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Vince DiGiulio
EMT-Critical Care, #FOAMed contributor, EM/EMS/CC/ECG/US nerd
EMT-Critical Care, #FOAMed contributor, EM/EMS/CC/ECG/US nerd

Vince's posts

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When confronted with a tracing where it's uncertain if the rhythm shows sinus tachycardia, one of the most common suggestions I get is to double the paper speed to see if we can "unmask" buried P-waves.

That doesn't work.

Here's a case where I run through why running the paper at 50 mm/s doesn't help and might actually prove misleading (unless you work with ECG's at the speed every day).

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Well hello there! I just wanted to check in with everyone and give you a quick update on the community.

Over the past year I've been managing this page but haven't been too active in actually posting content, but you'll be seeing more posts from me over the coming months.

Since Google+ is rolling out a new layout, I figured I'd remind everyone where you can turn notifications for new posts on this page on and off. The first image shows the old notification toggle, while the next three show the new process for adjusting your setting.

I hope everyone is well, and here's to another year filled with great ECG's!
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In a vein parallel to Hassan's recent post, here's a case of a large saddle embolus with normal RV systolic function.
The size of the clot doesn't always correlate to its effects on the RV.

I've been having trouble with one of the G+ communities I manage:

It seems that whenever members post content now, it gets automatically flagged as spam, hidden from the main page, and I do not get notified via email that a post has occurred. As a result, new content often fails to post for a couple of days until I approve it, and even then my members with notifications turned on are not getting emails to alert them to new posts.

Our community is discussion-based and depends on members being alerted of new posts, so at the moment it is useless and essentially dead.

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A 59 year old male presents feeling "unwell" with chest heaviness. What's you diagnosis and management?

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From the EMCrit page...
Question for the group regarding ultrasound: Is there a differece between the way a cellulitis and edema looks on bedside ultrasound? I've started using a linear probe to help confirm a diagnosis of cellulitis. However, if a patient has baseline pedal edema, and a cellultis in one of those legs, will the ultrasound image look different between the two legs? Or will both have that cobble stone appearance?

So here's a topic: rocuronium vs. succinylcholine in the patient with a possible acute CVA (either hemorrhagic or ischemic).

I ran into this issue at my hospital the other day when a patient needed to be intubated upon arrival in the ED but the team was a bit worried about a possible CVA. Unbeknownst to me, they had all been recently trained that Sux is contraindicated in acute CVA while Roc is preferred.

My experience has always been the exact opposite—that Sux is (usually) the preferred agent because it will wear off more quickly, allowing for a neurological exam sooner.

I know that Sux is obviously contraindicated in several chronic neurological (usually motor neuron) issues due to an upregulation in the acetyclcholine receptors, possibly leading to an excessive eflux of potassium when it is administered. I also know there there is VERY tenuous research showing that Sux might increase ICP in patients going for semi-elective brain tumor surgery.

I have not, however, seen a single piece of research showing that Sux is a poor choice for intubating the patient with signs and symptoms consistent with acute CVA in the emergency department.

Has anyone else run into this issue? I'm trying to get my hands on the training materials the staff cited to see if it has any references, but I rather doubt it will.

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Hi all! I try to post mostly original content to this site but I've spent a ton of time the past couple of years working out just why isolated posterior STEMI presents with the ECG pattern that it does. This is the distillation of some of that work, with more to come in a couple of days:

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A 52-year-old female presents with a chief complaint of "indigestion."

She had just finished lunch when she began to experience burning in her central chest which she rates as a 6/10. She denies nausea, vomiting, shortness of breath, dizziness, or any other major symptoms.

Past medical history is significant only for well-controlled hypertension and type II diabetes mellitus.

Vitals: BP 148/74 mmHg, HR 55 bpm, RR 15 /min, temp 36.8 C, SpO2 97% on room air.

Does she need the cath lab or an antacid?

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This is a phenomenon you need to recognize.

When a patient has an implanted pacemaker and experiences the equivalent of a brady-asystolic cardiac arrest there will still be apparent complexes on the monitor, like the ones displayed here. Be cognizant of how these complexes look compared to a typical paced rhythm because they are easy to miss, resulting in delayed recognition of cardiac arrest.

Luckily, in my experience, the monitors in my department are actually surprisingly good at detecting these changes and alarming "ASYSTOLE" in spite of the presence of electrical activity.

I didn't know that early in my career, however, the first time I saw this. Thinking it was a false alarm I sauntered over to the patient's room and was shocked when I opened the door and saw the patient exhibiting agonal respirations.

Most of the time when the monitors alarm at my department our first step is to try and troubleshoot at the monitor bank and see if it's artifact or legit (>99% of the time I'd say it's artifact). If there's a paced rhythm and the monitor alarms, however, my first step is to instead go immediately to the bedside to check the patient.

It's too easy to overlook badness otherwise.
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