Posted by: medicblog999 | January 31, 2010

What would you do? – ECG Geek 6

choices

Due to reader demand, I thought I would join two of my most popular types of post. My ‘what would you do?’ and my ‘ECG Geek’ series.

This one is going to come in three parts, with three distinct points for intervention and/or actions. I wanted to share it with you because it was a fairly rare occurrence, and you all seemed to enjoy my last ‘what would you do?’ post.

So without further ado, let me set the stage for you.

You are working on the Rapid response car, and you are sent to an elderly male (72 yrs old) called Jim. He has had a fall and now has a head injury. You proceed as normal with blue lights and sirens for the 6 minute drive to a local ‘sheltered housing’ scheme (for those not familiar with this phrase, it is a collection of small flats or bungalows which whilst not having direct access to carers 24 hours a day, has  a ‘warden’ who is responsible for assisting the residents in times of need etc)

Once on scene you take all of your equipment in (because you have been caught out before when going in for a simple fall, and of course you have learned from your mistakes in the past!)

On gaining entry to the flat you find Jim, sitting on the floor in the kitchen, fully conscious and alert. He appears to have a good colour, is not short of breath, has no evidence of diaphoresis (posh word for sweating) and seems able to support himself in his sitting position without any real problems what so ever.

A quick initial history reveals that Jim was standing in the kitchen, just about to make his morning cup of tea (the time is approximately 09:30). Whilst he was standing there he felt a little dizzy..

“although I get dizzy all of the time you know son”

This appeared to have come on fairly suddenly and wasn’t preceded by a sudden change in posture such as standing from a sitting position. As he felt dizzy, he thought he may be about to faint, so placed himself on the floor where he pulled on his call button around his neck, which placed him into contact with a call centre somewhere who ultimately called me to the scene. Jim denied losing consciousness at any time.

He didn’t have any apparent injuries from the fall other than a small bump to the back of the head (which went against his history of not ‘falling’ and also led me to believe that he did actually have a period of LOC) He had no neck pain or back pain and no new pains which where different from his usual aches and pains in his knees.

He now did not feel dizzy in any way..

“I feel fine now son, just get me off the floor will you? These damned knees wont do anything I want them to these days”

“No problem Jim, just let me check you blood pressure and everything else out before I get you off the floor ok?”

I had already had a feel of his radial pulse as I first knelt down next to him when I entered his flat. At that time it was strong but a slow, but then you tend to assume most patients his age with a slowish pulse is down to them taking a beta blocker, so I was not too concerned by it at that time, judging by his physical appearance and lack of symptoms for hypo perfusion.

His blood pressure, oxygen saturations and blood sugar were all within normal limits.

Pulse: 45, strong and regular

BP: 125/80

SaO2 on air: 97%

BM: 4.9 mmol

He had no chest pain at present and did not have any prior to the fall.

His medical history was pretty unremarkable too. He seemed fairly fit and well other than hypertension and hypercholesterolaemia which he was on a statin for.

All in all, everything seemed ok, with nothing pointing to anything too worrying (although that pulse rate would need checking again after he is back up off the floor). I got him off the floor with the assistance of the warden and started to complete my patient report form.

“Jim, I know everything seems alright now, but you have had a bit of a funny turn, and the fact that you have bumped your head makes me think that maybe you did black out and you just dont know. Your heart rate is quite slow too, which may be what caused you to feel dizzy for a while. All of this means that you should go up to the hospital and get checked out ok?”

“No, Im not going up there, Im ok! I dont need to be wasting anyones time by taking up a hospital bed. No, dont worry son I will be fine, you just get yourself away and help someone else”

This went on for about the next five minutes. Eventually I pulled out my normal ‘deal maker’.

“Right Jim, Ill tell you what. I will do an ECG, a heart tracing, and if that is ok, then we can talk about leaving you at home and getting your GP out. If there is anything abnormal, then you have to agree to come in then ok?”

(If I am concerned about a patient and want them to go in, I can always find something abnormal on an ECG, no matter how small!)

He agreed to this and I hooked up the Lifepak 12.

Now unfortunately, the 12 lead went with the crew who came and I didnt get a copy off the archives. What I do have though is a photocopy of the initial rhythm strip that I took whilst I was putting his chest leads on:

ECG pt 1

Click to enlarge

So, there you go. I at appears that Jim was one of these remarkable patients who can tolerate a large cardiovascular insult to his health without being symptomatic.

This is your first decision point.

What rhythm abnormality does this show and what are you going to do about it. I know this copy is a bit of a nightmare for looking at the big squares and small squares as it was reduced down to fit a good length of trace onto an A4 piece of paper, however I can tell you that the heart rate based on the R-R method is approximately 34 beats per minute.

I will not go into details about treatment options open to me as a UK paramedic yet because I am more interested in reading what you would do using what ever protocols and guidelines you have available to you.

Right then……Off you go, leave a comment and tell me how you would treat this patient.

Next part comes in two days time.

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Responses

  1. Okay, as a Paramedic student, I will take a crack and see what I learn. I'm going to say this is a 3rd Deg AV Block. With him being asymptomatic, I would transfer to the ED where a cardiologist can take over and hopefully install a pacer, but I would have TCP standing-by as an option incase he were to deteriorate since atropine probably wont help Jim. Okay, I'm ready to get schooled =).Oh, and I'd like to know what the 12 lead showed.

  2. Ok….. let's see how much of your teaching I remember!!Looks to me like 3rd Degree Heart Block, and some possible ST changes but I'm not sure cos I can't see properly with the size of the readout.I would rapidly transport him to hospital, and in the meantime, give him atropine to increase his heart rate to something acceptable so that he can tolerate it better and stop getting dizzy. If the 12 lead shows an MI, particularly an anterior MI, then I'd consider thrombolysis or transportation to the nearest PPCI centre instead of just the nearest hospital.Oh, and I'd monitor his conscious level as well due to the knock to the head.

  3. OK, I will be the 1st to admit that I am working on strengthening my EKG skills. But I will give it my best shot. The rhythm is bradycardic obviously and the patient is symptomatic. Our EMS protocol (cleverly named “Symptomatic Bradycardia”) would have us initiate IV access, place patient on high flow 02 via non-rebreather (probably not a necessity here as he seems to be oxygenating well) and administer atropine I.V. 0.5 mg. That can be repeated to a max of 3mg. Another option we are able to consider is to pace the patient. Units equipped with pumps may use a dopamine infusion (we are not equipped with pumps). Obviously monitor vital, breath sounds and treat any changes to rhythm, etc. Now, for the rhythm itself (look forward to learning from everyone here): rate is brady, p waves sometimes present and are upright, QRS complex is present and properly oriented and doesn't look wide or overly tall. However, it does not appear that a QRS follows all P waves, there seems to be a disconnect between the P waves and the QRS complex. So given that, this looks like a 3rd degree heart block. Hopefully I didn't bugger this up too much….

  4. Well, I'm going to have a stab at this. It looks like complete heart block to me. Being an ETA with St John, I would request an ambulance to transport to hospital as he's probably going to need pacing and just keep a close eye on him in case he gets worse. Not a lot I can do other than that I'm afraid.

  5. 3rd degree complete disassociation on the trace. Judging from your vital sign recordings and his presentation, he is in a stable, bradycardic 3rd degree AV block. A calm transport into a cath capable facility is warranted. Certainly getting a 12-lead, but with the absence of pain, just some O2 via NC and cannulation for now.Atropine not indicated, likely won't work anyhow. Might get those P waves moving faster though, but that's not our problem. We're dealing with an old injury as opposed to acute in my opinion.Mark, Mark, Mark, if this case gets complicated I will demand to see the 12 lead!

  6. I can't see anything on the strip but the block-would have liked to have seen the 12 lead to be sure. Given that he is currently asymptomatic, I'd get him in the bus, make sure the TCP pads are available, start an IV and some low flow O2 via cannula, and head for the hospital normal traffic-in my area it is a 5 minute trip . No sense making him more anxious with lights and sirens for a 30 second difference in transport time; his comment that he gets “dizzy all the time” tells me he has been tolerating this for awhile and he's still kicking. According to my protocols, atropine is a last resort and normally not indicated for a 3rd degree block.

  7. Interesting case, and I cna imagine it occurs fairly often. I'm still studying and learning ECGs, however it appears he's missing every 2nd QRS, so could this be a type of AV block? 2:1? And causing his slow heart rate?As for treatment, I haven't learnt enough to say what we in the land down under are able to do for this gentleman, bar rest and reassurance and convince him that a quick trip to hospital might not be a bad idea, while continiously monitoring.

  8. It's a Complete Heart Block, atrial rate is about 80, but the Ventricular Escape rate is only about 30 or so. For his age, this guy has a pretty good compensatory mechanism, but it falls down with changes in position, making him postural by definition. As any steady reader of my blog knows, I'm not a huge fan of Pulse Oximetry if there is no respiratory component, which there certainly appears not to be. Speaking of which, you didn't provide a respiratory rate, but you did say that he had no obvious respiratory distress. This is more a case of what I wouldn't do as opposed to what I would do. O2 by nasal cannula @ 4 lpm, IV KVO, keep him on the monitor, transport in a position of comfort. Unless the 12 lead was suggestive of STEMI, I wouldn't take him to a cath lab capable hospital unless it was the nearest hospital or his hospital of choice. Is he symptomatic? No. Was he symptomatic? Yes, and he gives a history of this having gone on for a while. He needs to be in a hospital where cardiology can evaluate him, he doesn't need paramedics throwing a bunch of medications at him. Sometimes it's important to resist the urge to just do something and stand there instead.

  9. See, this is where I see a weakness in my system. This patient is mostly stable with mild symptoms, yet if I were to blindly follow the protocol I would be pushing the atropine regardless of whether or not I thought this would work. Odds are that I would not be pushing the atropine because I do not agree with the “cookbook” methodology of my EMS system. But the pacing I would certainly consider, following proper pain management/sedation measures.

  10. What are you trying to correct with pacing? The patient is tolerating the rhythm quite well on his own as long as he doesn't stand and try to do too much. Here is a good rule of thumb; Do only what is necessary in the field. You can get your patient in a lot of trouble by over treating.

  11. Fair enough, 'preciate the advice

  12. Er, right, so I'm not trained on ECGs at all yet, but I'm a geek and I love learning so here goes for my first one…I noticed the P-waves but didn't click as to what they were until you mentioned “rhythm abnormality” in your text, which immediately made me click. The P-waves are nice and regular, the QRS complex is also nicely regular but there seems to be little or no association between the two rates, so looks like there's a complete block between the AV and SA nodes. I had to refresh my memory on the different types of blocks and what the correct name for a “complete heart block” is, but I'm going to go with 3rd degree heart block here. From the patient's history, he seems to have suffered this for a while. However, I'd call for a paramedic (because it's a cardiac problem which I can't treat) and probably transport to the nearest A&E, unless Mr. Paramedic says different.

  13. without reading through any of the comments yet, and being 3 1/2 yrs removed from medic school and ems (due to illness) i'm gonna see what i can come up with.- ekg shows heart block, i'm going with 3rd degree.- treatment – talk pt into transport, place on O2 4lpm N/C, 12 lead EKG. per protocols – no symptoms of poor perfusion (hypotension, shock, alt. mental status, ongoing CP) consider placing pacer pads, monitor during transport, obtain IV access, transport to closest appropriate facility and contact Med Command. If pt becomes symptomatic, admin atropine 0.5mg, up to 3mg total, preparing pacer, pace if needed, with sedation if needed. Med Command may order dopamine or epi drip if BP is an issue; also may order glucagon or calcium cl if hyperkalemia is suspected cause.- consider cause and treat as appropriate.

  14. oh, and since i'm single provider, get a crew to transport ASAP (just noticed that re-reading the intro)!

  15. Complete (3rd degree) heart block, well tolerated. Patients symptoms are related to postural changes, and he is asymptomatic at the moment, tolerating the dysrhythmia well. Talk him into transport, oxygen via NC, probably 4L, IV at TKO, have a pair of pacer pads on the bench, atropine isn't indicated for this dysrhythmia…

  16. oxygen via n/c 3-4 liters per minute, transport patient on stretcher, head elevated 30-45 degrees from flat. Temp pacer pads on just in case. Monitor/Transport to ED. Canidate for EPS and pacer.

  17. I agree 3rd degree HB, well tolerated for the moment. Asymptomatic. Oxygen NC 3/4 l/m, ECG monitoring, IV TKO. Med bag and pacer/defib pads close by and ready, just in case for further arrhythmia. Watch for pt alertness due to the fall. Transport to hospital ASAP. PT needs cardiologist intervention for pacermaker.

  18. I agree 3rd degree HB, well tolerated for the moment. Asymptomatic. Oxygen NC 3/4 l/m, ECG monitoring, IV TKO. Med bag and pacer/defib pads close by and ready, just in case for further arrhythmia. Watch for pt alertness due to the fall. Transport to hospital ASAP. PT needs cardiologist intervention for pacermaker.

  19. Complete heart block for sure…only sure tx is pacemaker placement….field tx for asymptomatic is monitor, O2 and IV TKO, use Atropine with caution in complete heart block per new ACLS, if pt becomes symptomatic…NS bolus if lung field are clear, TCP immediately and verify mechanical capture as well as electrical, and consider some sedation for pain due to TCP if time…do not delay TCP for pain control. Never over treat pt, you can always do more but never take back what you have done…

  20. The patient is describing a near syncope, which with a hematoma I would error on the side of true syncope since it is unwitnessed the general thought is he goes, with a EKG of 3rd degree heart block, he goes, and because I have been bit before, I put the pacer patches on just in case, he gets 4lpm O2 via NC, IV TKO. I would also try to sell a spine board, unless i was confident that the patient was competent to clear his spine. Because he has that low of a rate sitting, I would have performed a set of orthostatic vitals. Since he is asymptomatic in my presence I would not look at chemical interventions, especially seeing that he is on a blocker because, what I have will not work anyway,

  21. I think that a phrase that I utter quite often to new providers is in order here:”Treat the PATIENT, not the monitor”Yea, it's a 3rd degree AV block.. and those things are scary when they pop up on your EKG screen, but the patient Mark's describing is mostly asymptomatic and the evidence is that the patient has been living with this for quite some time. Remember, our treatments for this are all along the lines of “symptom relief” and will not fix the problem. If the patient doesn't have any symptoms to be relieved, you're not helping them by trying to do so. Our most important role is to recognize the problem, be prepared for the worst, and transport to someone who can definitively care for the problem. Start an IV, have the Pt on low-flow o2, and have the pacer pads ready. I'd not give atropine because vagal blockade probably isn't going to help. Oh, and be nice to the guy and don't scare him by getting all worked up because you think he's dying. That will only increase his cardiac workload. You wouldn't give him Epi… so don't scare the crap outta him either. However, if Mark had said the guy had a BP of 78/46 and was pale, cool, and diaphoretic… he would definitely be getting some “Edison Medicine”, maybe a pressor, and some diesel. Good post buddy, and interesting comments

  22. Not got much to add – I think the answer is probably a combination of several of the comments below. But I'd just like to throw my oar in and suggest that this patient isn't asymptomatic. He may not have pain or dypnoea – but he has probably had a period of unconsciousness. If that's not a symptom…. Our protocols would suggest (based on the fact that we have no 12-lead to go on at the mo…) that he DOES get the atropine, as this is an absolute bradycardia (below 40) although I agree that it probably won't do much. He needs pacing – which in the UK is probably a long way off yet from happening pre-hospital. As you're in the RR car – ambulance definitely required, and you have to find a way of convincing him that he needs to go. In 99% of these cases, we all have our tricks that eventually work. Oh – and CK is spot on: “Oh, and be nice to the guy and don't scare him by getting all worked up because you think he's dying. That will only increase his cardiac workload. You wouldn't give him Epi… so don't scare the crap outta him either. “Great post Mark – look forward to the next ones in this series!

  23. Not got much to add – I think the answer is probably a combination of several of the comments below. But I'd just like to throw my oar in and suggest that this patient isn't asymptomatic. He may not have pain or dypnoea – but he has probably had a period of unconsciousness. If that's not a symptom…. Our protocols would suggest (based on the fact that we have no 12-lead to go on at the mo…) that he DOES get the atropine, as this is an absolute bradycardia (below 40) although I agree that it probably won't do much. He needs pacing – which in the UK is probably a long way off yet from happening pre-hospital. As you're in the RR car – ambulance definitely required, and you have to find a way of convincing him that he needs to go. In 99% of these cases, we all have our tricks that eventually work. Oh – and CK is spot on: “Oh, and be nice to the guy and don't scare him by getting all worked up because you think he's dying. That will only increase his cardiac workload. You wouldn't give him Epi… so don't scare the crap outta him either. “Great post Mark – look forward to the next ones in this series!

  24. You're suspecting he fell from higher than standing?

  25. Looks like a complete heart block but since he is compensating well at this time….. Oxygen, IV, Monitor, 12-lead. Rapid transport to an appropriate cardiac facility.

  26. Mark it a appears to me that your pt is definately in a 3rd degree heart block (can't get any more classic that this)…..the treatment needs to first be based on your pt conditions….he appears to be stable at this time….does he have a pacemaker that has stopped working..with the info provded thus far rapid transport, IV, o2 and supportive measures at this time….also was you able to do a 12 lead and is so what if any elevations or depressions did he have….if he became unstable pacing is the best option…..atropine is not really desired with high heart blocks….

  27. Ditto.

  28. As has been said he is in a 3rd degree block. Is it new, most likley not could it have gotten worse today yes. Do you look at the monitor say OMG and grab the atropine I hope not. Number one it's not going to do what you wish it would. In the case of no pacing avalable if he is very symp your going to end up going to fluids if no congestive heart failure then epi, not my first or last choice. Now this is the confusing part for me being a medic in the US. YOU CAN GIVE LITICS BUT CANT PACE. WOW I just can't get my head arround that. I'v never seen someone killed with pacing, I'm not even sure it's possible (yes i know it is) but the chances of that are slim to none. I have seen a few clot busters go bust in a realy bad way. Now getting to the heart of the matter, of all the times that we “place” the pads we maybe would turn them on 1 out of 20. The point of the matter is that the junctional escape rhytm will keep most people, don't ask them to get up but they usualy don't die on you. The people that we do pace really needed it and it works about 80-90% of the time, the others end up getting a pressor to hold them untill a transvenous pacemaker can get placed. The other point is if the patient is stable and hospital A does not have a cath lab and ability to place a perm pacer but hospital B that is just a little bit further down the road do the patient a little fav and take them to B. Another thought if you think this may be a beta blocker OD glucagon is one drug you do carry, it has been used as a diagnistic tool in some cases.

  29. Ok, I too saw that it was 3rd degree block and I didnt look at the other comments first. I would transfer to hospital, I wouldnt give O2 as per new guidelines and treat patient as he presents en route.

  30. I believe that atropine is contraindicated on the 3rd degree block. My understanding is that it will increase the atrial rate w/o impacting the ventricular rate, this could make major problems. W/ a B/P like his and his lack of MAJOR immediate life threatening complaints, IV monitor, O2, and pacer pads on and ready would be my idea of the correct treatment. It is most definitely a 3rd degree block, so you got that right. As a comment to an earlier post who said this pt didnt need to go to a cath lab hospital, how do you think they put a temporary pacer in? This pt, especially being as stable as he is, would benefit from the transport to a hospital capable of definitive treatment. Just my two bits, but you werent off by much.

  31. Good call on the glucagon.

  32. You really treat a well perfusing 3rd degree block w/ atropine? Do you have good outcomes with that. I believe in most systems in the states that this treatment for any high level block (2nd degree type 2, or 3rd degree) is considered dangerous and harmful. Why is TCP not in place in the field?

  33. Rhythms like this I don't necessarily look at the little squares, I start looking at the PR intervals as well as looking for any funky looking T's which might actually be hiding a P. Those are my big tip-offs for a CHB.

  34. […] the first part of this tale click here, and thank you for all of your thought provoking comments. There will be many more people learning […]

  35. Hi emtpncv.Ill explain all of this in the next post.

  36. May I use this info for my paramedic class?

  37. May I use this info for my paramedic class?

  38. Put the pacer pads on… the atropine is shown not to be very effective with 3AVB…after you have the pacer pads on…do your IV and get ready…if A&O premedicate with (we use fentanyl and versed) if SBP is >90-100. ?

  39. I have read through most of the comments, and I would have to say I agree and disagree with some. I am an EMT-I with a volunteer service for about 8 months out of the year, I attend school for those 8 months and fight fire for the other 4. So I suppose I will take a crack at this as well. As far as symptomatic he was but is currently asymptomatic; I find this very surprising. The strip looks like a 3rd degree block to me; the qrs and p waves march out but are not together in any way. The ventricular rate appears to be around 35 “ish” which I agree is the bradycardia everyone seems to be referring to. However, in a few comments I have seen Epi and atropine are thrown out; where I come from as an intermediate those two meds are outside of my scope but if memory serves me right both of those meds are contraindicated in a 2nd or 3rd degree block. Pacing could be an option but he seems to be doing very well givin the situation. I would have to agree with everyone else on the 12 lead, O2 via NC @ 4 LPM, IV access ( I would consider 2 as pre caution) position of comfort, and monitor the pt. Pt's hx is minimal but the hypertension, hypercholesterolaemia, and the fact that he was “dizzy” without a postural change is enough to back up a cardiac theory. One comment on here read “treat your patient not your monitor.” I would like to point out the present hx and past hx. Let me remind you plenty of cardiac problems present with few findings such as dizziness or weakness and nothing else. Is the ECG finding just a coincidence or one more tool to use to support your thoughts on what is wrong with the patient? Closing I would like to reference a call I had 2 days ago; we were dispatched to a local hotel which is known for low income people staying long term. The dispatch was a female intoxicated who took some pills. The pt. was female approx 40 who had ETOH and 3 or 4 ambien on board, she was slow to respond, lethargic, and going in and out of consciousness. A 4 lead was applied which revealed V-fib that almost immediately turned into SVT. The SVT sustained for about 30 seconds and then went into V-Tach. After the V-Tach was seen the 4 lead was immediately taken off and defib patches applied. The defib patches caught the tail end of V-tach which went back into SVT then converted to sinus tach. This all elapsed within 45 seconds to a minute; now was the patient going in and out of consciousness and slow to respond because she had alcohol in her system or because she was having a major cardiac issue? Do you treat the patient or “treat the monitor”?

  40. Complete Heart BlockO2, 500 cc NS bolus, 0.5 mg ASA, TCP

  41. I have read through most of the comments, and I would have to say I agree and disagree with some. I am an EMT-I with a volunteer service for about 8 months out of the year, I attend school for those 8 months and fight fire for the other 4. So I suppose I will take a crack at this as well. As far as symptomatic he was but is currently asymptomatic; I find this very surprising. The strip looks like a 3rd degree block to me; the qrs and p waves march out but are not together in any way. The ventricular rate appears to be around 35 “ish” which I agree is the bradycardia everyone seems to be referring to. However, in a few comments I have seen Epi and atropine are thrown out; where I come from as an intermediate those two meds are outside of my scope but if memory serves me right both of those meds are contraindicated in a 2nd or 3rd degree block. Pacing could be an option but he seems to be doing very well givin the situation. I would have to agree with everyone else on the 12 lead, O2 via NC @ 4 LPM, IV access ( I would consider 2 as pre caution) position of comfort, and monitor the pt. Pt's hx is minimal but the hypertension, hypercholesterolaemia, and the fact that he was “dizzy” without a postural change is enough to back up a cardiac theory. One comment on here read “treat your patient not your monitor.” I would like to point out the present hx and past hx. Let me remind you plenty of cardiac problems present with few findings such as dizziness or weakness and nothing else. Is the ECG finding just a coincidence or one more tool to use to support your thoughts on what is wrong with the patient? Closing I would like to reference a call I had 2 days ago; we were dispatched to a local hotel which is known for low income people staying long term. The dispatch was a female intoxicated who took some pills. The pt. was female approx 40 who had ETOH and 3 or 4 ambien on board, she was slow to respond, lethargic, and going in and out of consciousness. A 4 lead was applied which revealed V-fib that almost immediately turned into SVT. The SVT sustained for about 30 seconds and then went into V-Tach. After the V-Tach was seen the 4 lead was immediately taken off and defib patches applied. The defib patches caught the tail end of V-tach which went back into SVT then converted to sinus tach. This all elapsed within 45 seconds to a minute; now was the patient going in and out of consciousness and slow to respond because she had alcohol in her system or because she was having a major cardiac issue? Do you treat the patient or “treat the monitor”?

  42. Complete Heart BlockO2, 500 cc NS bolus, 0.5 mg ASA, TCP

  43. […] @UKMedic999: New blog post: What would you do? – ECG Geek 6 http://999medic.com/2010/01/31/what-would-you-do-ecg-geek-6/ […]

  44. It hard to pass the whole night if your airway is not smooth, this is the great information about the nasal strips and how to buy it at http://www.breatherightnasalstrips.com/ hope all of you can sleep well.

  45. Nasal Dilators to avoid collapse of the nostrils and allow more air into the nose. For details go to http://www.breatherightnasalstrips.com/


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