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Sdiver
10-29-2009, 21:56
This one had us stymied. This is a call we ran today.

Got called to a Clinic for a 41 y/o male c/o CP.

Hx: 41 y/o Hispanic Male who came into the clinic to get checked out. Stated yesterday, he experienced substernal chest pain, radiating straight to is back at around 1000 hrs. Rated it as a 7 out of 10. Said that it lasted for about 4 hours. Said he took a Tylenol at 1400 hrs and that it resolved itself.

Went out and shoveled snow for about 3 hours. Didn't have any other complaints. Went to bed around 2200 hrs. At or about 0300 this morning, was awoken with the same pain, substernal radiating straight to back. Said he took a Tylenol, went back to bed and pain resolved itself. Awoke at 0600 with severe dyafaresius. Stated his bed sheets were soaked and that he went through 2 towels that his wife brought, just to dry off.

Denies any dizziness, SOB, nausea, vomiting, or any other pain.

At the clinic he stated he was pain free. No pertant past medical Hx. Is not on any medications. Does state that he has used Cocaine before in the past, but said he hasn't used it in years.

U/A, the clinic started an 18g IV NS Left hand, O2 2L NC, and had given him 324mg aspirin.

Vitals: Rate 112, BP 118/76, Resp 18

After loading him up on our cot and hooking him up to our monitor these are our strips.

Pic 1: Initial EKG
Pic 2: 1st 12 Lead
Pic 3: 2nd 12 Lead (taken a few seconds after 1st.

cont........

Sdiver
10-29-2009, 22:09
Initially, we were calling it a Junctional Tachycardia.

We placed him on 10L O2 NRB and loaded him in our truck. Took another set of vitals, which were virtually unchanged.

Rate 110, BP 122/74, Resp 20

Ran another set of strips.

1st pic: Per 10L O2
2nd pic: O2 10L NRB
3rd pic: O2 10L NRB
4th pic: full strip


We transported Pt to Hsp, which was across the street from clinic, transport time less than 5 minutes.

When we got to the ED, we had 3 Docs with us listening to our report and looking at our strips. One called it A-fib, another called it a 2nd degree block, and the 3rd called it a 3rd degree block.

After the call, my partner and I got a break and pulled out these strips and "Hemmed" and "Haughed" about we we had. There was a lot of, "There's no P-wave" and "The P-wave is buried in the T-wave" and "There's the P-wave" and "What the Hell is that????" (some guy was passing by our truck in nothing more than shorts and a t-shirt)

After awhile, we decided that it's a 2nd degree Type II Block "Mobitz".

I'd just like to see what anyone else here can determine that this might be.

Brush Okie
10-29-2009, 22:50
I havent looked at EKG's for years now.

It looks like the P wave intervol is very long and he is going in and out of A fib. Hard to tell without calipers etc. It looked like mobitz into a fib then back. Any chance he has some type of un DX'd problem like wolf parksons white syndrome?

PedOncoDoc
10-30-2009, 05:23
Prints 2-4 from the second post definitely lok like 2nd degree type 2 Moebitz to me with the lengthening PR interval followed by a dropped QRS. Can't be 3rd degree as the R-R and P-P intervals are not consistent and unmatched. The first post didn't seem to catch the rhythm.

Tatonka316
10-30-2009, 06:22
I agree with PedOncoDoc - looks like Mobitz Type II to me as well

Sdiver
10-30-2009, 20:22
I havent looked at EKG's for years now.

It looks like the P wave interval is very long and he is going in and out of A fib. Hard to tell without calipers etc. It looked like mobitz into a fib then back. Any chance he has some type of un DX'd problem like wolf parkinsons white syndrome?

Brush:
Unknown if he had any un DX'd problem. He said he didn't have any real past medical history, but that is an interesting possibility.


Prints 2-4 from the second post definitely look like 2nd degree type 2 Moebitz to me with the lengthening PR interval followed by a dropped QRS. Can't be 3rd degree as the R-R and P-P intervals are not consistent and unmatched. The first post didn't seem to catch the rhythm.

I agree with PedOncoDoc - looks like Mobitz Type II to me as well

Doc and Tatonka:
Thanks for the clarification. This is something that we don't really see all that much, so that's why we were stymied. :D

If we get a chance to get back to the Hsp, we'll try and get a follow up. Didn't get a chance today, but I'm sure we'll have an opportunity tomorrow. :D

Sdiver
10-31-2009, 20:20
Got a chance to do a follow up on this Pt. today. He's currently on a Tele floor at the hospital we transported him too. They are going to keep him over the weekend for further obs.

They confirmed a Right BBB. He was still having runs of Tachycardia while on the Tele floor. While we were there, he was showing a rate of 110 while laying in bed. 41 years old with a RBBB ...... WOW.

We left our information with the nurse, if anything new comes up, and if it does, I'll pass it along.

Brush Okie
10-31-2009, 21:22
Did his labs come back with an infarction? (sp) or pos for any type of drugs? Just wondering what would cause a BBB in the guy besides an AMI.

Box
10-31-2009, 22:13
I cant even spell EKG any more....

greenberetTFS
11-01-2009, 13:23
I cant even spell EKG any more....

Billy,

You must have gotten your medical training from Dozer...................;)

Big Teddy :munchin

thrilla82
11-01-2009, 21:40
their positive that it was a rbbb instead of a lbbb? v1 shows a downward qs complex which usually indicates a lbbb. interesting 12 lead though, was anyone able to do a 15 lead?

Dozer523
11-01-2009, 22:26
Billy,You must have gotten your medical training from Dozer...................;)

Big Teddy :munchin
I got my degree here. :munchin THIS! http://www.youtube.com/watch?v=kO8x8eoU3L4&feature=related