Case 11: Dialysis Dilemma

--> UPDATED: 01/03/2008 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER

EKG Case Discussion:
Each patient encounter requires a thorough assessment in order to determine what underlying medical conditions may be contributing to the patient presentation. While the presentation will help guide the EMS professional in their assessment methods, a baseline ECG should also be considered as a staple in every medical assessment. This week we will take a look at a life-threatening emergency that can be identified and potentially reversed in the field. Early treatment with notification to the receiving ED can prove to be a life saving factor. Review the following case and offer your thoughts in the discussion area below. 

EKG Case Presentation:
Medic 31 is dispatched for a "male not feeling well." Upon arrival at a residence, you are met at the door by the patient's wife. She explains that her husband has not been feeling well for the past 24 hours and has been unable to get out of bed. She shows you in to the bedroom where the patient is supine in bed and appears conscious and alert. He states that he missed a dialysis appointment because he felt so bad.
The patient is a 53-year-old male with renal insufficiency, Type I diabetes and hypertension. He denies symptoms of fever, nausea or vomiting, and states that he has not had an appetite. He mentions that he did eat some soup today for lunch. As you begin your assessment, you notice a rapid heart rate. You ask your partner to perform a baseline ECG. Here is the resulting printout for the 12-lead EKG:

Initial EKG (click for larger image):

Above is the EKG you are given. The computed interpretation is:

Abnormal ECG **Unconfirmed** 
***Suspect arm lead reversal, interpretation assumes no reversal 
Atrial fibrillation with rapid ventricular response 
Nonspecific intraventricular block 
Possible Right ventricular hypertrophy 
Lateral infarct, age undetermined 
Inferior infarct, age undetermined

Routine EKG Interpretation:

  • Rate & Rhythm
  • P-wave
  • PR interval
  • QRS interval
  • QRS complex & mean axis
  • ST segment
  • T wave
  • U wave
  • QT interval

Initial Assessment:
Patient is alert and oriented to time, place and location. His skin is pale, moist and warm.

HR 150
BP 95/58
RR 22
Pulse Ox 94 percent on room air 

Past Medical History:
Type I Diabetes 
Renal Insufficiency


Meds: (generic names)
Case 11 Discussion Questions:

  • Based on the presentation and findings, you and your partner quickly load the patient onto the stretcher and begin a 25-minute emergent transport. What are the capabilities of the hospital that impact your choice of facilities for this patient? 
  • What is the rhythm? What are the potential causes for this kind QRS morphology? Does the computed interpretation provide any clues for your consideration?
  • What other EKG findings could have been found in an earlier EKG, if one were taken prior to your arrival?
  • This patient is acutely ill and at great risk for cardiac arrest. What should be done now to potentially stop the progression of his condition and to potentially reverse it?

--> UPDATED: 01/03/2008 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER

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