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Stolen from a friend. 68 y/o female complaining of SOB x3 hours without relief from multiple home NRB treatments.
Ready? GO!!!
ECG Cold Read
- Thread starter Handsome Robb
- Start date
Stolen from a friend. 68 y/o female complaining of SOB x3 hours without relief from multiple home NRB treatments.
Ready? GO!!!
teedubbyaw
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Man, that's a tough one. The P waves appear disassociated, but it's difficult to see. Appears to be an S1Q3T3 pattern. Part of me wants to say CHB, but I don't think that's it. I can't rule out accel. idioventricular.
TransportJockey
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Almost looks like a Sine-type wave like you might get from hypokalemia... but damn that would take a LOT of neb treatments...
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15mg of albuterol will lower serum K up to 1 mEq/L.
"Multiple" home neb treatments could easily exceed that, and might be enough if the serum K is already lowered due to potassium-wasting diuretics.
teedubbyaw
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I've not heard of sine waves in hypOkalemia.
TransportJockey
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Doh uou got me on that one. I'm gonna go take a nap before I spew any other completely wrong info
teedubbyaw
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Still a really good thought. My mind wasn't even looking at the albuterol factor.
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I was gonna say..sine waves and hypoK? 
I'm not spilling the beans until later tonight or tomorrow once more people have a chance to see it.
I'm not spilling the beans until later tonight or tomorrow once more people have a chance to see it.
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He just thinks that way cause everything he runs into is a high acuity rainbow-striped zebra.
Burritomedic1127
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Initially +1 for hyper k but looking again it's has ERAD and maybe positive aVR?
Initial reaction: Yikes. Q: wtf? A: dunno, but bad. Pads, calcium, and maybe some bicarb to patient, incontinence aid to self.
Slower reaction: Without the history looks like hyperK as said...or maybe TCA OD/Na blocker OD. Maybe super acidotic? Also as said, rhythm looks idioventricular to me, though there might be some P's floating around for 3rd degree. I suppose there's inferior elevation at a minimum, but in this context I don't know what to do with that information.
No clue how the history matches up unless its resp acidosis - red herring maybe? Or maybe the SOB is just a bit of heart failure.
Slower reaction: Without the history looks like hyperK as said...or maybe TCA OD/Na blocker OD. Maybe super acidotic? Also as said, rhythm looks idioventricular to me, though there might be some P's floating around for 3rd degree. I suppose there's inferior elevation at a minimum, but in this context I don't know what to do with that information.
No clue how the history matches up unless its resp acidosis - red herring maybe? Or maybe the SOB is just a bit of heart failure.
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teedubbyaw
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hyperkalemia first came to mind, as well.
Hurry up, Robb, I don't want to wait.
Hurry up, Robb, I don't want to wait.
Angel
Paramedic
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im gonna say sine waves-hyperkalemia, but i really am not too sure. are we just talking ecg or full on assessment? I wonder what other collaborating factors this patient has to help us rule in/rule out whats going on.
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I'm going to throw some stuff out... HyperK. I'm pretty darned sure I can see some P waves in front of the QRS complexes that show them... but I'm also thinking possibly accelerated idioventricular rhythm if it's Type III block. Yet another possibility (because some bumps are there...) 2nd degree type II block, 4:1 conduction... maybe. In the V1 lead, there are some little bumps that seem to march out for that.
TomB
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Hyperkalemia, without a doubt. Even to the point of double-counting the QRS complexes which is often the case with the GE-Marquette 12SL interpretive algorithm. When the QRS duration is greater than 200 ms (one large block), the S and T waves merge together (sine wave or "Z-fold"), and the upslope of the T is steeper than the downslope, it's hyperkalemia with 99% certainty. Typically the history removes all doubt if you know what to look for. Regardless, calcium is cheap, benign, and life-saving. To paraphrase Dr. Smith, how many medical therapies can you say that about?
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Unfortunately I don't have a medication list for you guys. This is what I have.
Hx: copd, chf, previous mi, previous stroke, HTN, IDDM.
Ashen gray in color, so diaphoretic it looks like someone was washing her with sweat...you could wipe then she would be soaked again immediately.
Alert to voice, unable to speak or follow commands but responds to pain and stern voice.
Bp 80/50 manual, r-26 shallow, labored. 96%ra etco2: 28
P:60-90
No TCA med bottles were found on scene.
This patient coded just as they arrived at the hospital prior to entering the ED. I'm still waiting to hear back from my friend as to any labs that were drawn during the ED resuscitation attempts and a final Dx/CoD.
Hx: copd, chf, previous mi, previous stroke, HTN, IDDM.
Ashen gray in color, so diaphoretic it looks like someone was washing her with sweat...you could wipe then she would be soaked again immediately.
Alert to voice, unable to speak or follow commands but responds to pain and stern voice.
Bp 80/50 manual, r-26 shallow, labored. 96%ra etco2: 28
P:60-90
No TCA med bottles were found on scene.
This patient coded just as they arrived at the hospital prior to entering the ED. I'm still waiting to hear back from my friend as to any labs that were drawn during the ED resuscitation attempts and a final Dx/CoD.
Christopher
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Littmann's Sign you say!? Everybody loves that sign.