David Didlake @DidlakeDW EMS personnel responded to the residence of an 81 y/o Male with syncope. His spouse had called 911 after she heard a loud “thud” in the adjacent room. He was found altered, hypotensive, and with a large hematoma to the left periorbital region. No 12 Lead ECG was captured, but telemetry did reveal the following: The spouse offers a pertinent medical history to include HTN and HLD, and furthermore states that he hasn’t previously complained of any chest discomfort, or shortness of breath. He awoke earlier that morning in his usual state of health. His confusion prog ..read more

TCP In Transit: A case reviewing transcutaneous pacing, false electrical capture, and re-arrest. Josh Kimbrell, NRP @joshkimbre Judah Kreinbrook, EMT-P @JMedic2JDoc This is the first installment of a blog series showing how transcutaneous pacing (TCP) can be difficult, and how you can improve your skills. We will be using redacted information from different cases where paramedics attempted TCP in the field. Details are edited and redacted to preserve patient anonymity. In this case, paramedics were called to an elderly male's apartment, and after troubleshooting an inaccurate address from disp ..read more

David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath. She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease. Specific to the latter, she was previously deemed not appropriate for CABG (complex rationale) with preference for optimized medical management, instead. A 12 Lead ECG was captured. There is bradycardic Atrial Fibrillation with broad ST-depression in most leads and perceptible ST-elevation in aVR. This should prompt immediate investigation into supply-demand mismatching, or ACS. Bu ..read more

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith http://hqmeded-ecg.blogspot.com/ @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. She described it as tightness, centralized, and associated with both dyspnea and diaphoresis. She experienced the symptoms while helping a friend carry a rather cumbersome item up a flight of stairs at an apartment complex. She was forced to take pause and collect herself. The symptoms subseque ..read more

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (Ret) @DidlakeDW Expert contribution by Dr Robert Herman @RobertHermanMD @PowerfulMedical (Chief Medical Officer) An adult male called 911 for new-onset epigastric burning. Fire/EMS crews found him clammy and uncomfortable. Vital signs were noted to be unremarkable with respect to any hypo-hypertensive crisis, hypoxia, etc. Breath sounds were clear in all lung fields. No appreciable skin pallor. He denied any known medical history, specifically: coronary artery disease, hypertension, dyslipidemia, diabetes, heart failure, myoc ..read more

Accurate lead placement is invaluable, and makes a significant impact on appropriate care trajectory, or misdiagnosis with unnecessary utilization of resources. A common finding associated with V1 / V2 malposition is P wave inversion, and rSr’ QRS with T wave inversion -- potentially leading clinicians to suspect Brugada pattern, for example, when no such entity exists. Another spurious finding is a QS pattern that mimics Anterior MI, and in the acute setting this may elicit compulsory urge to pursue invasive coronary intervention that is entirely unwarranted. Tom Bouthillet demonstrates appro ..read more

Acute LAD occlusion in the setting of Right Bundle Branch Block and Left Anterior Fascicular Block. Case Review: https://www.youtube.com/watch?v=0Rs1_TpYMwE Key features of Right Bundle Branch Block: In general, there is no ST elevation throughout the 12 Lead ECG. RBBB has expected slight ST depression, with T wave inversion, in V1-V3 when discordant to a positive R' wave. A possible normal variant is lateral ST elevation (i.e., I/aVL/V5/V6) with bulky T waves when subsequent to a large, slurred S wave. This finding should be assumed new, until proven otherwise, during suspected Acute Corona ..read more

New onset chest discomfort with demonstrable Hyperacute T waves that went undetected by EMS, EM, and cardiology. Case review presentation: https://www.youtube.com/watch?v=r7MmoDJgba4 Below is the link for detailed review on the hyperacute T wave (with expert commentary by Dr. Steve Smith). https://www.ems12lead.com/post/the-hyperacute-t-wave ..read more

It's back to the basics! Take a seat and relax as the maestro, Tom Bouthillet, guides us through a stepwise approach to assessing Left Bundle Branch Block-- especially in the nefarious context of Occlusive Myocardial Infarction. Video presentation below: https://www.youtube.com/watch?v=bp-J6n-MPlU ..read more

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Expert commentary and peer review by Dr. Jesse McLaren @ECGcases https://emergencymedicinecases.com/ http://hqmeded-ecg.blogspot.com/ This case was kindly submitted by Dr. Paco Dardon (@PacoDardon), and it’s a privilege to present it as a formal review due to the many pathophysiological, and electrophysiological, phenomenon at play. A 65 y/o Female was admitted to the ICU for septic shock. She was critically ill despite aggressive vasopressor therapy. A 12 Lead ECG was recorded secondary to bizarre telemetry finding ..read more