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ECG: quick and dirty

I’ve had countless sessions and lectures on ECGs. I don’t know how many websites I have bookmarked, or how many times my eyes glazed over reading Dubin. I’m also terrible at cardiology. I was on my way to accepting my fate of being horrible at ECGs forever, until I had a life changing session on ECGs taught by a great ER doc. I want to post it here because it was probably the most useful thing I learned in med school, and it will stick with me for the rest of my career.

WHEN LOOKING AT ECGs FOR THE FIRST TIME:

1. One ECG is never enough. Always get old ones for comparison. If none available, do another one. Because. One ECG is never enough.

2. RATE. Look at the number on top of the printed ECG. It’s stupid not to use that number. Yes, you should know the rule, 300-150-100-75-60-50. People say you shouldn’t trust the machine because… well, it’s a machine, and it can make mistakes. This is true. I don’t like to look at their “diagnosis” until I have gone through it myself. But the rate is just a number. Plus you should be able to eyeball it and be able to tell if it’s tachy, brady, etc. If the machine is telling you it’s 200 and if it looks tachy, then it’s probably the right number.

3. RHYTHM. Is there a p-wave for every QRS and a QRS for every p-wave? Is the p-wave upright in lead II and down in aVR? Good. Done. BOOM. It’s sinus rhythm. ***if you cannot clearly see the p-waves then you cannot call sinus. move on.

4. AXIS. Again, look at the number at the top of the page. If it’s between 0 and +90, then it’s normal axis. If the number isn’t provided, or if your preceptor doesn’t believe in the convenience of machines/technology, look at the QRS complex of lead I and lead II.

up in lead I, up in lead II: normal axis

up in lead I, down in lead II: left axis deviation (most common causes are left anterior hemi block and left ventricular hypertrophy)

down in lead I, up in lead II: right axis deviation (most common causes are right ventricular hypertrophy…PE)

5. did someone say HYPERTROPHY?

look at V1

is the R wave tall? (greater than 7mm?) right ventricular hypertrophy.

is the S wave tall? (greater than 11mm?) left ventricular hypertrophy.

6. P-waves

look at lead II

is it wide? left atrial enlargement.

is it tall? right atrial enlargement.

7. PR interval

should be between 0.12 sec and 0.2 sec (3-5 small boxes). I used to always get this interval and QRS complex (less than 0.12 sec) mixed up. Think: atria depolarizing + shit getting to ventricles is gonna take longer than ventricles depolarizing. [2 things happening] versus [1 thing happening]. [0.12 sec-0.2 sec] versus [<0.12 sec].

long PR interval means there’s some sort of block at the AV node.

1st deg block. PR interval is long. everything else is normal. cool.

2nd deg block

type I: PR interval progressively gets long. eventually a dropped QRS.

type II: PR interval is constant, but randomly dropped QRS.

3rd deg block “complete block”

there is no association between P waves and QRS. they run separately. **QRS does NOT have to be wide. Just look for P wave/QRS complex disassociation. I sometimes get this and 2nd deg type II mixed up. The only difference I try to remember is that PR interval is constant in 2nd deg type II, but is variable in 3rd deg.

8. QRS complex

narrow or wide?

narrow: good. signal coming from somewhere above ventricles.

wide: think BBB (bundle branch block)

LOOK AT V1 ONLY.

if the last deflection of QRS is DOWN, then it’s a left BBB

if the last deflection of QRS is UP, then it’s a right BBB. super easy. no more of this bunny ears crap.

9. ST segment

always look from J point, and compare with the isoelectric line of T-P segment (NOT PR interval).

elevated/depressed… STEMI… duh. indicates ACUTE ischemic changes.

look for reciprocal changes of the heart. if ST elevation in lateral leads, could see ST depression in the septal leads. PAILS:

posterior up, anterior down

anterior up, inferior down

inferior up, lateral down

lateral up, septal down.

LBBB can look like STEMI. How to tell?

disconcordant changes is normal. (QRS and STEMI on opposite sides of the isoelectric line.)

concordant changes is abnormal.

massive discordance is abnormal. (STEMI is greater than 5mm)

this isn’t that important. Moving on.

Inferior STEMI. Could right ventricle be involved?

DO NOT GIVE NITRO DO NOT GIVE NITRO DO NOT GIVE NITRO.

order a 15 lead

is STE in lead III > lead II? likely RV involvement

INFERIOR MI? 15 LEAD NO NITRO

10. T waves

is it inverted? indicates recent ischemic changes.

11. Q waves

is it significant? indicates old ischemic changes. will likely be present if followed rule number 1 of reading ECGs. (1 ECG is never enough= look at old ECGs).

I literally go through this list of 11 points in my head when I’m reading an ECG, regardless of whether or not I have an atrial flutter jumping at my face or if I see a massive anterolateral STEMI. Obviously I needed background knowledge on ECGs and the physiology of the heart before constructing this list, but this basic checklist has been very, very useful to me so far. It might look lengthy, but it doesn’t take a lot of time at all- a patient is not likely going to have all these issues with their heart.

Anyway. I still don’t love ECGs, but it feels pretty wonderful to be able to be able to evaluate it in a systematic manner, and get the theory behind interpreting the scribbles of an ECG reading. I don’t get these moments as much as I would like to, but it’s that crosspoint where my classroom learning actually meets real-life applications that gives me happy brain-gasms for days. I love knowing things and more importantly, knowing why.

priorisn7-deactivated20180719

This is Medblr gold. Reblogging for anyone staring down the barrel at 1 July.

cranquis

I learned a lot here.

thegraymethod

When you have multiple continuous drips and IV antibiotics that aren't compatible

half-great-adventures

When I’m feeling extra sassy when I’m in charge

ermedicine

When I see ignorant idiots on Facebook start talking about the dangers of vaccines

dude-dude-dude-dude-dude-2

When I hear people telling me that there is no way to over vaccinate my children and that they are completely safe and the medical industry would never work with food industry and political power handlers to create a trillion dollar disease profit crop…. Ignorance! Monsanto delivers foods knowing they create kidney failure…then buys massive shares in dialysis companies. Congressional acts signed by President Obama blanket protects Monsanto from any legal action and allows Monsanto to seize private farms. Monsanto is owned by Bayer - the largest pharmaceutical in the world…creater of vast quantities of vaccines…unnecessary vaccines.

Theres a huge Fuck-You difference between an MMR shot and requiring six…SIX tetnus ahora in order to enter the first grade. Telling me im a bad parent because I dont want give the “required” HPV vaccine to my 8 year old (violation of freedom of religion by the way - we teach our children abstinence) or guilting us to give our children vaccines for a from of Meningitis that only is found in Madagascar…fuck you!!!

I know what industry does… I work in it. I’ve seen the massive increase in cancer, the avalanche of kidney failure, autism 800% increase, bipolar, schizophrenia, ADHD…. By all means give your children over to those would crop them out…the same ones buying and selling harvests of dead unborn children bits.

Dont shame me with shallow “Toy Story” gifs….

ermedicine

wayfaringmd

HPV Vaccine Masterpost

aivarobinson asked: What’s your opinion on the HPV vaccine, especially for those not sexually active? I’ve heard so many conflicting things and I was curious about your take on it.

Let me start by saying that my opinion shouldn’t matter.

What really matters is that vaccines save lives. It has been proven time and time again. (Sources at the bottom).

So let’s talk about HPV:

It causes cervical cancer, oropharyngeal cancer, anal cancer, vulvar/vaginal cancer, penile cancer, genital warts, and laryngeal papillomas. Risk factors for being infected are age less than 25, sexual activity prior to age 16, and multiple partners or a partner who has had multiple partners. Millions of Americans are infected and millions more will become infected every year.

The Gardasil-9 vaccine (the only HPV vaccine available in the US right now) protects against 9 high risk strains of HPV which are responsible for causing 70% of cervical cancers and 90% of genital warts.

The original Gardasil vaccine was studied in 29,000 patients and Gardasil-9 was studied in an additional 15,000 and continues to be studied now. The only significant adverse event was an increase in syncope (passing out) immediately after being given the shot, which is why it’s recommended to be observed for 15 minutes after getting the shot.

Keep reading

internallypediatric

When you start your first night as an ICU upper level flying solo

… and you suck at ICU

… and all of your patients are mad unstable

… and you have to call in multiple attendings overnight to do procedures on your patients

… and meanwhile you’re just watching them, hoping they don’t code before someone gets a line in them

medicalbasics

Complications of Peripheral IV Theraphy #nursingschool #nurse #rn #nursing #nurses #nursingstudent #resources #study #inspiration #school #tips

garden-of-everything

Anatomy Mnemonics

Below are some old Anatomy Mnemonics someone once gave me that I found in my hard drive. Hopefully they’ll come in handy for someone else.

BONES  6 cranial bones  Old People From Texas Eat Spiders.  Parietal, Ethmoid, Sphenoid, Temporal, Occipital, Frontal.   Leg Bones  TIBia is the Thick Inner Bone, and Fibula is Finer, Fluted, and Lateral.   8 facial bones  Common Love gone Zip?(Abbr. CMMNLVZP)  conchae, mandible, maxilla, nasal, lacrimal, vomer, zygomaticus, palatine.   *Applying the first-3-letters rule to the facial bones, I came up with  Con Man  Max and Pal   Bones of the Wrist  Some Lovers Try Positions That They Cannot Handle  Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, Hamate   Never Lower Tillie’s Pants, Mama Might Come Home.  navicular, lunate, triquetrum, pisiform, greater and lesser multangular, capitate, and hamate.   *To remember that the carpals are bones of the wrist and not the foot, Lunate, Triquetrum, remember that CARPenters use their hands.   7 types of bone fractures  C3-PO Breaks his Bones    Greenstick, Open, Complete, Closed, Comminuted, Partial, and Others.   MUSCLES  Muscles in gluteal region: from top to bottom: P-GO-GO-Q   Piriformis   Gemellus superior   Obturator internus   Gemellus inferior   Obturator externus   Quadratus femoris    Muscles whose tendons attach at the pes anserinus (medial tibia): SGT (“Sargent”)   Sartorius   Gracilis semiTendinosus    Four abdominal muscles –  TIRE: (deepest to most superficial)  Transversus abdominis, Internal abdominal oblique, Rectus abdominis, and External abdominal oblique   Functions of the Interossei muscles   PAD – Palmar ADduct   DAB – Dorsal ABduct   Attachments of Pectoralis Major, Teres Major and Latissimus Dorsi   A lady between two majors.   Pectoralis major attaches to lateral lip of bicipital groove.   Teres major attaches to medial lip of bicipital groove.   Latissimus dorsi attaches to the floor of bicipital groove.   The “lati” is between two “majors.“   A lady between two majors.   Four muscles which control the mandible  masseter, temporal, lateral and medial pterygoids  form the letters MTPP, which could be read as “Empty Peepee” which could be construed as a command (or wish) to empty one’s peepee via…oh we’d better not say it.   Four abdominal muscles Spare TIRE  transversus, internal oblique, rectus, and external oblique    On the floor of the mouth are two muscles Doctor on the Floor?  mylohyoid and digastric – MD.  Muscles which regulate breathing  You Will DIE! If you don’t have'em  Diaphragm, Inner costal, and External costal   The SITS muscles make up the rotator cuff:   Supraspinatus   Infraspinatus   Teres Minor   Subscapularis   NERVES  Radial n. innervates the BEST!!!!   Brachioradialis   Extensors   Supinator   Triceps   Hand muscles innervated by the Median nerve  LOAF   Lumbricals 1 + 2   Opponens pollicis   Abductor pollicis brevis   Flexor pollicis brevis   Innervation of phrenic nerve  c345 keeps the phrenic alive   c345 keep the diaphragm alive  Innervation of the penis:   Parasympathetic puts it up; sympathetic spurts it out   Point , Shoot, Score! (erection, emmision ,ejaculation)   Parasympathetic, Sympathetic ,Somatomotor    Innervation of the penis by branches of the pudental nerve  "S2, 3, 4 keep the penis off the floor”, derived from spinal cord levels S2-4    Long thoracic nerve innervates serratus anterior   c5-6-7 raise your arms to heaven   Lateral and Medial Pectoral Nerve  Lateral is less, medial is more.  Lateral pectoral nerves goes through pectoralis major while medial pn goes though both pectoral major and minor.   12 Facial Nerves  "At the OIL FACTORY, the OPTICIAN looked for the OCCUPANT of the TRUCK. He was searching because 3 GEMS had been ABDUCTED by a man who was hiding his FACE and EARS. A GLOSSY PHOTOGRAPH has been taken of him, but it was too VAGUE to use. He appeared to be SPINELESS and HYPOCRITICAL.“   In order, the oil factory is the olfactory nerve; the optician is the optical nerve; the occupant is the occulomotor nerve; the truck represents the trochlear nerve; the 3 gems are the trigeminal nerve; abducted is really the abducens; face is facial; ears really means auditory; glossy photograph is glosso-pharyngeal; spineless relates to the spinal accessory nerve; and hypocritical is the hypoglossal nerve.   Wrist Nerves and Prohibition  RUM, for radial, ulnar, and medial symptoms of nerve troubles are wrist drop, claw hand, and tunnel syndrome …  represented by the letters WCT (Women’s Christian Temperance Union).   Cranial Nerves  I-Optic  II-Olfactory  III-Oculomotor  IV-Trochlear  V-Trigeminal,  VI-Abducens  VII-Facial  VIII-Acoustic (Vestibulocochlear),  IX-Glossophrayngeal,  X-Vagus,  XI-Spinal Accessory,  XII-Hypoglossal  On Old Olympus Towering Tops, A Finn And German Viewed Some Hops   Branches of the Facial Nerve (CN VII):  To Zanzibar by Motor Car  Ten Zebras Bought My Car  Temporal, Zygomatic, Buccal, Masseteric,Cervical   Brachial Plexus:  Roots, Trunks, Divisions, Cords, Branches Robert Taylor Drinks Cold Beer. (or Richard Tucker Drinks Cheap Beer :-) )   Innervation of Extraocularmotor Muscles: LR6 SO4 Others 3   LR6–Lateral rectus - VI abductens   SO4–Superior Oblique - IV Trochlear   Others 3–The remaining 4 eyeball movers = III Oculomotor    For the order of nerves that pass through the superior orbital fissure:  "Lazy French Tarts Lie Naked in Anticipation.”  (Lacrimal, Frontal, Trochlear, Lateral, Nosociliary, Internal, Abducens)  9 branches of the abdominal portion of the aorta  "Celia Smith’s Supra Rams Green Impala Past Stop Light”  Celiac, Supra mesenteric, Supra-renal, Renal, Gonadal, Inferior mesenteric, Phrenic, Sacral, and Lumbar.   VESSELS Structures passing posterior to the medial malleolus of the foot:   Tom, Dick, And Harry  Tibialis posterior tendon, flexor Digitorum longus tendon, post. tibial Artery and tibial nerve, and  flexor Hallucis longus tendon. (i.e. Tibialis, Digitorum, Artery & nerve, and Hallucis)    Carotid Sheath– VAN   Internal Jugular Vein   Common carotid Artery   Vagus Nerve   Arteries as they come off the external carotid:  Superior thyroid, Ascending pharyngeal, Lingual, Facial, Occipital, Post Auricular, Superficial temporal, Maxillary  Some Angry Lady Figured out PMS   ABC’S of the aortic arch!  Aortic arch gives off the Brachiocephalic trunk, the left Common Carotid, and Left Subclavian artery   Branches of the aorta artery in the lower torso  Transsexuals Remember the Aorta  "Come on In Ex-Female, Pop And Prance Past Doors and Planters".  Common iliac, Internal iliac, External iliac, Femoral, Popliteal, Anterior tibia, Posterior tibia, Peroneal, Dorsalis, medial and lateral Plantars.   Branches of the axillary artery   Sally Thompson Loves Sex And Pot pie  Superior Thoracic, Thoracoacromial, Lateral thoracic, Subscapular, Anterior circumflex humeral, Posterior circumflex humeral, and Profunda brachii.   Arteries off the External Carotid  They are buried in the phrase Some Loser F*cked My Sister  Superior Thyroid, Lingual, Facial, Maxillary, Superficial Temporal    Vessels joining the inferior vena cava  "He Commonly Lumbers in the Viet Cong ReGion".  A Vietnamese Lumberjack’s Heart:   Hepatic, Common iliac, Lumbar, Vena Cava, Renals, Gonadals.  Stroke versus Aneurysm  STRoke is caused by arterial reSTRiction, and aneurysm is AN Erupting artery.   MISCELLANEOUS  checklist of factors causing back troubles  Dr. O. VESALIUS  O - Osteomyelitis  V - Vertebral fracture  E - Extraspinal tumour  S - Spondylolisthesis  A - Ankylosing spondylitis  L - Lumbar disk disease  I - Intraspinal tumour  U - Unhappiness  S - Stress   Cranial sutures  cranial sutures have CLASS!  Coronal, Lambdoid, Squamous, Sagittal.    five visceral sensors  Low TEMPeratures have BARe-CHEsted cOSMO-girls kNOCking. temperature, barometric, chemical, osmotic, nociceptors   Femoral Sheath (lateral to medial) order of things in thigh  NAVEL   Femoral Nerve,   Femoral Artery,   Femoral Vein,   Empty Space,   Lymphatics (or Lacunar Ligament)    Pelvic Diaphragm – PICOLO(A) -Posterior to anterior   PIriformis   COccygeus   Levator Ani    Location of Thoracic duct:  The duck is between two gooses (duck = thoracic duct)  2 gooses = azyGOUS and esophaGOUS    Structures perforating the diaphragm   “At T8 you see, perforates the IVC” (inferior Vena Cava) the “EsoVagus” pierce T10 (esophagus, vagus nerve)   T12 - red, white and blue (aorta,thoracic duct,azygous vein)    Course of Ureters  Water runs under the bridge (uterine a. and ductus deferens)   

regionstraumapro

Why Is NPO The Default Diet For Trauma Patients?

I’ve watched it happen for years. A trauma patient is admitted with a small subarachnoid hemorrhage in the evening. The residents put in all the “usual” orders and tuck them away for the night. I am the rounder the next day, and when I saunter into the patient’s room, this is what I find:

They were made NPO. And this isn’t just an issue for patients with a small head bleed. A grade II spleen. An orbital fracture. Cervical spine injury. The list goes on.

What do these injuries have to do with your GI tract?

Here are some pointers on writing the correct diet orders on your trauma patients:

Is there a plan to take them to the operating room within the next 8 hours or so? If not, let them eat. If you are not sure, contact the responsible service and ask. Once you have confirmed their OR status, write the appropriate order.

Have they just come out of the operating room from a laparotomy? Then yes, they will have an ileus and should be NPO.

Are they being admitted to the ICU? If their condition is tenuous enough that they need ICU level monitoring, then they actually do belong to that small group of patients that should be kept NPO.

But here’s the biggest offender. Most trauma professionals don’t think this one through, and reflexively write for the starvation diet.

Do they have a condition that will likely require an emergent operation in the very near future? This one is a judgment call. But how often have you seen a patient with subarachnoid hemorrhage have an emergent craniotomy? How often do low grade solid organ injuries fail if they’ve always had stable vital signs? Or even high grade injuries? The answer is, not often at all! So let them eat!

Bottom line: Unless your patient is known to be heading to the OR soon, or just had a laparotomy, the default trauma diet should be a regular diet!

Source: http://thetraumapro.com/?p=2424

half-great-adventures

^^^^^^THIS^^^^^^

You haven’t wanted to rip out your ear drums more than when you admit a 1 month old with a skull fracture and Trauma makes them NPO.