Cardiology Scenario

[Kiwiology]

This bloke has a BP drop of 50 points, thats pretty significant, it may be that he is hypertensive and 180 is normal for him so him going from 180 to 130 would be like the rest of us going from 120 to 70

[Asysin2leads]

I understand that kiwi, but I can't see a that BP being low enough to cause AMS, even in a hypertensive patient. I can't quote you the exact pathophysiology, but I assume that AMS secondary to hypotension has to do with decreased cerebral perfusion pressure, which is simply the difference between the MAP and the ICP. Before the drop, the MAP was 140 mm Hg, and afterwards it was 92.7 mm hg. Yes its a significant drop but still well above the ranges where I believe you'd start to see deficiencies in end organ perfusion. I've seen 70 mm Hg as the level where you start to get into ischemic brain damage, but actually I'm curious as to what pressure will lead to the beginnings of a decrease in mental status. Any physicians on the board want to weigh in?

Edited September 8, 2011 by Asysin2leads

[DwayneEMTP]

And this is exactly why cardiology is going to be the reason I fail out of medic school! Its disheartening to think of all I've been through to get to this point, only to get washed out by a damn squiggly line....

You know what's ironic to me about this thread? Not just the question, but that Asysin2leads is here.

I made nearly this exact same statement at nearly this exact same time. I was working, going to school, doing clinicals....I'd just come out of Pharm thinking, "Shit..if we'd just shut down school for two weeks I think maybe I could get caught up..just two friggin' weeks!" But of course we didn't..we sailed right into cardiology.

I was exhausted, and disgusted with myself...I was too tired, but much, much worse, I was simply to stupid to understand it. I couldn't get it...

And in that thread I was lucky to have Dust, and Ak, and Asysin2leads and Asys said something like, " I know it seem impossible, but it's not. I know it seems like it's all just a jumble in your head now, but that's going to change. One of these days it will all come together, just all of a sudden, and it will be a beautiful thing."

Now, remembering that probably seems silly to many, but it's truly the reason I didn't quite medic school. His posts are always smart, and intuitive. He didn't know me from Adam so had no reason to blow smoke up my skirt. But most importantly, I couldn't think of a single purposely bullshit statement he'd ever made. Nothing. So I trusted that he was telling me the truth.

I truly hung on that statement for weeks...until one day..pretty much from one day to another, it was as if someone hit me in the head with a board (again) and knocked all of the pieces into place...and it was friggin' amazing..just like he'd promised.

Any information I needed was simply there when I needed it. I couldn't imagine a cardiac issue without wondering how the pulmonary system might be involved..etc, etc. I felt like a friggin' genius! (Of course a million things have happened since then to show me that I commonly compete for the position of village idiot, but still).

The point is...he was right for me, and I know beyond any shadow of a doubt that he is right for you too. But you have got to back off of the "I'm going to fail!" bullshit...or you will in fact prove to be your own Prophet. All of that is a waste of time, and a waste of energy, and you are smarter and better than that. I know that for a fact.

You didn't know the answer to this question so you're an idiot? Yet I didn't see a concrete answer from anyone else in this thread either...a whole thread of people that make me feel like a monkey fucking a football anytime I want to disagree with them. So maybe this wasn't such an easy question?

Suck it up princess. And in this case you'll have to suck it up by backing off...take a deep breath Brother, get your mind off of 'what if' and back to a place where it is in the best possible shape to learn and understand new things.

All else is just pissing into the wind, right?

You've made all the right choices. You've taken all the right paths. You've proved yourself over and over again here to have grown in ridiculous leaps.

You got this Brett....There is not a single doubt in my mind.

Dwayne

[Lone Star]

This scenario was one of two that I was recently handed in a homework worksheet. When I saw that there was a recent hip surgery, I was considering that it might be an embolus from possible clotting. I based this conclusion on the fact that it was hip surgery, and the fact that the patient discussed wouldn't be doing a lot of moving around due to the possibility of being in a lot of pain from the surgery.

That being said, I suggested placing the patient on oxygen, establishing an IV of NS (or even the insertion of a saline lock), application of at least a 5 lead monitor (simply beacause we haven't learned how to apply a 12 lead yet) and administration of 325mg ASA to help with anticoagulation.

I further questioned the usage of beta agonists, because of the vasodilation properties. If it was an embolus (either PE or coronary), wouldn't vasodilation allow the possible embolus to migrate to the cerebral vascular system and potentially cause a stroke?

I think dobutamine was also mentioned for its dromotropic properties.

Like I've said before, I can follow the cardiac conduction pathways, I can explain what should be occurring during each segment of the EKG. Part of the problem occurs when I've got to start interpreting the rhythms.....

Obviously, when the dysrythmia is atrial in nature, the P wave is either going to be absent, or look screwed up and the PR interval is gong to be either longer or shorter. If its ventricular in nature, then the QRS complex is what's going to be affected.

With that being said, one would think that when you throw a 6 second strip at me, I should be able to identify disrythmias pretty quick...right?

Well, to furhter complicate things, lets throw in 'flutter waves', 'fib waves' and the ever popular delta waves, j-points and ectopy.....AAARRRGGGGHHH!

Oh, lets not forget to stir up some 'regular'/'irregular'/'regularly irregular'/'irregularly irregular' rythms, and the ever popular "Just because it's below 60 beats per minute or greater than 100 beats per minute doesn't necessarilly mean that it's brady/tachy".....

This is all off a simple 3/5 lead strip. I looked at a 12 lead printout and thought that it looked all screwed up!

Just as I'm trying to wrap my pea-brain around statements like "When you see this:" (i.e. p waves preceeding every QRS complex implies a sinus rhythm)....someone throws in the qualifier "Except when you see this:" (i.e. PR intervals greater than 0.12 seconds), because that means ..........."

It seems that every time I think I see an approaching "AHA! moment", one of those qualifiers gets introduced, and that "AHA! moment" decieds to wave bye-bye......and that nagging vioce of doom/failure jumps on the loud speaker....

I've always been in awe of those who hold a license level above mine, based on what you most of you guys/gals can do, and how impressive it was that y'all could keep all this stuff straight in your heads. Now that I'm trying to step into your world, I'm feeling like the village idiot who is nothing more than a poser.

I understand that this is all new information, and I'm not expected to know this without the attached education; but at this point, I don't know if I'm just trying to 'overthink things' or if it's that I simply "just don't get it"........

I've suggested that we start forming 'study groups' so that we can help each other along, but so far it appears to be falling on deaf ears. I don't want to wash out of the program (y'all know that I had to drop out once because of that motorcycle wreck). This is why I'm reaching out to people here.

I know I've aggrivated alot of y'all with some of my viewpoints (from "I don't need a degree to be a great medic!", to some of my unpopular personal beliefs). I know there's really no one on this forum that WANTS to see me fail (ok, maybe there's one or two....), but the place I'm in now; I feel like I've bitten off more than I can chew this time....

[Kiwiology]

What resources are you using to try and learn these rhythms?

Email me and we'll see if we can set up a live session mate

[systemet]

A couple of points to make:-

PE is definitely a possibility, and is extremely difficult to rule-in/out in the field. With any immobility there's a risk of forming a DVT, and having an embolic event. Also, if the patient is in a situation where they're prone to thrombus formation, it increases the risk of an MI, which could be this patients concern. There remain other issues, with the patient's hypertension. Could this be due to a TAA? Or could we be having a neurologic event, with concurrent MI.

The scenario seems to be pushing you towards treating this patient as a stable tachycardia who then decompensates. But that doesn't necessarily follow from the extremely limited information presented. I would have been frustrated and irritated if I had received something like this as an assignment.

If there's an altered mental status, and we're cardioverting this patient while their pressure is 130/80, or whatever, then we're saying that cerebral ischemia is happening at a relatively high MAP. This is only going to happen if there's some increase in ICP that's decreasing the cerebral perfusion pressure. This could occur secondary to a tumor, or intracranial hemorrhage. It suggests that something other than a simple tachycardia is occurring and that there's another (or more) disease process(es) ongoing. I'm not sure that's where the author intended you to take this. I suspect it's just badly written.

A couple of other points:

* Not sure why we'd be using beta-agonists, including dobutamine here?

* Beta-2 agonists can cause vasodilation, but I don't think you'd have to worrying about beta-agonism causing a thrombus to move into the CNS. If a thrombus is identified and present, the hospital needs to heparinise and deal with it.

With regards to ECG analysis:

There's a few good books out there.

This one is fantastic for explaining the basic mechanisms, although some of the nomenclature is non-standard (I think):

http://www.amazon.com/Rapid-Interpretation-EKGs-Sixth-Dubin/dp/0912912065/ref=sr_1_1?ie=UTF8&qid=1315561310&sr=8-1

This is good for a basic introduction to 12-lead

http://www.amazon.com/12-Lead-Coronary-Syndromes-Reference-Package/dp/0323047122/ref=pd_sim_b_3

Both these have a good library of 3-lead strips for basic rhythm identification practice:

http://www.amazon.com/Dysrhythrams-Interpretations-Management-Robert-Huszar/dp/0801672031/ref=pd_cp_b_3

http://www.amazon.com/Arrhythmia-Recognition-Interpretation-Tomas-Garcia/dp/0763722464/ref=pd_sim_b_5

This guy makes an excellent pocket reference guide, but is at a reasonable high level of detail. If you're having trouble, this isn't the best to start with. But its a useful tool for all paramedics, in my opinion.

http://www.amazon.com/ECG-Pocket-Brain-Guide-Interpretation/dp/1930553145/ref=sr_1_1?s=books&ie=UTF8&qid=1315561563&sr=1-1

I think with a lot of the interpretation you just have to look at lots and lots and lots of strips. Then it becomes easier. Treat it like doing IVs. You don't expect to be good at your 1st, 10th, or even 20th. You need a few hundred. Do the same with ECG analysis.

In the beginning it also helps to go through in a systematic approach:

(1) is the rhythm regular or irregular?

(2) is it fast, slow or normal?

(3) is the QRS wide or narrow?

(4) are there P waves present?

(5) are they present at a constant PR?

(5) are there any "extra" beats or "missed" beats?

Just work through these systematically with each strip, do a few hundred, and you'll find you improve dramatically.

The knowledge required to be a paramedic seems daunting at the beginning, but once you get finished the program, get done the licensing, and work for a couple of years, most of what's taught in medic school will seem very basic, and you're going to spend a lot of time realising how little you actually know, and how little you were taught. Don't worry, it will all come together.

[Asysin2leads]

Dwayne, let me say there I don't think there has been or ever will be an award or citation or medal or pin I could ever get that would be more meaningful than what you said. Thank you. Thats going to boost my ego nicely for a couple of weeks.

Lone, when you're first learning these rhythms, its sometimes useful to take one giant step back and focus on the basics. Cardiology is like an onion, you can keep pulling back layer after layer until the point you start crying. At this point, just try to focus on complex and pattern recognition and don't worry so much about things like arrhythmias arising from PE's or aberrancies, so long as you know they exist at this point and what causes them, don't worry too much about it.

By AHA algorithm standards, this person was in an unstable wide complex tachycardia to begin with, the chest pain and SOB was enough and they recommend beginning synchronized cardioversion for such an unstable patient. I have my own views that someone with chest pain and SOB with an arrhythmia is more symptomatic and less invasive procedures should be tried prior to cardioversion, but again, don't complicate things. The man is unstable. He needs to be cardioverted. When he deteriorated to AMS, he was definitely, definitely unstable. For unstable patients, strictly by the AHA standards, it doesn't matter if its a ventricular rhythm or an SVT (including a-fib) with an aberrancy, the treatment is the same, cardiovert and be merry.

Unstable tachycardias are easy, its cardioversion, cardioversion, cardioversion. My recommendation would be to know the standards for an unstable patient like you know your own name so that when they pop up in a scenario they jump out at you like a giant red flag, but it seems you're pretty much there already. Then you can boil a scenario down to blah blah blah blah blah chest pain blah blah blah blah wide complex tachycardia, game set and match. Probably what your instructor was getting at with this scenario is that normotensive BP should not be taken into consideration when determining the unstable vs. stable. Probably some not so bright paramedic student will say "Hey, he's not unstable, his BP is okay" and then your instructor can smugly explain the criteria for an unstable patient.

Edited September 9, 2011 by Asysin2leads

[DwayneEMTP]

...

Dwayne, let me say there I don't think there has been or ever will be an award or citation or medal or pin I could ever get that would be more meaningful than what you said. Thank you. Thats going to boost my ego nicely for a couple of weeks...

I can't tell you how glad I am to hear that. If it pays back even in a small measure what you've given me on these forums then I'm glad for that. It's really good to see you back man...

...Lone, when you're first learning these rhythms, its sometimes useful to take one giant step back and focus on the basics. Cardiology is like an onion, you can keep pulling back layer after layer until the point you start crying. At this point, just try to focus on complex and pattern recognition and don't worry so much about things like arrhythmias arising from PE's or aberrancies, so long as you know they exist at this point and what causes them, don't worry too much about it.

Man...great point. I read my ass off before going into cardiology in the hopes that I could somehow catch up. We were blessed to be taught cardiology by a very eccentric physician and I'd ask questions like, "But I know that X is supposed to happen but what if a leprechaun is dancing by, startles this patient into an electrical junction box that shocks him on accident.....!" (Hopefully not such stupid questions, but probably so.) and she would say, "I need you to trust me here. I promise that I'll spend all the time you want on that question, but can you trust me for a few days and believe that that is not a good place for you to be yet?" She was giving me the same advice.."I need you to back off. You're confusing yourself by trying to speak Mandarin, when I need you to master English first."

...My recommendation would be to know the standards for an unstable patient like you know your own name so that when they pop up in a scenario they jump out at you like a giant red flag...

I love this advice for one simple reason. The unstable patient is telling that they are trying really hard to die. At the time that you recognize this, one thing becomes very obvious. You must do something to stop it. And I think that you will be surprised at how clear things can become when you move from, "Maybe I should do something" to "Something MUST be done right now." For me, it truly is a game changer. It makes things calmer, and more clear. You're options have been narrowed for you.

...Probably what your instructor was getting at with this scenario is that normotensive BP should not be taken into consideration when determining the unstable vs. stable. Probably some not so bright paramedic student will say "Hey, he's not unstable, his BP is okay" and then your instructor can smugly explain the criteria for an unstable patient...

I'll bet a punch in the arm that you're spot on.

What an excellent thread. While all were dreaming of being flight medics, from the very first I always wanted to be a remote medic. Thanks to my friends here I've done a lot of it, and it has been all that I'd hoped. The one thing that I find is dangerous about it is that though I get to do a lot of interesting things and follow them to a resolution, the number of acutely unstable patients is small. I can't imagine staying even remotely current, or even relevant, without these conversations.

Thank you all for taking the time to participate.

Dwayne

[PCP]

Lone Star,

You can do this man! When I took my Primary Care Paramedic course I had some difficult times and thought I should drop out as I was having a hard time with certain portions of the program but I didn't as my wife would kicked my ass and I knew I could do it. I just had to study twice as hard as everyone else.

As many have mentioned there are plenty of people on this site who are willing and want to help you get through the program. Don't give up and don't ever ever think you bit off more than you can chew!

I wish I could help you but you are above my skill level so all I can offer is support and positive comments any time you need them. Keep your head up and remember there are many great medics on this forum who are your friends and can help.

YOU CAN DO IT!