ECG Case 6
11/06/2012 by Leave a Comment
You respond to a 72 y/o female complaining of shortness of breath. Upon arrival you find an average sized elderly female with tachypnea and pale, moist skin. She states that she can’t do anything without feeling very short of breath. This is the ECG you obtain on the patient, what are you thinking at this point?
ECG 6 – Click to enlarge
Watch the video below for the full case review and interpretation.
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ECG Case 5
11/05/2012 by 2 Comments
You respond to a 65 y/o Male at his residence. His daughter, on scene, called 911 because she is worried about her father’s health. She states that he just hasn’t been acting right. “He is weaker than normal, and becomes short of breath very easily”. The patient himself is not thrilled about your presence. He is a rather obese man (about 400 lbs), and he is sitting in his recliner sans shirt or pants. His immediate area provides evidence that he doesn’t move
from that chair very often.
S – The patient states that he is always weak and it is normal for him to get short of breath when he gets up.
A – NKDA
M – Glucophage, Gabapentin, Albuterol, Singulair, Prevacid, Carevedilol, Enalapril, Digoxin, Aspirin, Oxygen
P – AMI, CHF, Asthma, Non-insulin dependent diabetes, AICD
L – Oreos and Orange Juice
E – Sitting in his chair
B/P: 61/37, Left Arm
SpO2: 83, on 2 lpm O2,
Pulse: 40 & regular
Resp: 30 & regular
Skin: Pale, cool, & clammy
You place your patient on the monitor and obtain the following 12-lead. What would you immediately ask your patient? What is your interpretation of the ECG? What treatments would you provide?
The Capnography Tutorial
10/25/2012 by 1 Comment
I have put together a capnography tutorial for your education and enjoyment. The videos below are the capnography tutorial. There are 7 lessons, consisting of relatively short videos.
Enjoy.
Adam Thompson, EMT-P
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Download Video from YouTube | Convert YouTube to MP3
Download Video from YouTube | Convert YouTube to MP3
Patient Perceptions of Computed Tomographic Imaging and Their Understanding of Radiation Risk and Exposure – Part IV
09/12/2011 by 1 Comment
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Also posted over at Rogue Medic (now at EMS Blogs).
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Continuing from Part I, Part II. and Part III.
After assessing what it is that the abdominal pain patients want/expect from a visit to the ED (Emergency Department), how many X-rays it takes to deliver the same radiation as an abdominal CT (Computed Tomographic imaging), whether CTs increase the lifetime risk of cancer, and how many abdominal CTs equal some sort of measure of the radiation exposure of Hiroshima survivors, the authors conclude that people do not understand the risks of radiation.[1] This study is followed by an excellent editorial.
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The easy conclusion from these findings is, unsurprisingly, that patients are ill informed, and thus efforts to improve their education and awareness should help to mitigate the overuse of imaging and its consequent risks.[2]
Dr. Wears does not discuss the validity of assuming that there is only one right answer to the questions asked. There is also a podcast discussing this study and discussing the editorial, but the podcast is similarly missing the problem with the study taking for granted that there is a single right answer to the study’s questions.[3]
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First, the “rational person” assumption holds that, given correct information, people should arrive at consistent choices about alternatives (eg, to image or not) based on the net expectation of probabilities and outcomes.2[2]
If we make rational decisions, why do so many of us smoke?
If we make rational decisions, why do so many of us eat to the point of obesity?
If we make rational decisions, why do so many of us spend so much time watching reality TV?
Dr. Wears cites some of the studies that show that we do not make rational decisions. To insist that we make rational decisions is also irrational. Isolated examples of decisions that appear rational do not mean that a person makes rational decisions any more than a stopped clock being right twice a day means that the stopped clock keeps accurate time.
The authors provide excellent examples of irrationality in one question they present.
Click on images to make them larger.
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How a multiple choice question is presented will affect way the answers are chosen.
Why is there no choice for I don’t know?
For most people not familiar with X-rays and CTs, the only honest and rational answer is I don’t know.
When graphing the results, we can further distort the results by making the distances between numbers completely arbitrary. Why present the choices as the Same radiation (the same, or zero difference is 50 x 0), 50 times more (greater by a factor of 50 x 1), 100 times more (greater by a factor of 50 x 2), 250 times more (greater by a factor of 50 x 5), 300 times more (greater by a factor of 50 x 6), and Over 350 times more (greater by a factor of 50 x at least 7).
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Why blur the distinction between 100 times and 250 times? When the numbers become blurred, the numbers lose their meaning. When there is no difference in meaning between one number and a number 2 1/2 times as large, are we providing information or are we providing confusion?
We seem to most insist on stripping information of its meaning when we create multiple choice tests. Correct answers become a simple matter of memorization separated from understanding. This is one way to create the protocol monkey – the automaton, whom we claim is rendered harmless by being prevented from thinking. This desire to prevent the use of judgment may be the ultimate irrational decision.
If the difference between 100 and 250 is the same as the difference between 250 and 300, how do we expect anyone to notice differences in dosages? 100 mg – 200 mg – 300 mg – what’s the difference? With memorized answers, the only difference is whether it is graded as correct. With real patients, the differences can be fatal.
We memorize our way to recklessness.
We do not memorize our way to safety.
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Previous literature estimates the radiation dose for an abdomen-pelvis CT to be equivalent to 100 to 250 2-view chest series.2,10-12 For the purpose of this investigation, we used the conservative estimate of 1 abdomen-pelvis CT = 100 2-view chest radiographs.[1]
I agree with their choice to use the more conservative number, but what this still does not do is put this in a context that helps people to understand. Without understanding something about the radiation exposure of an X-ray, this is an unknown. 10 times an unknown – 100 times an unknown – 1,000 times an unknown – what’s the difference?
Presenting misleading information to medically naive people and proclaiming Eureka! is misleading. We are not finding anything. We are presenting a spectacle, although not as much of one as Archimedes did running naked through the streets (assuming the legend to be true).
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The second assumption is that the problem is “out there” in patients, not “in here” in physicians. This might be viewed as a form of the psychologist’s fallacy,3 the idea that although patients’ preferences might suffer from irrationality, ignorance, or irrelevant considerations, ours (physicians’) do not.[2]
An excellent point that should be extended to researchers.
How much of the problem is in the study design?
What are we measuring?
If the purpose of controlled trials is to examine things objectively, why use a study that seems to depend insist on subjectivity?
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I will write more about Dr. Wears editorial later, because it covers a lot of important material on making decisions.
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Footnotes:
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[1] Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure.
Baumann BM, Chen EH, Mills AM, Glaspey L, Thompson NM, Jones MK, Farner MC.
Ann Emerg Med. 2011 Jul;58(1):1-7.e2. Epub 2010 Dec 13.
PMID: 21146900 [PubMed - indexed for MEDLINE]
Free Full Text from Annals of Emergency Medicine with links to Free Full Text PDF Download
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[2] Risk, radiation, and rationality.
Wears RL.
Ann Emerg Med. 2011 Jul;58(1):9-11. Epub 2011 Apr 2. No abstract available.
PMID: 21459481 [PubMed - indexed for MEDLINE]
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[3] What patients understand about radiation exposure from CTs
David H. Newman, MD, and Ashley Shreve (spelling?)
Annals of Emergency Medicine podcast page
2011 July
Free Podcast in MP3 format
Annals of Emergency Medicine provides a podcast that summarizes the articles published that month. This is an excellent resource. The full July 2011 podcast is – Free Full Podcast in MP3 format. The full archives of Annals of Emergency Medicine podcasts is – Page with links to podcast segments and full month podcasts.
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Croup/Epiglottitis
12/19/2010 by 6 Comments
There is nothing scarier than a sick kid. I am becoming more and more obsessed with educating myself on pediatric emergencies. This is because of that fear, and the fact that I find it is one of those areas that I am less versed in. This post is aimed at identifying and treating the child who presents with an upper respiratory infection (URI) like croup or epiglottitis. These kids sound sick, look sick, and may get even sicker.
As always, aggressive airway management may be indicated if the child appears to have impending respiratory failure. Signs of this include severe hypoxia, bradycardia, and decreasing respiratory effort.
If the patient doesn’t present with imminent signs like those mentioned above, it is pertinent to obtain a good medical history.
History:
Has the child ever had a URI in the past?
- If so, did he/she present like this?
Was the onset acute or gradual?
- Epiglottits generally presents with an acute onset.
Has the child been sick, and is he up to date with vaccinations?
- Most cases of epiglottitis are caused by haemophilus influenza or H.flu
Has the child ever been intubated?
- This helps identify whether you will need to be aggressive, and a recent intubation could be the cause of hoarseness.
Epiglittits is actually inflammation of the epiglottis–you know, that flap that covers the trachea during swallowing? If this becomes inflamed, it swells, and that swelling could cause a partial or even a complete occlusion of the trachea, thus compromising ventilation.
- Usually febrile, without cough
- Patient may be in tripod position
- Drooling present
Treatment
- Immediate intubation may be indicated (may be very difficult!)
- Epinephrine may be administered in extremis
Croup or laryngotracheobronchitis is also an upper respiratory infection that may be mild, moderate, or severe. It tends to be worse at night, and is most commonly identified by the classic “seal-bark cough”.
- Inspiratory stridor & “barking cough”
- Often preceded by flu
- More likely if they have had croup before
Treatment
- Oxygen therapy
- Nebulized Saline
- If severely hypoxic, racemic epinephrine may be indicated.
- It is often taught to take these children outside, into colder air
So who is in extremis?
- The severely hypoxic child: Cyanosis, bradycardia
- Intercostal retractions with decreasing stridor is an ominous sign of impending respiratory failure
- Decreasing mental status means decreasing respiratory drive. TREAT AGGRESSIVELY
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Check out Justin, The Happy Medic, Schorr’s last run-in with croup in THIS POST.
Prehospital Drug Calculations
11/14/2010 by Leave a Comment
The following is a link to a tutorial that I have put together to do drug calculations.
View more documents from Adam Thompson.
Research: Termination of Resuscitation
11/11/2010 by Leave a Comment
Check this out…
Assessment of termination of trauma resuscitation guidelines: are children small adults? [Link]
Capizzani AR, Drongowski R, Ehrlich PF.
Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children’s Hospital, Ann Arbor, MI 48109, USA.
Abstract
BACKGROUND: Guidelines for termination of resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA) have recently been published for adults. Clinical criteria for termination of care include absent pulse, unorganized electrocardiogram (ECG), fixed pupils (all at the scene), and cardiopulmonary resuscitation (CPR) greater than 15 minutes. The goal of this study was to evaluate these guidelines in a pediatric trauma population.
METHODS: Pediatric trauma patients with documented arrest were included in the study. Data assessed were duration of CPR, ECG rhythm, pulse assessment, pupil response, transport times, and standard injury criteria (eg, mechanism of injury). Survivors were compared to nonsurvivors using descriptive statistics, chi(2), and Pearson correlation.
RESULTS: Between 2000 and 2009, 30 patients were identified as having had a TCPA. Of the 30 with a prehospital TCPA, there were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). Twenty-four patients (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. One-way analysis of variances demonstrated that CPR greater than 15 minutes (P = .011) and fixed pupils (P = .022) were significant variables to distinguish between survivors and nonsurvivors, whereas ECG rhythm (P = .34) and absent pulse (P = .056) did not, 42 +/- 28 minutes for nonsurvivors and 7 +/- 3 minutes for survivors.
CONCLUSION: Criteria for termination of resuscitation correctly predicted 100% of those who died when all the criteria were met. More importantly, no survivors would have had resuscitation stopped. Duration of CPR seems to be a strong predictor of mortality in this study.
The Terminator
Whether your patient is an adult or a child, transporting them without a pulse is senseless. ACLS treatment for the pulseless patient in the hospital is not much different than in the field. How good will your chest compressions be during transport? We know that good chest compressions is the single most influential factor in cardiac arrest care. The best chance that a dying patient has to regain a pulse is on scene–almost always. It is very difficult to not work a SIDS baby. SIDS has a 100% rate of resulting in death, otherwise it would be an ALTE–apparent life threatening event. I could never judge a colleague for not feeling comfortable with calling a kid on scene. Just keep in mind that you are not doing them any favors by transporting them without a pulse.
Differential Diagnosis: Headache
11/04/2010 by 3 Comments
Differential Diagnosis: Headaches
By Adam Thompson, EMT-P
Headaches account for a large volume of EMS responses. Most are benign, but a few could be an early symptom of a life-threatening cause. It may be beneficial to differentiate between the presentations. A good history is by far the most useful tool that any clinician has in determining a headache’s malignancy.
Common types of headaches:
- Tension-type headache
- Migraine headaches
- Cluster headaches
Tension-type the most common type of headache, and yet its causes aren’t well understood. A tension headache is generally a diffuse, mild to moderate pain that many people describe as feeling as if there’s a tight band around their head.It may feel as though muscle contractions are responsible for your head pain, but experts don’t think that’s the cause, which is why this type of headache is generally referred to as a tension-type headache. (from MayoClinic)
Migraine a common type of headache that may occur with symptoms such as nausea, vomiting, or sensitivity to light. In many people, a throbbing pain is felt only on one side of the head. Some people who get migraines have warning symptoms, called an aura, before the actual headache begins. An aura is a group of symptoms, usually vision disturbances, that serve as a warning sign that a bad headache is coming. Most people, however, do not have such warning signs. (from Google Health)
Cluster The term “cluster headache” refers to a type of headache that recurs over a period of time. People who have cluster headaches experience an episode one to three times per day during a period of time (the cluster period), which may last from two weeks to three months. The headaches may disappear completely (go into “remission”) for months or years, only to recur. A cluster headache typically awakens a person from sleep one to two hours after going to bed. These nocturnal attacks can be more severe than the daytime attacks. Attacks appear to be linked to the circadian rhythm (or “biological” clock). Most people with cluster headaches will develop cluster periods at the same time each year — either in the spring or fall or the winter or summer. (from WebMD)
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Symptom
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A
Tension |
B
Migraine |
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Intensity, Duration and Quality of Pain
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Mild or moderate pain intensity
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√
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√
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Severe
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√
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Duration of headache
30 min – 7 days
4-72 hours
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√
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√
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Intense pounding, throbbing and/or debilitating
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√
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Distracting but not debilitating
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√
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Steady ache
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√
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Location of Pain
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One side of head
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√
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Both sides of head
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√
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Associated Symptoms
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Nausea/vomiting
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√
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Sensitivity to light and/or sounds
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√
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Aura before onset of headache such as visual symptoms
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√
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Table 1
Comparing benign headaches
90% of all headaches are benign. Tension headaches are muscle-contraction headaches, and migraine or cluster headaches are vascular headaches. Below is a table of accompanying symptoms with each type.
| CHARACTERISTICS | MUSCLE-CONTRACTION HEADACHES | VASCULAR HEADACHES |
|---|---|---|
| Incidence |
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| Precipitating factors |
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| Intensity and duration |
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| Associated signs and symptoms |
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Image 2 – Click the image above to enlarge
Quickie Definitions of Headaches You Never Knew Existed
- Weight-lifters: Just like you’d think, this is a headache that occurs after a strenuous weight-lifting regimen.
- Histamine: A headache caused by histamine overload, from a source such a histamine injection or certain wines.
- Coital: A headache that occurs suddenly during sex or after orgasm. As if couples nowadays didn’t have enough issues – thankfully, these are very rare and actually occur more often in men.
- Analgesic-rebound: That medication you’ve been taking for your headaches could now be the underlying cause of new headaches. Removal of the medication is required.
- Hypnic: This is an oddball headache that awakens people from sleep. Clusters can do this as well but the pain of hypnic headaches are not as intense and are not localized around the eye.
High Priority Symptoms
- The worst headache someone has ever had
- Headache with stiff neck (especially with a high grade fever)
- A headache associated with loss of consciousness or altered mental status.
- A headache accompanied by severe eye or ear pain.
- A headache that occurs in an individual who has experienced recent head trauma.
- A headache accompanied by sudden, disabling pain or convulsions.
- Headache with parasthesia or paralysis
References:
- American Headache Society – Table 1
