the pot with me I've said repeatedly you need to treat both, with respect.

ACLS Principles and Practice - "When a LBBB is present, the delayed LV repolarization of LBBB distorts interpretation of the ST segment, preventing accurate identification of ST elevation." 2003, pp 407.

Ok so recap:

But kiwi says a RBBB and infarct and kevkie states LBBB ?

Pt. Refuses immediate transport until Oilfield Procedure "FRAC" should be completed in about an 45 minutes ...

Pt. SPO2 is 91% on .21 pulse ox is correlating with pulse rate of ~ 88, no ectopics noted, BP done again as above.

Pt. returns to "shack" accompanied by EMR just for CYA ps the EMR is a hot 22 y/o blonde and consultant is Ok with that.

Anything else anyone would like to know or perhaps a differential DX ?

NB this IS not something I pulled out of my ass its a real situation the strip's actually real show time and date.

[kevkei]

But kiwi says a RBBB and infarct and kevkie states LBBB ?

Actually, this isn't accurate

I'd say LBBB w/ anterior infarct so .....

Differential DX? I thought he walked away with a hot blonde?

[tniuqs]

'kevkei'

Differential DX? I thought he walked away with a hot blonde?

Keen EMR sent to "observe" patient as crusty, ugly, old Paramedic know's sex sells and wishes to contact with hospital (Quietly) very poor communications in this area Supervisor / MD conference.

Employing an Old Medic Philosophy:

ie: When in doubt use the Shout Out ?

VHF, UHF, CELL, in this case Globe Star satellite phone.

LBBB is highly likely Dx ~ states MD .. so convince patient to come in for work up, if patient does not want O2 and IV.

MD states do you have Entonox (ie Nitrous Oxide 50% O2 blend) on the truck ?

Comments/ Opinions / Conjecture ?

And might as well stick and observe around for 45 minutes as #1 ALS unit (on Scene) is 1.5 hours out and #2 ALS crew in Rural Town is having "nap time" only.

In any event, Diff Dx (only giving 2)

1- Pre existing LBBB?

2- New Onset LBBB (silent MI?)

Someone is missing an important question in History taking:

<edit for silent MI>

Edited December 3, 2009 by tniuqs

[Kiwiology]

Could we be getting ants in our pants over an undiagnosed, pre-existing LBBB?