Dr. Smith's ECG Blog

JANUARY 2, 2025

CASE CONTINUED She was admitted to the ICU. T-waves are quite tall and possibly peaked (HyperK?), but potassium returned normal. I do not see OMI here and all trops were only minimally elevated, consistent with either chronic injury from cardiomyopathy or with acute injury from sepsis. What is the QT interval? Bogossian et al. (1)

Coronary 116

Coronary OR Defibrillator ALS 116

The Skeptics' Guide to EM

SEPTEMBER 14, 2024

Date: September 12, 2024 Reference: Anderson et al. AEM August 2024. The use of direct oral challenges has been tried in the intensive care unit (ICU) setting to de-label patients. Koo et al showed that offering amoxicillin oral challenges to ICU patients with low-risk penicillin allergies. A pivotal study by Raja et al.

ICU 143

ICU Emergency Department ALS ED 143

Broome Docs

MAY 31, 2024

Welcome to the June edition of the Journal Club for 2024. 2024 Apr 1:e240167. Welcome to the June edition of the Journal Club for 2024. Articles linked below and podcast available on your favourite player or YouTube over at the First10EM channel. JAMA Pediatr. doi: 10.1001/jamapediatrics.2024.0167.

E-9-1-1 82

E-9-1-1 ED Critical Care ICU 82

REBEL EM

FEBRUARY 19, 2024

CHEST 2024. PMID: 37611862 Clinical Question: In patients treated in the ICU, can a protocol of peripheral IV catheter vasopressors safely reduce the number of days of CVC use and frequency of placement? CHEST 2024. Peripheral Administration of Norepinephrine: A Prospective Observational Study. References: Yerke JR et al.

ICU 137

ICU EMS ALS OR 137

EMDocs

JUNE 15, 2024

1: PREOXI RCT – Preoxygenation with Noninvasive Ventilation vs. Non-rebreather Mask Spoon Feed Noninvasive ventilation (NIV) was superior to a standard non-rebreather (NRB) oxygen mask for preoxygenation of critically ill ED or ICU patients requiring intubation, with a NNT of 11 to prevent 1 episode of hypoxemia <85%. 2024 Jun 13. #2:

ICU 97

ICU Emergency Department ED OR 97

EMDocs

JULY 20, 2024

Spoon Feed An international, multi-center RCT found that administering pantoprazole to intubated ICU patients lowered the rate of upper GI bleeding compared to placebo. Spoon Feed An international, multi-center RCT found that administering pantoprazole to intubated ICU patients lowered the rate of upper GI bleeding compared to placebo.

Emergency Department 97

Emergency Department ICU OR 97

REBEL EM

FEBRUARY 8, 2024

J Intensive Care Med 2024. PMID: 38215002 Clinical Question: In critically ill adults in the ICU is noninvasive blood pressure (NIBP) monitoring similar (≤10% difference) to invasive arterial blood pressure (IABP) monitoring? which was not statistically significant [2]. Paper: Haber, EN et al. to 1.12; p = 0.03 to 0.99; p <0.01

ICU 123

ICU MICU ALS EMS 123

EMDocs

AUGUST 17, 2024

2024 Jun 14. Spoon Feed In ICU patients with traumatic brain injury (TBI) and anemia, transfusing blood to a liberal hemoglobin threshold (10 g/dL) compared to a restrictive threshold (7 g/dL) did not lead to better neurological outcomes at 6 months. 2024 Jun 13. It’s time to learn smarter. 1: TNK Up to 24 Hours for Stroke?

ICU 95

ICU OR 95

Dr. Smith's ECG Blog

OCTOBER 8, 2024

A temporary pacemaker was implanted, and she was admitted to the ICU with cardiogenic shock. Available from: [link] Click here to sign up for Queen of Hearts Access == MY Comment , by K EN G RAUER, MD ( 10/8 /2024 ): == It’s always easier to look back at a case from the comfort of one’s home — and to criticize decisions that were made.

OR 122

OR STEMI ICU Coronary 122

Core EM

OCTOBER 23, 2024

The patient was admitted to the Medical ICU for aggressive electrolyte replacement, q2h BMPs, and due to concern for decompensation as signaled by his elevated troponin. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. [link] Read More and tends to occur in men of Asian descent. and tends to occur in men of Asian descent.

Emergency Department 130

Emergency Department Critical Care ICU Ambulance 130

REBEL EM

APRIL 22, 2024

Population: Adult patients ( > 18 years of age) admitted to the ICU with COVID-19 and severe hypoxemia (defined as receiving supplemental O2 with a flow rate of at least 10L/min or receiving mechanical ventilation or non-invasive ventilation. Lower vs higher oxygenation target and days alive without life support in COVID-19.

Life Support 74

Life Support ICU EMS OR 74

EMDocs

SEPTEMBER 7, 2024

Disposition: Consider ICU for many patients, especially if any signs of instability or repeatedly requiring blood products. Disposition: Consider ICU for many patients, especially if any signs of instability or repeatedly requiring blood products. Majority of RPH will stabilize on their own and not require intervention.

EMS 97

EMS E-9-1-1 Operating Room OR 97

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

His temperature was brought back to normal over time in the ICU. Altered Mental Status, Bradycardia == MY Comment , by K EN G RAUER, MD ( 2/2 /2024 ): == Dr. Meyers began today’s case with the clinical challenge of asking you to identify the underlying cause of ECG #2. He was extubated and had normal neurologic function.

ICU 137

ICU OR ALS ED 137

ACEP Now

JULY 7, 2024

Should emergency physicians rely on standard textbooks for diagnostic and treatment regimens? Or should recent literature guide diagnosis and management? Status epilepticus has previously been defined as seizure(s) greater than or equal to 30 minutes in which the patient does not regain normal mental status between seizures.

Emergency Department 52

Emergency Department Critical Care ALS ICU 52

Don't Forget the Bubbles

JUNE 17, 2024

The team sits down for a hot debrief once the patient is stabilised and transferred to the ICU. InHealthcare 2024 Jan 22 (Vol. While you are leading the resuscitation, one of your senior colleagues belittles a junior staff member for struggling to site an IV line. How do you manage this situation? cognitive rehearsal techniques ).

E-9-1-1 105

E-9-1-1 Critical Care CPR ICU 105

Dr. Smith's ECG Blog

JANUARY 9, 2024

The pacing rate was increased without clinical improvement and the patient was transferred to the ICU for closer monitoring/treatment. However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. Is this: 1. In either case, prompt cardioversion is indicated.

Coronary 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

JUNE 21, 2024

A patient in the ICU with significant underlying cardiac disease [HFrEF 30%, non-ischemic cardiomyopathy, LBBB s/p CRT-D (biventricular pacer), AVNRT s/p ablation a few yrs ago, hx sinus tachycardia while on max tolerated BB therapy] went into a regular wide-complex tachycardia after intubation for severe COPD exacerbation.

ICU 71

ICU OR 71

ACEP Now

APRIL 3, 2024

Accessed March 26, 2024. degrees Celsius. TTM2 was a multicenter, randomized trial that enrolled 1850 OHCA patients and randomized them to 33 degrees Celsius or normothermia. Patients were maintained at their assigned target temperatures for 28 hours and then maintained at normothermia less than 37.5 degrees Celsius for 72 hours. Circulation.

Advanced Life Support 40

Advanced Life Support ALS Life Support CPR 40

REBEL EM

FEBRUARY 29, 2024

3, 4 It is the most common nosocomial infection in patients on mechanical ventilation, and one of the leading causes of nosocomial infection among all patients in the ICU. Mimoz (2024). 1, 2 Its occurrence often portends worse outcomes in intubated patients, whose projected hospital course was already tenuous. Lasocki, T.

E-9-1-1 119

E-9-1-1 ICU ALS OR 119

Broome Docs

MARCH 28, 2024

2024 Jan 22;41(2):96-102. 2024 Jan 2;53(1):afad255. Although I miss performing the procedure, these days I almost always leave the central line until the patient is stabilized and settled into their ICU bed. 2024 Jan 29:jme-2023-109651. Emerg Med J. doi: 10.1136/emermed-2023-213285. Age Ageing. Is pregnancy a disease?

E-9-1-1 96

E-9-1-1 ICU Emergency Department ALS 96

Core EM

JANUARY 25, 2024

Disposition to ICU. 2007;33(11):2019-2024. Supplement additional dextrose prn, if hypoglycemia occurs do not stop the insulin, increase the rate of the dextrose drip. Potassium Shifted intracellularly by insulin, total body potassium is normal Replete to goal 3-3.5 Titrate to end organ perfusion as MAP may not change significantly.

Overdose 246

Overdose ALS Epinephrine Critical Care 246

EMDocs

OCTOBER 19, 2024

Question: What’s the next step in your evaluation and treatment, and what is the potentially life-threatening diagnosis? Answer : Bacterial tracheitis Introduction Bacterial tracheitis (BT), also known as bacterial croup or laryngotracheobronchitis, is a potentially lethal infection of the subglottic trachea. [2] to 1 case per 100,000 children.

EMS 110

EMS E-9-1-1 Epinephrine OR 110

Dr. Smith's ECG Blog

JUNE 23, 2024

Given the presentation, the cardiologist stented the vessel and the patient returned to the ICU for ongoing critical care. (TIMI 3 means the rate of passage of dye through the coronary artery is normal by angiography.) Lesions less than 70% are generally considered to be non-flow limiting. Two subsequent troponins were down trending.

Coronary 118

Coronary CAD CPR Critical Care 118

REBEL EM

AUGUST 12, 2024

PMID: 36038001 Clinical Question: In patients undergoing cardiac surgery with cardiopulmonary bypass, does the administration of intravenous amino acid therapy lead to lower occurrence of postoperative AKI when compared to placebo?

ICU 81

ICU Operating Room Critical Care ALS 81

Dr. Smith's ECG Blog

JUNE 17, 2024

The patient was upgraded to the ICU for closer monitoring. Accessed May 28, 2024. Supporting Kosuge, Ferrari found that anterior T-wave inversions were the most common ECG finding in massive PE. == MY Comment , by K EN G RAUER, MD ( 6/17 /2024 ): == Today's case by Drs. In fact, Kosuge et al. It is nearly pathognomonic for PE.

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

EMDocs

APRIL 22, 2024

Time was of the essence, the patient was intubated, ACLS measures were continued, and POCUS was performed. The POCUS findings enabled EPs to confidently recognize findings consistent with hemodynamically unstable (formerly sub-massive or massive) PE. Multiorgan POCUS The diagnostic power of POCUS often resides in combining multiple ultrasound exams.

ED 98

ED NARCAN ALS OR 98

ACEP Now

MAY 9, 2024

Nearly half of all post-AFT patients presenting to our emergency departments required admission and six percent required ICU admission. Or Helly Larson describing the first week after her Miami BBL as “absolute hell” to a Vox reporter. These questionable practices led to a rash of bad outcomes. units per patient.

Emergency Department 52

Emergency Department Operating Room Critical Care ICU 52

ACEP Now

MAY 9, 2024

After developing encephalopathy and hypoxemic respiratory failure, the patient was transferred to the ICU. Further diagnostic testing in the ICU identified salicylate toxicity. Further diagnostic testing in the ICU identified salicylate toxicity. Published 2024 Jan 19. Of these, the authors identified 550 (23.0

Emergency Department 52

Emergency Department ICU ALS ACS 52

ACEP Now

JUNE 14, 2024

4,6,11 Antibiotics Antibiotic use for AECOPD patients remains a contentious topic; however, data suggests AECOPD patients requiring admission, particularly to the ICU, should receive antibiotics. Common triggers include infections, recent medication changes, colder weather or air pollution, and medication non-adherence.

ALS 52

ALS Coronary OR ED 52

REBEL EM

NOVEMBER 11, 2024

Background: Patients with sepsis are routinely treated with empiric broad-spectrum antibiotics while awaiting source identification, as recommended by the surviving sepsis campaign.2 2 Vancomycin, in combination with either piperacillin-tazobactam or cefepime, is commonly used for empiric treatment in these cases. In 2021, Buckley et.

E-9-1-1 108

E-9-1-1 ALS ICU Critical Care 108

EMDocs

JANUARY 14, 2025

Anyone with progressive symptoms or more findings on exam than paresthesias alone should be admitted to the hospital, likely to an ICU setting, due to the risk of decompensation. 2024 Jan;75:90-97. Dysautonomia : Generally occurs in patients with more severe disease. Only persistent or sustained abnormalities should be treated.

Plasma 98

Plasma Epinephrine ICU ED 98

REBEL EM

NOVEMBER 25, 2024

2024 Feb 83(2):132-144. Intubation performed in all settings (out-of-hospital, emergency department, ICU, and operating room). Clinically Diverse Patient Population : The study included patients from varied clinical settings (ED, ICU, OR, and pre-hospital). Paper: von Hellmann R, Fuhr N, Maia IWA, et al. Ann Emerg Med.

Operating Room 104

Operating Room Emergency Department ICU ALS 104

REBEL EM

DECEMBER 23, 2024

Both these physiologic principles and recent preclinical evidence have called into question whether NS is the best resuscitation fluid for patients experiencing VOE due to concerns its tonicity and tendency to induce acidosis may promote sickling ( Carden 2017a , Carden 2017b , Alwang 2024 ).

ALS 128

ALS ED ACS EMR 128

Don't Forget the Bubbles

FEBRUARY 17, 2025

Approximately 20% of adults with septic shock in the ICU exhibit venous congestion, with significant implications for prognosis and treatment.[3] He was previously healthy and presented with a 3-day history of cough, fevers, low appetite, and decreased energy. On examination, he was mottled with cool extremities. Is more fluid the answer?

Critical Care 78

Critical Care ALS OR ICU 78

The Curious Clinicians

FEBRUARY 19, 2025

It’s easy to think of bacteria as always “wanting” to infect a host as quickly and aggressively as possible (and if you’ve ever taken care of someone with an acute PA bloodstream infection, you know how fast they can go from healthy to needing the ICU). Episodes prior to January 1, 2024, will remain free.

ACS 52

ACS ICU OR 52

EMDocs

JUNE 27, 2024

Left lower lung field end demonstrates expiratory wheezing on auscultation. Other lung fields unremarkable. smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02 mg/kg, max 0.4 C or 100.4

E-9-1-1 97

E-9-1-1 ICU ACS EMS 97

EMDocs

FEBRUARY 8, 2025

The most appropriate disposition for this patient is admission to an ICU due to increasing oxygen requirements, high mortality rates of IPA, and IDSA recommendation for bronchoscopy with lavage/tissue sampling. Vital Signs: HR 105, RR 24, SpO2 93% on 6 LPM NC, BP 143/88, T 101.1F million patients with acute IFIs per year globally 3 >1.5

ED 71

ED E-9-1-1 EMS ICU 71