Peaked T-Waves

What is this?

Go to Medscape and find out. This is a good learning experience.

A 70 yo woman came to the ER. She had chest pain. VS 97.3-42-14-162/96. SpO2 was 92% on room air. She was in no acute distress. The pain was along her left mid-clavicular line at the 5th ICS. She described the pain as strong (10/10), radiating through the back, and had the sensation of "an elephant" on her chest. Her EKG was unremarkable (other than the bradycardia). O2 was started at 2L/min nasal cannula. An IV was started, lab was drawn, and fentanyl 75mcg was given. Her past med hx included pancreatitis,hypertension, MI, 9 (yes nine) cardiac stents, and 1 pancreatic stent. Her meds included metoprolol 100mg, clonidine 0.1 mg, plavix 75 mg, and norvasc 5 mg, lisinopril 25 mg, ranitidine 150mg, crestor 10 mg, lexapro 20 mg, and diclyclomine 10 mg.

Her troponin was 0.01, CBC was hgb 12.2, hct 37.4. Na+ was 137, K+ was 3.9, BUN 22 Cr 1.1. Amylase and lipase were normal.

The fentanyl gave only short acting relief, so a nitro drip was started at 10 mcg, and she was admitted to ICU.

When I saw her the pain was gone, she was comfortable and in no distress. Her VS were OK except her blood pressure was 91/48. I took the nitro down to 5 mcg and waited one hour. BP at that time was 99/52. She was pain free, so I stopped the nitro. Her MD showed up shortly thereafter, increased her blood pressure meds notibly her clonidine went from 0.1 mg to 0.3 mg. He planned to send her home later that afternoon after I monitored her, ambulated her, and gave the increased dose of antihypertensives. He felt the pain was due to the elevated BP putting stress on her heart.

A couple hours after giving the Clonidine 0.3 mg, I noted her BP to be 79/48, no chest pain, no c/o except feeling tired. Well, I monitored her, got her to the chair (I didn't want to ambulate her with her SBP's in the 70's and 80's). Her pain had came back. I gave her 25 mcg of fentanyl, then another 25, then another 25 before there was any relief. I was afraid to give the whole dose of fentanyl, because I didn't know what would happen to her BP. Then I called her doc back with my assessment.

He decided to keep her overnight. Her 2D echocardiogram report came back (at the top of this post). Well, an ejection fraction of 8% and the internist measuring found it to be 20%. Because of this, the weakness, and continual low BP, he elected, and she agreed to be transported to her cardiologist.

Note the chest wall action in the report. I hope all goes well.

Sinusitis into sepsis

It's been awhile since I posted, but most of what has come through was pretty routine: high risk surgeries, trouble extubating after surgery, Over doses, electrolytes imbalances, etc.

This case, however, was a little different. This patient had a sinus infection under treatment by her physician for over one week. Her relatives found her on the floor, unconscious, and laying in vomit. They brought her to the hospital. VS were 97.0-130-28-40/0. She had cyanotic extremities. O2 was started at 15+L/min on nonrebreather mask. The first ABG's and CMP are shown. An art line was started with difficulty. She was bolused with 3L of NS and brought to ICU. The morning came, she was put on nasal cannula after her first gases. She was awake, warm and dry, pain free, no resp distress. Pretty remarkable after only a few hours. Her morning CBC and ABGs are shown. Her antibiotic was changed to clindamycin. She was stable enough to be moved out to the floor.

Ringo

This is Ringo. I named him that because of his accident. He is a mixed breed, young rooster from our flock. We had a broody hen that we allowed outside the chicken coup. She had a wire cage over her plus other armament, but one night a coon dug under everything, killed the hen, a keet, and stripped the skin off all around Ringo's neck.

The poor guy had no skin or feathers around his neck, but he was alive, so in the house he came. He wanted to eat and drink, so, OK, we'll give him a chance. Triple antibiotic, food, and water.

Well, he had done pretty well as you can see. The hole in his neck is healing nicely and scar tissue is growing well. He spends the day on his perch (a cardboard box with newspaper), and the night in a box with cross-hatched cover (for plenty of air) at night. If we are not in the room, he calls out to us.

I told my wife, "Maybe we could liter train him and keep him inside." Well, I'm sure you know what she thought of that plan. "Won't it be cool to have an chicken inside for a pet; visitors would love him." Well, I'm sure you know what she thought of that as well.

Well, Ringo, another week or so and back to the flock you go.

I'm sure by now most have seen and/or heard the comments made by James Fagan, Democratic Massachusetts State Representative, concerning "Jessica's Law" legislation.

I wrote him an e-mail:

I read your comments and saw the Fox video on your comments about Jessica's law.

You said, "And I'm [going to] rip them apart. I'm [going to] make sure that the rest of their life is ruined -- that when they're eight years old, they throw up; when their 12 years old, they won't sleep; when they're 19 years old, they'll have nightmares. And they'll never have a relationship with anybody."

You want to "ruin their life"?

You should be ashamed of yourself. I can't believe you want to ruin the lives of these children.

I'm a RN and have been in nursing for 33 years. I have seen children whose lives have been ruined by physical abuse, verbal abuse, and emotional abuse. These are the very abuses you plan to do?

Here's the video:

A great site for anatomy

If you want a easy start on radiological anatomy, I think you'll like this site. It has drawings, images of the body in cross-section, and CT images. The images are labeled so you can relate what you're seeing to what it is. Next time you look at some CT scans you'll know what you're looking at. This is in pdf format.