The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. She arrives in the emergency department (ED) with decreased level of consciousness and shock. She has a history of hypertension and non-insulin dependent diabetes mellitus.

EMR 130

EMR Coronary Defibrillator Life Support 130

The Skeptics' Guide to EM

APRIL 10, 2021

He is a GP by training but works in Emergency Department, Anaesthesia, Internal Medicine and Paediatrics. He has a wonderful #FOAMed blog and podcast called Broomedocs and also work […] The post SGEM#326: The SALSA Study: Hypertonic Saline to Treat Hyponatremia first appeared on The Skeptics Guide to Emergency Medicine.

Emergency Department 130

Emergency Department Coronary ED OR 130

Dr. Smith's ECG Blog

MARCH 10, 2025

Our data corroborate that immediate management of a patient with a normal automated triage ECG reading is not modified by real-time ED physician ECG interpretation." But troponin is a rear-view mirror which shows damage that has already occurred, and is often within the normal range within only 2 hours of onset of acute coronary occlusion.

STEMI 87

STEMI OR Coronary Emergency Department 87

EMS 12-Lead

MAY 20, 2022

Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. Below is the initial ED ECG.

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). The patient was rushed to the nearest emergency department (non-PCI facility) for stabilization.

Coronary 130

Coronary ACS Emergency Department Epinephrine 130

The Skeptics' Guide to EM

MAY 28, 2022

Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. What do you think?

E-9-1-1 140

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

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. They too have dense white masses consistent with coronary atherosclerosis. Annals of Emergency Medicine 2011; Suppl 58(4): S211.

CAD 127

CAD STEMI Coronary ACS 127

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

EMS 12-Lead

AUGUST 14, 2022

The specific ST/T pattern was not fully appreciated by the attending EMS personnel, yet alarming enough to convince the patient to be seen in the Emergency Department despite his intentions of seeking evaluation on his own accord through his respective family physician. But the lesion is still active! MICU transport was unremarkable.

MICU 130

MICU STEMI CAD Coronary 130

EMDocs

SEPTEMBER 26, 2024

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits , a monthly email newsletter for ED physicians. Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Someone should have – either the first ED doc, the second ED doc, or my PCP.

Emergency Department 93

Emergency Department ED Coronary ALS 93

Dr. Smith's ECG Blog

OCTOBER 18, 2023

If you were working in a busy emergency department, would you like to be interrupted to interpret these ECGs or can these patients safely wait to be seen because of the normal computer interpretation? Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med.

STEMI 120

STEMI Emergency Department Coronary OR 120

EMDocs

SEPTEMBER 19, 2023

On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Official diagnosis requires EEG, which is not something we can typically obtain in the ED. STEMI vs. NSTEMI dichotomy is not sensitive for true occlusion MI or acute coronary occlusion. J Am Coll Cardiol.

STEMI 90

STEMI Coronary Emergency Department ICU 90

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI 118

STEMI Coronary ACS ED 118

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Adult cardiac arrest in the emergency department – A Swedish cohort study.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

EM Didactic

OCTOBER 7, 2018

It is commonly used in Emergency Departments, especially in febrile and possibly infectious patients. Take Home In the ED, CRP should not be used to make a diagnosis but to assist evaluation and support your clinical suspicion. In clinically unwell patients, a normal CRP level should never delay antibiotic coverage in ED.

Emergency Department 40

Emergency Department ACS Critical Care Coronary 40

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). link] ] Outcome The patient emerged neurologically intact. Clinical Cardiology 2019.

STEMI 98

STEMI Coronary Defibrillator EMS 98

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.

Coronary 52

Coronary STEMI ACS ALS 52

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. Western Journal of Emergency Medicine, 18 (4), 752-760. [2]

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.

Defibrillator 137

Defibrillator Coronary STEMI CPR 137

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy.

Emergency Department 52

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

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. The undergraduate is now willing to identify himself: Hans Helseth. No ECG was ordered on Day #1.

Coronary 121

Coronary STEMI Emergency Department OR 121

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. Guagliumi, G., Iwaoka, R.

E-9-1-1 132

E-9-1-1 OR Coronary ACS 132

EMS 12-Lead

APRIL 28, 2022

Upon arrival at the receiving emergency department, however, she precipitously degenerated into VF and could not be resuscitated. In most cases, rather, the culprit is gross ischemia due to myocardial infarction, cardiomyopathy, or advanced coronary artery disease. Chou’s Electrocardiography in Clinical Practice (6th ed).

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

JANUARY 9, 2024

She presented to the emergency department after a couple of days of chest discomfort. The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). This patient presented to the ED “after a couple of days of chest discomfort”.

Coronary 120

Coronary ACS ED OR 120

EMDocs

OCTOBER 30, 2023

Belcher, MD (EM Attending Physician, University of Kentucky, Department of Emergency Medicine) // Reviewed by: Jessica Pelletier, DO (EM Education Fellow, Washington University School of Medicine); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit) “What do you call an IV contrast shortage? Alternative contrast agents.

E-9-1-1 92

E-9-1-1 Emergency Department ALS CCT 92

Dr. Smith's ECG Blog

OCTOBER 12, 2024

A man in his 90s with a history of HTN, CKD, COPD, and OSA presented to the emergency department after being found unresponsive at home. Vital signs were within normal limits on arrival to the Emergency Department. EKG on arrival to the ED is shown below: What do you think? Blood glucose was not low at 162 mg/dL.

STEMI 117

STEMI Coronary Emergency Department ACS 117

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. A recent angiogram report indicated a totally occluded left anterior descending artery (LAD) and right coronary artery (RCA), with 30-40% narrowings in the left circumflex artery (LCx).

Coronary 114

Coronary EMR STEMI Emergency Department 114

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. Am J Emerg Med. I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. 2022 Jan;51:384-387.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. Figure-1: The first 2 tracings in today's case. The Need for Immediate Transport?

OR 131

OR STEMI Coronary Emergency Department 131

Dr. Smith's ECG Blog

JUNE 11, 2024

Many systems now refrain from showing computer "normal" ECGs to the busy emergency physicians at triage because of very poorly conceived articles that say that if the computer algorithm says "normal," the emergency physician should not be bothered. It is clearly missed by the conventional algorithm.

STEMI 114

STEMI Coronary Emergency Department OR 114

EMDocs

MARCH 25, 2024

2, 3 Biliary POCUS can help decrease patient length of stay in the Emergency Department. 2, 3 Biliary POCUS can help decrease patient length of stay in the Emergency Department. Utility of common bile duct measurement in ED point of care ultrasound: A prospective study. Am J Emerg Med. 2022;7:188-189.

ALS 98

ALS Coronary Emergency Department ED 98

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. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. He survives.

ACS 85

ACS ALS ED Coronary 85

ACEP Now

AUGUST 12, 2024

A 35-year-old male presented to the emergency department complaining of chest pain that started 1.5 FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. Dr. Young is an emergency physician at Saint Francis Hospital and Medical Center, Hartford, Conn. Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52

ACEP Now

APRIL 4, 2024

A 59-year-old male with a past medical history of a repaired ventricular septal defect (VSD), dextrocardia, hypertension, hyperlipidemia, and current smoker presented to the emergency department (ED). The patient initially presented to an outside ED and was subsequently transferred to our facility for continuity of care.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Here is the first ED ECG, with no pain: Sinus rhythm. Akkerhuis KM, et al.

Coronary 52

Coronary STEMI ALS Emergency Department 52

Dr. Smith's ECG Blog

OCTOBER 20, 2013

She was hypotensive in the ED and her bedside echo showed a normal RV and LV. Two prehospital 12-lead ECGs looked similar to this ED ECG: This shows diffuse ST depression (I, II, III, aVL, aVF, V3-V6) with reciprocal ST elevation in lead aVR. BP gradually rose. Results: Over 8.5

STEMI 52

STEMI Coronary ACS Emergency Department 52