Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. ECG 1 What do you think? Grines, C.

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EMDocs

MAY 28, 2024

Sickling leads to vascular occlusion, end-organ ischemia, and decreased RBC lifespan, which, in turn, leads to pain crisis, acute anemia, sequestration, infection, and acute chest syndrome (ACS). ACS is lung injury due to vaso-occlusion in the pulmonary vasculature; many with ACS will have a concomitant vaso-occlusive pain crisis.

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Broome Docs

DECEMBER 22, 2024

2024 Oct 9. There were no differences in survival (12% with IO vs 10% with IV) or neurologically intact survival (9% vs 8%). 2024 Nov 1. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial. doi: 10.1001/jama.2024.20424. 2024.20424. Shorter courses of antibiotics.

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REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Guideline-based and restricted fluid resuscitation strategy in sepsis patients with heart failure: A systematic review and meta-analysis [published online ahead of print, 2023 Aug 9]. References: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM.

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Don't Forget the Bubbles

JUNE 30, 2023

He has already climbed Ben Nevis in Scotland, visited the Gobi desert (possibly from the comfort of his parents 4 x 4, but who’s judging) and has his bronze D of E nailed. She calls out her findings: A – OK B – 1 puncture mark to the anterior left chest wall, covered with a three-sided dressing. Actively oozing.

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Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. IMPRESSION: 1. hours T-wave are getting larger again The patient went for an angiogram at about 7 hours after arrival. Stroke-volume:50 ml.

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Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Learning Point: 1. For examples of such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 posts in Dr. Smith's ECG Blog ). Figure-1: Comparison between the first 3 ECGs in today's case. How Would YOU Interpret the Serial Tracings in Figure-1? So they looked into the patient's chart.

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Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Despite not being considered in this category, opioid medications are sometimes given for ACS. Am Heart J.

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Pediatric EM Morsels

AUGUST 18, 2023

Myth #1: Musculoskeletal Adverse Events (MAE) This concern is likely the most common reason fluoroquinolones are rarely used in children. Which is a risk of 1 event for 62.5 References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. PMID: 26407358 Meesters K, Mauel R, Dhont E, Walle JV, De Bruyne P. Pediatrics.

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FOAMfrat

APRIL 22, 2024

This kid had sticks go through his cheek from running with a lollipop, hit by a car, almost kidnapped, attacked by a dog, and almost burnt his house down by throwing a 9-volt battery in the trash. References Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J. 2024 Mar 15:1-9.

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EMDocs

OCTOBER 8, 2024

Discharging a patient with abnormal vital signs has been linked to unanticipated death (1-4). Lactate Troponin Could this be ACS or myocarditis? 2005;2(1):44-52. doi:10.1038/ncpcardio0068 Sklar DP, Crandall CS, Loeliger E, Edmunds K, Paul I, Helitzer DL. 2016.12.010 Brugada J, Katritsis DG, Arbelo E, et al.

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Don't Forget the Bubbles

SEPTEMBER 13, 2023

When considering tumours, 37 observation studies involving 2661 children found that 3% (95% CI 1-7%) had tumours. Reaffirmed October 17, 2020 Jaffe M, Bar-Joseph G, Tirosh E. 2021;26(1):50-57 NICE. 2006;67(9):1542-1550 Royal Children’s Hospital Melbourne. 2000; 55(5):616-623. Pediatrics. 2000;41(8):950-954. doi:10.1111/j.1528-1157.2000.tb00277.x

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Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS. 4 important features that indicate acute right hear strain: 1. looked at consecutive patients with PE, ACS, or neither. Tachycardia (or nearly) 2. Poor R-wave progression 4.

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Dr. Smith's ECG Blog

MARCH 1, 2023

This pattern occurs regardless of whether the cause is ACS (decreased supply) or any other cause of decreased supply or increased demand. You must understand that this pattern does not differentiate ACS from other causes of supply/demand mismatch. ST depression will not always be present in 9/12 leads — as is seen in Figure-1.

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ECG & Echo Learning

MARCH 8, 2023

All patients with NSTE-ACS ( NSTEMI or unstable angina) are treated similarly with respect to anti-ischemic and anti-thrombotic drugs. Guidelines recommend the use of validated risk models to estimate the risk of acute myocardial infarction , 30-days and 1-year mortality in patients with NSTE-ACS. Circulation.

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Dr. Smith's ECG Blog

NOVEMBER 9, 2023

Over the last 1 week, her exertional chest pain became worse both in intensity and triggering threshold. This case fits this definition of cardiac memory. == MY Comment , by K EN G RAUER, MD ( 11/9 /2023 ): == I found Dr. What Can Sometimes Be Learned from Intermittent BBB Conduction! link] Shvilkin et al. It is NOT Wellens' syndrome.

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Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pain is described as located in the midsternal area, radiating to the right arm, described as 8-9/10 and worse with deep inspirations. In the evening, he became diaphoretic and complained of 9/10 continuous chest pain. Today’s case provides perhaps the best example of s erial E CG e volution of this elusive entity.

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Dr. Smith's ECG Blog

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. On review of systems the patient reported back pain for approximately 1 week which he was treating with NSAIDs with minimal relief. 15-9/6/2017 ). His first troponin T then resulted elevated at 0.19

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AAEM RSA

APRIL 1, 2021

1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 in the 1:1:1 group vs. 17.0%

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Dr. Smith's ECG Blog

FEBRUARY 16, 2019

mm in just one lead V7-9), but as far as I can tell all of these documents specifically avoid calling this condition STEMI and specifically avoid using any terminology similar to "STEMI equivalent." I focus My Comments on 3 of the ECGs that were shown in this case ( Figure-1 ). This was interpreted as "no significant change."

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Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. mm of ST segment elevation, V2 and V3 have 1 mm of elevation, v4 has 2 mm of elevation and v5 around 1.5 Learning Points: 1. What do you think? V1 has 0.5

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FOAMfrat

OCTOBER 20, 2023

As reported within the 6th edition Manual of Emergency Airway Management, there are cardiac arrest rates between 1% and 4%, with other complications (mostly hypoxemia and hypotension) as high as 30% in patients with first-pass success [1, pg 29; 4-10]. Recommendations : 1. Why is Physiologic Optimization Important?

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Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. Note baseline wander in lead aVL of ECG #1. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. Therefore this is " Transient ST Elevation Unstable Angina." Why is this important?

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ECG & Echo Learning

OCTOBER 2, 2022

Most agents exhibit both vasopressor and inotropic effects (Figure 1). μg/kg/min Bolus : 1 mg IV every 3 to 5 min (max 0.2 mg/kg) IM: (1:1000): 0.1 mg (max 1 mg) Safe for peripheral use ++ + N/A Beta-effect more pronounced at low doses. De Backer D, Creteur J, Silva E, Vincent JL. Kill C, Wranze E, Wulf H.

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Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Here they are: Learning Points: 1. 7 These 3 studies, as well as 1 smaller meta-analysis, 6 and another small study, 8 make it clear that troponin is associated with increased severity and mortality in COVID when adjusted for multiple other variables. Am J Med [Internet] 2017;130(12):1431–9.e4. Available from: [link] 9.

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ACEP Now

NOVEMBER 7, 2023

1 Overall, survival is poor following cardiac arrest, and is affected by factors including age, comorbidities, witnessed arrest, early CPR, early defibrillation, and return of spontaneous circulation (ROSC). 2018;13(9):e0204169. Margey R, Browne L, Murphy E, et al. Emmerson AC, Whitbread M, Fothergill RT. 20(S1):S67.

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ACEP Now

NOVEMBER 14, 2023

1 However, it is important to understand that death from hemoptysis is almost always due to hypoxia or asphyxiation (blood impedes gas exchange in the lungs, typically because of bleeding from high-pressure bronchial arteries into the lungs) as opposed to hemodynamic instability. References Deshwal H, Sinha A, Mehta AC. 2023;23(1):87.

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Dr. Smith's ECG Blog

JULY 30, 2023

Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). STD maximal in V1-V4, without a QRS abnormality causing it, and in the setting of ACS symptoms, is posterior OMI until proven otherwise. In Figure-1 — The ST-T wave abnormality in lead V2 of ECG #1 is obvious.

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Dr. Smith's ECG Blog

AUGUST 3, 2017

There are two main etiologies of ischemic ST-depression: 1) subendocardial ischemia 2) reciprocal to ST-elevation in an opposite wall Here there are distinct R-waves with marked ST-depression throughout most of the precordium. Tips for recognizing Acute Posterior STEMI: 1. References: 1. This can help in confirmation.

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EMDocs

JANUARY 11, 2024

The neurologic section was divided into (1) brain oxygenation, perfusion, edema, and intracranial pressure (ICP); (2) seizures and the ictal-interictal continuum (IIC); and (3) sedation and analgesia. Reference: Hirsch KG, Abella BS, Amorim E, et al; American Heart Association, Neurocritical Care Society. 2023 Dec 1.

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EMDocs

JANUARY 20, 2024

She describes the pain as left-sided, non-radiating, and 9/10 in severity. Answer: Takotsubo Cardiomyopathy 1-18 Background: Also known as transient apical ballooning syndrome, apical ballooning cardiomyopathy, stress-induced cardiomyopathy, stress cardiomyopathy, Gebrochenes-Herz syndrome, and broken-heart syndrome.

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Don't Forget the Bubbles

JULY 22, 2024

study from 200 9. A large proportion of the trials come from Finland (3) and The UK (2) and also from Australia (1) and the US (1), but only a small number took place in the ED. Castro-Rodriguez JA, Beckhaus AA, Forno E. Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, et al. Pediatr Pulmonol.

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EMDocs

FEBRUARY 12, 2024

Introduction Arterial blood gas (ABG) or venous blood gas (VBG) testing is used to assess the pH and systemic carbon dioxide tension in patients, and, therefore, provide a more complete picture of their acid-base status than an isolated basic metabolic panel (BMP) (1). However, ABGs have many drawbacks compared to VBGs.

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EMDocs

JANUARY 6, 2024

1 Indications for transplant include: Non-ischemic cardiomyopathy (49%) Ischemic cardiomyopathy (35%) Restrictive cardiomyopathy (4%) Retransplantation following failed prior transplant (3%) Hypertrophic cardiomyopathy (3%) Congenital heart disease (3%) Valvular cardiomyopathy (3%) The median survival after heart transplant is over 12 years.

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EMDocs

OCTOBER 7, 2023

1-3 Common causes: Natural disasters such as tornadoes or earthquakes 4,5 Structure or building collapses from home fires or bombings. 2016;20(1):135. Goodman AD, Got CJ, Weiss AC. Stahl K, Rastelli E, Schoser B. 2012;27 Suppl 1:i1-67. Critical Care. Genthon A, Wilcox SR. J Emerg Med. 2014;46(2):313-319.

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AAEM RSA

DECEMBER 3, 2020

1 His description of cases of life-threatening infections in the perineal, genital or perianal regions were thought to be idiopathic in previously healthy men. 3-5 Fournier gangrene is a type of necrotizing soft tissue infection, which can be categorized into four types based on the infectious organism involved and other features (Table 1).

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Dr. Smith's ECG Blog

APRIL 8, 2015

Cardiac Syncope ("True Syncope") Independent Predictors of Adverse Outcomes condensed from multiple studies 1. Palpitations preceding syncope (highest value on EGSYS score) 9. It's complicated, but they derived a score based on these variables: 1. h/o heart disease (+1) 3. Troponin greater than 99th percentile (+1) 5.

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