Interesting Case: Interesting Case:

C. Rebus R3-EMC. Rebus R3-EM

DrRebus.comDrRebus.com

Conflict of Interest

• None.

• Names changed to protect the innocent.

Table of Contents

Introductions

http://www.pengrowthsaddledome.com/seating.html

Day 1, Hour 1, Patient 1

http://www.cs.uleth.ca/~vpak/spring2008/gram3710/

Someone in the Code Room

• Clerks: General Approach?

Someone in the Code Room

• Clerks: General Approach?– 1* Survey

• Airway• Breathing• Circulation• Disability• MORE HERE

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

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

EKG

EKG

Idioventricular RhythmHR 37No P wavesQRS 154Axis ****ADD****

• > 6 consecutive ventricular escape beats.

• HR 30 – 40• QRS >0.16, similar to PVC

Idioventricular Rhythm

...his cardiologist is on the phone.

http://en.wikipedia.org/wiki/File:God2-Sistine_Chapel.png

What is happening?

EKG

EKG

Sinus bradycardiaHR 31Abnormal P wavesQRS 148Axis ****ADD****RIGHT BBBLEFT anterior fasicular block

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.

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.

Pacing

• Indications– Theraputic – correct rhythm disturbance–Prophylactically – anticipation of

conduction problem / failure

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.

Questions?

Joan Oliver and guide, Chris Hasler,

on mountain climb, Lake Louise area, Alberta.

c. 1936

Mitre

Mount LeFroy