Monday, January 7, 2019

SSmith Blog- that he duplicated-HyperK-Low Ca (1-7-2019)

Comment by KEN GRAUER, MD (1/3/2019):
I call this a, “Who done it?” — because it’s the type of tracing that you look at, and hopefully (as per Dr. Smithinstantly recognize Hyperkalemia. Dr. Smith highlights a number of interesting points about this dialysis patient:
  • The initial ECG shown in this case ( = ECG #in Figure-1) — was not recognized by the treating clinician as abnormal — and as a result, the patient was discharged home. Perhaps the reason for the missed diagnosis was that the computer interpretation (which said, “Normal ECG” ) was trusted. Regardless of the reason — the diagnosis was missed ...
  • Despite the marked change in ECG appearance between the 2 ECGs in Figure-1 — the increase in serum K+ corresponding to these tracings was modest (from only 4.6 to 5.6 mEq/L). KEY Point — it sometimes doesn’t take that much of an increase in serum K+ to significantly affect the ECG (and the resultant risk for VFib).

To these points, I’d add the following:
  • The treating clinician said, “No change in ECG #1 from the prior ECG”. This prior ECG = ECG #2, which was recorded just 1 day earlier. From this written statement in the chart ( = “No change from previous” ) — it is implied that comparison between ECG #1 and ECG #2 was made — though if true lead-to-lead comparison had been done, it is difficult to conceive that the change in ECG appearance could have been missed. Comparison between 2 tracings can be EASY — if one simply takes a moment to go lead-to-lead to note potential differences.
  • The 1st difference between ECG #1 and ECG #2 is in frontal plane axis. Note that the net QRS deflection in lead III of ECG #1 was isoelectric — whereas there is a small-but-definitely positive net QRS deflection in lead III of ECG #2. While this minor amount of axis deviation is not clinically important in this case — by training yourself to religiously pick up any change in axis, you will then recognize larger axis shifts that are clinically important.
  • Did YOU notice that there probably was malposition of leads V1, V2 in ECG #2 — because there is a deeply negative P wave in these 2 leads — and — an rSr’ complex that closely resembles the QRST appearance in lead aVR. (For more on how to quickly recognize lead V1,V2 misplacement — Please see My Comment at the bottom of Dr. Smith’s 11/4/2018 Blog).
  • The main difference between ECG #1 and ECG #2 (which was done a day earlier) — is that T waves are not only very tall and peaked (pointedin leads V2,V3,V4 in ECG #1 — but the base of these T waves has become much more narrow. This symmetric, very steep ascent and descent of peaked T waves is highly characteristic of HyperKalemia — and especially in a patient with a “reason” to be hyperkalemic (this is a dialysis patient) — hyperkalemia must be presumed!
  • In addition — I suspect HypoCalcemia in ECG #1. Corrected for heart rate, I estimate the QTc in ECG #1 at ~440-450msec ( = upper normal). Characteristic ECG changes of hypocalcemia typically include QT lengthening, with an unexpectedly long isoelectric ST segment, at the end of which the T wave appears. Given common clinical occurrence in renal patients of hyperkalemia with hypocalcemia — I’d be very curious to learn the serum Ca++ level at the time ECG #1 was obtained.

Wednesday, December 27, 2017

Catherine's TESLA - Instructions (12-27.1-2017)

Testa-Related VIDEOS:
Tesla Instruction Videos (Justin, Joe) — 43:15 minutes:
 i) Part 1 — 9:10 minutes — —

ii) Part 2 — 10:25 minutes — 

iii) Part 3 — 7:00 minutes — —

iv) Part 4 — 16:40 minutes — —


Tuesday, December 12, 2017

LINKS (Part 3) - Justin Dance Lesson Videos (12-12.1-2017) — Lessons #41-to-Present

LINKS to Our Ballroom Classes (Justin Brochetti):
Lindy Hop-43E: Lindy Circle / Lindy Throw Out (12/7/2017) — 2:25 minutes — — from Justin's 12/7/2017 Group Class on LINDY HOP.
Samba-43D: Botofogo-Volta Step (12/5/2017) — 3:35 minutes — — from Justin's 12/5/2017 Group Class on SAMBA.
Lindy Hop-43A (12/4/2017) — 4:40 minutes — — The dance is LINDY HOP — with review of the Side-to-Side movement (Don’t turn over my wrist, but just go side-to-side) — Us sitting back more (not standing upright as in Swing) — and me waiting until my L.Foot is free before getting back into Lindy Circle.

XXX — —

Ken-Cathy-Waltz-43B (12/4/2017) — 2:40 minutes — — Ken & Cathy dance WALTZ (GOAL: We need to "milk" our Opening Out movements more ). 

Waltz-43C (12/4/2017) — 8:35 minutes — — The dance is WALTZ — with focus on “showcasing” our Opening Out movements more. Introduced technique for Left & Right Hairpin Turns (“sling shot” feeling — my elbows back).
Swing-42E: Sliding Doors (11/28/2017) — 3:20 minutes — — from Justin's 11/28/2017 Group Class on SWING.
 V. Waltz-42A (11/27/2017) — 4:20 minutes — — The dance is VIENNESE WALTZ— with focus on  always using Hip Swing, especially on Right-Sided Turns.

Ken-Cathy-V.Waltz-42B (11/27/2017) — 1:40 minutes — — Ken & Cathy dance VIENNESE WALTZ (GOAL: Ken to use more Hip Swing on Right Turns from the very start of the dance … ). 

Cha Cha-42C (11/27/2017) — 4:50 minutes — — The dance is CHA CHA — with focus on taking “liberties” — but then knowing to GET BACK together again with Cha Cha Timing … (NOTE: After a free spin, I should not chase after Cathy … ).

Lindy Hop-42D (11/27/2017) — 5:20 minutes — — The dance is LINDY HOP — with focus on Technique (I must avoid “pulling — but instead drop down to initiate my lead; Cathy to also drop down at start of the step … ).
Lindy Hop-41A (11/20/2017) — 5:30 minutes — — The dance is LINDY HOP — with focus on technique (the KEY is the “bounce” to “soak up” time — then lower before the next step). Use gravity & Momentum (not extreme shape change) to lead lindy hop steps.

Tango-41B (11/20/2017) — 9:30 minutes — — The dance is TANGO — with focus on technique (Man’s R. Shoulder must stay back; Reviewed Cathy’s position in Tango Hold). Also, Cathy “stealing” her moments in Tango! (this is not led! ).

Samba-41C (11/20/2017) — 3:50 minutes — — The dance is SAMBA — with focus on technique (incorporating the “earthiness” of Samba into all movements of the dance … )..

Wednesday, November 11, 2015

Great Regular WCT with P Waves — ME NOT GIVING AWAY ANSWER

Here is the case:
Blaine's case on EKG Club

Here is the tracing:
The ECG — This is obvious VT!

I have rotated this tracing. Rather than “spilling the beans” with full interpretation — I will simply describe the 2 things that every provider needs to consider in their evaluation BEFORE arriving at a presumptive diagnosis.

#1) Is this patient in front of me hemodynamically stable or not? The answer is not necessarily a “Yes” or a “No” — but may be in a gray zone in between (which translates to a need to within short order arrive at a better resolution of the clinical situation). WHAT is suggested here?

#2) The 5 parameters to always assess in rhythm interpretation are recalled by “Watch your Ps, Qs & the 3 Rs”. Isn’t the rhythm here a regular WCT ( = Wide-Complex Tachycardia) at ~150/minute without clear sign of sinus P waves? Even BEFORE considering QRS morphology — WHAT is the differential diagnosis for such a rhythm?

For those wanting to review the Basics of Rhythm Interpretation — Please check out the Contents to my 3-part ECG Video series on this subject — — :)

For those wanting to be walked through the process of what to consider for the regular WCT rhythm — Please GO TO — — :)

Please TAG ME when there have been additional responses to this case! I will then gladly respond in more detail!

NOTE: Blaine Holman posted this on 11/11/2015 — but then TOOK DOWN this post after I wrote the above ... so I messaged her. I LIKE MY ANSWER — as my goal is to get others to think.

Tuesday, September 15, 2015

Regular WCT - Is this VT or SVT? (ECGs & Cardiology-9-15-2015)

CASE — This ECG was posted by David Richley on the ECGs & Cardiology Fans site on 9/15/2015. 
  • Unfortunately, there was no history (we don't even know the age of the patient ...) — but it makes for a very interesting discussion. Spurred by a flurry of 1-line answers (predominantly in favor of SVT as the answer) — I added the Comment below.
Figure-1: Original ECG posted on ECGs & Cardiology Fans.
Interesting case. In the hope of making a constructive and educational comment — I will suggest that EVERYONE so far has given a suboptimal answer … Perhaps the BEST constructive feedback I can offer is that the MINDSET should be CHANGED with how you answer this question!

It is a GREAT case! It would be nice to know the history (and the age of the patient) — but sometimes you don’t, and we need to deal with this …

The MINDSET that I suggest you strongly consider adapting is that there are 3 (not 2) possible answers !!!! These answers are: i) that you KNOW this is an SVT rhythm; ii) that you KNOW this is VT; or iii) that you are NOT certain what the rhythm is (SVT or VT) — in which case you can then provide a “relative likelihood” as to which you think it is. This is “real life” — because often we will NOT be certain what a rhythm is at the time we need to treat it — AND, it is OK not know for certain. I fully acknowledge that I am not 100% certain as to what this rhythm is based on this single rhythm strip. That’s fine — because the rhythm clearly needs to be treated NOW, and if on the scene I’d know hemodynamic status and would then know how to act accordingly.

In my opinion — an OPTIMAL ANSWER to this tracing is to state what we DO know — which is that there is a regular, slightly widened QRS rhythm at ~ 210-220/minute without clear evidence of sinus P waves. FAR BETTER than to randomly guess “SVT” or “VT” — is to DESCRIBE what you see. Here, you see a regular WCT ( = Wide-Complex Tachycardia) without sinus P waves.This should take no more than 5 seconds to establish ...

Starting from this premise — We need to remember the STATISTICS — which are that in > 80% of cases, a regular WCT without sinus P waves is VT. So even BEFORE you look at the actual ECG — if told you have a regular WCT without sinus P waves, you should GUESS VT — and you’ll be right >80% of the time! If the patient is “older” (perhaps anything over 50 or so) AND has underlying heart disease — you are already up to ≥90% of regular WCT rhythms without sinus P waves being VT. Those are pretty good odds. In view of these odds — your mindset SHOULD BE that the burden of proof is to prove this is SVT and NOT the other way around. Instead, assume VT and treat accordingly. That doesn’t necessarily mean you need to shock the patient (if they are hemodynamically stable) — and I would NOT necessarily shock this patient … — but you need to be coming from the mindset that this is VT until you prove otherwise.
Figure-2: Labeled tracing (See text).
P.S. The QRS complex IS wide. I would not be certain of that from looking at every lead (ie, the QRS in V1, aVR, aVL looks narrow) — but it clearly is wide in leads like V5,V6 … It is not “very wide” — but it IS wide.

The rate is ~ 210-220/minute (NOT ~250/minute!). When the rhythm is fast and regular — the EASY way to accurately estimate rate is by the Every-other-Beat method. I pick a QRS that begins or ends on a heavy line (See my vertical BLACK lines in V1) — and then measure the R-R interval of every other beat ( = half the rate). The R-R interval of every-other-beat is just less than 3 large boxes — so half the rate is a little faster than 300/3 or ~ 105-110/minute) — so the actual rate is TWICE that or ~ 210-220/minute. This is relevant, since a rate of 210-220/minute is perfectly within the range for VT — and it virtually excludes AFlutter from consideration (too fast for 2:1 flutter).

I review my approach to distinguishing between SVT vs VT in my ECG Blog #42 — —

My thoughts on this tracing are that QRS morphology in the chest looks consistent with LBBB, because the QRS is negative in lead V1 and all upright in lead V6. The axis is directed inferiorly (probably ~ +75 degrees, judging from QRS amplitudes in the limb leads) — so the combination of LBBB-like appearance in chest leads (implying RV origin) and inferior axis (implying the impulse starts from the top = base of the heart, and heads south) = RV OT VT ( = Right Ventricular Outflow Track VT) until proven otherwise.

So WHY isn’t this aberrantly conducted VT? There are several reasons I think this is unlikely: i) Statistics (>80% pre-ECG probability as I describe above); ii) Aberrant conduction should ideally manifest a QRS morphology that looks like some form of conduction defect — and this tracing does NOT. With typical LBBB — you just don’t get such rapid progression from the all negative QRS in V1 to already all positive by lead V3 ….); and iii) I think there is AV Dissociation …

When you see AV Dissociation — it PROVES VT. That said, it is rare in my experience that one can be 100% certain of seeing AV dissociation in most cases of WCT when the rate is fast. I think this is an exception — as RED arrows in V1 highlight what clearly looks like independent P waves in V1. Dropping a vertical line down to the long lead II rhythm strip suggests we DO periodically (albeit not completely at a regular R-R interval) see this deeper-than-expected dip in the ST segment. But I’m not certain of this …

Finally — there looks to be ST segment elevation in at least 2 leads (within the BLUE rectangle). It is really lead I that caught my eye, as the coved shape to the elevate ST segment with associated Q wave in this lead looks REAL. And of course a common clinical setting for sustained VT is acute MI, so perhaps that is what is going on.

BOTTOM LINE: I am not certain what this regular WCT rhythm at ~ 210-220/minute without sinus P waves is …. but my hunch (with my estimate of >90% likelihood) is that it is VT. If the clinical setting was an adult of a certain age with chest pain — then I’d strongly suspect associated acute STEMI and cardiovert. If on the other hand, there was no clinical suggestion of acute MI and the patient was young and totally stable — then I’d probably start with adenosine given likely RVOT VT that may respond to adenosine. “Ya gotta be there” to know what one would do clinically.

I wonder what David Richley thinks?

I do hope the above is constructive and serves to change the mindset a bit — :)
NOTE: The tracing contributed by David Richley. Below, a slightly better resolution copy.
Dave sent me this — slightly better resolution ...

Tuesday, September 8, 2015

  • Tango Workshop Video Linked CONTENTS (Luis Bianchi & Daniela Pucci) — September 4-6, 2015 (Gainesville, FL).