#female cardioversion

[tangocardiaca]

Looks like drums also have the power of cardioversion and defibrillation. Shakira knows it best. I'd really love to shock her heart to stop fibrillation. She's so sexy.

[kk095]

Gabby’s Cardioversion

*hey everyone! I came up with a new story and wanted to try something different. Hope you all like it!*

On a chilly fall evening, an ambulance arrives at our emergency department where our usual team waits in the trauma room. In come Tracy and Stephanie with the next patient. “37 year old female, fainting episode but regained consciousness. Patient is complaining of chest pains, palpitations, and dizziness. EKG abnormal, tachy at 140bpm.” Stephanie rattles off. On that gurney was Gabby, the 37 year old basketball coach at the local college. She had fainted during practice that evening and one of her players called 911. Gabby was a tall glass of water, standing at 6’3, with a slim but toned, athletic build. She had blonde hair that was usually in a ponytail, beautiful bluish gray eyes, and had a cute tomboy appearance. Gabby was sitting in the upright position on the gurney when she was brought in, stripped down to just her purple sports bra and matching underwear (the team’s primary color of course). She had EKG electrodes stuck onto her chest, had IVs going in both arms, and had a nasal cannula in her nostrils. Coach Gabby was visibly uncomfortable, clenching her chest with one hand, groaning every so often.

Gabby was transferred onto the table, where she still sat in the upright position. “My chest…” Gabby says to herself, still clenching her chest, taking a few breaths. Dr Sarah lowers her stethoscope onto the coach’s chest for a listen. It sounded like Gabby’s heart was going to leap right out of her chest, but at the same time, there were no abnormal heart sounds, and her lungs were clear. “lets get labs going. Let’s do a CBC, BMP, tox screen, cardiac enzyme test, and a d-dimer. We gotta know what we’re up against.” Said Lindsay, taking some initiative in the situation. The team asked Gabby a handful of questions: “has anything like this happened before?” “any history of heart problems?” “any drug use?” “any other health problems that need to be disclosed?” But the answer to all these questions remained consistent- no!

“I wonder if I’m just stressed out. We haven’t had the best season, and rumor has it they’re gonna get rid of me if the season doesn’t turn around.” Gabby said, trying to take a stab as to why she was in our emergency department. The team continued to wait on labs, so the doctors decided to do a chest x ray and an echocardiogram to see if that could shed any light on the coach’s issues. The chest x ray showed completely normal anatomy, as did the echocardiogram- back to the drawing board. Since the ER team couldn’t find an obvious cause for the coach’s ailment, they decided to treat the symptoms and see if that helped. Gabby was given meds via IV to calm her heart down, and to help with her chest discomfort.

The evening droned on and coach Gabby only appeared to be getting worse. Her heart rate was still high, and her was EKG definitely off. “Something’s off with the QT interval. I know it might be subtle, but something just doesn’t look right there.” Said Lindsay, taking a long, detailed look at Gabby’s EKG. “she’s tall, so I wonder if she has undiagnosed Marfan syndrome or EDS?” Sarah suggested. “Yeah, but wouldn’t there have been a structural heart issue or something else we could work with on either chest x ray or the echo?” Lindsay rebutted. “Could be an electrical issue, but I wanna see what the labs end up saying. Is she on something? Are her electrolytes out of whack? Is there a blood clot or heart attack? There’s a lot consider.” Sarah countered. The two doctors respectfully disagreed with one another, unable to figure out what was wrong with the coach.

More time had passed, and coach Gabby’s vitals were starting to become worrisome. Her heart rate was through the roof, in the verge of v-tach. Gabby was leaning back with her eyes shut, holding her chest, moaning from the worsening pain she was experiencing. The monitors were chirping loud and fast, and only got faster. “I’ve got stable v-tach on the monitors.” Nurse Nancy tells the two doctors. At that point, Gabby’s bra was snipped off and the defibrillator pads were stuck onto her bare chest. “gabby? Your heart is in a dangerous rhythm. We have to give your heart a quick shock to make it all better, ok?” Dr Lindsay attempted to explain. “just make it stop…” coach Gabby replies, visibly uncomfortable. The doctors wanted to start Gabby off with a smaller jolt, so they went with 125j. The pads were charged up, and the first shock was delivered. Gabby’s body tensed up and her shoulders shrugged forwards. “AHH!” Gabby winced, feeling the electricity run through her. Post shock, the team looked at the monitor. “she’s still in stable v-tach. Let’s shock at 150.” Sarah decided. “Gabby? The first shock didn’t work, so we’re gonna do it 1 more time.” Lindsay explained. The defib pads were charged up to 150 joules, and the shock button was hit. Gabby jolted sharply, making strong fists with both her hands, letting out a yelp from the pain of the shock. Dr Lindsay lowered her stethoscope onto the coach’s bare chest and listened to her heart, and Sarah studied the monitors for a moment. “no change. Let’s go again at 175.” Said Sarah. The electrical whirring sound of the pads charging filled the room, followed by a weak thump when the shock was delivered. Her body tensed up and her toes scrunched up at the end of the table, showing off prominent, medium sized wrinkles in the soles of her size 14 feet. “pleaae… make it stop…” Gabby said in a worried tone, on the verge of tears. The rhythm wouldn’t go away, so it was decided to shock Gabby again at 200. Her long, slender body twitched sharply in reaction to the next shock. “am I gonna die? I don’t wanna die…” a terrified Gabby asked. “charge again to 225.” Sarah said. “no! Please…no more! No more!!!” coach gabby begged. Her chest shot forward and her back arched, but it didn’t look quite the same as the typical Hollywood style defibs since she was sitting in the upright position still. The next shock was at 250. The tall blonde winced in pain once more from the shock. She leaned back and her eyes opened wide, taking rapid, shallow breaths. She mouthed “I don’t wanna die” to Dr Lindsay, but didn’t have the energy to get the words out.

Suddenly, coach Gabby’s rapid breaths came to an abrupt stop. Her pretty blue eyes remained wide open, staring up above with an absolutely terrified expression on her face. “she’s in v-fib! Lower the bed and start compressions!” Dr Lindsay shouted urgently. The bed was lowered, and nurse Heather began going to town on Gabby’s chest. Her chest caved in, and her toned belly and abs bounced outwards. “I’m intubating. 8.0 ET and a laryngoscope.” Sarah called out. “pushing epi and atropine.” Lin announced. Heather continued pumping the coach’s chest, and Sarah got the breathing tube in, securing it with a blue tube holder. Once she was intubated and the meds were in, it was decided to switch over to the defib paddles. The pads were quickly peeled off, and the paddles were gelled, charged up to 250, and pressed up against the coach’s bare chest. Her chest was picked up and her arms flailed weakly towards the center of her body before falling limp again. “no change, charge to 300.” Lindsay ordered. KA-THUNK!!! The shock threw Gabby’s large, lanky body around on the table effortlessly, but didn’t restart her heart. ”360! Everyone….CLEAR!” Sarah called out, pressing the paddles back up against Gabby’s chest. Her feet leapt above the table, slamming back down a moment later, showing off coach Gabby’s hot wrinkly soles once more. “PEA, start compressions!” Lindsay yelled out. Nurse Jamie took over CPR this time, pumping the basketball coach’s rhythmically.

CPR, ambu bagging, and pushing meds went on for a bit. It took some time and hard work from the team, but Gabby converted back to v-fib around 17 minutes into the code. The defibs were gelled, charged to 360, and the next shock was delivered. Gabby’s body jolted violently from the controlled dose of electricity. Her eyes remained wide open, staring up above while the fight for her life went on. The team shocked Gabby another 2 times unsuccessfully, but v-fib looked like it was winning this battle. “should we crack her chest? Get better perfusion?” Lindsay asked. “I don’t know, I’m not feeling it here.” Replied Sarah. A few cycles of CPR and ambu bagging were performed, hoping to stimulate the tall blonde’s heart, but no change was noted. The team defibbed Gabby another 4 times, before flatlining after that last shock. Dr Sarah lowered her stethoscope onto the patient’s bare chest. “no heartbeat. No respirations.” Sarah stepped back, shaking her head. Lindsay did a quick bedside echocardiogram and looked over at the monitor. “no cardiac activity, down 27 minutes, pupils fixed and dilated.” Lindsay added. “it’s over. Time of death, 21:45.” Sarah said reluctantly, pulling the gloves off her hands.

The flatlined monitors were turned off and the ambu bag was detached from the ET tube while her pretty blue eyes stared up above helplessly. The EKG electrodes were plucked off Gabby’s chest, the defib gel was wiped off, and the IVs were taken out. Her body was covered with a sheet, and a toe tag was placed. The toe tag dangled in front of her big, wrinkly, size 14 soles, bringing a sad, and seemingly surprising end to the case.

[drwcn]

How to Write a Realistic Hospital Au/Setting

Because I’m frustrated with real life work stuff :( I’ve decided to distract myself by doing this. Disclaimer: I obviously only have my own country (the Handsome Ryan Factory) as reference, so if this isn’t how it is where you’re from, sorry. :/

The Environment

Hospitals do not smell like disinfectants. Hospitals smells like....nothing. If it’s a nice hospital and the facilities are relatively new/renovated, hospitals are generally scentless places (the ventilation system is better). The only time it’ll smell like disinfectants is when the housekeeping staff just cleaned a room after a patient has been discharged. Older hospitals and units like internal medicine which takes care of a lot of longer term patients and older folks smell...well not great. It seems like people and bodily fluids.  

Hospitals are cold. The OR is even colder (unless for whatever reason you need it to be warm for a specific procedure). 

Background noise. There are machines making noises the background, little beeps of the IV pumps or the heart monitor. Normal beeps are slow, alerts are fast. 

Intercom - every time something happens that requires a code to be called, it’ll come on the intercom and the entire hospital hears it. Common ones are: code blue = adult cardiac arrest (ex: Code Blue - K6, Code Blue K6) They tell you what the code is and where to go. The code team (usually an ICU team) will show up. Code pink = neonatal cardiac arrest. Code red = fire. Code yellow = missing patient. Code white = violent encounter (security will be called up). Code orange = external disaster (a train derailed). Code Silver = deadly weapons (gun, knife). Code Brown = hazardous spill. Code Black - bomb threat/suspcious object. Code Green= evacuation Etc. 

There will be rooms on “precaution”. Signs will show up on certain doors/rooms, because that patient might have some kind of communicable disease through contact/droplet/air. 

The Staff

Nurses are not rude (unless you’re writing a rude character). I see a lot of “the good tough nurse” caricatures where it’s like jab and shove - No. A good nurse can be assertive, can be knowledgeable, can be no non-sense, but they shouldn’t be rude and patient consent is always present. If a patient says they don’t want a shot, they don’t get the shot. No matter how seasoned, how tough, how burned out a nurse is, everyone is habituated to start a conversation with introducing themselves. “Hi, Mr/Ms/Mrs/Miss ____, my name is _______ and I will be your nurse today.” Once the nurse and the patient is acquainted with each other, they can be a little bit more casual. 

Hand washing is a constant thing. The most often thing you see is staff rubbing their hands together in and out of rooms because they just pumped a handful of hand sanitizer. 

There are other people other than the medical and nursing staff. Personal Support Workers (PSWs) are very present and they help with the washing and the bathing, and changing incontinence briefs. Nurses also do this as well in some hospitals. You might see Nurse Managers come around for administrative stuff (ie discharge), Physiology Therapy and Occupational Therapist will make their rounds on those that need it (especially after an accident), Speech Language Pathologists for those with swallowing problems after a stroke. Social Worker for those who are going through a difficult life situation. 

The medical team gets confusing. Because there are medical students (clerks), junior residents, senior residents, and there are attendings. Your patient character can be confused. 

Internal Medicine - the “ologys” : general internal medicine is where typically a lot of folks get admitted. The doctors who take care of these people are internists. Other popular sub specialties of internal medicine that sometimes get their own wing/unit are: cardiology, neurology, respirology and oncology. If a specific specialty is needed, the doctors of that specialty is paged for a consult.  

Surgery - do not have every surgical specialty in one team. That’s not how the surgical teams are divided. If one of your character is in Gen surg, and the other is in Neuro, they’re not gonna be spending their day constantly bumping into each other unless their surgeries are adjacent OR rooms for some reason. Their patients probably won’t even be on the same unit. 

If you’re writing surgery, don’t forget Anesthesiology. Patients coming out of surgeries can either go to PACU  Post Anesthesia Care Unit or the ICU (intensive care unit). 

Specialists can read scans by themselves, but most of them time, they need a Radiologist to do it. Biopsies are processed and read by pathologists. 

The Action 

If a patient flat lines, don’t “shock” or defibrillate them. TV shows constantly gets it wrong. The only two shock-able rhythms are ventricular fibrillation (V-fib) and ventricular tachycardia (v-tach). (There are other pathological rhythms that require cardioversion, but we won’t get into it). Your fictional patient could still have a rhythm and be unconscious. 

If a patient is unconscious or has either V-fib or V-tach or flatlined, call Code Blue. Literally have one of your character say it, “Call Code Blue.” Or press the code blue button that’s above the bed on the wall. 

If a patient flat-lines, your characters should start CPR and inject epinephrine (1mg and every 3-5 minutes). 

Don’t “lost 3L of blood”. If they did...they’re gone. Exsanguinated...unless they’re being transfused at the same time. A 70 kilo man typically has 5L of blood. A lot of preg fics have the woman lose a ton of blood during childbirth. Remember 500cc or 500 mL of blood in a nonsurgical setting is considered hemorrhage, and 1L in surgical setting. As a 5′3′’ female I can tell you I probably only have 2-3L of blood in my body. 

Things to talk about in conversation between two staff: heart rate (normal in adult 60-100), blood pressure (ex” 120/80 systolic/diastolic) normal systolic 100-140 normal diastolic 60-90); respiratory rate (normal 12-20 per minute), O2Sat (you want most people above 95%), temperature.

Red blood cell count and hemoglobin being low indicate anemia. High white blood cell count typically mean infection. Electrolytes can be out of wack: sodium, potassium, calcium, magnesium, are some of the typical ones. Blood pH can be either high or low. High pH is alkalosis. Low pH is acidosis. 

Hypothermia (because this is a popular one). Don’t do what Rose did in Titanic. You’re not dead until you’re warm and dead. Rewarming for severe hypothermia should be slow and in a hospital setting. For mild to moderate hypothermia, if it helps with your plot, yeah they can cuddle skin to skin. 

[wiccan-succulento]

Aconitum Napellus

*This is a POISON.

(I know a lot of this is medical terms and may be hard to understand- I basically look up every term I come across. I’ve included definitions for most, but not all. I have tried finding my list of sources, but I have lost them. I have NOT personally had experience with this; therefore, some information may be slightly off, or not accurate according to new studies. Feel free to add new information, definitions, or facts. I am NOT a health professional.)

Common Names: Aconite, Monk’s Hood, Wolf’s Bane, Blue Rocket, Queen of Poisons, Soldier’s Helmet, Devil’s Helmet, Mouse Bane, Leopard’s Bane, Women's’ Bane, Brute Killer, Dog Killer

Native to: Central and Western Europe, Asia

Toxicity: Severe. All parts of the plants are toxic, especially the roots and root tubers

Poison will enter the body through contact with skin, contact with broken skin or wounds, ingestion, consuming any part of the plant. 

The taste of the poison is a very bitter one, followed by a burning of the mouth and possibly esophagus, then numbing of the mouth.

Toxins in the plant include:

Aconitine- cardiotoxin (heart toxin) and neurotoxin (nerve toxin)

Mesaconitine

Hypaconitine

Side Effects can take a few minutes to a few hours to show. 

Side Effects Include:

Abdominal Pain

Nausea

Vomiting

General Numbness

Partial Paralysis

Respiratory Paralysis

Paresthesia- abnormal sensation of the skin (tingling, numbness, chilling, burning, prickling) with no apparent physical cause

Diarrhea

Bradycardia- abnormally slow heart rythym

Hypotension

Chest pain

Palpitations

Sinus tachycardia- elevated sinus rhythm characterized by an increase in the rate of electrical impulses arising from the sinoatrial node (group of cells in the wall of the heart’s right atrium). In adults, sinus tachycardia is defined as a heart rate greater than 100 beats/min (bpm)

Ventricular ectopics- extra heart beats originating in the bottom heart chambers

Ventricular tachycardia- fast abnormal heart rate

Ventricular fibrillation- rapid and erratic electrical impulses of the heart

Defective color vision 

 The main causes of death are refractory ventricular arrhythmias & asystole. The severity of the toxins are related to the onset of rapid heart rhythm changes

Preexisting health conditions, old age, pregnancy, and breast feeding may amplify the side effects.

Overall in-hospital mortality is 5.5%

Antidotes & Remedies-  

It has been reported that the effects of aconite can be buffered/eliminated by various alchemical methods. 

Management is supportive, including immediate attention to vital functions and close monitoring of blood pressure & cardiac rhythm. 

Inotropic therapy** is required if hypotension persists. Atropine*^ should be used to treat bradycardia. 

Aconite-induced ventricular arrhythmias are often refractory to direct current cardioversion & antiarrhythmic drugs. 

Available clinical evidence suggests that amiodarone & flecainide are reasonable first-line treatment.

In refractory cases of ventricular arrhythmias & cardiogenic shock, it’s most important to maintain systemic blood flow, blood pressure, & tissue oxygenation by early use of cardiopulmonary bypass. 

The role of charcoal hemoperfusion to remove circulating aconitine alkaloids is not established.) 

The early use of cardiopulmonary bypass is recommended if ventricular arrhythmias and cardiogenic shock are refractory to first-line treatment 

**An inotrope is an agent that alters the force or energy of muscular contractions

*^ Atropine is a medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate, and to decrease saliva production during surgery

Reducing toxicity-

Boiling, steaming, or soaking the plant may reduce toxicity due to the toxins being heat sensitive alkaloids. Since the toxic effect of raw aconite can be buffered/eliminated altogether by various alchemical methods, early Chinese medical texts focus much attention on processes involving the production of processed aconite. This includes procedures with special growing & harvesting techniques, special processing techniques, & herb combining techniques that blend the processed root with other foods and medicinal substances to safeguard against negative side effects. 

Ancient Chinese herbalists espoused a distinct concept of space referred to as “daodi yaocai” (herbs grown in a proper location). This concept is especially used when dealing with a variation of the Aconitum Napellus plant.

Li Shizhen and other ancient authorities of Chinese materia medica invariably state that “the best [aconite] is produced in Mianzhu in the region of Shu (northern part of today’s Sichuan province). Although aconite plants can also be found in other areas, they are unsuitable for treating disease.” A Song dynasty account gives a description of this particular region that is still known for producing China’s only “genuine” aconite 

The Chinese materia medica contains about 70 recorded types of post-harvest processing techniques aimed at reducing the toxic potential of aconite. The toxic effect of aconite stems from its alkaloids, especially aconitine. Since this ingredient is sensitive to heating, the processes of roasting, boiling or in most recent times, pressure-steaming, can reduce the effects of most alkaloids. Ancient Chinese texts specify that before heating, the aconite tuber should be peeled with bamboo knives. This labor-intensive technique has been abandoned in the modern production of medicinal aconite.

There is emphasis on the removal of the salt used for preservation of the aconite tubers after the harvest before they are brought to market. After the harvest, the unprocessed aconite root will decay rapidly (within a week) unless it is immediately immersed in brine. Brine immersion will embalm the root during the time when the entire year’s harvest is waiting for the typical step-by-step detoxification process consisting of skin removal and the application of heat. Traditional paozhi techniques specify that all brine is removed from the raw aconite slices before steaming or baking them, by soaking and rinsing them repeatedly in basins of fresh water. Seasoned Fire School practitioners, i.e. the contemporary scholar-physicians Drs. Lu Chonghan and Liu Lihong, have observed that industrial aconite production during the last two decades has flooded the market with high salt content aconite slices. To most kidney deficient patients, this significant salt residue in most pharmacy grade aconite (70% in most contemporary aconite products) is harmful and may be partially responsible for some of the side effects associated with aconitine alkaloids in the pharmacological literature. In addition, it has become common practice in recent years to remove the root peel by immersion in hydrochloric acid, defying the stringent alchemical experience of aconite detoxification garnered during the last two millennia.

Medicinal Uses -

Medicinal applications of aconite were not fully explored until the 18th century when Viennese physician Anton Stoerck published his clinical observations about benefits of the “internal use of aconite in humans” in 1762. Alleged therapeutic uses include treatment of joint & muscle pain. As a tincture applied to skin, it’s claimed to slow heart rate in cardiac patients. Other claimed uses: reduction of fevers & cold symptoms. Some take it by mouth for facial paralysis, joint pain, gout, finger numbness, cold hands & feet, inflammation, painful breathing & fluid in space surrounding the lungs (pleurisy), certain heart problems (pericarditis sicca), fever, skin diseases, & hair loss. Aconite is also used as a disinfectant to treat wounds & promote sweating. Some apply aconite to skin in liniment as a “counter irritant” for treating facial pain, joint pain, & leg pain (sciatica). Aconite root contains chemicals that may improve circulation, but also contains chemicals that can harm the heart, muscles, & nerves

.

History-  

Aconitum Napellus was used in ancient times as poison on spears and arrows for hunting and battles. The tips and (possibly) shafts pf arrows were covered with the poison so anyone helping a wounded soldier may get poisoned as well by skin contact.

As wolfsbane, it was believed to repel werewolves and wolves. The poison was placed in raw meat which would kill wolves attacking livestock.

 Ancient Romans used it as a method of execution. 

In Hong Kong, aconite is the most common cause of severe poisoning from herbs. In Asia, toxicity is related to the use of aconite in traditional medicines. In western countries, aconite poisoning is associated with consuming the plant 

Supposedly used in times of war by retreating armies to poison enemy water supplies. Generals would realize the poisoning and be forced not to pursue the enemy. 

The poison was placed on the tips of harpoons to kill whales more easily. 

The murder of Percy John by his brother-in-law, Dr. George Henry Lampson, was carried out using aconite

“If [aconite] sap is condensed by simmering, it is called Shewang (Shooting Net) and used to kill wild animals.” The 5th century Daoist hermit Tao Hongjing elaborates further: “When the sap of the raw [aconite] vine is extracted by mortaring it to a pulp, and then concentrating it by simmering, the paste yielded from this process is called Shewang. Arrows dipped into it can be used by hunters to shoot wild animals; when hit by such an arrow, an animal will fall to the ground after 10 steps. If a human is struck by such an arrow, s/he will die as well, unless the poison is swiftly neutralized by an antidote.

Known Cases

Very low margin of safety between therapeutic and toxic doses of aconitine.

A 66-year-old female with no known heart disease obtained Aconite from an herbalist. She was instructed to make tea with it to treat her osteoarthritis*. About 90 minutes after consuming the tea she developed numbness of the face, arms, & legs. Rapidly followed by nausea, weakness, & chest pressure. In an Emergency Room, she was found to have an abnormal heart rhythm. After 4 hours of treatment with drugs & electrical shocks to her heart, a normal heart rhythm was restored.

* most common form of arthritis. It occurs when the protective cartilage cushioning the ends of bones wears down over time

There are cases of poisoning in which people intentionally swallow Aconitum napellus they grow because of claimed therapeutic effects. A 21-year-old male acquired Aconitum napellus plants after reading a book on herbal medicine. He ground up the dried roots & filled capsules with the material. He took 1 capsule daily for several months to treat anxiety. (No symptoms were reported during that time) In order to increase the effects one evening, he swallowed 3 capsules and went to sleep. Five hours later he awoke with generalized numbness, nausea, diarrhea, dizziness, chest pain, shortness of breath, & defective color vision (seeing purple). It was believed that early symptoms went unnoticed because he was asleep. In an ER, his heart rate was 43 bpm, and he had an abnormal heart rhythm. Plasma concentrations of aconitine supported poisoning by A. napellus. He spent 48 days in the hospital.

SOURCES: N/A, my list was lost when moving my information to a new document. I know for a fact I have spanned at least 6 websites, and 2 YouTube videos (only one of which was helpful) as well as the materia medica of John Henry Clark

[step2ckmap]

Atrial Dysrhythmias

Atrial Fibrillation/Flutter

Unstable: Synchronized Cardioversion

Stable: BBlockers, CCB, Digoxin to get rate <100. then anticoagulate

CHADS 1- Aspirin, CHADS >/= 2, Warfarin, Dabigatran, Rivaroxaban

CHADSVAS: CHF, HTN, >75yo (2), DM, Stroke (2), PAD, 65-74yo, female

Multifocal Atrial Tachycardia

Seen with COPD. 3 different P wave morphologies. “Polymorphic P waves”

Treat COPD, Treat like Afib, but NO BB

Caused due to low O2, so correct O2 FIRST (also caused by electrolytes)

Give O2 first, then Diltiazem

Supraventricular Tachycardia (SVT)

rate: 160-180, no P waves, no fibrillatory waves, narrow QRS

Unstable: synchronized cardioversion

Stable: #1-Vagal/Valsalva/Ice –> IV Adenosine –> BB, CCB, digoxin

Best long term–> Radiofrequency catheter ablation

[unabashedlystupendousbeliever]

Abasia, Abdominal Compartment Syndrome, Abdominal Discomfort, Abdominal Distension, Abdominal Pain, Abdominal Pain Lower, Abdominal Pain Upper, Abdominal Strangulated Hernia, Abdominal Symptom, Abnormal Behaviour, Abnormal Chest Sound, Abnormal Dreams, Abnormal Sleep-Related Event, Abortion Incomplete, Abortion Induced, Abortion Missed, Abortion Spontaneous, Abscess, Accident, Accidental Death, Accidental Drug Intake By Child, Accidental Exposure, Accidental Overdose, Acetonaemia, Acidosis, Acne, Activated Partial Thromboplastin Time Prolonged, Activities of Daily Living Impaired, Acute Abdomen, Acute Coronary Syndrome, Acute Hepatic Failure, Acute Myocardial Infarction, Acute Prerenal Failure, Acute Psychosis, Acute Pulmonary Oedema, Acute Respiratory Distress Syndrome, Acute Respiratory Failure, Acute Sinusitis, Acute Tonsillitis, Adenoma Benign, Adverse Drug Reaction, Adverse Event, Affect Lability, Affective Disorder, Ageusia, Aggression, Agitation, Agitation Neonatal, Agonal Rhythm, Agranulocytosis, Akathisia, Akinesia, Alanine Aminotransferase Decreased, Alanine Aminotransferase Increased, Albuminuria, Alcohol Interaction, Alcohol Poisoning, Alcohol Problem, Alcohol Use, Alcohol Withdrawal Syndrome, Alcoholism, Alopecia, Amblyopia, Amenorrhoea, Ammonia Increased, Amnesia, Anaemia, Anaemia Macrocytic, Anaemia Megaloblastic, Anal Candidiasis, Anal Infection, Analgesic Drug Level Increased, Anaphylactic Reaction, Anaphylactic Shock, Aneurysm, Anger, Angina Pectoris, Angina Unstable, Angioneurotic Oedema, Angiopathy, Angle Closure Glaucoma, Anhedonia, Anion Gap Abnormal, Ankle Fracture, Ano-Rectal Stenosis, Anorexia, Anorgasmia, Anosmia, Anoxic Encephalopathy, Anticholinergic Syndrome, Anticoagulation Drug Level Below Therapeutic, Anticonvulsant Drug Level Below Therapeutic, Anticonvulsant Drug Level Decreased, Anticonvulsant Drug Level Increased, Antidepressant Drug Level Above Therapeutic, Antidepressant Drug Level Increased, Anti-Hbc Antibody Positive, Antinuclear Antibody Positive, Antipsychotic Drug Level Above Therapeutic, Antipsychotic Drug Level Increased, Anuria, Anxiety, Anxiety Disorder, Aorta Hypoplasia, Aortic Arteriosclerosis, Aortic Disorder, Aortic Rupture, Apallic Syndrome, Apathy, Apgar Score Low, Aphagia, Aphasia, Aphonia, Aphthous Stomatitis, Aplastic Anaemia, Apnoea, Appendicectomy, Appendicitis Perforated, Apraxia, Aptyalism, Arachnoid Cyst, Arrhythmia, Arterial Thrombosis, Arteriosclerosis, Arteriosclerosis Coronary Artery, Arteriovenous Fistula (Acquired), Arthralgia, Arthritis, Arthritis Bacterial, Arthropod Bite, Ascites, Aseptic Necrosis Bone, Asocial Behaviour, Aspartate Aminotransferase Increased, Aspiration, Asterixis, Asthenia, Asthma, Ataxia, Atelectasis, Atherosclerosis, Atonic Urinary Bladder, Atrial Fibrillation, Atrial Flutter, Atrioventricular Block, Atrioventricular Block Complete, Atrioventricular Block First Degree, Atrioventricular Block Second Degree, Atrophie Blanche, Atrophy, Attention-Seeking Behaviour, Aura, Auricular Swelling, Autism, Autoimmune Disorder, Autoimmune Hepatitis, Autoimmune Thyroiditis, Autonomic Nervous System Imbalance, Azoospermia, Azotaemia, Back Injury, Back Pain, Bacteraemia, Bacteria Sputum Identified, Bacteria Urine Identified, Bacterial Infection, Balance Disorder, Benign Intracranial Hypertension, Beta Haemolytic Streptococcal Infection, Bile Duct Cancer, Bile Duct Obstruction, Bile Duct Stenosis, Bile Duct Stone, Biliary Neoplasm, Biliary Tract Disorder, Bilirubin Conjugated Increased, Biopsy Liver Abnormal, Bipolar Disorder, Bipolar I Disorder, Bipolar II Disorder, Bite, Bladder Dilatation, Bladder Disorder, Bladder Obstruction, Bladder Pain, Bladder Prolapse, Bleeding Time Prolonged, Blepharospasm, Blindness, Blindness Transient, Blindness Unilateral, Blister, Blood Albumin Decreased, Blood Alcohol Increased, Blood Alkaline Phosphatase Increased, Blood Amylase Increased, Blood Bilirubin Increased, Blood Bilirubin Unconjugated Increased, Blood Chloride Decreased, Blood Chloride Increased, Blood Cholesterol Increased, Blood Count Abnormal, Blood Creatine Increased, Blood Creatine Phosphokinase Increased, Blood Creatinine Increased, Blood Culture Positive, Blood Disorder, Blood Electrolytes Abnormal, Blood Electrolytes Decreased, Blood Ethanol Increased, Blood Glucose Abnormal, Blood Glucose Decreased, Blood Glucose Fluctuation, Blood Glucose Increased, Blood Lactate Dehydrogenase Increased, Blood Magnesium Increased, Blood Osmolarity Decreased, Blood PH Decreased, Blood Phosphorus Increased, Blood Potassium Decreased, Blood Potassium Increased, Blood Pressure Abnormal, Blood Pressure Decreased, Blood Pressure Fluctuation, Blood Pressure Immeasurable, Blood Pressure Inadequately Controlled, Blood Pressure Increased, Blood Pressure Orthostatic, Blood Pressure Orthostatic Decreased, Blood Pressure Systolic Decreased, Blood Pressure Systolic Increased, Blood Proinsulin Increased, Blood Prolactin Increased, Blood Sodium Decreased, Blood Sodium Increased, Blood Test Abnormal, Blood Triglycerides Abnormal, Blood Triglycerides Increased, Blood Urea Decreased, Blood Urea Increased, Blood Urea Nitrogen/Creatinine Ratio Decreased, Blood Urine, Blood Urine Present, Bloody Discharge, Body Temperature Decreased, Body Temperature Increased, Bone Density Decreased, Bone Disorder, Bone Marrow Depression, Bone Marrow Disorder, Bone Marrow Failure, Bone Neoplasm Malignant, Bone Pain, Bradycardia, Bradycardia Neonatal, Bradykinesia, Bradyphrenia, Bradypnoea, Brain Abscess, Brain Damage, Brain Death, Brain Neoplasm, Brain Oedema, Brain Scan Abnormal, Brain Stem Syndrome, Breast Cancer, Breast Cancer Female, Breast Cancer In Situ, Breast Discomfort, Breast Pain, Breast Swelling, Brief Psychotic Disorder With Postpartum Onset, Bronchial Infection, Bronchiectasis, Bronchitis, Bronchitis Acute, Bronchopneumonia, Bronchospasm, Bruxism, Bulimia Nervosa, Bundle Branch Block, Bundle Branch Block Bilateral, Bundle Branch Block Left, Bundle Branch Block Right, Burning Sensation, Bursitis, Caesarean Section, Calcinosis, Campylobacter Infection, Candidiasis, Carbon Monoxide Poisoning, Cardiac Arrest, Cardiac Death, Cardiac Discomfort, Cardiac Disorder, Cardiac Failure, Cardiac Failure Acute, Cardiac Failure Congestive, Cardiac Fibrillation, Cardiac Flutter, Cardiac Hypertrophy, Cardiac Malposition, Cardiac Murmur, Cardiac Pacemaker Insertion, Cardiac Valve Disease, Cardioactive Drug Level Decreased, Cardiogenic Shock, Cardiomegaly, Cardiomyopathy, Cardiopulmonary Failure, Cardio-Respiratory Arrest, Cardiotoxicity, Cardiovascular Disorder, Cardioversion, Carotid Artery Occlusion, Carotid Artery Stenosis, Carpal Tunnel Syndrome, Cataplexy, Cataract, Cataract Subcapsular, Catatonia, Catheter Related Infection, Cellulitis, Central Venous Pressure Decreased, Cerebellar Haemorrhage, Cerebellar Infarction, Cerebral Arteriosclerosis, Cerebral Artery Occlusion, Cerebral Artery Stenosis, Cerebral Atrophy, Cerebral Disorder, Cerebral Haemorrhage, Cerebral Infarction, Cerebral Ischaemia, Cerebral Thrombosis, Cerebrovascular Accident, Cerebrovascular Disorder, Cervical Vertebral Fracture, Cervix Carcinoma, Cheilitis, Chest Discomfort, Chest Pain, Chest X-Ray Abnormal, Cheyne-Stokes Respiration, Chills, Choking, Choking Sensation, Cholecystitis, Cholelithiasis, Cholelithotomy, Cholestasis, Chondromalacia, Chorea, Chorioamnionitis, Chromatopsia, Chromaturia, Chronic Myeloid Leukaemia, Chronic Obstructive Pulmonary Disease, ;.......................................................................

There it is on the bottom. Chronic Obstructive Pulmonary Disease, What I’ve had for almost 3 years after a cold withdrawing from “antipsychotics.”

The reason I feel like I have no energy and can’t breathe and  sound like Marianne Faithful from a constantly inflamed throat.

https://www.futurity.org/lungs-copd-inflammation-1752872-2/  I wonder if I’ll live long enough to take these drugs they’re deveolping to stop the high white blood cell counts that’s causing my body to destroy my lungs. How do I get on a trial...

[juniperpublisherscasestudies]

Juniper Publishers- Open Access Journal of Case Studies

Tremors Mimicking Atrial Flutter in an Elderly Lady

Authored by Aamir Hameed Khan

Abstract

We present an interesting case where electrocardiogram (ECG) recording in a patient with tremors mimics atrial flutter. A 77-year-old south Asian lady with history of hypertension and Parkinson`s disease presented to a tertiary care hospital in Pakistan with cough and fever. On second day of admission she started having pleuritic chest pain, Initial ECG was interpreted as atrial flutter. When her ECG was reviewed by a cardiologist, several features questioned the diagnosis of atrial flutter. A repeat 12 lead ECG clearly demonstrated normal sinus rhythm and the patient remained completely asymptomatic throughout the hospital stay. Tremor induced artifacts can be mistaken for arrhythmias. Correct diagnosis is critically important, in order to avoid wrong treatment and unnecessary interventions.

Keywords:Tremors; Atrial flutter; Parkinson`s disease

Introduction

Parkinson’s disease is a degenerative neurological disease caused by the loss of dopaminergic neurons in the substantia nigra [1]. Around 2% of the population above the age of 65 years develop Parkinson`s disease. Parkinson`s is characterized by bradykinesia, rigidity, postural and gait impairment, and resting tremors.

Atrial flutter is a macro reentrant supraventricular tachyarrhythmia characterized by an atrial rate of more than 300 beats/minute with the saw-tooth appearance of p waves [2]. Patients with atrial flutter commonly present with palpitations, fatigue, dizziness. Sometimes transient ischemic attacks or stroke may be the initial manifestation of atrial flutter. Other than thromboembolism, atrial flutter is associated with tachycardia induced cardiomyopathy, and heart failure [3]. Without proper anticoagulation, the risk of cerebral embolization with atrial flutter is equal to atrial fibrillation [3].

12 electrocardiogram plays a pivotal role in the diagnosis of atrial flutter and electrocardiographic artifacts are a common finding in the in-patient setting [4]. It is reasonable to consider the possibility of artifacts while making a diagnosis of tachyarrhythmia, this may save an unnecessary intervention in the form of antiarrhythmic medications, anticoagulation and even electrical cardioversion. Parkinsonian tremors are one of the major causes of electrocardiographic artifacts resembling atrial flutter. We present an interesting case of tremors mimicking atrial flutter and will discuss the existing literature

Case Presentation

A 77-year-old south Asian female with a history of hypertension and Parkinson`s disease presented to a tertiary care hospital in Pakistan with 2 days history of fever and nonproductive cough. She denied chest pain, shortness of breath, palpitations and syncope. Her home medications included carbidopa-levodopa, amlodipine, multivitamins and esomeprazole. On initial examination her heart rate was 96 beats per minute, blood pressure was 100/70mmHg; the respiratory rate was 18 breaths per minute and she was afebrile. Her chest exam revealed signs of consolidation in right lower lung zone. The neurological exam showed bilateral resting tremors and rigidity in both the upper and lower extremities. Her initial laboratory investigations included hemoglobin of 11.9g/dl, total leukocyte count 9400/micL, sodium of 135mmol/L, potassium of 3.9mmol/L, chloride of 102mmol/L, creatinine of 0.8mg/dl, magnesium of 2.1mg/dl, and pro-BNP of 19. Her x-ray chest demonstrated right lower lung zone alveolar infiltrates with air bronchogram.

She was admitted and started on intravenous antibiotics along with intravenous hydration and antipyretics as needed. On the second day of hospitalization, she started having right-sided pleuritic chest pain. Cardiac monitor and rhythm strip showed atrial flutter (Figure 1). Initial 12 lead ECG was interpreted as atrial flutter (Figure 2).

After review of her ECG by a cardiologist, several ECG features including sharply contoured p waves, different “flutter” wave morphologies in the same leads and more prominent “flutter” waves in the limb leads compared to the precordial leads, questioned the diagnosis of atrial flutter. A repeat 12 lead ECG was done after immobilizing her limbs, which clearly demonstrated normal sinus rhythm (Figure 3).

Discussion

Artifacts in electrocardiograms are common in a hospital setting. These artifacts can mimic several arrhythmias leading to unnecessary and potentially harmful interventions in the form of antiarrhythmic drugs and even electrical cardioversion [5]. In our patient, a misdiagnosis of atrial flutter could have led to lifelong anticoagulation as her CHA2DS2-VASc score was 4.

Hwang et al. [6] enrolled 100 patients with Parkinson`s disease with resting tremors to study the frequency and patterns of tremor-induced artifacts in an outpatient setting. The study demonstrated baseline undulation in 78% of the patients and artifacts mimicking atrial flutter/fibrillation or ventricular tachycardia were found in 11% of the patients [6]. 12 lead ECGs were evaluated by postgraduate, neurology residents, internal medicine residents and cardiologists, who were given relevant medical information. The rate of ECG misinterpretation leading to the spurious diagnosis of atrial flutter /fibrillation or ventricular tachycardia was 14.3% with an automated electrocardiograph, 45% with postgraduate year one resident and 9.1% with neurology residents, Cardiology residents and fellows correctly identified all artifacts, indicating the importance of professional training to reduce the potential complications [6].

Tremor induced artifact can be misinterpreted as supraventricular as well as ventricular arrhythmias. Several clinical and electrocardiographic characteristics should be observed o differentiate tremor induced artifacts from cardiac arrhythmias. While recording 12 lead ECGs, it is mandatory to minimize environmental interference, such as patient movement, electromagnetic interference from cell phones and tremors [7]. ECG characteristics which suggest tremor induced “pseudo” atrial flutter, include abrupt onset and termination, presence of normal p wave before and after arrhythmia, atypical p wave morphology with sharp contours, prominence flutter waves in limb leads and on careful inspection the presence of normal p wave that marches out throughout the event. In the setting of suspected tremor induced ventricular arrhythmias, hemodynamic stability is expected and supports the artifacts.

It is essential to note that Parkinsonian tremor is present in the limbs and face but not in the trunk; therefore, the tremor induced artifacts are more prominent in limb-leads as compared to the precordial leads.

Prescription of anticoagulation with the spurious diagnosis of atrial flutter increases the risk of serious intracranial hemorrhage in patients with advanced age and Parkinson`s disease as they are at increased risk of falls due to postural instability [8]. It leads to unnecessary emotional stress on patients and families and associated hospital/clinical visits contribute towards increasing health care cost burden.

Conclusion

In conclusion, our case report highlights several differentiating electrocardiographic features of tremor induced artifacts Correct and accurate diagnosis requires careful inspection and interpretation of the ECG in the context of history and clinical examination. This is critically important, to avoid wrong treatment and unnecessary interventions.

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[juniperpublishers-oajnn-blog]

Adenosine -Induced Flow Arrest and Microsurgerical Clipping in Difficult Cerebral Aneurysm Surgeries

Authored by  Mannará Francisco Alberto

Abstract

Transient flow arrest caused by induced Adenonsine administration has been used to facilitate microsurgical clipping in some cases of cerebral aneurysms. Here, we described our experience in two cases where adenosine induced flow arrest facilitate to place the clip in the neck of aneurysm without any complication, in cases where proximal control is not possible.

Keywords: Adenosine; Flow arrest; Cerebral aneurysm; Aneurysm clipping

Go to

Introduction

Endovascular techniques in the treatment of cerebral aneurysms had evolved advances in the field, however, microsurgery with clip occlusion of the aneurysm´s neck is still a mainstay in definitive treatment. Intraoperative rupture of the cerebral aneurysm can have undesired consequences. To avoid rupture, proximal temporary arterial occlusion is used to decrease the turgor of the aneurysm neck, thereby facilitating clip occlusion of the aneurysm or clip reconstruction of the carotid artery. Sometimes, it is difficult to find an anatomically suitable place for temporary arterial occlusion for carotid paraclinoid aneurysms or giant aneurysms, even with clinoidectomy performed. In such cases, the use of adenosine can facilitate surgery, producing reversible flow‑arrest. This helps in decompressing the aneurysm sac and improve visualisation to facilitate clip application. We present two cases where the use of induced adenosine flow arrest facilitate to place the clip in the prompt positition without any complication.

Go to

Case Presentations

Case 1

51 years old female patient, antecedent of endovascular coiled left paraclinoid aneurysm 2 years before, with posterior amaurosis. She was admitted at hospital with a ruptured carotid ophthalmic on the right side (Figure 1). She was scheduled for surgical clipping of the aneurysm. In anticipation of intra- operative rupture, we planned administration of intravenous adenosine. The patient was placed with external defibrillator paddles in position. We performed a right frontotemporal craniotomy with intradural clinoidectomy. When we exposed the neck, we confirmed a great tension on wall of the artery, with the optic nerve displaced uprighted, so it was difficult to clip the aneurysm with safety (Figure 2). We administered 18 mg (0.3 mg/kg)adenosine via central venous catheter in a quick bolus with 20 ml of normal saline flush, which resulted in flow‑arrest and transient asystole lasting for 20 seconds .This facilitated further dissection, softing the walls of the dome and neck, (Figure 3) and application of permanent clip . Exclusion of aneurysm was confirmed with Doppler ultrasonographic device. (20 MHZ Mizuho Doppler). Sinus recovery occurred after about 20 s and normal sinus rhythm was recovered. The patient did not suffer any cardiological or neurological consecuence. We repeated electrocardiograms (ECGs), echocardiograms and Troponin I assay post‑operatively at 6 and 24 h, respectively, which were within normal limits.

Case 2

35 years old patient with subarachnoid haemorraghe, Hunt and Hess grade IV, Fisher 4, with left giant supraclinoid carotid aneurysm (Figure 4, Figure 5). We planned treatment by clip reconstruction and anticipated the use of adenosine to facilitate dissection and deal with a possible intra‑operative rupture. During dissection, the aneurysm ruptured.

Adenosine 18 mg IV was administered as a quick bolus through the central line with 20 ml of normal saline flush. Asystole was achieved for 25 seconds, during which, we could reconstructed with fenestrated multiclipping technique the parent artery, with exclusion of aneurysm. With Mizuho Doppler we confirmed patency of internal carotid artery. Following asystole, the patient heart rate recovered spontaneously without any haemodynamic sequelae.

Go to

Discussion

Adenosine is an endogenously occurring nucleoside analogue, which reduces heart rate and prolongs conduction through the sinoatrial and atrioventricular nodes, acting on cardiac A1 receptor to decrease cyclic adenosine monophosphate. It has an ultra‑short half‑life <10 s, secondary to reuptake by red blood cells and vascular endothelial cells [1].

Due the very short negative dromotropic and chronotropic effect on cardiac sinoatrial and atrioventricular nodes, Adenosine is usually indicated in paroxysmal supraventricular tachyarrhythmia. The administration of adenosine in patients with normal sinus rhythm induces a rapidly reversible cardiac arrest. The intravascular half-life of adenosine at the physiologic level is less than a second [1-3].

Adenosine-induced flow arrest offers a unique method to reduce cerebral perfusion pressure briefly and controllably and can facilitate the clip ligation of many aneurysms that were previously treated with deep hypothermic circulatory arrest, temporary occlusion of the extracranial carotid artery, or endovascular balloon catheter retrograde suction deflation [4,5].

In the case number 1 we used adenosine because the great tension on the wall of the aneurysm. Sometimes, we had opened the aneurism and, deflate it to perform the clipping, but this option we used it when the wall is calcified or with thrombosis. The patient was young, and didn´t have calcified wall, so adenosine induced flow arrest facilitate the clipping, softing the walls without the need to retract optic nerve.

In a case of an aneurysm rupture, adenosine has been used successfully to induce transient cardiac arrest to stop the bleeding when suction fails to clear the operative field, allowing the surgeon to place temporary or permanent clip under visual control [6-10].

In our experience, when we deal with an intraoperative aneurysm rupture, we try to gain proximal control, and transient clip is used. Furthermore, lowering systolic pression facilitate to face this situation. In such circumstances, maybe we don´t need to use adenosine. In the case number 2, we didn´t have proximal control to manage the bleeding. In such circumstance, adenosineinduced flow arrest was useful to clip aneurysm. However, the surgeon should think in this possibility to prepare the patient prior to perform the surgery, considering the placement of external defibrillator pads on all patients who might receive adenosine, to provide external pacing capability if prolonged asystole/ bradycardia were to develop, or cardioversion in the face of hemodynamically unstable atrial fibrillation. In addition, monitoring all these patients for biochemical evidence of myocardial injury (e.g., troponin I) in the postoperative period has now become our standard practice to perform appropriate subsequent evaluation for those with a positive response.

Go to

Conclusion

The use of adenosine- induced flow arrest, in cerebral aneurysms in which temporary occlusion is impractical or difficult, provides a safe option to facilitate microsurgical clipping.

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https://juniperpublishers.com/oajnn/OAJNN.MS.ID.555574.php

[restingnurseface]

30 Questions Thanks for the tag @londonerbecky 1. Nicknames: Spock ( I had a misshapen ear as a child, my brothers were a bit harsh) 2. Gender: Female 3. Star Sign: Aries 4. Height: 5’ 6" 5. Time: 21:36 BST 6. Birthday: 24th March 7. Favorite Bands: I have pretty eclectic tastes....Five Finger Death Punch, Pearl Jam, Iron Maiden, Beastie Boys, Queen 8. Favorite Solo Artists: Yellawolf, Kacey Musgraves, Maria Callas, Johnny Cash, Etta James, Elvis 9. Song Stuck in my Head: Insane in the Brain by Cypress Hill. Reminds my of my last ski holiday 10. Last Movie I Watched: Rewatched Brief Encounter yesterday because it's one of my faves, being so terribly clipped and English and repressed. 11. Last Show I Watched: Ray Donovan latest episode but I'm holding off watching Game of Thrones until husband home from work. Anyone else think Liev Schreiber looks like a sexy otter??? Just me? Oh...ok 12. When Did I Create This Blog: A couple of weeks ago 13. What do I Post: Politics/ intersectional feminism, Outlander, Game of Thrones, Specialist/critical care/ECMO nurse related posts and random shit that amuses me. 14. Last Thing I Googled: "nebivolol as an adjunct to chemical cardioversion" because I'm a hideous saddo and it was at work. Outside of work it was, "Edinburgh mini breaks" 15. Do You Have Any Other Blogs: Nope 16. Do You Get Asks: Alas not yet!  17. Why Did You Choose Your URL: I'm still working on it..... 18. Following: 12 19. Followers: 3 21: Average Hours of Sleep: depends what shift I'm on! Usually between 5-10 hours 22. Lucky Number: ?  9 23. Instruments: cello. Badly. 24. What Am I Wearing Right Now: Boston Bruins pyjamas ( best ice hockey team ever) 26. Dream Job: Being paid to read novels 27. Dream Trip: Bear watching in BC or a far east grand tour culminating in Raffles bar, Singapore 28. Favourite Food: Sashimi ....mmmmmmm 29. Nationality: British, English mainly with a dollop of Scots 30. Favorite Song: That's a tricky one, it depends on the genre but my favourite piece of music is Chopin's Fantasie Impromptu in C# minor op 66, although I have a real soft spot for "Who wants to live Forever?" by Queen because they were the first rock band I truly loved I tag...@carriesbridal #personal #30 questions  

[tangocardiaca]

One more time for Jill, but this time she wears AED pads connected to portable mini defibrillator. Creator and source in first post about Jill.

[robtshelton6-blog]

Creating A Peg Tree

Hyperacusis is actually a clinical health condition wherein the person's endurance for usual sound in his environment is actually decreased. There numerous kids in our planet who are actually being made use of by the identical people which are actually meant to take care of all of them. If your life vest performs certainly not come furnished with a whistle, you may desire to acquire one in the event of unexpected emergency, especially if you are taking a household team out onto the water. Children that acknowledge and also could recognize a multitude of fast food ads are actually extra obese than their a lot less television know-how versions, 2018sportblog.info states Dr Auden C. McClure. Low-cost earphones commonly do not remove spikes of audio that are of an extremely higher intensity and also probably unsafe to hearing, but they occur thus promptly that you do not also notice all of them. Examining your habits and your house life might be the key to helping your over weight kid burn fat. Fast food usage has actually raised fivefold among children given that 1970. Make sure to practice analysis this out loud prior to showing to your group.

Foster as well as adoptive parents are actually a vital information for the body, delivering houses for youngsters which discover themselves in state guardianship via no shortcoming of their personal. He would certainly certainly not merely have actually been pleased to perform his punctuation phrases, he will likewise have know them more quickly as well as Leslie would possess enjoyed also. Chief Executive Officer Mark Zuckerberg will definitely stand up onstage at F8 and also wax poetic regarding the beauty of linking billions of people across the globe, while all at once patenting modern technologies to determine customers' social lessons and also enable discrimination in the loaning method, and also enabling casing marketers to leave out indigenous as well as racial groups or even households with females and also kids from their directories. This children's traditional has an amusing peek under the bed at a little bit of kid's going to bed concerns. They won't want to go if a little one just connects school along with being actually distressed. Find specialist support if just receiving in the college door everyday is actually complicated.

( HealthDay)-- The number of ADHD diagnoses among kids has actually risen considerably before two decades, going coming from 6 percent to 10 percent, a brand-new document programs. When there is a sensitiveness to sound because of listening to loss, audiologists get in touch with the condition employment".

This message is not indicated to urge or inhibit women from going on a fast, instead that is actually to deliver info that could help mommies keep healthy and balanced if they choose to take on also a handful of times of starting a fast. Kids with ventricular tachycardia could require cardioversion, or even electricity surprises, to send back the heart to its ordinary rhythm, especially if the youngster is actually uncertain and also in jeopardy for heart attack. Following their initial task, parents and also kids possessed the chance to obtain lunch in the lunchroom and join a plethora from other tasks throughout the time. In the meantime, I possess high hopes that with restored management, DC can easily make vulnerable kids a much higher concern. Nonetheless, as no songs or flick is all loud all the time for an hour straight, we definitely would not mention that reasonably exceeding 85 dBA constituted a failing. Having said that, this vital technique could be essential in the discovering procedure of kids. Analysis Investigation Quarterly, 92, 605-619. As your child grows older, urge her or him to explore music utilizing musical tool toys like those through Janod. Whether a kid is actually worried, bored, or even overloaded, good as well as unfavorable stress and anxiety could lead to tough stimming habits that humiliate or even frustrate brother or sisters, instructors, and also moms and dads.

[tangocardiaca]

Strago: There, this should do it. Locke: What happened? She was breathing like crazy. Strago: The magic in our Terra was too chaotic. It can have some side effects. Her heart was beating too fast and irregular. Celes: Will she be alright? Strago: I used Ramuh and his lightning powers to set Terra's heart to right rhythm. It took two shocks to do it, after first shock, her heart was quivering. Fortunately after the second one, she came back to regular heartbeat. Those magicites were very helpful in controlling the power of electricity, or she would not be able to survive. Celes: Terra... Strago: She'll be okay, but now she needs rest. Source: terra branford (final fantasy and 1 more) drawn by kirishima_satoshi | Danbooru (donmai.us) Original creator: Kirishima Satoshi

[tangocardiaca]

Haru Okumura and Makoto Niijima resus roleplay [reupload]

I once posted it before removing my profile here, but I decided to post it again. Both characters are from Persona 5 and are above 18 years old in this fanfic.

                Haru was walking up the stairs to Makoto’s room. She was invited by Makoto, so she can show her something interesting. “I wonder, what that might be.” Haru thought to herself. Suddenly she stood in front of the door and opened it. “Hello? Makoto?” Haru asked and took a look around the room. She noticed, that slim woman was standing near the window. That was Makoto, but she was wearing something, no one would think about. Makoto was wearing blue wool bra or crop top, black shorts with blue side skirts attached to those shorts. She also had blue arm warmer and wore brown high boots. With that composition she looked like princess.

                “Is that a Dion Rogers design of Rinoa Heartilly?” Haru asked. “Yeah, it’s not something you’d see me wearing, but at least once I wanted to feel like a princess in need of rescue.” Said Makoto as she placed her hands on Haru’s hips. “Princess? What are you talking about?” Haru was confused and she did not know, what was going on. Makoto asked “Have you ever done CPR? Have you ever done defibrillation with AED? See, it’s weird, but at least once I want to act like I am in need of saving, or rather my heart is in need of saving.” Saying that, Makoto laid on bed and started breathing heavily. “My heart is racing, I think it’s tachycardia. Please Haru, put ECG leads on my chest and read the rhythm. Quickly!” Haru understood, that it’s a roleplay and she giggled. “Ok, I see, that I need to save your heart.” She placed ECG leads on Makoto’s chest the way it was shown on manual. “Oh no, it’s ventricular tachycardia. I can barely feel pulse. I need to defibrillate you.” And Haru placed AED pads on Makoto’s chest. “I’m sorry Makoto, this might hurt a lot. Charging! Clear!” And Haru pushed the button. Makoto’s chest made an arc and jumped. She still breathed heavily. “Still in V-Tach. Charging once again. Clear!” Haru pushed the shock button again. The same chest jump happened and Makoto kept breath as if she wasn’t breathing.

“Ventricular fibrillation!” Said Haru and she pitched Makoto’s nose while tilting her chin. She gave two breaths to Makoto and started doing chest compressions. “1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30” Haru stopped chest compressions and she gave two additional breaths to Makoto. And once again she compressed Makoto’s chest 30 times. “Time to analyze. She’s still in V-Fib. Charging. Clear!” And she once again pushed the shock button. Makoto’s chest jumped and made an arc. After the shock, Haru said, that it was sinus rhythm. “What happened?” Said Makoto, still acting like cardiac patient. “You had cardiac arrest. You were lucky, that I was here.” Haru giggled with a smile. “How did you like being resuscitated?” Makoto smiled and said “It was something interesting. Like giving my heart a shock of love. I really felt like a princess in need of a rescue. And you were my shining knight. Maybe we should do this more often?” Haru gently grabbed Makoto’s hand. She said “With pleasure.”, and she placed gentle kiss on Makoto’s hand. Side note: I'd really like to see this one turned into comic, so if anyone wants to make comic pages, go ahead.

[tangocardiaca]

Cardioversion of woman from Polish Doctor Drama. Woman was electrocuted at home and while she was at the hospital she was stressed out and needed cardioversion to restore her heart to normal rhythm.

[tangocardiaca]

Looks like your heart beats irregulary. We have to bring your heart rhythm. I am applying AED pads and we'll shock your heart now. Okay, we can-... Lady Tsunade!!! Why are you up? I understand that you want to have some fun, but this situation is not a joke. After all this kind of fun is not recommended after cardioversion. Original creator: Krazykamikaze44 Source: Tsunade (11) by KrazyKamikaze44 on DeviantArt