Just checking… I have a CRAZY 12 lead I'd like to post if anyone is interested. If so, give me a day or so.

I'm going to regret this, but post it up

I suck, so I need this thread.  
oh, and in before Dale Dubin the PedoPhile

Post it up.

Hi guys

Thanks for your patience.

A little background... I work overseas at a small hospital providing medical services for American Expats and foreign nationals. This gentleman was a 48yo male who came to the walk-in clinic c/o RIGHT neck and shoulder pain with SOB, his neck pain increased upon palpation. He was tachycardic, increased WOB, slightly hypertensive and O2 sat around 91-92% on room air. He was observed to have this ECG. We have NO cardiologist on staff, just an ER physician, Surgeon, two PA's and a CRNA... of course a few nurses and some paramedics. The decision was made to have him MedEvac'ed out so he was "admitted" overnight until arrangements are finalized.

The only thing abnormal from his labs were increased white count around 12.5 and a glucose level of about 160... cardiac enzymes are negative.

That look like cardiac damage from a previous issue to me.  And the increase of pain upon palpation kinda sound like something else is going on

LoL yea but his orange book was quite good

Initial thought was a PE. He received fluids but never had any urine output through the night. He was working the breathe with a RR 30-32, no improvement of sats. The ER doc was racking his brain trying to figure out what was going on.

Looking at the potential RBBB in V1 with Slight ST depression, I was thinking posterior MI along with some type of AV dissociation.

I came in early just to see what was going on and the pt looked like crap. I listened him and he was wet with slight audible rhonchi and worsening sats. I suggested CPAP and the doc said sure. Sats came back up to high 80's/low 90's.

The CRNA came in a couple hours later with our surgeon and decided to intubate him. Lung compliance was good but could never get sats out of the low 90's and pressure becomes unstable. An hour later he arrest.

1. First degree block






ETA: I just saw your newest post, 7 seconds before mine.




 

ETA2: Can you get a CT where you're working? What about a dissecting thoracic aneurysm?

Unable to obtain a good patient history as he was a foreign national. No CT available and our Rad Tech for the portable X-ray was entering the country coming off of R&R status.

D-Dimer negative.

He went into PEA four times over the course of about 6 hours and was successfully resuscitated.

I will post some other 12 Leads later with more info.

With PEA, what about the H's and T's?


Hypovolemia


Hypoxia


Hydrogen ion (acidosis)


Hyper/Hypo-kalemia


Toxins


Tamponade (no trauma, but maybe a contained dissection?)


Tension pneumo (probably not)


Thrombosis (but a negative D-dimer?)




CMP? What were his kidneys, K and CO2 showing? Do you have an iStat there? Tox screen, even a urine dipstick/cup tox?




I love these cases. How am I supposed to sleep now? And stupid daylight savings is coming this weekend.


 

This guy had cath lab tattooed on his forehead even before the PEA. When he lands in the states, he won't even come to a complete stop in the ER. They'll just slow the gurney a bit for the ER doc to say, "Yup. Cath lab stat. KThanksBye".

 
 
 

 


And as AGW's northern neighbor, I really wish Utah could figure out the Arizona plan and stop with the time changes. It's not like most of us are out bringing in the crop this weekend.


 

Here is an ECG between one of his PEA episodes; a trigeminal rhythm.

All I can say is he is of Eastern European descent, and a normally healthy looking male.

Cardiac Enzymes and D-Dimer continued to be negative to this point. Our Lab guy even ran controls just to make sure his machines were functioning properly.

ER Doc was stuck on diagnoses of Myocarditis. His rationale was that the right neck pain could have been from inflammation of the right carotid artery, coming off the brachiocephalic branch of the aorta, and similar ECG findings during his research. Also his white count went from 12.5 to 22, but he was afebrile.

Before he was tubed, a foley was put in and they got around 400cc of clear urine.

I am not sure of all the meds the CRNA used for RSI, but I know she used Rocuronium, possibly versed and fentanyl. No Succ.

We have a portable sonogram and one of the docs took a quick look at the patients heart and saw no pericardial fluid.

No pneumothorax noted or suspected

Lab Chemistry I cannot remember specifically. But I do know his K+ was low normal. And a negative on the ABG's.

It was a pain trying to maintain his pressure. He would be good one minute and drop the next. He finally leveled out with an Isoproterenol drip. Before that he was on an Amiodarone and neosynephrine.

He converted to sinus rhythm and maintained it for a while; note the ST depression in the inferior and lateral leads:

I mean... WTF was going on with this guy!!

Prior to this thing kicking off, his pressures were 140-150/100ish. Following intubation, 70-80/50ish. No edema or murmurs were noted on PE.

I sent this in a PM to GypsyDoc and he didn't laugh me off the internet, so I thought I'd post it up here to see if anyone else wants to chime in...



Ok, I've been debating whether or not to expose myself to potential ridicule here for the last few days, but what the heck, here we go. Bear in mind I am a lowly little paramedic student, so I'll just be over here in my glass house not throwing any big stones I didn't have the guts to post in the thread so you're stuck with an IM  


I am seeing 3rd degree junctional in that first strip in addition to the RBBB. I see extra p-waves in Lead I and they do not appear to have any correlation to the (narrow) QRS complexes. We have been taught to drop into V1 first, and it looks like there are embedded p-waves there as well. Am I just seeing things that aren't really there? Wouldn't 3J and a RBBB correspond with the symptoms the PT was experiencing as well as not responding to the amiodorone drip? It's a shame we don't know if the RBBB is new onset or not, that could have helped you out tremedously.

12 leads are far and away my weakest area so I am trying to take every opportunity to learn that I can get. Please don't mistake this as second guessing your actions; it is 12 lead interpretation afterall  

Also, a long shot here, but how were his teeth? We recently had a PT in the ED who presented in a similar manner (we could not get their sats up no matter how much O2 we gave). Turns out they had a sensitivity to 'caine' drugs. Our PT had been taking orajel and had an unknown sensitivity to it. There was oxygen on their hemoglobin but the meds were preventing the body from being able to utilize it. Wouldn't necessarily be caused by orajel but a similar med could do it. Treatment for it was Methyl Blue.


ETA: I may have missed where you ran the appropriate labs that would have identified this. We caught it because their PAO2 was over 300 but they were still sating in the 70's and 80's.

Interesting theory, but I am not sure how "caine" drugs would affect the transfer of O2 to or from hemoglobin. Most "caine" drugs act a Na+ channel blockers, thereby inhibiting depolarization of the cellular membrane. O2 binds to hemoglobin through a process of coopertivity (SP?)... as one O2 molecule binds to hemoglobin it increases the affinity of the next O2 molecule to bind, the second O2 molecule then increases affinity for the 3rd O2 molecule and so forth. CO2 and O2 then transfer (diffuse) to and from tissue-vessel due to pressure and concentration gradient differences. So I am curious how this would affect arterial PO2... interesting!

Who'd a thunk you could have so much fun talking medical crap on a gun website!!

I have to admit, I never expected this kind of discussion here either!



We actually attended an airway lecture during one class given by the head of Vanderbilt's Respiratory department and he mentioned the methemoglobinemia. At the time I thought "I'll never remember that, it's way too rare, I'll never see it" and promptly forgot. About 2 weeks later, it comes across the ED I was doing a clinical in. I'd like to say I remembered and caught it, but that would be a lie . It's also worth noting that the ED doc caught it fairly quickly due to the fact that he had seen it once before. He said the first time didn't go so quickly and took a fair bit of research to figure out!


I'd also like to say that I'm spouting this next part from memory, but, well, you know






http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2263062/



Also (emphasis mine):









http://emedicine.medscape.com/article/204178-overview


The head of the pharmacy personally delivered the methyl blue due to 'abnormal' dosage ordered. He wanted to make sure we ordered correctly and see the situation first hand. It worked relatively quickly and IIRC we discharged the PT.


Those were two quick links that popped up on google, there's plenty more out there.


I'm still not convinced it fits all the criteria of what your guy had, but I would have loved to see what his PaO2 was! The neck pain is a bit of an outlier, as well as the fluids, but nothing says he didn't have some comorbidities.




Also, I ran the 12 leads past the rest of the class. So far everyone in my class that has replied has called the first one as a 3rd degree block (not surprising since we all learned to read them the same way haha). I'll be back in class tomorrow and I'll try and see what the head of the program thinks. He is an ECG 'Guru', so it should be interesting.

Awesome! I read the article, very cool! Now I need to find out how this stuff converts at the biochemical/cellular level.

I have nothing really useful to add, my only exposure was to a 3-wire in Physiology lab, but even I could tell there was something extremely wrong with that.

The consensus from my class was 3*I, but again, not surprising since we all learned from the same set of rules. I also sent it to the medical officer for my agency and got this back :









Did you ever get any update on the guy?

Yes, I received an update the other day… The guy just got extubated and is receiving, or has received, some type of ventricular pump. I will have to ask Monday for more details.

I am interested to hear what else your medical officer says.

Interesting. I was wondering if he boxed his LV and went into acute edema. It would make sense if he's getting an LVAD or Impella. The PEA instead of VF makes me scratch my head a bit, as do the funky rhythm changes. I have seen one case of presumed viral myocarditis that temporarily took out the conduction system (AV dissociation/3rd degree) of a marathon runner in her 20s.