R.E.B.E.L. ECG of the Week #1

08 Nov
November 8, 2013

R.E.B.E.L. EM ECG of the Week #168 year old hispanic female with a chief complaint of weakness/syncope.  PMH of type 2 diabetes mellitus and hypertension.  She was brought in via EMS due to the family calling 911 as she had an episode of syncope while at the dinner table.  At the time of arrival:

VS: 96/48   43     18     99% on RA  98.7

ECG obtained at arrival is shown…

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CPR: Hands-on or Hands-off Defibrillation

01 Nov
November 1, 2013

CPRPauses in chest compressions are known to be detrimental to survival in cardiac arrest, so much so that the 2010 American Heart Association (AHA) emphasize high-quality compressions while minimizing interruptions. There have been some studies that now advocate for continuous chest compressions during a defibrillation shock. There have been substantial changes to external defibrillation technology  including:

  • Biphasic shocks with real-time impedance monitoring to reduce peak voltages
  • Paddles being replaced by adhesive pre-gelled electrodes
  • Enhancement in ECG filtering permitting rhythm monitoring during chest compressions.

So the mantra of “hard and fast” may be true when it comes to CPR, but the real question now becomes, should we be continuing CPR during defibrillation?

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Bundle Branch Blocks: 101

01 Nov
November 1, 2013

Electrical Conduction System of the HeartRecently, I have been asked by several students at my home institution (UTHSC at San Antonio) to help them understand bundle branch blocks.  This is different than some of my usual posts because it is meant to be more educational than evidence based.  So here we go.  The normal conduction system of the healthy heart is shown to the right.  If there is a delay or block in the left or right bundle, depolarization will take longer to occur. Therefore we get a widened QRS (>0.12 sec or >3 small boxes).

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The Importance of Reciprocal Changes in aVL

01 Nov
November 1, 2013

Reciprocal Change in aVLECG interpretation is one of the most important skills to master as an emergency  physician, and its interpretation can be very complex and frustrating. ECG manifestations can be very subtle, and sometimes the earliest and only ECG change seen will be reciprocal changes alone. To further complicate this, many patients have the atypical symptoms of nausea/vomiting, weakness, or shortness of breath and not chest pain.

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Is ATLS wrong about palpable blood pressure estimates?

01 Nov
November 1, 2013
ATLSIn Advanced Trauma Life Support (ATLS), we learned that a carotid, femoral, and radial pulse correlates to a certain systolic blood pressure (SBP) in hypotensive trauma patients.  Specifically ATLS stated:
  •  Carotid pulse only = SBP 60 – 70 mmHg
  •  Carotid & Femoral pulse only = SBP 70 – 80 mmHg
  •  Radial pulse present = SBP >80 mmHg

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