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Vince DiGiulio
Attended Binghamton University
Lives in Binghamton, NY
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Vince DiGiulio

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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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Why not trying to tube without any NMB agent at all? Do you guys ALWAYS have to use either agent? 
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Vince DiGiulio
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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:

http://www.ems12lead.com/2015/02/16/12-leads-of-christmas-v3/
This is the eleventh and penultimate article in our latest series, The 12 Leads of Christmas, where each day we examine an individual electrocardiographic
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Not wanting to give away anything from Vince's SUPERB post (which features phenomenal illustrative figures) - the "culprit artery" for the above isolated posterior is revealed in the very last figure in Vince's blog - :)
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Vince DiGiulio
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I've got a new case up and haven't seen a treatment plan I agree with yet. Maybe the folks from ECG+ can do better!

http://www.ems12lead.com/2014/10/29/86-yo-m-sob/
You are called to the residence of an 83 year old male with a chief complaint of shortness of breath. On arrival you find a sick-appearing gentleman working
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Conclusion is up here: http://www.ems12lead.com/2014/11/06/83-yo-m-sob-conclusion/

I'm glad to see most of what I wrote matches the thoughts of the folks here.

Regarding the type of MI (I vs. II), I was a bit rushed in how I described my reasoning on here since I planned on writing quite a bit about the case on the blog, but I agree whole-heartedly. I've seen a number of clear subtle STEMI's with single-digit trop's (in ng/ml) and critically ill patients with double-digit trop's simply due to their terrible hypotensive/inflammatory state.

From this patient's presentation and clinical course, through hindsight, it was clear this patient was experiencing a type II MI and that's what I meant to convey. The low trop "bump" was just icing on the cake with the rest of the clinical picture. I agree that if you just showed me the initial ECG and told me the patient was SOB there would be no way to discern the type, even with only minor troponin elevations.

Sorry for the confusion but it spurred some great comments!
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Vince DiGiulio
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Cases  - 
 
Case #057

73-year-old female presents lethargic with a BP of 85/47 mmHg and a pulse of 163 bpm. What is her rhythm?
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Hassan Almaateeq's profile photoKen Grauer's profile photoCharles Spencer's profile photoTürküler celik's profile photo
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I see a regular SVT ,if it is true first choice in the treatment carotid massage if we see the vagal maneuvers We can confirm the diagnosis ? 
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Vince DiGiulio

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Nice case! I think another learning point from this case is that the rhythm channel at the bottom of the EKG should be programmed to a more useful lead, like II or V1. When complex size permits (which is most of the time), I always try to set up three rhythm channels with leads II, V1, and V5.

It always bothers me that seemingly inconsequential but modifiable factors, like how the electrocardiograph is programmed (probably by a non-clinical technician), can actually have a notable effect on patient diagnosis and management down the line. Sure, there's countless bigger worries in medicine, but when you're going to be performing tens of thousands of EKG's on a single electrocardiograph over its lifetime (maybe even hundreds of thousands), a tiny change to improve clinician accuracy can make a big difference.
Sorry but I don't have any clinical information on this ECG at all but that hasn't stopped us before. So what's going on here ? Check out the great discussion on this ECG in the comments section from our original post. C...
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Vince DiGiulio

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Dr. Mattu rightly doesn't focus on this minutia, but the wide complex at the start of each group is due to an infra-nodal escape mechanism. The beats are probably fusion complexes but could be pure escape beats, a result of the long pause that precedes each one.

The evidence for this is that there is a fixed R-R interval between the last conducted QRS complex and the next (wide) beat, however the PR-interval of the wide beat varies between the groups.
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Ever wanted to see the M-mode image of an ultrasound but only had a clip? It's a rather simple proposition, but most (all?) ultrasound machines won't let you do this post-hoc. Enter... M.mode.ify!!

Check out the example and try it out on your own (de-identified) clips. It's pretty elegant and awesome.

http://www.ultrasoundoftheweek.com/2014/09/10/m-mode-ify/
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Vince DiGiulio
owner

Cases  - 
 
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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Stephen Smith's profile photoZeeshan Siddiqui's profile photoKen Grauer's profile photoFloyd Miracle's profile photo
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Just seeing this now. NO DOUBT she needs the cath lab for likely acute proximal LAD occlusion. While not "typical" DeWinters pattern (because there is NO J-point ST depression in any of the precordial leads - the T waves are dramatically peaked in V3,V4,V5 - with some ST elevation in these leads. ST elevation begins in V1,V2 - and is also present in "tell-tale" aVL - AND - there are reciprocal ST-T wave changes in the inferior leads - so likely identical clinical implications of true DeWinter T waves.

For those interested in more on DeWinter T Waves - see - https://www.dropbox.com/s/8rr2rzmt8q2hqtg/10.57-%20ECG-2014-e-PUB-DeWinter-%2810-16.1-2014%29-LOCK.pdf?dl=0
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This new post is part II in one of my favorite series of articles I've worked on so far in my informal, non-paying, ECG writing "career."

I hope the concepts are helpful!

http://www.ems12lead.com/2014/10/21/the-360-degree-heart-part-ii/
The first post in our "360 Degree Heart" series attempted to visualize how the different frontal plane (limb) leads relate to one another. We also introduced
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Nice case that is worth reading. Interesting ECG - and nice vector diagrams by Vince - :)
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Vince DiGiulio

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I agree with Dr.'s Grauer and Smith: the T-waves are just a little too symmetrical and the QRS complexes a little too wide. I think this shows electrocardiographically subtle hyperkalemia as well. Good tracing!
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Vince DiGiulio

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+umemergencymed Do you have any information on Sx duration or the initial troponin level? Those marked T-wave inversions in the inferior leads are highly indicative of either subacute STEMI (in which case, why is the patient presenting so sick just now? (? papillary rupture)), or a stuttering, dynamic lesion. Thanks in advance; I'm just trying to make sense of such an unusual EKG.
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Here's something I wish someone had explained to me sooner: how the limb leads interact to provide a 360-degree view of the heart in the frontal plane. Laying the groundwork for some more advanced stuff based on these ruminations in the coming weeks....

http://www.ems12lead.com/2014/09/11/the-360-degree-heart-part-i/
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Have him in circles
180 people
asad mohammad's profile photo
Nick Genes's profile photo
Floyd Miracle's profile photo
Derek Sifford's profile photo
Tiến Thịnh Trần Danh's profile photo
Claire Murphy's profile photo
Diana Guadalupe's profile photo
Oliver Hawksley's profile photo
Khalid Bahar's profile photo
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Binghamton, NY
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Clifton Park, NY
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EMT-Critical Care, #FOAMed contributor, EM/EMS/CC/ECG/US nerd
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    Mechanical Engineering
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