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Old 06-15-2013, 12:33   #31
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Originally Posted by longrange1947 View Post
Hey, old SF medic, usually stay out of these, my memory is not that god anymore.
A little Freudian slip there LR ???
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Old 06-15-2013, 13:15   #32
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The T-waves in this patient are highly irregular. May be fused P waves or U waves or both. Definitely not hyperkalemia. May be hypokalemia. Has the patient been having diarrhea? On diuretics?

May also be fused P wave and now were back to BrushOkie's heart block (probably Stage 1).

What are the chances of both hypokalemic and stage 1 heart block?

Will IV KCL (bolus, 1100 mg) be differentiating? If so I would monitor the T waves to see if a normal T wave appears. If not then we may be dealing with heart block and IV lidocaine (50 mg IV bolus) would be indicated.

I am still leaning more towards AF with hypokalemia.
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Old 06-15-2013, 18:28   #33
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Originally Posted by Brush Okie View Post
How about a digitalis OD
Did you see Foxglove in her garden?
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Old 06-19-2013, 14:33   #34
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SDiver- Are you going to post the answer to this one? Will there be prizes like the last time?
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It's funny you should mention this Trap. It's still being discussed over on my other board. .....

I'll let ya know what's determined once it's posted.
Well, they posted a Dx today .....

Quote:
Revisiting this strip from last week... The majority of responses called for either cardioversion or rate control for our sick patient... However, she was in septic shock, and needed several liters of fluid before the rate returned to a normal range. Determining treatment for patients in AFib w/RVR is not easy!
She must've had an underlying condition of HTN, because her MAP (Mean Arterial Pressure) wasn't below 65 .... (although, <65 is what we use to call a Sepsis alert.) .... so her lactate must have been out of wack.

MAP formula ..... Systolic X's 2 plus diastolic divided by 3

86(2) + 60 / 3 .... 172+60 / 3 = 77.3 MAP

Trap .... Your prize, along with everyone else's is ...... Greater Knowledge and Understanding. (looks like you're stuck with that nipple ring)
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Old 06-19-2013, 14:48   #35
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Thanks for this one. Very interesting. And, yes I did learn a few things on this one too.

One question: If she was in septic shock wouldn't she have presented with fever?

Brush Okie, I know you really wanted my nipple ring. Maybe next go around?
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Old 06-19-2013, 17:26   #36
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I do believe it was the nipple ring that caused the underlying sepsis.

Doom on you whosoever reuses a nipple ring.
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Old 06-19-2013, 17:39   #37
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I do believe it was the nipple ring that caused the underlying sepsis.

Doom on you whosoever reuses a nipple ring.
Ooops
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Old 06-20-2013, 17:16   #38
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Systemic Inflammatory Response Syndrome or SIRS is a syndrome characterized by at least 2 out of 4 criteria.

1. Temperature- greater than 38 (100.4 F )or less than 36 (96.8 F)
2. Heart Rate- greater than 90
3. Respirations- greater than 20
4. White Blood cell count- less than 40000 or greater than 12,000

SEPSIS- is SIRS criteria (atleast 2 of 4) plus a presumed source of infection.

Therefore- A septic patient can be hypothermic, normothermic, or hyperthermic.

Blood pressure is not a criteria to define sepsis. In fact, early in sepsis in healthy individuals blood pressure is usually normal. They are still compensating well enough to maintain a normal BP. Also you can have elevated lactate ( an indication of inadequate tissue perfusion or SHOCK) with a normal blood pressure.


When you have sepsis plus low blood pressure that is not responsive to fluid boluses alone you have SEPTIC SHOCK.
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Old 06-20-2013, 18:32   #39
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Originally Posted by Patriot007 View Post
Systemic Inflammatory Response Syndrome or SIRS is a syndrome characterized by at least 2 out of 4 criteria.

1. Temperature- greater than 38 (100.4 F )or less than 36 (96.8 F)
2. Heart Rate- greater than 90
3. Respirations- greater than 20
4. White Blood cell count- less than 40000 or greater than 12,000

SEPSIS- is SIRS criteria (atleast 2 of 4) plus a presumed source of infection.

Therefore- A septic patient can be hypothermic, normothermic, or hyperthermic.

Blood pressure is not a criteria to define sepsis. In fact, early in sepsis in healthy individuals blood pressure is usually normal. They are still compensating well enough to maintain a normal BP. Also you can have elevated lactate ( an indication of inadequate tissue perfusion or SHOCK) with a normal blood pressure.


When you have sepsis plus low blood pressure that is not responsive to fluid boluses alone you have SEPTIC SHOCK.
If Sepsis is at least 2 of the 4 criteria listed above, one of which is unavailable to a first responder, then from an EMTs POV its at least 2 of the three (WBCs not available) So, what conditions that an EMT responds to do not meet conditions 2&3 above? (Other than dead ones and opiod alcohol poisoning. ) Should these be Dx as Sepsis? As a DDx tool for first responders - I think this is of very limited value.

Just my $0.02 worth.
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Old 06-21-2013, 04:41   #40
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Originally Posted by Trapper John View Post
If Sepsis is at least 2 of the 4 criteria listed above, one of which is unavailable to a first responder, then from an EMTs POV its at least 2 of the three (WBCs not available) So, what conditions that an EMT responds to do not meet conditions 2&3 above? (Other than dead ones and opiod alcohol poisoning. ) Should these be Dx as Sepsis? As a DDx tool for first responders - I think this is of very limited value.

Just my $0.02 worth.
Agreed - a physiologic pain response will get you a heart rate >90 and repiratory rate >20. That does not equate with SIRS.

Hell - running 5 miles will give you SIRS by those criteria.
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Old 06-21-2013, 08:00   #41
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Originally Posted by Trapper John View Post
If Sepsis is at least 2 of the 4 criteria listed above, one of which is unavailable to a first responder, then from an EMTs POV its at least 2 of the three (WBCs not available) So, what conditions that an EMT responds to do not meet conditions 2&3 above? (Other than dead ones and opiod alcohol poisoning. ) Should these be Dx as Sepsis? As a DDx tool for first responders - I think this is of very limited value.

Just my $0.02 worth.
Agreed. Often times in medicine definitions arise from the need for standardizing conditions for the purpose of research and are not that helpful to the ones who first reach patients at Death's door and do initial stabilization. This is one of the challenges of field and emergency medicine as when the dust settles there will always be someone standing there in a controlled environment with more stable vitals, a full set of labs, and a CT result with a diagnosis saying "duh stupid!".

Remember, rapid afib for some patients is their sinus tachycardia. If you are sick or stressed and have afib, your afib just beats faster, just like your heart does. There are times when this will get the patient in trouble but often times rate control is contraindicated if you are blunting the patient's normal physiologic response E.G. sepsis, dehydration, hemorrhagic shock.

I've seen and given rate control in several instances where it was hard to pick up on an underlying cause. It happens. It is one of the perils of treating an undifferentiated patient without the luxury of time. It is our job to try to minimize this risk by doing the best quick review of systems that we can (including bystanders) AND realizing when an intervention is not needed just as much when it is needed.
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Old 06-21-2013, 08:24   #42
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Originally Posted by Patriot007 View Post
Agreed. Often times in medicine definitions arise from the need for standardizing conditions for the purpose of research and are not that helpful to the ones who first reach patients at Death's door and do initial stabilization. This is one of the challenges of field and emergency medicine as when the dust settles there will always be someone standing there in a controlled environment with more stable vitals, a full set of labs, and a CT result with a diagnosis saying "duh stupid!".

Remember, rapid afib for some patients is their sinus tachycardia. If you are sick or stressed and have afib, your afib just beats faster, just like your heart does. There are times when this will get the patient in trouble but often times rate control is contraindicated if you are blunting the patient's normal physiologic response E.G. sepsis, dehydration, hemorrhagic shock.

I've seen and given rate control in several instances where it was hard to pick up on an underlying cause. It happens. It is one of the perils of treating an undifferentiated patient without the luxury of time. It is our job to try to minimize this risk by doing the best quick review of systems that we can (including bystanders) AND realizing when an intervention is not needed just as much when it is needed.
Agree 100%. A good case for "less is sometimes more". As I said earlier, this is particularly true for cardiac cases IMO. Pharmacological intervention in these cases scare the crap out of me. No margin of error and when it goes badly it really goes badly very fast. Very unforgiving of error.

Thanks for the post. Learning here.
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