Dr. Smith's ECG Blog

AUGUST 14, 2024

R waves 6 through 9 have no preceding P waves and are suspiciously regularly spaced. Depolarization wavefronts exit the sinus node through one or several sinoatrial conduction pathways (SACP) as seen in the histology section below taken from Li et al. Impulses E, F, G, H, and I were blocked. This is consistent with sinus rhythm.

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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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E-9-1-1 OR Coronary ACS 116

REBEL EM

FEBRUARY 29, 2024

1, 2 Its occurrence often portends worse outcomes in intubated patients, whose projected hospital course was already tenuous. 1, 4, 6 The overall incidence of VAP is somewhere around 5%-40% of all intubated patients, depending on the study and country from which it is reported. 4, 8 Paper: Dahyot-Fizelier, C.,

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E-9-1-1 ICU OR ALS 126

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. C Examination notable for diaphoresis, 1+ bilateral lower extremity edema, regular heart rate and rhythm, and no signs of respiratory distress with normal breath sounds. In fact, Kosuge et al. In fact, Kosuge et al.

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E-9-1-1 ACS Emergency Department Coronary 136

REBEL EM

AUGUST 30, 2023

Epidemiology 1 to 2.4 cases per 100,000 people ( Zimmerli 2010 ) More common in males with M:F of 3:1 Rate is also increasing due to increased number of spinal procedures Typically affects adults, with most cases occurring in patients over 50 years old. Other pathogens include: E. PMID: 26316526 Boody B, et al.

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E-9-1-1 ALS ED OR 104

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]. Am J Emerg Med. 2023;73:34-39. Results: 26,069 studies met initial inclusion criteria.

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E-9-1-1 ALS ACS ICU 122

REBEL EM

NOVEMBER 6, 2024

1998 Jan-Feb;6(1):15-23. PMID: 32644703 Robinson PM, Griffiths E, Watts AC. 2017 Jul;9(3):195-204. PMID: 29681420 Gottschalk HP, Eisner E, Hosalkar HS. 1999 Jan;13(1):58-9. Commentary on an article by Marc Schnetzke, MD, et al.: “Determination of Elbow Laxity in a Sequential Soft-Tissue Injury Model.

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E-9-1-1 ACS OR Emergency Department 59

REBEL EM

JANUARY 25, 2024

Article: Arvig MD, Lassen AT, Gæde PH, et al. What They Did: Design: Randomized, controlled, blinded-outcome trial Sites: Three emergency departments in Denmark Duration: October 9, 2019 to May 26, 2021. The first evaluation of the patient was to be done within 1 hour of arrival to ED (Including the first POCUS). Emerg Med J.

ED 130

ED E-9-1-1 Emergency Department ALS 130

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% per year incidence of SCD in this cohort [1].

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E-9-1-1 CAD OR STEMI 70

FOAMfrat

MAY 19, 2024

This blog is an example of exactly that. While transporting to the emergency department, the patient’s mother informed me that PDCD affects less than 1 in 50,000 individuals and is more common in males than females. 6. Giribaldi G, Doria-Lamba L, Biancheri R, Severino M, Rossi A, Santorelli FM, et al. Always look it up!

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E-9-1-1 ALS Emergency Department EMT 97

EMS 12-Lead

APRIL 28, 2022

Initial vital signs include: NIBP 99/58 HR 150-160 (trend) RR 10 (spontaneous, but shallow) SpO2 86 (RA) BBS CTA The initial rhythm strip is attached: Figure 1 There is a wide complex tachycardia of varying morphology, amplitude, and R-R cycle length. A prominent vertical scar, however, is noted at the sternum.

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E-9-1-1 ALS Coronary EMS 130

EMDocs

MAY 11, 2024

CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis? Rosh Review Website Link Further Reading: FOAMed: [link] [link] [link] [link] [link] [link] [link] References : Turi B, Smith D, Kusel K, et al. Updated November 9, 2023. link] Sharma R, Gaillard F, Bell D, et al.

EMS 89

EMS E-9-1-1 ALS OR 89

REBEL EM

SEPTEMBER 13, 2023

Features Urticaria and pruritis Rapid onset (1-2 hours) IgE Dependent (Type I Hypersensitivity) Reactions An allergen cross-links two or more IgE molecules on mast cells or basophils and initiates a signal cascade leading to degranulation. PMID 25629740 Hassen GW et al. PMID 23062323 Kostis JB et al. Zuraw et al.

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Frozen Plasma Allergic Reaction FFP Plasma 105

FOAMfrat

OCTOBER 20, 2023

Previously, I wrote a blog on pre-oxygenation, referencing my personal “weapon of choice” as chosen from the 7 Ps of RSI. But, putting them both into one blog would make for a read far too long to maintain even my attention span (which honestly is pretty short). And according to a paper from Russotto et al.

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E-9-1-1 ALS ACS OR 52

REBEL EM

MAY 27, 2024

No significant differences in heart rate 1 minute after cardioversion were observed between the three groups. References: Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. 2010;17(1):44-49. Duration of Antiarrhythmic Effect: MVM group: 35.44 seconds (SD = 7.73) Adenosine group: 24.24 seconds (range: 22.5,

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OR E-9-1-1 ED ALS 137

REBEL EM

FEBRUARY 5, 2024

Article: Marx T, Joly LM, Parmentier AL, et al. Sites: Investigators recruited patients at 31 French emergency departments at university and nonuniversity hospitals Duration : June 1, 2009 to March 31, 2015. Recurrence of pneumothorax within 1 year. Panacek, E. Cochrane Database of Systematic Reviews 2017, Issue 9.

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E-9-1-1 ALS Emergency Department OR 105

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. Figure-1: The initial ECG in today's case — obtained after ROSC.

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E-9-1-1 Defibrillator CPR STEMI 89

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. link] Shvilkin et al. By contrast with today's case — I offer this tracing from a 60-year old woman with dyspnea and the ECG in Figure-1 showing LBBB conduction every-other-beat. is diagnostic of cardiac memory.

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E-9-1-1 ACS ALS OR 78

REBEL EM

FEBRUARY 21, 2024

Read More REBEL EM: The Ketorolac Analgesic Ceiling References Irizarry E et al. PMID: 34133820 Arora S et al. Can J Emerg Med 2007; 9(1): 30-2. PMID: 17391598 Wright JM et al. PMID: 7618770 Neighbor ML et al. PMID: 9492131 Mixter CG et al. PMID: 9565125 Qureshi I et al. 2019; 36: 401-6.

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E-9-1-1 Emergency Department ALS ED 64

Dr. Smith's ECG Blog

MARCH 22, 2022

After having learned about benign T wave inversion pattern years ago on this blog, and having seen many cases on this blog and in my practice since then, I instantly recognize this as BTWI, a fairly common normal variant. see below for more info on this) 1. POINT # 2: The E CG F indings C hanged !

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E-9-1-1 ALS OR 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Post cath ECG: Now there are hyperacute T-waves again, and recurrent ST depression in V2 This ECG would normally diagnostic of OMI until proven otherwise No further troponins were measured, but it looks like there is recurrent OMI Next day: A CT Coronary Angiogram was done (CTCA) CARDIAC MORPHOLOGY AND FUNCTION: 1. IMPRESSION: 1.

Coronary 101

Coronary E-9-1-1 STEMI ACS 101

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. 2021;42(1):145-159. Li H, Ding X, Zhai S, et al.

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E-9-1-1 ALS Emergency Department OR 52

Dr. Smith's ECG Blog

MARCH 9, 2023

He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. Proven STEMI has an open artery in 19% to 36% of cases, depending on whether it is TIMI −1, −2, or −3 flow. 25] Stone et al found that 72% have TIMI 0 or 1 flow.

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E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 22, 2022

But these cases show the potential dangers of delayed recognition and treatment of inferior reperfusion Take away 1. ECG’s can be labeled as ‘normal’ by the computer (and confirmed by cardiology) even with diagnostic signs of occlusion or reperfusion References 1. Backus BE, Six AJ, Kelder JC, et al. JAMA Intern Med 2019 9.

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E-9-1-1 STEMI ALS ED 52

REBEL EM

AUGUST 28, 2023

Read More REBEL EM: The Ketorolac Analgesic Ceiling References Irizarry E et al. PMID: 34133820 Arora S et al. Can J Emerg Med 2007; 9(1): 30-2. PMID: 17391598 Wright JM et al. PMID: 7618770 Neighbor ML et al. PMID: 9492131 Mixter CG et al. PMID: 9565125 Qureshi I et al. 2019; 36: 401-6.

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E-9-1-1 Emergency Department ALS ED 52

REBEL EM

SEPTEMBER 26, 2022

Article: Kumar M et al. 2020;71(1):235-246. Plt 37×10^9/L and 40×10^9/L, SOC and TEG, respectively) All patients enrolled had an upper endoscopy and verified the source of bleeding. Hepatology. Significant coagulopathy: INR > 1.8 Significant coagulopathy: INR > 1.8

FFP 52

FFP E-9-1-1 ICU ALS 52

Dr. Smith's ECG Blog

MAY 5, 2023

. = Dr. Smith was reading ECGs — and he sent myself and Dr. Meyers the tracing shown in Figure-1. Figure-1: The initial ECG in today's case. Our Initial Thoughts on the ECG in Figure-1: Dr. Meyers said the following: "I see 2 different atrial foci — one sinus and one ectopic. At the time we did not yet know the history.

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E-9-1-1 NARCAN Naloxone Overdose 52

REBEL EM

OCTOBER 5, 2023

1-6 We now have the Community-Acquired Pneumonia: Evaluation of Corticosteroids (CAPE COD) Trial. Paper: Dequin P, Meziani F, Quenot J, et al. Patients admitted to the ICU with severe community-acquired pneumonia were randomized in a 1:1 ratio to receive hydrocortisone or a placebo. N Engl J Med. 2023;388(21):1931-1941.

Critical Care 94

Critical Care ICU E-9-1-1 ALS 94

REBEL EM

JULY 3, 2023

Article: Rossi N et al. Investigators enrollend 660 patients in 9 years in 5 EDs; or approximately 6 patients per month; or 1 patient per /month for each ED. The inclusion of p-values in Table 1 might lead to misinterpretation or improper use of statistical significance. Am J Emerg Med.

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E-9-1-1 EMR Emergency Department ED 98

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

4 important features that indicate acute right hear strain: 1. Kosuge et al. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with APE (p less than 0.001). Witting et al. Finally, Stein et al. Tachycardia (or nearly) 2.

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E-9-1-1 ACS ALS OR 52

REBEL EM

JANUARY 23, 2023

Article: Abella BS et al. Patients were randomized in a 1:1 ratio. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. 2005 Sep;116(3):643-9. Zuberbier, Torsten, et al. Moreover, the FDA approved intravenous (IV) cetirizine to treat acute urticaria in 2019. Ann Emerg Med 2020.

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Allergic Reaction ED E-9-1-1 Emergency Department 52

REBEL EM

OCTOBER 26, 2023

1–4 Antimicrobial resistance is a global health crisis, underscoring the importance of antibiotic stewardship. Paper: Zaoutis T, Shaikh N, Fisher BT, et al. After consent, children were randomized 1:1 to receive 5 additional days of antibiotics or 5 days of a matching placebo. 9 excluded after randomization.

E-9-1-1 81

E-9-1-1 OR Emergency Department ALS 81

REBEL EM

MAY 8, 2023

Paper: Smith JA, Secombe P, Aromataris E. Only 1 RCT and 1 cohort study had only mechanically ventilated patients. However, this data was driven by a single small trial (Enderson et al.), References: Smith JA, Secombe P, Aromataris E. appeared first on REBEL EM - Emergency Medicine Blog. in ICC group, 5.8%

E-9-1-1 59

E-9-1-1 Critical Care ICU OR 59

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

mm of ST segment elevation, V2 and V3 have 1 mm of elevation, v4 has 2 mm of elevation and v5 around 1.5 Note 1: Levels were significantly lower in takotsubo that presented with T-wave inversion. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Learning Points: 1. What do you think?

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Emergency Department E-9-1-1 Coronary STEMI 52

REBEL EM

AUGUST 21, 2023

Paper: Eastwood G, et al. Figure 2 : Extended Glasgow Outcome Scale (GOS-E) (credit: Doc_HG ) Secondary Modified Rankin Score Secondary outcomes included death within 6 months. PMID: 33571603 Part 9: Post–cardiac arrest care | circulation – aha/ASA journals. link] Petran J, et al. PMID: 35644204 Zhou D, et al.

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E-9-1-1 Critical Care CPR ALS 98

Dr. Smith's ECG Blog

MAY 19, 2022

The Cardiorespiratory Implications of Ultra-marathon Bjørkavoll‐Bergseth et al. Paana et al. Regarding the History: It sounds from the History as if this patient has at least a significant component of EIA ( E xercise- I nduced A sthma ). Dr. Indeed, they have a higher incidence of structural problems. ng/L; 3 hours, 38.3

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E-9-1-1 Coronary OR ED 52

Dr. Smith's ECG Blog

MAY 26, 2023

This was a very complex case and the details are too much for an ECG Blog, but suffice it to say that, s hortly thereafter, the patient had an asystolic arrest and was resuscitated. Learning Points: 1. For clarity in Figure-1 — I've reproduced and put these first 2 ECGs together. Figure-1: The first 2 tracings in today's case.

Overdose 88

Overdose E-9-1-1 Coronary OR 88