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21 Jul 16:01

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.

14 Jul 03:05

A Dad Makes His Six-Year-Old Son a LEGO ‘Star Wars’ Boba Fett Minifigure Costume

by Justin Page

LEGO Boba Fett

The Dented Helmet member and father CGS1 recently made his six-year-old son an awesome LEGO Star Wars Boba Fett minifigure costume to wear at a local ToyCon. You can view more “making of” photos on the The Dented Helmet forums.

We took the costume for a trial run at a local toycon this past Sunday. I still have to finish building the arms and blaster, as well as tweaking a few things such as the cape fabric. I approached the components of this project as if they were actual Lego elements. In doing so, I created the jetpack to be removable as it appears in the actual minifigure as well as the range finder stalk. The entire costume is built from scratch using photo references and scans I took myself. The costume is built primarily out of sintra with pink insulation foam used to carve the helmet dome and a small amount of plastazote foam used on the tips and base of the jetpack rockets. Torso and leg graphics are printed on adhesive vinyl while a custom green was used to colour match the helmet and jetpack.

LEGO Boba Fett

photos via The Dented Helmet\

via reddit, Fahionably Geek, Archie McPhee’s Endless Geyser of AWESOME!

14 Jul 02:59

LEGO Sculptures That Portray Iconic Superheroes and Movie Characters as Lazy Couch Potatoes

by Justin Page

Bat Couch

Pixar director and LEGO fan Angus MacLane has built a great series of LEGO sculptures that portray iconic superheroes and movie characters as lazy couch potatoes. More characters from MacLane’s collection can be viewed online at Flickr.

Optimus Couch

Iron Couch

Robo Couch

Kane Couch

photos by Angus MacLane

via Geek Art, DesignTAXI

06 Jul 22:47

Goodnight Darth Vader, A ‘Star Wars’ Children’s Book by Jeffrey Brown Filled With Bedtime Stories for Future Jedi

by Justin Page

Goodnight Darth Vader

Goodnight Darth Vader is a fun new Star Wars children’s book created by cartoonist Jeffrey Brown and published by Chronicle Books that is filled with bedtime stories for future Jedi. The book is a follow-up to Brown’s children’s stories, Darth Vader and Son and Vader’s Little Princess. Hardcover editions of Goodnight Darth Vader are available to purchase from Chronicle Books and Amazon.

It’s bedtime in the Star Wars galaxy, and Darth Vader’s parenting skills are tested anew in this delightful follow-up to the breakout New York Times bestsellers Darth Vader™ and Son and Vader’s™ Little Princess. In this Episode, the Sith Lord must soothe his rambunctious twins, Luke and Leia—who are not ready to sleep and who insist on a story. As Vader reads, the book looks in on favorite creatures, droids, and characters, such as Yoda, R2-D2, Han Solo, Chewbacca, Darth Maul, Admiral Ackbar, Boba Fett, and many others as they tuck in, yawn, and settle down to dream. As ever, Jeffrey Brown’s charming illustrations and humor glow throughout, playing on children’s book conventions to enchant adults and kids alike.

Goodnight Darth Vader

Goodnight Darth Vader

Goodnight Darth Vader

images via Chronicle Books

submitted via Laughing Squid Tips

06 Jul 22:46

A Delicious Life-Size Chocolate Replica of a Human Skull

by EDW Lynch

Life-Size Chocolate Replica of a Human Skull

UK-based chocolatier BlackChocolate uses a mold based on an actual human skull to cast a life-size, anatomically correct Belgian chocolate human skull.

Life-Size Chocolate Replica of a Human Skull

Life-Size Chocolate Replica of a Human Skull

photos via BlackChocolate

via Joanne Manaster, Boing Boing

06 Jul 19:54

Bunday Morning Comix

by Brinke

1959217_10152179505267549_6270182706573710006_nAs seen on the Hundeurlaub FB page, original artwork by “Ayka.” We think. Thanks to Aunt Bonnie P.


Filed under: Uncategorized Tagged: Bunday Morning Comix
06 Jul 05:14

Dogs of the World Illustration Series by Lili Chin

by Katherine Becker

Dogs of the World Illustration Series by Lili Chin

We love keeping up with what the fabulous Lili Chin is up to, and her newest collection of illustrations totally rocks our world. Lili’s been compiling a massive Dogs of the World illustration collection – a breakdown of dog breeds by the region of their provenance, all rendered in Lili’s distinctive, adorable style. Check out the full collection on tumblr as well as prints, tees, and other goodies for sale!

Dogs of the World Illustration Series by Lili Chin in other for humans

Dogs of the World Illustration Series by Lili Chin in other for humans

Dogs of the World Illustration Series by Lili Chin in other for humans

Dogs of the World Illustration Series by Lili Chin in other for humans


Share This: Twitter | Facebook | Don't forget that you can follow Dog Milk on Twitter and Facebook.
© 2014 Dog Milk | Posted by Katherine in For Humans, Other | Permalink | 4 comments
22 Jun 22:51

A Knife Holder Shaped Like an X-Wing Starfighter From ‘Star Wars’

by Justin Page

Star Wars X-Wing Knife Block

The officially licensed Star Wars X-Wing Starfighter Knife Holder from The Fowndry will “give your regular old kitchenware a rebellious kick in the vegetables.” Their chrome-effect plastic knife holder comes loaded with five stainless steel knives and is available to purchase online.

Chrome finished and standing over 20cm high, the X-Wing Knife Block raises the status of the humble knife holder. Heck, with this in the kitchen even Aunt Beru would be signing up to give the Empire one in the eye. And as for the Force? Well… it’s useful. But can it chop an onion, dice peppers, and slice a loaf? Can it? We’ll ask George, as soon as he picks up.

Star Wars X-Wing Knife Block

Star Wars X-Wing Knife Block

Star Wars X-Wing Knife Block

images via The Fowndry

submitted via Laughing Squid Tips

22 Jun 22:25

How to Cut a Cake Using Scientific Principles in Order to Best Maintain Freshness

by Brian Heater

Math writer Alex Bellos demonstrates a more scientific alternative to cake cutting which better maintains the moistness of the innards in the latest episode of the Mathematical Science Research Institute series Numberphile. The method dates back to a 1906 letter to Nature by renowned British scientist Francis Galton, entitled, “Cutting a Round Cake on Scientific Principles”, detailing a method that involves removing thin slices from the cake’s center. Galton also suggested employing a rubber band to help keep the segments together.

via The Presurfer

22 Jun 22:24

Future Lifelong Companions Ruuxa the Baby Cheetah and Raina the Puppy Meet For First Time at San Diego Zoo

by Lori Dorn

Ruuxa the baby cheetah and Raina the Rhodesian ridgeback puppy meet for the very first time, clumsily climbing all over each other, biting each other and cementing their lifelong friendship through the San Diego Zoo’s Ambassador program in this adorable video posted by the San Diego Zoo.

A 6-week-old cheetah cub at the San Diego Zoo Safari Park is spending lots of time with his new dog companion. The young cheetah, Ruuxa, was chosen to be raised as an animal ambassador at the Safari Park after he was rejected by his mother and had to be hand raised by keepers…Safari Park cheetahs selected for training as ambassadors are paired early in life with a domestic dog. As the two companions grow up together, the dog’s body language will communicate to the cheetah that there’s nothing to fear in new or public surroundings, which relaxes and calms the cheetah. The Safari Park currently has four cheetah ambassadors all of which are trained to participate in the Park’s Cheetah Run experience.

Raina the Puppy

Raina the Puppy

Raina the Puppy

via Daily Picks and Flicks

22 Jun 22:22

A Behind the Scenes Look at Sophie Gamand’s ‘Wet Dog’ Photo Shoot

by Lori Dorn

Photographer Sophie Gamand goes behind the scenes of her imaginative award-winning photo series “Wet Dog” to talk about how she framed and styled the shots (with the help of pet stylist Ruben Santana), what camera equipment she used and the book she has planned for the future in this video posted by Sony. We previously wrote about this photo series in November 2013.

via PictureCorrect, PetaPixel

22 Jun 22:17

Soldier Comes Home to an Exuberant Greeting at the Door by His Cat

by Lori Dorn

An Army Reserve soldier, returning home from drills, was exuberantly greeted at the door by Finn, his beautiful and very vocal ragdoll cat in this video posted by wildlimeyogi

via reddit

17 Jun 18:22

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

17 Jun 18:20

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

17 Jun 18:11

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

17 Jun 18:10

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 18:02

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

12 Jun 04:52

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

12 Jun 04:39

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 23:15

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 23:15

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.

09 Jun 01:17

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!








07 Jun 00:10

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 18:18

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 18:10

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 04:42

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 23:39

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 23:38

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 23:37

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

04 Jun 02:53

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