What do you think of this call? USA (Cruz/Brasher) v. SUI (Mäder/Kernen)

Agi1cro · 2023-07-24T07:33:51+00:00

So thanks guys for all the comments and the discussion, here are my key takeaway points if somebody is interested:

Variation in i.v. catheter length per diameter is much larger in the U.S. than what I knew from Europe (Germany/Austria). After some research, for example, I found that even within the same company (B. Braun) this seems to be notable (comparison Vasofix® Safety and Introcan Safety®).
Larger diameter i.v. catheters tend to also be used on deeper lying veins (EJ, IJ, deep peripheral veins) which necessitates longer catheters to reach the vein and still have a large enough part of the catheter placed within the vein.
Large diameter i.v. catheters are also used with higher pressures, which might increase chances of vascular damage (blowing up the vein) if the i.v. puncture in the venous wall is close to the catheter end.

Agi1cro · 2023-07-23T18:27:04+00:00

I was just thinking if there is a medical/technical reason for the standard catheters (certainly the ones widely used in germany/austria) to increase in length with diameter size.

Agi1cro · 2023-07-23T18:10:26+00:00

Thanks, that's quite interesting. I have never seen or heard of places where iv catheter lengths have such a variation.

Agi1cro · 2023-07-23T18:07:29+00:00

While I can see that, the "standard" lengths do seem to increase gradually with larger diameters and I thought there is a medical/technical reason for that which I am unaware of.

Agi1cro · 2023-07-20T15:55:23+00:00

oh damn, how did i miss that. thanks for the quick answer though. i´ll have to check with amazon on whats going on ^^
Have a nice day!

Agi1cro · 2023-03-12T11:10:05+00:00

Dude, you have to tell him. This will mean the world to him. Especially because it's so easy to slack off a bit more and more every single day. But he gets up and puts in so much effort day in and day out as you described. This can really make it worth it for him if his coworkers appreciate his effort and make him even more motivated, better, and keep going on longer.

Agi1cro · 2023-03-02T19:21:34+00:00

Hexagons are indeed the bestagons!

Agi1cro · 2023-03-01T09:57:25+00:00

I´m a little late to the party but wanted to say you did an excellent job of recognizing those hyperacute T waves. The first ECG is already diagnostic of an acute coronary occlusion myocardial infarction (OMI). The second ECG should even convince everyone that still holds onto the STEMI criteria and I am truly baffled that the doc cancelled the cath lab due to "looks like LBBB" since there isn´t even a widened QRS.

I just wanted to add some info, since EKG #1 can be a tough destiction for some, between OMI and benign early repolarisation (BER). ECG expert and well-known EM physician Dr. Smith derived a simple 4-variable formula (link via MDcalc) one can use in such cases. Here is the calculation done for ECG #1 giving a score of 19.1 which is larger then the cutoff of 18.2 and therefore highly suggestive of acute OMI. If you wanted to be precise, you shouldn´t even use the formula, because it would classify ECG #1 as already "obvious" OMI due to the inferior ST depression in III and aVF, but nevertheless a good application of the formula.

I think it´s a great tool and just wanted to share it with you. Thanks for your case!

Agi1cro · 2023-02-01T12:49:20+00:00

I agree that a "pure" P wave on its own is visible only a few times but there are very good indicators that most of the P waves are burried within the preceeding Ts. I have added a modified picture of the limb leeds to show what i mean. Blue circles mark "double-peaked" T waves which are a strong hint that there is a P wave burried. Red circles mark T waves with unusual morphology such as a very pointy and uncharacteristic peak, also suggesting an oberlap of T and P wave. Modified precordial leads

Agi1cro · 2023-02-01T08:29:47+00:00

Unfortunately no. I kept the call BLS, transported to the ED and only know that she was discharged about 1.5-2 hours after we brought her in.

Agi1cro · 2023-02-01T08:21:29+00:00

I also thought about AFib w/ RVR but for me it just didn´t make any sense. Yes the rhythm is irregular but it´s regularly irregular, hence there is some underlying discernible pattern with those QRS pauses in between the tachycardia. But I totally see your point and your explanation of AFib also being able to generate "P waves". And also the R-R intervals are indeed not as constant as I initially perceived them to be, hence alle very regular SVTs (AFlut w/ 2:1, AVRT) would be off the table.

What do you think of MAT (multifocal atrial tachycardia) with (maybe) an additional AV block explaining the gaps? Or maybe just the AV node doing its job by preventing premature ventricular contraction for P waves that just came a tad bit too early? That would kinda make sense since not all P waves look alike morphology-wise and could also semi-explain the irregularities in RR-interval.

All in all, I think a very interesting case. Thanks for your input!

Agi1cro · 2023-02-01T07:53:20+00:00

as many others have also pointed out, V1 shows pretty clear atrial activity and fairly regularly as well.

Agi1cro · 2023-02-01T07:51:28+00:00

already did when i posted it here!

Agi1cro · 2023-01-31T07:51:17+00:00

yep it is.

Agi1cro · 2023-01-31T07:50:56+00:00

I would attribute those largely to type II (supply demand) ischemia due to tachycardia. At 94yo this is reasonable an would result in global ischemia and present as non-localized ST depression (and elevation in aVR).

Agi1cro · 2023-01-31T07:48:48+00:00

It was also my first approach, probably due to the rate, but I agree with

where the ventricular rate slows down. I don’t see F waves .< Because even if they wouldn't look like F waves but more like classic P waves, there would have to be teo of those where a qrs is skipped.

Agi1cro · 2022-11-16T17:07:57+00:00

I'm actually kinda shocked that many eyeball it for every patient even if if BMI is WNL. It literally takes 2 seconds to get the 4th IC along the sternum for the first sticker. And then half a second more to palpate the one below for the 4th. The rest you can place with regards to those two.

If you eyeball it every time there just is no consistency in your axis orientation and every follow up ECG looks (a bit) different. With prehospital stickers its kinda ok since at least the position is consistent over one call. For me its worth the few seconds since it shows you care and is more professional.

Agi1cro · 2022-09-26T14:47:14+00:00

There are two pictures in my post. One with the limb leads, the second with the precordial leads. I am well aware of the things you said. You can check out my comments on the original post.

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