EMS 12-Lead: The 12 Rhythms of Christmas – First Degree AV-Block

This article is the fourth in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It’s a continuation of the theme behind last year’s 12 Leads of Christmas.

An 84 year old male presents with a chief complaint of abdominal pain. The ECG below is performed:

What is this rhythm?

For the answer and the rest of the discussion please follow this link or click the ECG above.

EMS 12-Lead: The 12 Rhythms of Christmas – Atrial Flutter

This article is the third in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It’s a continuation of the theme behind last year’s 12 Leads of Christmas.

This is a new edit of the first article I ever published on this blog, so it may seem familiar to some readers.

Have you slammed adenosine to cure a patient’s SVT with a fluorish?

Atrial flutter with 2:1 conduction

Figure 1. Pre-adenosine.

*PUSH* – *FLUSH* – “You’re gonna feel funny.”

Atrial flutter during adenosine bolus

Figure 2. A few seconds after the adenosine push.

…only to see the saw-tooth waves of atrial flutter marching across the monitor?

While you may have performed a successful diagnostic test, your unsuspecting patient has just been given a sneak peek of the day their heart quits beating with no relief from the arrhythmia actually causing their symptoms.

Well, you need-not make that mistake again, because I’ve put together a rough list of (almost) every tip out there for diagnosing subtle atrial-flutter with 2:1 conduction. In the end you’ll be talented enough to recognize this arrhythmia with your monitor upside-down (hint)!

For the rest of this article please follow this link or click on the rhythm strips above.

EMS 12-Lead: The 12 Rhythms of Christmas – Sinus Bradycardia

This article is the second in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It’s a continuation of the theme behind last year’s 12 Leads of Christmas.

Last year I posted a nearly identical article titled Don’t let your bradycardic patient D.I.E., but this is an update focused on sinus bradycardia and with a slightly new mnemonic. Our new post should be called, Don’t let the cause of bradycardia H.I.D.E..

I’ve told you before that I’m terrible with mnemonics, but there is one I used to find both memorable and useful: the DIE mnemonic for insidious but reversible causes of bradycardia in the emergency medicine and acute care setting. DIE stands for drugs, ischemia, electrolytes. While I love its simplicity, I no longer rely on that exact mnemonic because it leaves out an important cause of bradycardia you do not want to miss—hypothyroidism.

Unlike ischemia, hypothyroidism is not a major concern from a prehospital perspective, and unlike hyperkalemia, it’s not quickly reversible, but given its importance in the trajectory of a patient’s care and how easily it can be overlooked, I think it still deserves a spot in my favorite memory aid.

[H]ypothyroidism
[I]schemia
[D]rugs
[E]lectrolytes

Yes, there are other causes of bradycardia that should be on your differential, but what makes this list special is that all four have specific emergency treatments, the standard ACLS trio of pacing, atropine, and dopamine/norepi does little or nothing to address them, and, if missed, patients are unlikely to get better with only supportive care.

For the rest of this article please follow this link or click on the ECG below.

EMS 12-Lead: The 12 Rhythms of Christmas – Sinus Tachycardia

This article is the first in our latest series, The 12 Rhythms of Christmas, where each day we examine a new rhythm disorder. It’s a continuation of the theme behind last year’s 12 Leads of Christmas.

It’s one of the first arrhythmias we all learn and it seems so simple. Sinus tachycardia is a regular rhythm faster than 100 bpm with a sinus P-wave before each QRS, right?

Well, let’s examine some of its finer points.

I’m going to tell you that the ECG above does not show sinus tachycardia.

For the rest of the discussion, please follow this link or click the ECG above.

EMS 12-Lead: Spot the STEMI #1

You have a 50/50 shot at getting this one right. Are you feeling smart… or lucky?

Two 50-year-old men present complaining of chest pain x 1 hour. One patient is suffering from a very subtle acute STEMI while the other has a non-cardiac cause for his chest pain.

For the conclusion of this challenge please follow this link or click on the ECG above.

EMS 12-Lead: 43 Year Old Female – Chest Discomfort After Eating

A 43-year-old female presents feeling like there’s a knot behind her sternum. It began suddenly just after eating lunch. This is her initial ECG:

For the description of the patient’s initial presentation and reader comments please follow this link.

For the conclusion to this case please follow this link or click on the ECG above.

EMS 12-Lead: 59 Year Old Male – Unwell

It’s the middle of the afternoon when you are dispatched to the residence of a 59 year old male with a chief complaint of general illness.

When you arrive on scene you encounter a middle-aged man in obvious distress, lying on a couch. He is pale, gray, diaphoretic, and drowsy. He states that he has felt drained for the past 8 hrs—unable to catch his breath or get up off the couch—with a heavy sensation in his chest. 30 minutes prior to your arrival he vomited and felt like he was going to pass-out so he decided to call 911.

For the details of the initial case description and reader comments please follow this link.

For the conclusion of the case and its discussion please follow this link or click the ECG above.

EMS 12-Lead: What If We’re Wrong? Prehospital ECG Interpretation

This article is part of a special one-day EMS blogging event called the What If We’re Wrong a-Thon. Spearheaded by Brandon Oto over at EMS Basics, the WIWWAT is an exercise in self-reflection where EMS writers examine a topic on which that they’ve historically taken a strong stance, but from the opposite point-of-view. For more posts from around the EMS community as part of the What If We’re Wrong a-Thon, check out this page.

What if we’re wrong about the utility of prehospital interpretation of 12-lead ECG’s? What if they don’t actually improve patient outcomes and lead to better prehospital care?

For my critical examination of those questions follow this link or click on Dr. Perry Cox’s face above.

EMS 12-Lead: Snapshot Case – What Happened?

This is a patient who required emergent cardioversion for unstable rapid atrial fibrillation. What happened?

For comments and discussion of this tracing follow this link or click the rhythm strip above.

EMS 12-Lead: Transcutaneous Pacing Success!!! Part 2

This is the second half of a two-part case presentation examining transcutaneous pacing. If you didn’t see yesterday’s post I highly suggest checking out Part 1 before continuing, but if you hate learning I suppose you can start here.

Yesterday we examined a series of tracings that depicted transcutaneous pacing (TCP) in all its stages: initiation, false-capture, intermittent capture, successful capture, and finally, spontaneous resolution of the bradycardia that necessitated pacing in the first place. It was a whirlwind!

For the rest of this article follow this link or click the rhythm strip showing intermittent capture above.