EKG Strips Part ?

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More than just strips, there is a case to go with them. I’ll present Part 1 today and the answers tomorrow. As always, details are changed to obscure patient identities without changing the clinical portions of the case.

The patient.
65 year old male complaining of more than one week of “general malaise” for lack of a better term. No specific complaint, just not feeling good. Has had decreased PO intake secondary to “not feeling like eating” over the same time period.

History of Hypertension, “irregular heart beat”, but no specific cardiac diagnosis. Medications are Coumadin, Digoxin, Lisinopril, Klor-Con, and Lasix. No Known Drug Allergies.

Presentation.
Conscious, alert, oriented to time, place, and person. Answers appropriately, but it is obviously an effort to concentrate. Skin is ice cold, but dry. Breath sounds are clear, equal, and with good tidal volume. Thready and intermittent radial pulses felt, but no blood pressure can be auscultated or palpated. No neurological deficit noted. Blood Glucose (patient is not diabetic) is 47 mg/dl. No pedal edema noted. No O2 saturation can be obtained.

EKG.

And a 12 Lead EKG

What is the rhythm? Is the rhythm causing the malaise or is whatever is causing the malaise also causing the rhythm? What is your plan of treatment?

Answers tomorrow, as well as what how we treated this gentleman. I’m also not going to reply to comments until tomorrow. Which should not stop my readers from commenting.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

4 COMMENTS

  1. What an ugly 12-lead….It looks like this patient is having an inferior wall MI – on the 12-lead I see ST segments that have the classic "tombstone" appearance. And the tachycardia associated with this has to be ventricular in origin; with those wide complexes showing, how could it not be?That this patient has both going on is, for lack of a better word, ominous. Adding the hypoglycemia and hypotension to this – the inability to get an SO2 is because of the lack of perfusion to his extremities – and what is here is one incredibly sick patient who is in big trouble.As you say, it's a case of figuring out which came first, the malaise or the rhythm. That said, because of the underlying MI, I'd have to think that treating the tachycardia aggressively (with synchronized cardioversion, for example) could complicate matters with the MI. And both beta-blockers and CCB's are out because of the lack of blood pressure.As I said, though, it looks like an IWMI, and the best way I know of to deal with something like this is to challenge the right ventricle with a fluid bolus. I would start at 250, re-assess (including lung sounds to ensure we're not causing problems there) and go with 250 more if indicated. While that certainly won't cure this problem, it's a start at working on putting this right. It should also help with what sounds like some moderate dehydration. If he can tolerate aspirin, I'd give him 325 mg PO, and I would take a hard look at the hypoglycemia and treat that also.Rapid transport it mandatory.I can't help thinking that there is some sort of metabolic problem here also. And if there is, it may have been contributory to all of this starting in the first place. While I wouldn't think it would have caused the MI, the possibility of its presence surely can't be overlooked. It would be interesting to know what lab values for this patient looked like; not just the cardiac workup but his electrolyte panel. I'd want to know how far out those values are.If this was something ongoing, I'd wonder what the long term outcome is. Provided the patient survives, of course.Sorry for the length, TOT – lots to consider with this one.

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