The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. The TOMAHAWK Investigators.

EMR 130

EMR Coronary Defibrillator Life Support 130

EMS 12-Lead

AUGUST 18, 2024

David Didlake EMT-P, RN, ACNP @DidlakeDW An adult male self-presented to the ED with palpitations and the following ECG. I interpreted the ECG as VT with two primary etiological possibilities: 1. Abrupt plaque ulceration of Type 1 ACS leading to VT. The patient was very uncomfortable, dyspneic, and displayed an SpO2 90% on RA.

CAD 147

CAD EMT EMT ACS 147

EMDocs

OCTOBER 21, 2023

We’ll keep it short, while you keep that EM brain sharp. The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. Median time from ED arrival to diagnosis was 8 hours 24 min in one study, with only 19% being diagnosed within the 4.5-hour Post TW, ed. hour IV thrombolytic window.

EMS 98

EMS ALS OR ACS 98

REBEL EM

SEPTEMBER 11, 2023

However, many institutions’ surgical teams still require or request a formal study over a bedside exam, likely due to a lack of confidence in the accuracy of POCUS, resulting in longer ED stays. ACS surgeons appeared to select surgery as their initial choice substantially more frequently than other subspecialties.

ED 69

ED ACS Emergency Department OR 69

Dr. Smith's ECG Blog

JULY 25, 2024

EMS arrived and found him in Ventricular Fibrillation (VF). The patient was brought to the ED and had this ECG recorded: What do you think? Then assume there is ACS. They started CPR. He was defibrillated into VT. He then underwent dual sequential defibrillation into asystole. After 1 mg of epinephrine they achieved ROSC.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

Dr. Smith's ECG Blog

MAY 3, 2024

But this time the Queen gets it wrong (thinks it is not OMI): There were runs of VT: Tha patient arrived in profound shock and had an ED ECG: Now there is some evolution to include the ST elevation (rather than ST depression) in V4-V6. RBBB + LAFB in the setting of ACS is very bad. Posterior and high lateral OMI. Learning Points: 1.

ACS 127

ACS ED Coronary EMS 127

EMDocs

SEPTEMBER 25, 2023

However, RSI has never been shown to reduce the risk of aspiration in the ED (13) or during emergent OR cases (14). While RSI should remain the gold standard in the vast majority of patients in the ED, FI presents an additional technique to mitigate anatomic or physiologic risk. To date, ketamine has been the agent of choice (12).

ED 93

ED Emergency Department ALS Paramedic 93

EMS 12-Lead

APRIL 14, 2022

He presented to EMS with extreme pallor, Levine sign, diaphoresis, bilateral arm pain, and an apprehensive sense of doom. It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). In the case of ACS, the ECG can rapidly change from this. ECG's are difficult.

ACS 130

ACS Paramedic Coronary ALS 130

REBEL EM

OCTOBER 23, 2023

His parent noticed a dental problem and immediately brought the patient to the ED. Rezaie, MD (Twitter: @srrezaie ) The post Rosh Review EM Scholar Monthly Question appeared first on REBEL EM - Emergency Medicine Blog. The patient was walking his dog when it ran after a squirrel. The physical exam is shown below.

EMS 59

EMS ACS ALS ED 59

Dr. Smith's ECG Blog

JUNE 17, 2024

Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. showed that , when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS. looked at consecutive patients with PE, ACS, or neither.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Written by Pendell Meyers A man in his 40s called EMS for acute chest pain that awoke him from sleep, along with nausea and shortness of breath. Because the most severe LAD OMIs can cause ischemic failure of the RBB and LAF, any patient with ACS symptoms and new RBBB and LAFB with any concordant STE has LAD OMI until proven otherwise.

STEMI 121

STEMI EMS ACS ED 121

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic.

CAD 126

CAD STEMI Coronary ACS 126

The Skeptics' Guide to EM

MAY 28, 2022

AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

EMS 12-Lead

APRIL 8, 2022

He reported to EMS a medical history of GERD only. 1] Here is the admitting ED ECG after cancellation of Code STEMI. V2 – in the final EMS ECG the ST segment was baseline. V3 – in the final EMS ECG the ST segment was still slightly depressed. The patient continued to verbalize cessation of symptoms while in the ED.

STEMI 130

STEMI ALS Coronary CAD 130

The Skeptics' Guide to EM

MAY 29, 2021

The patient is an adult male with a gunshot wound to the chest, and they’re combative with emergency medical services (EMS). According to a recent study in the Journal of Surgical Research [3] , 44% of all penetrating thoracic trauma patients presented to a non-trauma center (not a level 1 or level 2 ACS defined trauma center).

Emergency Medical Services 130

Emergency Medical Services ACS ALS Emergency Department 130

EMS 12-Lead

JULY 30, 2023

David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath. This should prompt immediate investigation into supply-demand mismatching, or ACS. She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease.

EMT 130

EMT EMT ACS Coronary 130

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. The patient is admitted for ACS to a cardiologist who says he will see the patient in the morning.

ACS 85

ACS ALS ED Coronary 85

EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. A 12 Lead ECG was captured on her arrival.

Coronary 130

Coronary ACS CAD ED 130

Dr. Smith's ECG Blog

APRIL 2, 2024

He was unidentified and there were no records available After 7 shocks, he was successfully defibrillated and brought to the ED. Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. Here is the initial ED ECG. Patient received 11 shocks by ICD and was in V-fib when EMS arrived.

Defibrillator 133

Defibrillator Coronary Epinephrine CPR 133

Dr. Smith's ECG Blog

AUGUST 11, 2024

The machine indicated STEMI (but it barely meets STEMI criteria, if at all) and the patient was brought to the ED: On arrival 20 minutes later the pain had reduced to 1/10 after aspirin, and the patient had repeat ECG at triage: Now the ST segments and T waves have normalized, and the only abnormality is sinus bradycardia and loss of R waves.

STEMI 100

STEMI Paramedic Coronary EMS 100

Dr. Smith's ECG Blog

MARCH 13, 2023

This is acute ACS, but it almost always seen in a pain free state. An ED ECG, if recorded with pain, should show LAD OMI. That said — severe chest pain was present at the time the patient arrived in the ED ( corresponding to the time ECG #2 was recorded ).

ED 52

ED ACS Coronary Paramedic 52

Broome Docs

DECEMBER 22, 2024

PARAMEDIC 3 randomized 6,000 (but they were supposed to get to 15,000) patients with out of hospital arrest from multiple EMS agencies in the UK to either an IO or IV to start. PMID: 39480221 We have 2 studies looking at the same question published in the same edition of the NEJM, so I will tackle them together. ( of the IO group and 5.1%

E-9-1-1 52

E-9-1-1 ACS Paramedic Emergency Department 52

EMS 12-Lead

JUNE 1, 2022

EMS finds him supine, alert and oriented, and without any gross distress. He advises, however, recurrent syncopal episodes for the past six months, some of which have resulted in ED admission, yet no identifying mechanism could be determined. Chou’s Electrocardiography in Clinical Practice (6th ed). References [1] Surawicz, B.

Coronary 130

Coronary ALS ED ACS 130

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL. EMS arrived — and recorded 2 ECGs. The 3rd tracing in Figure-1 was the initial ED ECG — obtained at a time when the patient's CP had resolved. 14 minutes later — ECG #2 was recorded by EMS.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Dr. Smith's ECG Blog

DECEMBER 19, 2023

EMS obtained the following vital signs: pulse 50, respiratory rate 16, blood pressure 96/49. It appears EMS obtained two EKGs, but unfortunately these were not saved in the medical record. The EMS crew was only BLS certified, so EKG interpretation is not within their scope of practice. After all, there is no S wave in lead V3.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

EMDocs

AUGUST 17, 2023

Welcome back to the “52 in 52” series. This collection of posts features recently published must-know articles. Today we look at the CENSER trial. vs 48.4% (OR 3.4, 5.53) Takeaways: Positive trial => there was a statistically significant rate of shock control attained with the treatment arm. vs 48.4% (OR 3.4,

Overdose 95

Overdose ACS Critical Care OR 95

EMS 12-Lead

APRIL 21, 2022

The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. Such aggressive investigation was particularly warranted in this case because of symptoms compatible with ACS, as well as an equally frightening revelation of family history. 5] Surawicz, B.

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

OCTOBER 12, 2024

With EMS, patient had a GCS of 3 and was saturating 60% on room air. He improved to 100% with the addition of non-rebreather, however remained altered and was intubated by EMS with ketamine and succinylcholine. EKG on arrival to the ED is shown below: What do you think? or basilar ischemia. Version 2 = 0.0272.

STEMI 116

STEMI Coronary Emergency Department ACS 116

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. In our opinion it should not be given in ACS unless you are committed to the cath lab. He was diagnosed as NSTEMI.

ACS 83

ACS Coronary ALS CAD 83

Don't Forget the Bubbles

MAY 17, 2023

Arch Dis Child Fetal Neonatal Ed. Hegeman EM, et al. Schwindt EM, et al. Arch Dis Child Fetal Neonatal Ed. De Alwis AC, et al. 2023 Apr 20:fetalneonatal-2022-324835. Osteomyelitis in Sickle Cell Anemia: Does Age Predict Risk of Salmonella Infection? Pediatr Infect Dis J. 2023 Apr 18. Eur J Pediatr. 2023 Apr 19.

ALS 72

ALS ACS Emergency Department EMS 72

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS.

Coronary 52

Coronary ACS EMS STEMI 52

ACEP Now

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. Per EMS, the patient was found at the bottom of a high voltage line with diffuse burns and amputation of his left forearm.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

EMS 12-Lead

APRIL 2, 2022

Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. Chou’s Electrocardiography in Clinical Practice, 6th ed. Goldberger’s Clinical Electrocardiography: A Simplified Approach, 9th ed. Annals of Noninvasive Electrocardiology, 18 (1), 21-28.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

OCTOBER 10, 2022

He reportedly told his family "I think I'm having a heart attack", then they immediately drove him to the ED, and he was able to ambulate into the triage area before he collapsed and became unresponsive. CPR was initiated immediately. It was reportedly a PEA arrest; there was no recorded V Fib and no defibrillation.

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. There is no age cut-off for ACS. 1] Wereski, R.,

OR 52

OR ACS STEMI Coronary 52

Don't Forget the Bubbles

JUNE 30, 2023

All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. The ODP is caught up leaving theatres and has not yet made it down to ED. Back in ED with Ranulf, and pack two has gone through. The trauma call goes out. Would you like a pigtail catheter or a surgical chest tube?

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). The average time to control HR in the IV amiodarone was 1.7h, which is usually the average time for disposition from the ED. Paper: Mason JM, et al.

Emergency Department 52

Emergency Department ALS Critical Care ED 52