ALiEM

APRIL 12, 2024

Traditionally large-bore tube thoracostomy has been the standard of care for treating many acute intrathoracic pathologies [1]. Pigtails provide a less invasive and often better tolerated alternative to traditional chest tubes and allow for adequate treatment of pneumothoraces and uncomplicated pleural effusions [1-5]. 1999;3(1):57-61.

E-9-1-1 183

E-9-1-1 ALS Critical Care Emergency Department 183

Pediatric EM Morsels

OCTOBER 27, 2023

Initially tested in Johannesburg, South Africa: 1 month old to 12 years old Broselow predicted within 10% of weight in 63.6% Reduces dosing errors during resus, up to 33.88%. Recommended by ATLS and PALS. Broselow-Luten System: Supportive Data Physician estimates of weight can underdose children by 49% or overdose by up to 116%. x exp[0.02

E-9-1-1 271

E-9-1-1 Emergency Medical Services Life Support ALS 271

This Podcast Will Kill You

FEBRUARY 11, 2025

Journal of Zoological Systematics and Evolutionary Research, 46(1), pp.19-23. Anais da Academia Brasileira de Cincias, 96(1), p.e20230706. Now imagine that your tongue suddenly shriveled up and fell off and that in its place is a tongue-sized isopod aka rollie pollie aka pillbug. Just there, hanging out, forever. How are you feeling?

E-9-1-1 97

E-9-1-1 ALS OR 97

Pediatric EM Morsels

SEPTEMBER 22, 2023

Negative E-FAST and no signs of long bone injuries should raise concern for neurogenic shock in the hypotensive trauma patient with suspected spinal injury. Alpha 1 agonists are necessary to maintain appropriate blood pressure. Tenenbein M, Macias CG, Sharieff GQ, et al, eds. Thought to be a “stunning” of the spinal cord.

E-9-1-1 304

E-9-1-1 Epinephrine ALS EMS 304

ALiEM

AUGUST 9, 2023

Technique Positioning and Probe Figure 1: Younger children can sit in their parent’s lap and give a hug for lateral and posterior lung scanning. The patient should be in a position of comfort: supine, sitting, or in parent’s lap (Figure 1). Identify anatomical landmarks on ultrasound (Figure 3, Video 1).

E-9-1-1 246

E-9-1-1 Emergency Department ALS OR 246

Core EM

JANUARY 25, 2024

7 86% of burn injuries are thermal burns (as opposed to chemical or electric), with 43% resulting from a direct exposure to fire, 34% from scalding liquid, and 9% from a hot object. 4 Survival rate for all burn injuries is around 97%, which is a notable increase from 75% in the 1960’s.

ED 246

ED E-9-1-1 First Aid OR 246

ALiEM

OCTOBER 11, 2023

Most pufferfish contain tetrodotoxin , a dangerous marine toxin up to 1200 times more toxic to humans than cyanide [1]. 4, 9-12] Consider activated charcoal for patients presenting within 60 minutes of ingestion if the patient’s airway is not an imminent threat or has been secured. Hassoun AER, Ujević I, Jemaa S et al.

E-9-1-1 204

E-9-1-1 ALS OR 204

ALiEM

NOVEMBER 1, 2023

Iron toxicity treated with deferoxamine Background Deferoxamine is the treatment for severe iron toxicity [1]. Deferoxamine 1] Initial dosing starts at 5 mg/kg/hr intravenously. 1, 3, 4] Hypotension is generally the rate-limiting factor for the infusion rate. McGraw-Hill Education; 2019 Madiwale T, Liebelt E. 2023 May 22.

E-9-1-1 161

E-9-1-1 ALS OR ED 161

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.

E-9-1-1 132

E-9-1-1 OR Coronary ACS 132

ALiEM

MARCH 7, 2024

Ultrasound probes from left to right: linear (nenoates), phased array (infants/younger children), and curvilinear (older children/adolescents) Pro tips for performing renal/bladder POCUS on a child [1] Addressing potential anxiety leads to a more efficient and comfortable examination. Pre-warmed ultrasound gel is helpful when available.

E-9-1-1 177

E-9-1-1 Emergency Department ALS ED 177

REBEL EM

MAY 27, 2024

No significant differences in heart rate 1 minute after cardioversion were observed between the three groups. What they did: Prospective randomized controlled trial, unblinded, multicenter study Conducted from January 2017 to December 2022 Patients with confirmed PSVT were randomly assigned to receive MVM, IV Adenosine, or combined therapy.

OR 134

OR E-9-1-1 ED ALS 134

ACEP Now

DECEMBER 17, 2024

1 His tragic loss underscores the urgent need for mental health support for residents and fellows. Accessed December 9, 2024. Accessed 9 December 2024. Ahmed AM, Kadakia K, Ahmed A, et al. This victory is about more than just numbers. link] Published October 25, 2023. Adelman LC. Is it time to unionize? Beresford L.

E-9-1-1 105

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

REBEL EM

MAY 25, 2023

mental status, urine output, capillary refill) is more important than an actual goal PERMISSIVE HYPOTENSTION IN PTS WITH TBI Brotfain E et al. mental status, urine output, capillary refill) is more important than an actual goal PERMISSIVE HYPOTENSTION IN PTS WITH TBI Brotfain E et al. Richards JE et al.

E-9-1-1 145

E-9-1-1 Plasma ALS OR 145

ALiEM

MAY 13, 2024

Her symptoms started 1 week ago as a scratch which progressively got more red and painful. Pediatric Soft Tissue POCUS Ultrasound Technique Figure 1. Cellulitis with cobblestoning Video 1. Abscess with irregular borders and surrounding cellulitis E. Superficial abscess with well-circumscribed borders Table 1.

E-9-1-1 161

E-9-1-1 ALS Emergency Department OR 161

ACEP Now

DECEMBER 7, 2024

1 A wide spectrum of severity exists in PE presentations, ranging from mild shortness of breath to cardiac arrest. Approximately 60,000 to 100,000 patients die from pulmonary embolism (PE) each year in the United States, and PE is the third leading cause of cardiovascular mortality.

E-9-1-1 52

E-9-1-1 ALS Critical Care OR 52

ALiEM

OCTOBER 30, 2023

It should be no surprise that academic clinical educators are at high risk for burnout, stalled career advancement, and abandonment of academic medicine altogether [1, 2]. After spending her first year acclimating to the new department and achieving board certification, Dr. Garcia finds herself at a bit of a crossroad. In short, no.

E-9-1-1 161

E-9-1-1 ALS OR 161

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. Challenge QUESTION: The relative change in T-QRS-D is not the only thing that changes during period of time that passed between recording of the 2 ECGs shown in Figure-1.

E-9-1-1 128

E-9-1-1 Coronary ACS BLS 128

Dr. Smith's ECG Blog

OCTOBER 3, 2024

I agree, however: 1) I don't think you can get a good enough ech o without bubble contrast. 3) E cho is another step that takes time. I had only 9 false positives but I missed 2 OMI. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al. I assumed it was a patient with acute chest pain. Full text !

E-9-1-1 125

E-9-1-1 Coronary ALS ED 125

ALiEM

AUGUST 16, 2023

Common agents include local anesthetics, dapsone, quinones, sulfonamides, phenazopyridine, and nitrites [1, 2]. Treatment for methemoglobinemia in G6PD deficiency may consist of ascorbic acid, exchange transfusion, and hyperbaric oxygen [7, 9]. PMID 23953868 Mack E. What are the symptoms of Methemoglobinemia? doi:10.1053/j.jvca.2013.02.005.

E-9-1-1 130

E-9-1-1 ALS OR 130

Pediatric EM Morsels

NOVEMBER 17, 2023

Bibl K, Pracher L, Küng E, Wagner M, Roesner I, Berger A, Hermon M, Werther T. 1994 Jul;125(1):57-62. 2019 Sep;74(9):1186-1190. 2016 Feb;30(1):3-11. On this 10 year anniversary, we chose to throw this one back in the oven to include some even more delicious data on cuffed endotracheal tube (ETT) use. 1.70) and 0.78 (0.46–1.35),

E-9-1-1 187

E-9-1-1 Operating Room Emergency Department ALS 187

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.

E-9-1-1 140

E-9-1-1 ACS Emergency Department Coronary 140

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

ECG #1 Interpretation: ECG #1 shows sinus rhythm at a heart rate of 77 bpm. Following more detailed questioning — it turned out the patient had started taking 9 different herbal remedies to ease lethargy and unspecific neurological symptoms. For clarity in Figure-1 — I've reproduced the initial ECG in today's case.

E-9-1-1 114

E-9-1-1 ALS Defibrillator OR 114

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.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Don't Forget the Bubbles

NOVEMBER 29, 2024

Step 1: Conversion to Formaldehyde Methanol is broken down in the liver by an enzyme called alcohol dehydrogenase at a fixed rate. This zero-order elimination occurs at about ~8–9 mg/dL/hour. Let’s break down the science, signs, and solutions for managing this stealthy poison—especially in children. What is Methanol?

Plasma 64

Plasma E-9-1-1 OR ALS 64

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. Janssen, P. & Fedorov, V.

E-9-1-1 111

E-9-1-1 OR ALS 111

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Here is lead I from ECGs 1 and 2 shown side-by-side to highlight the change in axis from borderline right to completely normal. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ). Answer : Bedside ultrasound!

E-9-1-1 129

E-9-1-1 Coronary STEMI ALS 129

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.

E-9-1-1 118

E-9-1-1 ALS ACS ICU 118

This Podcast Will Kill You

JULY 23, 2024

Official journal of the American College of Gastroenterology| ACG , 118 (1), pp.59-76. Annals of internal medicine , 172 (1), pp.ITC1-ITC16. Caio, Giacomo, et al. ” BMC medicine 17 (2019): 1-20. . ” BMC medicine 17 (2019): 1-20. Cenit, María Carmen, et al. Gastroenterology , 160 (1), pp.63-75.

E-9-1-1 98

E-9-1-1 ALS OR 98

EMDocs

SEPTEMBER 23, 2023

Answer : Brugada Syndrome Epidemiology and Etiology Rare genetic disorder that affects approximately 1 in 5,000 individuals worldwide 1. More common in males than females, with a male-to-female ratio of approximately 8:1 1. Type 1 “Brugada sign” The only type that is considered diagnostic.

E-9-1-1 102

E-9-1-1 EMS ALS Defibrillator 102

Broome Docs

SEPTEMBER 3, 2024

In a surprise to no one who reads First10EM, clinical judgment is better than all decision tools for sepsis Knack SKS, Scott N, Driver BE, Prekker ME, Black LP, Hopson C, Maruggi E, Kaus O, Tordsen W, Puskarich MA. Epub 2024 Apr 9. 2024 Mar;27(1):26-29. Cook D, Deane A, Lauzier F, et al. 2024 Jul 4;391(1):9-20.

E-9-1-1 95

E-9-1-1 Emergency Department ICU ALS 95

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.,

E-9-1-1 111

E-9-1-1 ICU ALS OR 111

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. RR 25-30. Actively oozing.

E-9-1-1 139

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

EMDocs

FEBRUARY 20, 2024

Fluids in Pancreatitis #1 : de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. 2: Li XW, Wang CH, Dai JW, et al. 2023 Mar 22;27(1):122. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000. to 9.8L) Moderate: 5.5L (Range 4.0

E-9-1-1 97

E-9-1-1 ICU ALS OR 97

EMS 12-Lead

AUGUST 22, 2022

Question 1: What is the rhythm? Beat 1 : Sinus, narrow QRS complex. The assumption is that a premature complex discharged prior to Beat 1, which prolonged its respective refractory period in the same manner as Beat 5. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside. Said differently, it’s a mess.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

ACEP Now

NOVEMBER 8, 2024

1 Prehospital endotracheal intubation and EGAs are typically placed without paralytics and are reserved for unconscious, apneic, and out-of-hospital cardiac arrest patients. 9 LMAs use an inflatable mask expanded using a similar technique to the endotracheal tube cuff. Benger JR, Kirby K, Black S, et al. 2018;320(8):779-791.

E-9-1-1 40

E-9-1-1 Emergency Medical Services Emergency Medical Technician AEMT 40

EMDocs

MAY 11, 2024

CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis? On exam, the patient opens eyes to voice, has extraocular movements intact, is unable to speak, and has 0/5 strength in all extremities. The patient was intubated for acute hypercapnic and hypoxic respiratory failure and airway protection.

EMS 107

EMS E-9-1-1 ALS OR 107

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% He denied chest pain or shortness of breath.

E-9-1-1 91

E-9-1-1 CAD STEMI OR 91