You respond to a 70 y/o male with chest pain and shortness of breath. He has no other complaints and states that this began while working in the garage.
S – Chest pain & dyspnea
A – Aspirin and codeine
M – Coreg, Novolog, Gabapentin, Ni
P – CHF, CABG, Insulin dependent diabetes, HTN
L – Budweiser while working in garage
E – Working on lawn mower in garageO – Began suddenly
P – Exertion worsens pain
Q – Pressure
R – Non-radiating
S – 3/10
T – Began about 30 min. ago
You obtain a 12-lead ECG. What is your impression of this ECG?
You respond to a community college for a 22 y/o male who was having chest palpitations. Bystanders on scene state that the patient “looked like he was going to pass out”. As you arrive, you find a seemingly healthy male, sitting upright in no distress. He states that this happens all the time, and he doesn’t want to go to the hospital. He feels fine now.
A – NKDA
M – No meds
P – No known medical history
L – Red Bull and a muffin before class
E – Walking to classroomVitals:
HR: 75 & regular
RR: 22 & regular
Skin: Pink, warm, & dry now but bystanders state that he was pale and clammy when they called 911.You obtain the attached ECG on the patient. What is your interpretation? Should you encourage him to go to the hospital? Does this explain his symptoms?
Watch video below for full case review.
You respond to a residence for a 53 y/o female who fell unresponsive in her bathroom. As you arrive, you discover that she is in full cardiac arrest and you begin to attempt resuscitation. The patient is in v-fib and after two shocks, vas
Watch the full interpretation and case review below.
You respond to a 70 y/o female with chest pain & dyspnea. Upon arrival you see that she is sitting upright with labored respirations, clinching her chest. She states that this has been getting worse all day, and it is currently 1700.
S - Chest Pain, dyspnea, and swelling
A – PCN & Sulfa
M – Lisinopril, Digoxin, Furosemide, Plavix, Omeprazole, Albuterol, and Singulair all on scene.
P – Patient’s dyspnea inhibits her from providing this info.
L – Cheeseburger for lunch at noon
O – Gradual
P – Laying down increases pressure
Q – Chest Pressure
R – Non-radiating
R – No relief
S – 6/10
T – Started this morning around 0700
The attached 12-lead was obtained. What assessment findings would you be interested in. What is your interpretation of the 12-lead ECG? Does this ECG fit with the patient presentation?
I wanted to share my favorite resource for medical information. By far the best resource I have found is the EMCrit blog. The author is Scott Weingart, an ED Intensivist from New York. I spend much of my time listening to the EMCrit Podcast, which is available free from iTunes. This is an amazing resource for both new and veteran medics. Lots of new and up to date information. He is based in an Emergency Department so some of this information will not directly apply to Paramedicine but is still loaded with great information. Hope you take the time to check out this amazing resource. Located at EMCrit.org.
My name is Brenton Birr. I was asked by Adam Thompson to contribute to the Paramedicine 101 blog. I currently work for Lee County EMS in Fort Myers, Florida and have worked the past seven years at a level two trauma center. I am here to bring some of that knowledge to the Paramedicine 101 blog. Through this blog I would also like to emphasize the more basic concepts of paramedicine that are many times overlooked by both new and veteran paramedics. Please bear with me as I am new to blogging, but will be adding my first informative post very soon.
It’s all in a P-Wave
You know, the more you learn about medicine, the more you will realize how much there is out there that you will never know. ECGs are no exception. My obsession with cardiology began in paramedic school and it was only natural for me to grow a similar love for ECG interpretation.
Unfortunately, the usual prehospital training for 12-lead ECGs is limited, and generally doesn’t cover much more than STEMI and bundle branch blocks. The traditional resistance to further education usually involves a phrase like “well how is that going to change your treatment?” Nothing irks me more than hearing that stupid question. As if gaining new treatment strategies was the only reason to learn something. In this collection of posts, we will discuss some of the other things that an ECG can be used for, and you may find that it just might change your treatment.
The p-wave is the graphical representation of atrial depolarization. With normal physiology, this is initiated by the sinoatrial, or SA node. The p-wave can tell us many different things. A normal p-wave, married to a normal QRS lets us know that the patient has normal conduction.
There are many abnormals that may clue us in to a few pathologies though. If a p-wave is too tall, or peaked, right atrial enlargement is likely. A p-wave with two humps might indicate left atrial enlargement. The absence of a p-wave lets us know that the pacemaker is somewhere else in the heart. A p-wave that follows the QRS is likely not being used, and indicates that the AV junction is probably controlling the heart rate.
Maybe you have a p-wave that is slowly gaining distance between itself and it’s QRS complex, until finally there is no QRS; which indicates a Wenkebach pattern. The p-wave could be completely divorced from the QRS complex, indicating atrioventricular disassociation, or a complete heart block. It’s funny how much that little deflection can tell us. We often take it for granted, but when it is absent, we want it back desperately.
Above you can see a relatively normal location for a P-wave. 99% of your patients will probably have a similar variation to this.
Below is an example of p-pulmonale, which is an indication of right atrial enlargement.
Why is it called p-pulmonale?
Well, this is enlargement if the right atrium. The right atrium pumps its contents into the right ventricle which eventually empties its contents into the pulmonary trunk, pulmonary arteries, and eventually the lungs. When the pressure is backed up or increased in the lungs from chronic respiratory conditions like COPD, or asthma, or as a result of left ventricular failure, the right ventricle has to work harder. When the right ventricle works harder, so does the right atrium. Consisting of mostly muscle, when the heart works harder it gets bigger, just like your biceps. Consequently, right-sided heart failure is known as cor pulmonale. There are other causes, such as a right ventricular myocardial infarction, but the concept remains the same.
Above, you will see a p-wave with two humps. These p-waves are usually wider than normal, and are an example of p-mitrale, which is indicative of left atrial enlargement.
How does the left atrium enlarge?
The left atrium generally hypertrophies as a result of heart failure. To be more specific, left-sided heart failure. Left ventricular hypertrophy can be expected as well. This doesn’t have to be the case though, anything problem that causes the left atrium to increase its workload may result in an increased size.
While biphasic p-waves may be a normal finding in V1 on a 12-lead ECG, if it is deeper than it is tall, it is likely representing left atrial enlargement as well.
You may find that many of your patients have both atria enlarged, and maybe even all four chambers. This cardiomegaly is a very good indicator that your patient may be suffering from heart failure. When you see left atrial enlargement on the 12-lead, don’t forget to look for LVH. Remember that LVH can present with a left ventricular strain pattern, and this can mimic STEMI quite well. Check out ems12lead.com for more about that STE-Mimic.
The p-wave and its relationship with the QRS complex can tell you about abnormal conduction from the atria to the ventricles. More specifically, you can diagnose an atrioventricular block by closely examining the p-wave and pr-interval.
How to identify which AV block you are looking at:
Is the PR-Interval a constant length?
Yes > Are there any dropped beats? No > P wave for every QRS?
- Yes = Mobitz 2 – Yes = Mobitz 1/Wencheback
- No = 1st Degree AV Block – No = Complete Heart Block
(Also posted at My Variables Only Have 6 Letters)
It’s a summer afternoon and you’re dispatched to a 9 year old male patient involved in an ATV accident. The nearest ALS engine company has been dispatched as well. Upon your arrival you find an ATV on its side, another ATV upright, and a crowd gathered on the porch of a nearby house. A paramedic from the engine is assessing a distraught young boy, sitting in his mother’s lap, holding an obviously deformed right forearm. The officer on the engine informs you that the boy and his father were riding alongside the road, traveling at 20-30 miles per hour, when the boy lost control and was thrown from the ATV (his father insists he was wearing his helmet).
You introduce yourself to the child, assuring him you’re here to help, and ask him what happened. The boy states that when he fell he put his arms out and he heard a loud pop when his right hand hit the ground. He denies passing out or any other injuries but says his arm, “really hurts”. He reluctantly allows you to assess his radial pulse in the affected arm, which is rapid but easily palpable. There appears to be distal involvement of both the radius and ulna, however he does not tolerate any further assessment of the arm and screams if there is any movement. The remainder of your physical exam reveals only minor abrasions to exposed skin. The engine company reports tachypnea, tachycardia, and a normal blood pressure.
It appears the child has suffered a Colles’ Fracture of the right distal forearm. Appropriate treatment would include splinting, ice packs, and pharmacologic pain control. However, given the current state of the patient, it may not be possible to splint the extremity due to anxiety and pain. Traditional prehospital pain management would require intravenous access or intramuscular administration. Both of these routes are likely to cause increased anxiety in this patient, which is best avoided.
Pain management in the pre-hospital setting is fraught with problems. Most studies have found poor provider perception of pain, underutilization of analgesics, and a hesitance to treat pediatric pain (Thomas; Greenwald). Often times, studies find that even if patients are provided analgesia, they do not feel their pain was managed adequately at all (Thomas). For pediatric patients, this problem is compounded as pre-hospital providers are often wary to provide pain management or may be unable to obtain invasive IV access to provide pain management (Greenwald). Moreover, pre-hospital providers are often placed in situations where access to patients is limited to provide pain-management, often times resulting in painful patient movements.
The addition of a noninvasive means of pain management would be an invaluable aid to pre-hospital providers and would remove a potential barrier to care. In pediatric populations, the importance of noninvasive pain management procedures is easy to grasp, as this patient population is often unable to comprehend the benefits of initially painful procedures. Improvements in “time to analgesia” will likely lead to and have a direct, positive impact on patient care and satisfaction.
Efficacy and Safety of Intranasal Fentanyl
The efficacy and safety of intranasal fentanyl (INF) has been the focus of multiple studies, both in-hospital and pre-hospital. Finn et al conducted an in-hospital randomized double-blind placebo controlled trial and found INF to have the same efficacy as oral morphine during procedural wound care in adult burn patients (n=26, 35.5 ± 12.4 years). The concentration of INF used in this study was 50 µg/mL, initial dosages of 1.48 ± 0.57 µg/kg, and no difference in the number of adverse events. Finn et al concluded that while patients receiving INF were more satisfied with their level of pain relief (p = 0.009) that overall only half of the patients in the trial reported they were “satisfied” or “very satisfied”.
In a randomized, controlled, open-label study of pre-hospital INF versus IV morphine,Rickard et al found no significant difference in efficacy or safety (n=258, 42.3 ± 13.7 years). This study differs from Finn et al in that there were a multitude of chief complaints treated due to an “all-comers” design. Moreover, the doses used of INF was significantly higher at 180 µg divided evenly between the nares with up to two repeat dosages of 60 µg. Patients in the INF group received pain medication earlier than in the IV morphine group, likely owing to the simpler route of administration. Adverse effects were noted to occur more frequently in the INF group (relative risk 2.09, 95% CI 0.92-4.78, p = 0.07), however, the Rickard et alwas not powered to adequately detect any statistical difference. One incidence of a significant adverse effect required a termination of the INF protocol, but it was unclear from the study if this was related to the treatment or the patient’s condition. Rickard et alconcluded that given the safety and efficacy of INF, it is a valuable option in patients where intravenous access is “undesirable or impossible”.
Borland et al 2005 and Borland et al 2007 were inpatient randomized double-blind crossover studies evaluating the efficacy and safety of INF versus oral or IV morphine, respectively, in pediatric patients. Borland et al 2005 studied INF in pediatric burn patients requiring daily dressing changes and found no significant difference in outcomes (n=24, median 4.5 IQR 1.8-9.0 years). The INF dosage was calculated against the bioavailability of the IN route (listed as 70%) with 1.4 µg/kg fentanyl equating to an IV dosage of 1 µg/kg. There were no incidents of significant adverse events, although this was likely due to the study size. However, sedation scores recorded found that INF patients recovered earlier than their oral morphine counterparts. Overall, Borland et al 2005 found INF to be safe and efficacious, but more importantly well tolerated by pediatric patients.
Borland et al 2007 found INF to be comparable to intravenous morphine in pediatric patients presenting to the emergency department with acute long-bone fractures (n=67, 10.9 ± 2.4 years). The median total dose was 1.7 µg/kg fentanyl with repeat doses given PRN. The impetus of the study was to find alternative methods of analgesia to intravenous narcotics in the pediatric population. The study authors note that given the comparable efficacy, INF is invaluable as a means to decrease “time to analgesia” in the pediatric population with potential for pre-hospital adoption.
Mudd conducted a systematic review of the available literature for INF in the pediatric population and graded 12 studies with evidence qualities of four Level I/A, one II/A, two II/B, one III/A, and four at III/B. There was a wide variation in dosing of INF amongst the studies, with a common range of 1-2 µg/kg fentanyl. Differences in concentrations existed as well, owing to the fact that in the US fentanyl is commonly available at 50 µg/mL and is used IV/IM/IO/IN yet overseas it is often given IN with a more concentrated 100-150 µg/mL solution. No differences in significance in pain reduction were found between concentrations, only in the volume of medication delivered. While no studies found a significant difference in adverse effects, many studies had small sample sizes and no long-term studies have been completed on the action of fentanyl on the nasal mucosa. However, the evidence in the reviewed studies demonstrated three clear points: (1) that INF is as efficacious as IV/IM/PO morphine or IV fentanyl, (2) it has no difference in adverse effects, and (3) it decreases the time to analgesia administration and pain relief.
Intranasal Fentanyl Protocol
Based on the research available and the existing 2009 NC EMS protocols, an appropriate pain management protocol for the administration of intranasal fentanyl is given below:
- Adult patients with indications for narcotic analgesia for whom intravenous access is not feasible, not available, or at the discretion of the lead Paramedic, an initial dose of 50-75 µg fentanyl may be delivered intranasally. The total volume to be administered should be divided equally between the two nares (not to exceed 1mL per nare).
- If intravenous access is not available, repeat with 25 µg fentanyl delivered intranasally every 20 minutes to a maximum total dose of 200 µg.
- Pediatric patients with indications for narcotic analgesia an initial dose of 1-2 µg/kg fentanyl up to a total dose of 50 µg may be delivered intranasally. The total volume to be administered should be divided equally between the two nares (not to exceed 0.5mL per nare).
- In order to decrease the anxiety of pediatric patients requiring analgesia and invasive procedures (such as intravenous access), it may be prudent to begin with intranasal fentanyl.
- M. Borland, I. Jacobs and I. Rogers, Options in prehospital analgesia, Emerg Med (Freemantle) 14(2002), pp. 77–84.
- M. Borland, I. Jacobs and G. Geelhoed, Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study, Emerg Med (Freemantle) 14 (2002), pp. 275–280.
- J. Finn, J. Wright, J. Fong, E. Mackenzie, F. Wood, G. Leslie and A. Gelavis, A randomized crossover trial of patient controlled intranasal fentanyl and oral morphine for procedural wound care in adult patients with burns, Burns 30 (3) (2004), pp. 262–268.
- M. Borland, R. Bergesio and E.M. Pascoe et al., Intranasal fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study, Burns 31 (2005), pp. 831–837.
- M. Borland, I. Jacob and B. King et al., A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in the emergency department, Ann Emerg Med 49(2007), pp. 335–340.
- C. Rickard, P. O’Meara, M. McGrail, et al., A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting, Amer J Emerg Med 25 (2007), pp. 911-917.
- S. Thomas, S. Shewakramani, Prehospital Trauma Analgesia, J Emerg Med 35 (2007), pp. 47-57.
- M. Greenwald, Analgesia for the Pediatric Trauma Patient: Primum Non Nocere? Clin Pedi Emerg Med 11 (2010), pp. 28-40.
- S. Mudd, Intranasal Fentanyl for Pain Management in Pediatrics: A Review of the Literature, J Pedi Health Care (2010), Article in Press. doi:10.1016/j.pedhc.2010.04.011.
So the new AHA guidelines have been released. Go here to read them for yourself.
PDF - New Guidelines 2010
From A-B-C to C-A-B
Much research has been done to conclude that the best course of action for all unresponsive and apneic or barely breathing patients is to immediately begin chest compressions. No wasting time checking for a pulse (less than 10 seconds). No, “well I think they are breathing”. If they are unresponsive, you don’t immediately feel a pulse, and there are very few or no respirations, then begin chest compressions. No more Look, Listen, Feel.
- The vast majority of cardiac arrests occur in adults, and the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia (VT). In these patients the critical initial elements of CPR are chest compressions and early defibrillation.90
- In the A-B-C sequence chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths or retrieves a barrier device or other ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions (30 compressions should be accomplished in approximately 18 seconds).
- Fewer than 50% of persons in cardiac arrest receive bystander CPR. There are probably many reasons for this, but one impediment may be the A-B-C sequence, which starts with the procedures that rescuers find most difficult: opening the airway and delivering rescue breaths. Starting with chest compressions might ensure that more victims receive CPR and that rescuers who are unable or unwilling to provide ventilations will at least perform chest compressions.
- It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest. For example, if a lone healthcare provider sees a victim suddenly collapse, the provider may assume that the victim has suffered a sudden VF cardiac arrest; once the provider has verified that the victim is unresponsive and not breathing or is only gasping, the provider should immediately activate the emergency response system, get and use an AED, and give CPR. But for a presumed victim of drowning or other likely asphyxial arrest the priority would be to provide about 5 cycles (about 2 minutes) of conventional CPR (including rescue breathing) before activating the emergency response system. Also, in newly born infants, arrest is more likely to be of a respiratory etiology, and resuscitation should be attempted with the A-B-C sequence unless there is a known cardiac etiology.
The changes this year are minute in comparison to the changes back in 2005. One thing noted has been a decreased emphasis on ALS medications during treatment of cardiac arrest. There is still almost no evidence of improved outcomes due to any drug given in cardiac arrest. Post-arrest cardiac catheterization is being advocated. This has shown to increase chances of neurological recovery more than induced hypothermia in some studies. In conjunction with hypothermia, PCI is even more beneficial.
Thanks for stopping by,
Adam Thompson, EMT-P