Interesting Case:
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Interesting Case: Interesting Case:
C. Rebus R3-EMC. Rebus R3-EM
DrRebus.comDrRebus.com
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Conflict of Interest
• None.
• Names changed to protect the innocent.
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Table of Contents
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Introductions
http://www.pengrowthsaddledome.com/seating.html
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Day 1, Hour 1, Patient 1
http://www.cs.uleth.ca/~vpak/spring2008/gram3710/
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Someone in the Code Room
• Clerks: General Approach?
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Someone in the Code Room
• Clerks: General Approach?– 1* Survey
• Airway• Breathing• Circulation• Disability• MORE HERE
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72 yr M, Dizzy on standing
• One episode 11:00 AM. SOB.– Now resolved. Nausea persists.
• No Hx similar. • No chest pain.• PMHx:
– DM2 2002, Oral Rx– CABG x3 1987– MI: 2005 stent, 2008 stent
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Hx cont
• Meds– ASA 81 mg OD– Atenolol 150 mg OD– Clopidogrel 75 mg OD– Diltiazem XR 120 mg OD– Ezetimbe 10 mg OD– Felodipine XR 10 mg OD– Furosemide 120 mg AM / 40 mg afternoon– Metformin 1000 mg BID– NTG patch 0.8 mg on 8am– NTG SL PRN– Ramipril 10 mg BID– Rosuvastatin 10 mg OD
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EKG
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EKG
Idioventricular RhythmHR 37No P wavesQRS 154Axis ****ADD****
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• > 6 consecutive ventricular escape beats.
• HR 30 – 40• QRS >0.16, similar to PVC
Idioventricular Rhythm
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...his cardiologist is on the phone.
http://en.wikipedia.org/wiki/File:God2-Sistine_Chapel.png
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What is happening?
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EKG
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EKG
Sinus bradycardiaHR 31Abnormal P wavesQRS 148Axis ****ADD****RIGHT BBBLEFT anterior fasicular block
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Events
• Atropine x3• IJ and transvenous pacing• Dopamine 5 mcg/kg/min, 10, 15.• Cardiology consult at bedside with echo
– LVEF <5%, Massive LV thrombus.
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Events - Cont.
• 'By the way, I have a burning between my shoulder blades... been there all day.'
• CODE– CPR, epi x3, Ca++, intubated with glide.– 11 minutes.– RIP.
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Pacing
• Indications– Theraputic – correct rhythm disturbance–Prophylactically – anticipation of
conduction problem / failure
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Bibliography
• CURRENT Diagnosis & Treatment: Emergency Medicine, 6e, Ch 33. Accessed online: http://www.accessmedicine.com.ezproxy.lib.ucalgary.ca
• Bessman Edward S, "Chapter 22. Invasive Monitoring, Pacing Techniques, and Automatic and Implantable Defibrillators" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=586856.
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Questions?
Joan Oliver and guide, Chris Hasler,
on mountain climb, Lake Louise area, Alberta.
c. 1936
Mitre
Mount LeFroy