# just ran a call



## remt (Nov 18, 2010)

just ran this call:

called for sob and vomiting to nhf. Pt. has been throwing up clear fluid for 2 hours, developed sob 30 min ago. 79 on room air. 92 on nrb. Gurgling in upper airway, lungs are clear. Pt is confused per norm. V/s: 146/100, 132, 46(resp rate). Pt. has history of: dm, htn, afib, dementia, seizures, cva. Tried to suction, pt. vomited. ETA to the hospital 3 mins. Called an abbreviated report and went. En route put her on the monitor: irregular rhythm with wide QRS, pt. has an irregular pulse.
Dropped the pt. off, gave report, went to do paperwork, they called code blue. Pt. is jumping between v-fib, v-tach, and a-fib, ST Elevation in all septal leads. Pt. went to cath lab before I was done. i think they also put her on bi-pap. 
Just wanted to share this with others. This call really surprised me. First time I was so far off. I was sure she aspirated, wasnt even thinking cardiac. The nurse on-line had the same opinion. Too bad we dont have 12 leads.


----------



## usalsfyre (Nov 19, 2010)

An elderly female patient with a history of diabetes and vague non-specific complaint should ALWAYS, ALWAYS, ALWAYS be evaluated for ACS.


----------



## firecoins (Nov 19, 2010)

considering he had a monitor, might he be "ACS"?


----------



## remt (Nov 19, 2010)

good point about evaluating for cardiac. One of those things that I learned in school but wasnt thinking about when I was on the call...now I know.

Also after I looked at the strip again, I think I can safely say that the patient was in V-Tach, although I didnt recognize it then...no p waves, wide QRS at a rate of 130. the problem was the pt. had h/o afib and the strip was irregular, so it made it seem like this could be normal for the pt. Neways hope this helps someone else.


----------



## Epi-do (Nov 19, 2010)

remt said:


> good point about evaluating for cardiac. One of those things that I learned in school but wasnt thinking about when I was on the call...now I know.
> 
> Also after I looked at the strip again, I think I can safely say that the patient was in V-Tach, although I didnt recognize it then...no p waves, wide QRS at a rate of 130.* the problem was the pt. had h/o afib and the strip was irregular*, so it made it seem like this could be normal for the pt. Neways hope this helps someone else.



Just some food for thought.  Although not always, wide & fast typically tends to be a ventricular rhythm.  If it is fast enough, it can have an appearance of being irregular, and the p waves can get buried, so you don't necessarily see them.  You pulse may also feel irregular since not all of the beats may be perfusing.  Furthermore, a tachy rhythm can cause issues with preload, since there isn't enough time for blood to get into the chamber before the next contraction.  If this continues for long enough, things back up, and where do the back up to?  It could explain the gurgling you were hearing.  

I am guessing you haven't been out of school for very long, although I could be wrong.  Don't beat yourself up over it, and tuck away what you learned for the next pt.  All of us miss things from time to time, even the ones who have been doing this "forever".  Think of it as a reality check to help keep you on your toes.


----------



## remt (Nov 20, 2010)

Epi-do said:


> Just some food for thought.  Although not always, wide & fast typically tends to be a ventricular rhythm.  If it is fast enough, it can have an appearance of being irregular, and the p waves can get buried, so you don't necessarily see them.  You pulse may also feel irregular since not all of the beats may be perfusing.  Furthermore, a tachy rhythm can cause issues with preload, since there isn't enough time for blood to get into the chamber before the next contraction.  If this continues for long enough, things back up, and where do the back up to?  It could explain the gurgling you were hearing.
> 
> I am guessing you haven't been out of school for very long, although I could be wrong.  Don't beat yourself up over it, and tuck away what you learned for the next pt.  All of us miss things from time to time, even the ones who have been doing this "forever".  Think of it as a reality check to help keep you on your toes.



Thanks man....yeah out of school for a year


----------



## Melclin (Nov 21, 2010)

Can you post the strip?


----------



## remt (Nov 22, 2010)

best i could do


----------



## Melclin (Nov 23, 2010)

Hard to say with that pic, but I'd put my money on Af with a ventricular conduction deficit of some kind. 

Either way, pretty sure that's not VT.

So don't beat yourself up.


----------



## MrBrown (Nov 23, 2010)

Thats not VT ... looks like some sort of flutter and a block that got in a traffic accident :unsure:


----------



## CAOX3 (Nov 23, 2010)

How about the airway, gurgling, I would say this needs to be addressed immediately,  BVM, ETI, CPAP,whatever you have at your disposal.

If you can't get that under control the underlying cause is going to be irrelevant.


----------



## Yurong (Nov 25, 2010)

Agreed, not VTACH...


----------



## katgrl2003 (Nov 25, 2010)

Haven't studied much of cardio, but that's one of the strips that has me looking like a monkey doing a math problem. :wacko:


----------

