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

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic @DidlakeDW A 50 y/o Male was taking his dog for a leisurely stroll through the park when he suddenly experienced new onset chest discomfort. He waited for it to subside, but after 30 minutes of persistence he called 911. EMS personnel found him seated on a bench, uncomfortable, but without gross distress. There was no obvious pallor, diaphoresis, or dyspnea, and he denied any prior episodes of vomiting. He described the pain as “nagging,” and equally not exacerbated by any kind of movement. A pertinent medical history remarkab ..read more

Original publication date July, 2009. Concept Review How do you identify right bundle branch block (RBBB) on the 12 lead ECG? Most of us were told to look for “bunny ears” or to use the “turn signal” method, but all you really need for the ECG diagnosis of RBBB are the following: Supraventricular rhythm QRS duration equal or greater than 120 ms (0.12 s) Terminal R wave in lead V1 Slurred S wave in lead I Let’s look at an example. What’s the rhythm? We have borderline sinus bradycardia with 1°AVB and occasional PACs. Is that a supraventricular rhythm? Yes. Let’s look at the 12-lead ECG. Is ..read more

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith @SmithECGblog I was conducting QA/QI on two very recent cases and was struck by the uniqueness of both. CASE 1 A 45 y/o Male called 911 for new onset central chest discomfort, non-radiating, 5/10 pain scale, and without any vomiting, diaphoresis, or pallor. Moreover, he had no pertinent medical history to report in terms of CAD, HTN, HLD, or DM, for example. His vital signs were unremarkable, and the lung fields were free of fluid congestion during auscultation. A 12 Lead ECG ..read more

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith http://hqmeded-ecg.blogspot.com/ @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated. This occurred in a public place, so bystanders rushed to his aid and provided immediate assistance to protect against any associated fall or head strike. It’s reported that he regained consciousness after 30 seconds, approximately. EMS finds him supine, alert and oriented, and without any gross distress. Crew members note residual pallor and clammy skin. He reports a vague ..read more