Dr. Smith's ECG Blog

DECEMBER 27, 2023

Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present." It relies on an 1 mm cut point, which this blog does not favor as an approach to ECG. Smith comment: But the tests (ECG and troponin) are extremely specific and so the post test probability is nearly 100%.

E-9-1-1 117

E-9-1-1 OR Coronary ACS 117

REBEL EM

JANUARY 25, 2024

In many emergency departments (ED), US machines are readily available and can be used to rapidly assess and monitor patients with acute dyspnea at the bedside. US, compared with CXR and CT, offers the absence of ionizing radiation and high reproducibility. Emerg Med J. 2023;40(10):700-707.

ED 130

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

REBEL EM

MAY 27, 2024

Clinical Question: Does simultaneously performing the modified valsalva maneuver and administering intravenous adenosine, compared to either treatment alone, have greater success in achieving normal sinus rhythm in patients presenting to the ED with PSVT? This absence of detail leaves the study open to bias.

OR 137

OR E-9-1-1 ED ALS 137

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

male presents to the ED at 6:45 AM with left sided chest dull pressure that woke him up from sleep at 3am. He arrived to the ED at around 6:45am, and stated the pain has persisted. Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. The pain radiated to both shoulders.

Coronary 115

Coronary ACS OR EMR 115

Dr. Smith's ECG Blog

MARCH 28, 2024

Here is the prehospital ECG: First ED ECG What do you think? Here is the prehospital ECG: First ED ECG What do you think? He states that he maybe missed a dose or two during recent illness. On EMS arrival, patient's oxygen saturation was in the high 80s and improved on 4L O2 via nasal cannula. SVT with aberrancy?

OR 122

OR Emergency Department Ambulance EMS 122

Dr. Smith's ECG Blog

OCTOBER 27, 2024

The cath lab was deactivated by cardiologist on arrival at ED because it was "not a STEMI". He presented to the ED for evaluation chest pain. It was in his central and left chest, radiated to his left arm, and he experienced some cold sweats and nausea prompting him to call 911 and he was brought to ED via ambulance.

STEMI 116

STEMI ED Coronary EMS 116

REBEL EM

JULY 17, 2023

REBEL Cast Ep120: Etomidate vs Ketamine for RSI in the ED? PMID: Clinical Question: Does a single dose of ketamine or etomidate used for rapid sequence intubation (RSI) of critically adults in the ED impact the SOFA score within 3 days of hospitalization? Click here for Direct Download of the Podcast Paper: Knack SKS et al.

ED 98

ED ICU Emergency Department Overdose 98

EMS 12-Lead

MAY 15, 2024

TCP in the ROSC Patient: False Electrical Capture at 75mA Josh Kimbrell, NRP @joshkimbre Judah Kreinbrook, EMT-P @JMedic2JDoc This is the second installment of a blog series showing how transcutaneous pacing (TCP) can be difficult and how you can improve your skills. Pacing was continued in the ED, with identical settings.

Epinephrine 331

Epinephrine Paramedic CPR ED 331

ALiEM

FEBRUARY 5, 2024

8 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. More specifically, we identified 3 AIR and 5 Honorable Mentions. Please go to the above link.

Overdose 215

Overdose Critical Care EMS Emergency Department 215

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. The patient had no chest symptoms until he had been in the ED for many hours and had been undergoing management of his DKA. The patient was under the care of another ED physician. Another ECG was recorded: What do you think?

ED 103

ED Coronary CAD STEMI 103

EMOttawa

NOVEMBER 14, 2024

Urine drug (or toxicologic) screens are a fairly standard tool used in addictions, psychiatry and the Emergency Department (ED), often employed to detect substance use in patients presenting with altered mental status, trauma, psychiatric or abnormal behaviour.

Emergency Department 71

Emergency Department ED OR 71

EMOttawa

JANUARY 25, 2024

There is certainly a need for more practical application for the ED doc or initial setup of patients on the vent. With both ER and ICU experience, this post acts as a quick […] The post Mechanical Ventilation Basics appeared first on EMOttawa Blog.

ICU 141

ICU ED OR Critical Care 141

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. A healthy 45-year-old female presented with chest pain, with normal vitals. The computer interpretation was “ST elevation, consider early repolarization, pericarditis or injury.”

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Both were awake and alert with normal vital signs.

OR 116

OR STEMI EMS ED 116

The Skeptics' Guide to EM

SEPTEMBER 21, 2024

He currently practices emergency medicine in New Mexico in the ED, in the field with EMS and with the UNM Lifeguard Air Emergency Services. Background: We’ve discussed out-of-hospital cardiac arrest (OHCA) at least once or twice on the SGEM (see long list at end of blog). Your partner asks if you want to administer naloxone as well.

Naloxone 242

Naloxone NARCAN Overdose CPR 242

REBEL EM

NOVEMBER 20, 2023

Early expeditious definitive hemorrhage control is a major focus in trauma resuscitation. Patients with torso hemorrhage present a clinical conundrum often requiring interventional radiology or surgery, both of which take time to mobilize. 2 Despite these recommendations there are no randomized clinical trials to help guide practice until now.

OR 91

OR Emergency Medical Technician CPR Emergency Medical Services 91

ALiEM

OCTOBER 14, 2023

6 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. More specifically, we identified 3 AIR and 3 Honorable Mentions. Please go to the above link.

Critical Care 169

Critical Care EMS Emergency Department ALS 169

REBEL EM

JUNE 5, 2023

These statistics make the ED a crucial treatment initiation point to prevent further morbidity and mortality from opioid overdoses. The benefit of accessibility, availability, and safety of buprenorphine compared to methadone makes it a viable option for opioid use disorder treatment initiation in the ED. PMID 33392580.

Naloxone 98

Naloxone ED Overdose Emergency Department 98

EMOttawa

FEBRUARY 22, 2024

In 2013, in the United States there were 7 million visits to the emergency department (ED) for lacerations making up a total of 5.2% of ED visits(1).

Emergency Department 89

Emergency Department ED OR 89

REBEL EM

NOVEMBER 13, 2024

Rezaie, MD (Twitter/X: @srrezaie ) The post REBEL Core Cast 131.0 – Traumatic Arthrotomy appeared first on REBEL EM - Emergency Medicine Blog. Saline load test Has mainly been supplanted by CT scan due to ease in obtaining, reported performance characteristics, consultant recommendation and difficulty in interpreting test.

ED 105

ED OR EMS 105

Dr. Smith's ECG Blog

OCTOBER 8, 2024

I interpreted this tracing knowing only that the patient was a woman in her 60s, with a prior history of proximal LAD OMI — who now presented to the ED with a history of new chest discomfort and shortness of breath. For more on Precordial Swirl — See the October 15, 2022 post in Dr. Smith's ECG Blog ).

OR 108

OR STEMI ICU Coronary 108

EMDocs

JUNE 16, 2023

Podcast: Play in new window | Download (Duration: 13:57 — 19.2MB) Subscribe: Apple Podcasts | Google Podcasts | RSS Management of the child with mental health problems who is boarding in the ED In episode 1 of this series, we discussed differentiating organic vs psychiatric causes of agitation in children.

ED 52

ED Mental Health Services Emergency Department Emergency Medical Services 52

Dr. Smith's ECG Blog

OCTOBER 1, 2023

He called EMS who brought him to the ED. ED Diagnoses: 1. The basic principles of emergency ECG interpretation in patients who present to an ED with new symptoms include the following: Respect the History. He had active chest pain at the time of triage at 0137 at night, with this triage ECG: What do you think? Epigastric pain 2.

OR 126

OR STEMI Coronary CAD 126

ALiEM

APRIL 14, 2023

6 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 2 AIR and 4 Honorable Mentions. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

EMS 246

EMS Emergency Department ED OR 246

REBEL EM

JANUARY 23, 2023

Key Secondary Endpoints: 5 (3.9%) patients in the IV cetirizine group returned to any ED or clinic within 24 hours compared to 15 (11.1%) in the IV diphenhydramine group; P=0.04 7 (5.5%) patients in the IV cetirizine group returned to any ED or clinic within 48 hours compared to 19 (14.1%) in the IV diphenhydramine group; P=0.02

Allergic Reaction 52

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

The Skeptics' Guide to EM

NOVEMBER 11, 2023

DISCLAIMER: THE VIEWS AND OPINIONS OF THIS BLOG AND PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US MILITARY. Case: A 24-year-old manual labourer presents to the emergency department (ED) after drinking a few too many beers, having a disagreement with another beer drinker and gets knocked down.

ALS 244

ALS Emergency Department ED OR 244

Dr. Smith's ECG Blog

OCTOBER 3, 2024

While statistical likelihood of acute OMI is clearly lower in younger adults — nothing is ruled out by age alone ( as per My Comment in the January 9, 2023 and December 5, 2023 posts in Dr. Smith's ECG Blog ). This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. I assumed it was a patient with acute chest pain.

E-9-1-1 111

E-9-1-1 Coronary ALS ED 111

REBEL EM

JUNE 29, 2023

Back on June 1 st , 2023, Swami wrote a blog post on REBEL EM titled, The CT FIRST Trial, Should We Pan-CT After ROSC? REBEL EM Blog, June 1, 2023. Back on June 1st, 2023, Swami wrote a blog post on REBEL EM titled, The CT FIRST Trial, Should We Pan-CT After ROSC? Below you will find some of the points we discussed.

CPR 145

CPR ICU EMS ALS 145

EMS 12-Lead

MARCH 30, 2024

Josh Kimbrell, NRP @joshkimbre Judah Kreinbrook, EMT-P @JMedic2JDoc This is the first installment of a blog series showing how transcutaneous pacing (TCP) can be difficult, and how you can improve your skills. On ED arrival ROSC is achieved. They are unable to feel a pulse and resume CPR.

CPR 312

CPR Paramedic Ambulance Defibrillator 312

Dr. Smith's ECG Blog

JUNE 27, 2024

By Sofiya Diurba MD, reviewed by Meyers, Grauer A woman in her 50s with PMH known RBBB and prior syncopal events presents to the ED for five syncopal events over the last 24 hours. This is her first ECG in the ED: What do you see? See these blog posts. Vital signs were within normal limits at the time of triage.

ED 118

ED OR Emergency Department Emergency Manager 118

Dr. Smith's ECG Blog

JUNE 17, 2023

EMS recorded this ECG during active symptoms and transmitted it to the ED: I had no information when I was shown the ECG. Written by Pendell Meyers A middle aged man called EMS for acute chest pain. I said "Not OMI. Some probably thought the inferior leads showed findings of OMI, but that's a fake."

OR 52

OR STEMI ALS EMS 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

He was intubated on arrival at the ED for mental status and airway protection due to vomiting. See our other blog posts of hypothermia and Osborn waves -- Massive Osborn Waves of Severe Hypothermia (23.6 There is also large T wave inversion and long QT. Initial vitals included heart rate 109 bpm and BP 145/92 mmHg.

ICU 132

ICU OR ALS ED 132

FOAMfrat

NOVEMBER 21, 2024

If all of that sounded like nonsense, you can read more about it in my ABG blog. upon ED arrival incur mortality rates of up to 3-5x that of patients without coagulopathy. Acidosis Existing literature demonstrates mortality rates up to three times higher in trauma patients presenting with extreme acidosis (pH <7.0) respectively.

ICU 111

ICU Emergency Department OR Ambulance 111

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

Here is her ECG on arrival to the ED: Improved, but still some signal of posterior OMI. Angiogram was done rapidly after arrival to the ED: Culprit mid LCX 90% TIMI 3 flow, PCI performed with resultant TIMI 3 flow. Figure-1: Comparison between the initial EMS ECG and the repeat ECG in the ED. Just not yet. Very frustrating.

STEMI 81

STEMI OR ED EMS 81

EMOttawa

OCTOBER 10, 2024

1 […] The post PoCUS Pearl – Tibial Nerve Block appeared first on EMOttawa Blog. Fortunately, there’s a better way to anesthetize the plantar foot, and avoid getting kicked in the face or causing a needle-stick injury: performing an ultrasound-guided tibial nerve block.1

OR 69

OR ED 69

Dr. Smith's ECG Blog

APRIL 14, 2024

A 56 year old male with PMHx significant for hypertension had chest pain for several hours, then presented to the ED in the middle of the night. He reported chest pain that developed several hours prior to arrival and was 5/10 in intensity. The pain was located in the mid to left chest and developed after riding his bike.

ED 108

ED OR EMS 108

Dr. Smith's ECG Blog

MARCH 4, 2024

Algorithm: Marquette 12 SL (GE) The Queen gets it right Case 9 (prehospital and ED ECGs). The Queen gets it right First ED ECG: Hyperacute T-waves persist. I have often written about how an ECG interpreted as "normal" by a conventional algorithm may well be manifesting OMI, or even long QT or hyperkalemia. 2 cases at once!

STEMI 110

STEMI OR ED ALS 110