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09 Jun 10:00

R.E.B.E.L. ECG of the Week: LBBB and STEMI

by Salim Rezaie

R.E.B.E.L. ECG of the Week

89 year old male with PMH of hypertension, stage 3 chronic kidney disease with chief complaint of shortness of breath. Several days ago patient had a laminectomy for radicular pain. He was doing fine post-operatively and began to develop gradual shortness of breath.  He had no complaints of chest pain, nausea/vomiting, fevers, diaphoresis, but did have some weakness.  There were no prior ECGs for comparison.

BP: 98/48 HR: 103 RR: 18 O2 on RA: 94% Temp: 38.6

JVD to the angle of the mandible
Bibasilar Crackles
Sinus Tachycardia
Bilateral lower extremity pitting edema

Labs: Na 125, K+ 4.2, Creatinine 2, BNP > 2500

ECG from triage is shown…

Before reading on, try to come up with your own interpretation of this ECG before moving on to the final impression

R.E.B.E.L. ECG of the Week: LBBB and STEMI

Rate: 103
Rhythm: Normal sinus Rhythm, 1st degree AV Block
Axis: Normal Axis
QRS: Left bundle branch block (LBBB)
ST/T Waves: Flattened ST depression in Leads II, III, aVF and V5 – V6, J point elevation in leads V2 – V3, V3 concordant ST depression
Final ECG Interpretation: LBBB with concordant ST depression in lead V3

Putting all this together we have a patient with new onset congestive heart failure based on physical exam, and based on the fact that there is no old ECG it is unknown if this LBBB is new, but there is concordant ST depression in lead V3.  In this case cath lab should be activated.

What is the ACC/AHA STEMI guideline recommendations for LBBB and STEMI?

The 1996 and 2004 ACC/AHA STEMI guidelines recommended emergent repercussion therapy including fibrinolytics or primary percutaneous coronary intervention (PCI) in patients with symptoms compatible with STEMI and new or presumably new LBBB if these symptoms arose in the prior 12 hours (Class I Indication)

The 2012 European Society of Cardiology STEMI guidelines also recommend early PCI or fibrinolytics in patients with a clinical presentation of STEMI and new or presumably new LBBB if symptoms arose in the prior 12 hours (Class Ia Indication)

The 2013 ACC/AHA STEMI guidelines changed previous recommendations for patients with suspected ischemia and new or presumably new LBBB should not be treated as a STEMI equivalent

What is the role of the Sgarbossa criteria and modified Sgarbossa criteria in patients with LBBB?

  • For a complete explanation checkout this post from REBEL EM, Modified Sgarbossa Criteria: Ready for Primetime?
  • The bottom line of that post:
    • Suspected Acute Myocardial Infarction (AMI) + LBBB needs to have emergent primary PCI or fibrinolysis IF:
    • Hemodynamic instability or acute heart failure (Validated)
    • Sgarbossa score ≥ 3 (Validated)
    • ST/S ratio < -0.25 (Proposed, NOT Validated)

R.E.B.E.L. ECG of the Week: LBBB and STEMI

Image modified from:[1]

Conclusion to the case:

  • This patient has an ECG with LBBB and hemodynamic instability with signs of acute congestive heart failure which according to the above algorithm requires primary PCI or fibrinolysis
  • It was decided to activate the cath lab, and patient was found to have a 100% RCA lesion, and 80% LM stenosis.
  • Sensitive Troponin I showed an initial Troponin of 45 before cath was performed

Take Home Point for R.E.B.E.L. ECG of the Week: LBBB and STEMI

Patients with LBBB, concordant changes in any one lead (i.e. Sgarbossa Criteria ≥3), and signs of hemodynamic instability or congestive heart failure, STEMI is the diagnosis until cardiac catheterization proves otherwise

 

There has been more discussion about this case at:

REBEL EM Google+ Community

ECG+ Google+ Community

References

  1. Q. Cai, N. Mehta, E.B. Sgarbossa, S.L. Pinski, G.S. Wagner, R.M. Califf, and A. Barbagelata, "The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time?", American heart journal, 2013. http://www.ncbi.nlm.nih.gov/pubmed/24016487

The post R.E.B.E.L. ECG of the Week: LBBB and STEMI appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.

13 Jun 20:23

Buddy the Iguana Comes Running Like A Dog When His Human Calls

by Lori Dorn

Buddy, a very clever 12-year old iguana comes running like a dog when his human calls, as demonstrated in this video posted by Dave Durham.

via reddit, Tastefully Offensive

14 Jun 18:02

Custom Engraved Rolling Pins That Imprint Designs into Dough

by EDW Lynch

Custom Engraved Rolling Pins That Imprint Designs into Dough

Polish designer Zuzia Kozerska uses a laser engraver to engrave custom designs into wooden rolling pins. In addition to being pleasing to the eye, the engravings will imprint custom patterns into dough for patterned cookies, pastries, and other dough-based creations. Kozerska makes a variety of standard designs and will also customize pins to order.

Custom Engraved Rolling Pins That Imprint Designs into Dough

Custom Engraved Rolling Pins That Imprint Designs into Dough

Custom Engraved Rolling Pins That Imprint Designs into Dough

photos via Zuzia Kozerska

via swissmiss

16 Jun 20:43

Wolf Puppy Is Confounded By a Case of the Hiccups

by Lori Dorn

8-week old Nikai, the big-eyed, big-pawed, insanely adorable wolf puppy, is utterly confounded by a case of the hiccups that’s plaguing his little body in this video posted by the Wolf Conservation Center in South Salem, New York.

Wolves can make a variety of vocalizations. They growl, whimper, whine, bark, huff, howl… Although the wolf’s howl is has been the inspiration for films, essays, poems, etc… we think there is another sound that evokes equal levels of emotion and excitement – a wolf pup’s hiccup!

Nikai the Wolf Puppy

image via Wolf Conservation Center

via Tastefully Offensive

16 Jun 22:33

Ethereal Underwater Fashion Photos Taken at a Shipwreck Off the Coast of Bali by Benjamin Von Wong

by EDW Lynch

Ethereal Underwater Fashion Photos by Benjamin Von Wong

Photographer Benjamin Von Wong recently shot these ethereal underwater fashion photos in a complex shoot at a shipwreck off the coast of Bali. Von Wong describes the many complications of such a shoot on his blog, which included finding underwater models — they are all free-divers — and convincing a designer to create clothes that would be destroyed by the water. This behind-the-scenes video offers a good glimpse of the complexity of Von Wong’s project.

Ethereal Underwater Fashion Photos by Benjamin Von Wong

Ethereal Underwater Fashion Photos by Benjamin Von Wong

photos by Benjamin Von Wong

via PetaPixel

17 Jun 16:29

SoundWorks Collection Interviews the Sound Team Behind ‘Maleficent’

by Brian Heater

For their latest video, “The Sound of Maleficent,” SoundWorks Collection talks to Tim Nielsen of Skywalker Sound, the sound designer for the Disney film Maleficent.

The one sound reoccurring moment that we refer to the original is the classic Maleficent laugh — the deep, bellowing evil laugh. A lot of work was done to pay homage to it.

submitted via Laughing Squid Tips

11 Jun 19:02

Hyperrealistic Wax Sculptures of Famous Actors and Movie Characters by Bobby Causey

by Justin Page

CHRISTOPHER REEVE SCULPTURE

Allen Park, Michigan-based professional sculptor Bobby Causey has created a beautiful collection of hyperrealistic latex sculptures based on famous Hollywood actors and movie characters. You can view more from Bobby’s series on his website and deviantART gallery.

HEATH LEDGER JOKER

David The Lost Boys

Jack Nicholson shinning wip

NINA1

Working on David

photos via BobbyC1225

via Daily Art, DesignTAXI

11 Jun 20:58

Smile, Eet’s Time For Yer Bath!

by Brinke

This Little Orang Bebeh doesn’t seem to mind it one beet!!!

BIdDJRi
Imgur.


Filed under: Uncategorized Tagged: Orangutan
09 Jun 22:35

Loyal Service Dog Gets His Own Photo In His Human’s 7th Grade Yearbook

by Lori Dorn

Yearbook Photo

Taxi, a loyal service dog in San Antonio, Texas, took his place in the 7th grade school yearbook right next to Rachel Benke, the young girl with epilepsy who had been in Taxi’s charge for the past four years.

He goes everywhere with the soon-to-be eight-grader, including accepting awards at school, celebrating birthdays, and even on the school track where he one day sprung into action. “Her aide was holding Taxi on the side and he just started pulling away from the aide as hard as he could trying to get to Rachel,” [Theresa] Benke said. She said once they got her inside, Rachel had a grand mal seizure, and Taxi wouldn’t leave the girl’s side. “I don’t know how Taxi new this, but he wouldn’t let anyone near her until the paramedics arrived,”- KHOU 11.

image by Theresa Benke

via KHOU 11, Doggington Post, ABC 15, KRON 4, Huffington Post

09 Jun 22:43

California Extreme 2014, A Celebration of Coin-Operated Arcade Games in Santa Clara

by EDW Lynch

California Extreme 2014

California Extreme 2014, a celebration of coin-operated arcade games, takes place at the Hyatt Regency Santa Clara on July 12 and 13. The show will feature pinball machines, video games, and other arcade novelties, all available for free play. As the games are all in the hands of private collectors, the show is also a venue for buying, selling, and trading of vintage arcade machines.

07 Jun 14:22

Calvin And Hobbes Creator Bill Watterson Secretly Returned To Comics

by Sean Fallon

pearls top

I was obsessed with Calvin and Hobbes and The Far Side as a kid. When those strips were shut down in 1995 I completely abandoned newspaper comics. Clearly, I should have been following Pearls Before Swine because I would have been very curious to know why panels in some of his recent comics looked a hell of a lot like something Bill Watterson would draw.

Well guess what.

Pearls Before Swine‘s Stephan Pastis has revealed that he secretly collaborated with Watterson on a series of strips. The reclusive genius behind Calvin and Hobbes had returned to the comics page.

Pastis tells the story behind the collaboration on his blog. It started when he sent Watterson this strip:

pearls 1

To his surprise, Watterson actually responded. And he proposed a collaboration based on Pastis’ tendency to make fun of his own art skills. Watterson thought it would be funny if he secretly drew panels in Pearls Before Swine for a few days. As you might expect, Pastis thought he was living a dream:

Let me tell you. Just getting an email from Bill Watterson is one of the most mind-blowing, surreal experiences I have ever had. Bill Watterson really exists? And he sends email? And he’s communicating with me?

But he was. And he had a great sense of humor about the strip I had done, and was very funny, and oh yeah….

…He had a comic strip idea he wanted to run by me.

Now if you had asked me the odds of Bill Watterson ever saying that line to me, I’d say it had about the same likelihood as Jimi Hendrix telling me he had a new guitar riff. And yes, I’m aware Hendrix is dead.

He went on to say:

At every point in the process, I feared I would say something wrong. And that Bill would disappear back into the ether. And that the whole thing would seem like a wisp of my imagination.

But it wasn’t that way.

Throughout the process, Bill was funny and flexible and easy to work with.

Like at one point when I wanted to change a line of dialogue he wrote, I prefaced it by saying, “I feel like a street urchin telling Michelangelo that David’s hands are too big.” But he liked the change. And that alone was probably the greatest compliment I’ve ever received.

In the strip at the top, Watterson’s hand is clearly present in the first and second panels with both the drawings and majority of the lettering. In the comic below, the same is true for the second panel.

pearls 2

The entire series can be viewed on GoComics starting here. Watterson worked on three strips in total. There is also an interview with Bill Watterson about his involvement in The Washington Post. He notes:

“I had expected to just mess around with his characters while they did their usual things,” Watterson tells me, “but Stephan kept setting up these situations that required more challenging drawings .?.?. so I had to work a lot harder than I had planned to! It was a lot of fun.”

Keep in mind that Bill Watterson is like the J.D. Salinger of comic strips, so this is a rare and wonderful moment. However, it seems that Watterson has taken steps to get back into the comics game a bit starting with his involvement in the Stripped documentary earlier this year. Could he be getting an itch to make a full blown comeback? I wouldn’t hold my breath for new Calvin and Hobbes, but I’ll be dammed if that wouldn’t be a dream come true.

Thanks to Jenn for the tip!








06 Jun 21:00

Bane Cat Is Back, And This Time He’s Got Company [Video]

by Nicole Wakelin

bane cat

Previously, Bane Cat had tortured his owner enough that the evil cat had been put up for sale. Bane Cat did not approve. Now he’s back, still for sale, but with a plan for vengeance. He’s not alone this time, and that spells trouble for his poor owner. When cats team up, you don’t even stand a chance.

See the video after the break.

(Death and Taxes via The Mary Sue)








06 Jun 16:33

Simon’s Cat In “Pawtrait”

by Brinke

Someone else gets all the attention in this latest and greatest from Simon Tofield. A certain cat does not appreciate this, either.


Filed under: Uncategorized Tagged: Simon's Cat, This Just In!
06 Jun 16:29

You’re Getting Old!, A Fascinating Website That Offers Facts and Statistics About Your Lifetime

by Rollin Bishop

You're Getting Old!

You’re Getting Old! is a fascinating website that offers facts and statistics relating to a person’s lifetime once their date of birth is entered. For example, someone born on February 25th, 1987 is currently 9,963 days old, and they were 13 when Wikipedia launched. The website also includes a pie chart featuring an approximation of how many people born on that date are currently alive versus dead as well as many more features.

Do you think time is catching up with you? Perhaps it’s already overtaken you and left you in the dust.
Do the years seem to be going ridiculously quickly now? There’s a reason for it. You’re getting old.

via I Love Charts

06 Jun 01:37

Happy (Late) First Baroo-Day, Lulu!

by Brinke

“This is our Alaskan Malamute, Lulu. (Her full name is Honolulu Lulu Surfer Queen. I named her after the Jan & Dean song, Honolulu Lulu!) Monday was her first birthday, so we celebrated with silly hats and pupcakes. Pardon the mess; we closed on our first house last week!

unnamed (1)


Filed under: Uncategorized Tagged: Baroo, Happy Birthday, puppeh
05 Jun 17:24

Food Zombies, Reusable Plastic Toothpicks Shaped Like the Undead Emerging From Their Graves

by Brian Heater

Food Zombies

Brazilian product design firm Meninos has created Food Zombies, reusable plastic toothpicks designed to look like zombies emerging from their graves. The “party picks” come in packs of a dozen with six green and six gray brain-eaters.

Food Zombies

Food Zombies

images via Meninos

via Sweet Station, Who Killed Bambi

05 Jun 18:51

A Chart That Measures Human Life in Weeks

by EDW Lynch

Your Life in Weeks

What But Why has created a chart that depicts a 90-year human life in weeks. In addition to a blank chart, they made a chart that depicts the typical phases of an American life, and a chart of famous deaths. For anyone who would like to stare at the sum total of their life in poster form, the blank chart is available for purchase.

Your Life in Weeks

Your Life in Weeks

images via What But Why

via Visual News

05 Jun 18:53

BaneCat Returns in Episode 2 and Gains a New Evil Friend to Both Play and Joke Around With

by Justin Page

BaneCat returns in Episode 2 of the ongoing webseries of the same name by BloodBlitz of Robs Rants. In this devilishly good episode, BaneCat teams up with a new evil friend that he can both play and joke around with.

BaneCat Episode 2

03 Jun 17:30

Beautiful Carved and Painted Skull Art in Mother of Pearl

by EDW Lynch

Beautiful Carved and Painted Skull Art in Mother of Pearl

Artist Gregory Raymond Halili makes incredible skull art by hand carving and painting mother of pearl in oyster shells.

 Beautiful Carved and Painted Skull Art in Mother of Pearl

 Beautiful Carved and Painted Skull Art in Mother of Pearl

 Beautiful Carved and Painted Skull Art in Mother of Pearl

 Beautiful Carved and Painted Skull Art in Mother of Pearl

photos via Gregory Raymond Halili

via Moshita, Junk Culture

31 May 17:54

Fantastic Coral Reef Sculptures Made out of Household Objects

by EDW Lynch

Coral Reef Sculptures by Lynn Aldrich

Artist Lynn Aldrich has created a fantastic series of coral reef sculptures out of household objects like plungers, mop heads, and sponges. She has more sculpture work, much of which is made from found objects, on her website.

Coral Reef Sculptures by Lynn Aldrich

Coral Reef Sculptures by Lynn Aldrich

Coral Reef Sculptures by Lynn Aldrich

photos via Lynn Aldrich

via Junk Culture

30 May 16:32

Finnish Man Has An Incredibly Close Relationship With the Fully Grown Black Bears He Raised

by Lori Dorn

Sulo Karjalainen, the proprietor of Kuusamo Large Carnivore Centre in Kuusamo, Finland, has become locally famous as the “bearman” due to the incredibly close bond he has with the fully grown black bears that he raised from tiny cubs.

The 73-year-old runs Kuusamo Large Carnivore Centre with his brother Jalo, which has been home to more than 20 orphaned brown bears. After working on a research project studying Finnish carnivores, Sulo was asked if he would mind taking in some cubs. And over the years a deep bond has grown up between Sulo and his furry companions.

30 May 20:45

Bodyscapes, Black Light Body Art by John Poppleton

by EDW Lynch

Bodyscapes by John Poppleton

“Bodyscapes” is a body art series by artist John Poppleton that uses fluorescent pigment to paint landscapes on female models. He then photographs the models under UV light for the final fluorescent effect.

Bodyscapes by John Poppleton

Bodyscapes by John Poppleton

Bodyscapes by John Poppleton

Bodyscapes by John Poppleton

photos by John Poppleton

via Distractify, My Modern Metropolis

30 May 21:01

An Incredible Glowing Dress That Is Covered in Fiber Optic Filaments

by EDW Lynch

F29C8XBHTIWHFHP.LARGE

Instructables designer Natalie Walsh has created a stunning fiber optic dress that is covered in a free-flowing array of fiber optic filaments. She’s posted detailed instructions on how to make the dress on Instructables. We previously posted about her Disco Ball Helmet.

FUCW30FHTHKFLIH.MEDIUM

F7DI29QHTHKFLIK.LARGE

FHLW6XQHTHKFLJ9.LARGE

photos by audreyobscura

submitted via Laughing Squid Tips

30 May 22:42

Colorful City Landmark Silhouette Illustrations by Yoni Alter

by EDW Lynch

Colorful City Landmark Silhouette Illustrations by Yoni Alter

Designer Yoni Alter has created a delightful print series in which he represents different cities around the world with overlapping silhouettes of their most famous landmarks. The illustrations are part of his series “Shapes of Cities.” Prints are available for purchase.

Colorful City Landmark Silhouette Illustrations by Yoni Alter

Colorful City Landmark Silhouette Illustrations by Yoni Alter

Colorful City Landmark Silhouette Illustrations by Yoni Alter

Colorful City Landmark Silhouette Illustrations by Yoni Alter

images by Yoni Alter

via Colossal

29 May 16:10

Inventor Shoots 12-Foot Flames From His Wrists with a Homemade X-Men Pyro Flamethrower

by Justin Page

British inventor Colin Furze heats things up as he shoots 12-foot flames from his wrists with a homemade X-Men Pyro flamethrower. Colin also made a 9-minute video tutorial that shows how he created the wrist-mounted flamethrower. We previously wrote about Colin’s homemade Wolverine claws and magnetic Magneto shoes.

music by March to the Grave – “BMX Haircut

29 May 20:41

An Interactive Infographic Showing the Global Migration of People Between 1990 and 2010

by EDW Lynch

The Global Flow of People
2005-2010. Image via Wittgenstein Centre

“The Global Flow of People” is a fascinating interactive infographic that visualizes human migration between world regions from 1990 to 2010. The visualization can be viewed in five year increments, which gives a sense of how population flows have changed in recent decades. The infographic was created by Nikola Sander, Guy J. Abel, and Ramon Bauer at the Wittgenstein Centre for Demography and Global Human Capital and was published back in March in Science magazine.

The Global Flow of People
1990-1995. Image via Wittgenstein Centre

via Boing Boing

29 May 21:37

An Adorable Plush Octopus Backpack

by EDW Lynch

An Adorable Plush Octopus Backpack

Artist Jennifer Mones recently made an adorable plush octopus backpack. Mones is also an illustrator in addition to her design work — her illustration work (some of which is also octopus-themed) is available for purchase.

An Adorable Plush Octopus Backpack

photos via Jennifer Mones

via Dragons, Doodles, and Doodads, Boing Boing

29 May 13:02

So Majestic

Ray tries to fly - AnimalsBeingDicks.com

C’mon Benny, it’s your time to FLYYYYY…SHIT!

28 May 15:16

Lomo’Instant, An Instant Camera Featuring a Variety of Lenses

by Rollin Bishop

Lomo’Instant is an instant camera by Lomography featuring a built-in wide-angle lens with a fisheye lens and a portrait lens both available as attachments. The camera can take multiple exposures, long exposures, and can use color gels to infuse photos with color.

Lomography is currently raising funds via a Kickstarter crowdfunding campaign for the design and production of the Lomo’Instant.

Lomo'Instant Camera

Lomo'Instant Camera

Lomo'Instant Photo

http://kck.st/TPKqIM

photos via Lomography

via Lomography

28 May 06:00

Great Little Backyard Coop

by Ivory Soap

IMG_1001
We’ve learned the hard way, that a “free range” chicken is pretty much a “dead” chicken.  Out of 15 chickens we’ve owned.  We have 4 left.  Four were predator deaths.  One was old age.  Six were killed by their own stupidity: hanging themselves on fences they couldn’t quite jump, ramming themselves under fences they couldn’t escape, chasing dogs, fighting goats for domination of the yard, etc.  So that, and the constant splats on the back porch convinced us to get a Precision Pet Products Hen House Chicken Coop.  We actually got ours on sale at Tractor Supply for under $200.

It assembled in under an hour.  However, don’t drag it across the concrete after you build it; the wood is soft.  See below.

IMG_1002Also notice the bricks under the coop.  The wood is SOFT, y’all.  So unless you’re yard is bone dry year round, you will need to put it up on something.   We built two brick outlines so we can hop it to the next square for scratching variety.  If you don’t toss straw in there, though, you would need to move it every few days.

Totally unnecessary is the Retractable Wheel Kit.  The whole thing is so light, my 8 and 10 year old can put it anywhere I want.  However, be it known that the ramp WILL pull away from the screws when you lift it (or roll it on that wheel set).  If you plan to move it often, do secure that ramp, bottom and top.  In the top picture, you can see that our ramp is gone.  We gave up reattaching it when we realized the chickens could just jump up there anyway.

Below you can see there are an assortment of doors on this contraption.  To the right is the “big door” that you can almost crawl into.  The window door is almost never used by us.  Under the window door is a tray that pulls out for easy cleaning.  The next box in the back has it’s own door and there’s a little door on the opposite end.  All that is super-convenient for cleaning and feeding.
IMG_1003
Overall, we’ve been very pleased with the coop.  We’ve had it for months.  I would like to add on the Chicken Coop Extension Pen some day to give the girls more room.  (It seems too cramped in there for four chicks, but I’m sure they much prefer being ALIVE to having unlimited elbow room.)  That and there’s no ROOST.  Chickens want to sleep in tree branches.  This coop doesn’t come with a roost, but you can buy a Roosting Bar or just wedge a dowel in there.