Go Back   Professional Soldiers ® > TMC 14 > Medical Pearls Of Wisdom

Reply
 
Thread Tools Display Modes
Old 06-15-2013, 12:33   #31
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Quote:
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 ???
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!
Sdiver is offline   Reply With Quote
Old 06-15-2013, 13:15   #32
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
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.
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 06-15-2013, 18:28   #33
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by Brush Okie View Post
How about a digitalis OD
Did you see Foxglove in her garden?
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 06-19-2013, 14:33   #34
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Quote:
Originally Posted by Trapper John View Post
SDiver- Are you going to post the answer to this one? Will there be prizes like the last time?
Quote:
Originally Posted by Sdiver View Post
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)
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!
Sdiver is offline   Reply With Quote
Old 06-19-2013, 14:48   #35
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
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?
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 06-19-2013, 17:26   #36
MR2
Quiet Professional
 
MR2's Avatar
 
Join Date: Nov 2011
Location: Location, Location
Posts: 3,997
I do believe it was the nipple ring that caused the underlying sepsis.

Doom on you whosoever reuses a nipple ring.
__________________
The two most powerful warriors are patience and time - Leo Tolstoy

It's Never Crowded Along the Extra Mile - Wayne Dyer


WOKE = Willfully Overlooking Known Evil
MR2 is offline   Reply With Quote
Old 06-19-2013, 17:39   #37
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by MR2 View Post
I do believe it was the nipple ring that caused the underlying sepsis.

Doom on you whosoever reuses a nipple ring.
Ooops
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 06-20-2013, 17:16   #38
Patriot007
Guerrilla
 
Join Date: Nov 2006
Location: Free Pennsylvania
Posts: 138
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.
Patriot007 is offline   Reply With Quote
Old 06-20-2013, 18:32   #39
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
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.
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 06-21-2013, 04:41   #40
PedOncoDoc
Area Commander
 
PedOncoDoc's Avatar
 
Join Date: Oct 2009
Location: Northeast Utah
Posts: 1,712
Quote:
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.
__________________
‎"The dignity of man is not shattered in a single blow, but slowly softened, bent, and eventually neutered. Men are seldom forced to act, but are constantly restrained from acting. Such power does not destroy outright, but prevents genuine existence. It does not tyrannize immediately, but it dampens, weakens, and ultimately suffocates, until the entire population is reduced to nothing better than a flock of timid, uninspired animals, of which the government is shepherd." - Alexis de Tocqueville
PedOncoDoc is offline   Reply With Quote
Old 06-21-2013, 08:00   #41
Patriot007
Guerrilla
 
Join Date: Nov 2006
Location: Free Pennsylvania
Posts: 138
Quote:
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.
Patriot007 is offline   Reply With Quote
Old 06-21-2013, 08:24   #42
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
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.
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Reply


Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
 
Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is Off
HTML code is Off

Forum Jump



All times are GMT -6. The time now is 08:46.



Copyright 2004-2022 by Professional Soldiers ®
Site Designed, Maintained, & Hosted by Hilliker Technologies