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Interesting Case:

Interesting Case:. C. Rebus R3-EM DrRebus.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/.

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Interesting Case:

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  1. Interesting Case: C. Rebus R3-EM DrRebus.com

  2. Conflict of Interest • None. • Names changed to protect the innocent.

  3. Table of Contents

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

  5. Day 1, Hour 1, Patient 1 http://www.cs.uleth.ca/~vpak/spring2008/gram3710/

  6. Someone in the Code Room • Clerks: General Approach?

  7. Someone in the Code Room • Clerks: General Approach? • 1* Survey • Airway • Breathing • Circulation • Disability • MORE HERE

  8. 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

  9. 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

  10. EKG

  11. EKG Idioventricular Rhythm HR 37 No P waves QRS 154 Axis ****ADD****

  12. Idioventricular Rhythm • > 6 consecutive ventricular escape beats. • HR 30 – 40 • QRS >0.16, similar to PVC

  13. ...his cardiologist is on the phone. http://en.wikipedia.org/wiki/File:God2-Sistine_Chapel.png

  14. What is happening?

  15. EKG

  16. EKG Sinus bradycardia HR 31 Abnormal P waves QRS 148 Axis ****ADD**** RIGHT BBB LEFT anterior fasicular block

  17. 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.

  18. 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.

  19. Pacing • Indications • Theraputic – correct rhythm disturbance • Prophylactically – anticipation of conduction problem / failure

  20. 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.

  21. Questions? Joan Oliver and guide, Chris Hasler, on mountain climb, Lake Louise area, Alberta. c. 1936 Mount LeFroy Mitre

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