A couple of weeks ago Google+ introduced the concept of “communities,” where like-minded individuals can meet up to discuss their common interests. So, with great fanfare, I’d like to formally announce the creation of the ECG+ community!
Click our logo to check out ECG+
We’re already a few posts deep, so check out the cases and comments and please share your own!
So here’s the case: You’ve just run an 12-lead on a patient experiencing chest pain and recognized ST-depression in leads V2-V4. Being some manner of an astute provider, your next move is to set up posterior electrodes for leads V7-V9 to confirm the hidden STEMI. You’re about to press the print button, but suddenly your monitor dies. How can you confirm that this patient is experiencing an isolated posterior STEMI and would benefit from immediate PCI as opposed to medical management?
Click image to enlarge. Click here for source. Courtesy of LifeintheFastLane.com.
I was doing some light reading the other day and stumbled upon this article by R. Shinde et al, entitled Occurrence of “J Waves” in 12-Lead ECG as a Marker of Acute Ischemia and Their Cellular Basis. I don’t have access to Pacing and Clinical Electrophysiology, but the authors’ original manuscript is available for free here and can’t be too different from the finished product. In the end I wasn’t too intrigued by their whole J-wave hypothesis, but an ECG in their case study did catch my eye.
Serial 12-leads from a 28 year-old man experiencing chest pain. Click image for source.
I’m not that great with mnemonics.
I can never remember all the terms involved, often I screw up the mnemonic itself, and I’m always scared that I’m going to substitute something that isn’t actually part of the differential. It’s as though one day I’m going to debate with myself whether hyperthyroidism falls under “H-for-hyper” or “T-for-thyroid” while reviewing the H’s-and-T’s during a cardiac arrest and miss the patient’s tamponade.
Still, there’s one mnemonic that I live and die by, and that is the DIE acronym for bradycardia.
People still make Borat references, right?
Anyway, I’ve got a quick one for you today. This patient was being evaluated for possible pericarditis. What’s the rhythm?
Click to enlarge.
Aortic dissection is a disease that commands a lot of respect. Thankfully, it’s also quite rare, and as a result, we don’t cross its path very often. While the scarcity of this disease is good for the population at large, it ends up being quite detrimental to our individual patients because we simply don’t have a lot of experience identifying it. What follows are just some ideas I’ve picked up over the past few years that I figure are worth sharing and considering…
Testing for arm drift is a standard part of the simplified three-part neurological exam we all perform, technically called the Cincinnati Prehospital Stroke Scale. It’s a fairly crude examination, but when even one finding is positive in the right clinical scenario, there’s a pretty good likelihood that the patient has experienced a stroke. The problem is that testing for arm drift isn’t perfectly sensitive and it will miss a certain number of acute lesions that could be amenable to treatment.
One way to increase the yield of the physical exam is to expand beyond the basic maneuvers we are taught early in training. Doing so, however, has costs in terms of time and memory, two things we are often short of in emergency medicine. We can’t afford to be doing complete neurological exams, nor remember the numerous steps involved, but by adding a couple of simple, high-yield maneuvers to our repertoire we can really improve our patient assessment.
It’s classic teaching that in supine patients who are pregnant, the weight of the gravid uterus will compress the descending aorta and inferior vena cava. Respectively, this will increase afterload and decrease preload, with the end result being a reduction in cardiac output and blood pressure. On an average day in a pregnant woman’s life this doesn’t result in too much distress, but, since most of our sickest patients end up supine while we are treating them, it becomes a bigger issue should a gravid patient require resuscitation.
As we’ve all been trained, the answer to this problem is simple, of course – tilt the patient on her side and boom, she’s better. However, like most of what we are taught in the classroom, there’s a lot more nuance to how we should handle these patients in actual practice, so lets review some finer points..
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Ever given a patient adenosine to cure their SVT with a flourish,
Click image for source. ©Charles Gomersall, June 2007
*PUSH* – *FLUSH* – “You’re gonna feel funny,” ¹
Click image for source. ©Charles Gomersall, December 2007
only to see the tell-tale saw tooth waves of atrial flutter marching across the screen? While you may have performed a successful diagnostic test, your patient has been given a sneak peek of the day their heart quits beating with nothing to show for it. Well you need not make this mistake again, because I’ve put together a rough list of (almost) every tip out there for diagnosing atrial-flutter with 2:1 conduction. In the end you’ll be talented enough to recognize this arrhythmia with your monitor upside-down (hint)!