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.

E-9-1-1 145

E-9-1-1 Plasma ALS OR 145

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-9-1-1 131

E-9-1-1 OR Coronary ACS 131

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-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

EMDocs

OCTOBER 19, 2024

to 1 case per 100,000 children. 2][3] Definitive diagnosis is made by laryngoscopy or bronchoscopy showing normal or mildly erythematous epiglottis and an erythematous, edematous trachea with thick mucopurulent exudates. [3] 2][3][9] Glucocorticoid were not shown to alter clinical course or patient outcomes. [2][3]

EMS 110

EMS E-9-1-1 Epinephrine OR 110

Dr. Smith's ECG Blog

AUGUST 14, 2024

R waves 6 through 9 have no preceding P waves and are suspiciously regularly spaced. Impulses E, F, G, H, and I were blocked. Progress in Biophysics and Molecular Biology , 120 (1–3), 164–178. Science Translational Medicine , 9 (400). Figure-1: I've labeled the initial ECG in today's case to illustrate my theory.

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E-9-1-1 OR ALS 110

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 ).

E-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

Dr. Smith's ECG Blog

OCTOBER 1, 2024

== MY Comment , by K EN G RAUER, MD ( 8/30 /2024 ): == I was sent the ECG shown in Figure-1 — knowing only that the patient was being seen in the ED ( E mergency D epartment ). Figure-1: The initial ECG in today's case. After seeing ECG #2 — Can you explain: i ) Why no negative P wave was seen in lead V1 of ECG #1? —

E-9-1-1 113

E-9-1-1 STEMI ED OR 113

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]. Let’s start with the obligatory definition of coaching. 2022; 11(1):45-52. 2019 Nov 27;4(Suppl 1):S130-S139. But what can Dr. Garcia – or you – do?

E-9-1-1 161

E-9-1-1 ALS OR 161

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. Actively oozing.

E-9-1-1 139

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

REBEL EM

SEPTEMBER 27, 2023

REBEL Core Cast 109.0 – Na Channel Blocker Poisoning Click here for Direct Download of the Podcast Definition and Physiology Standard definition of a wide QRS is anything > 120 msec (3 small boxes on the ECG) In the context of poisoning, a “wide QRS” is anything greater than 100 milliseconds. 1985 Aug 22;313(8):474-9.

E-9-1-1 100

E-9-1-1 Overdose EMS 100

EMDocs

SEPTEMBER 7, 2024

1 Risk Factors: 1-4 Spontaneous Anticoagulants (Apixaban, Rivaroxaban, etc.) Older Age (median age of 70 years) 1 Abnormal vasculature/neoplasm of the kidney (e.g., 5 Clinical Presentation: 1-3 Variable presentation but may present with dropping hemoglobin/hematocrit without other findings in spontaneous cases.

EMS 97

EMS E-9-1-1 Operating Room OR 97

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

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

ACEP Now

NOVEMBER 8, 2024

Historically, the endotracheal tube (ETT) has been considered the definitive airway of choice in both the prehospital and in-hospital setting. 1 Prehospital endotracheal intubation and EGAs are typically placed without paralytics and are reserved for unconscious, apneic, and out-of-hospital cardiac arrest patients. 2014;4(1):77-87.

E-9-1-1 40

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

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].

E-9-1-1 92

E-9-1-1 CAD OR STEMI 92

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Learning Point: 1. For examples of such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 posts in Dr. Smith's ECG Blog ). Figure-1: Comparison between the first 3 ECGs in today's case. How Would YOU Interpret the Serial Tracings in Figure-1? No wall motion abnormality identified.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

EMDocs

MAY 25, 2024

On examination, she has erythema and tenderness overlying her left parotid gland. Massaging the gland causes expression of purulent material. What is the diagnosis?

EMS 98

EMS E-9-1-1 OR ED 98

REBEL EM

AUGUST 30, 2023

REBEL Core Cast 107.0 – Vertebral Osteomyelitis Click here for Direct Download of the Podcast Definition Inflammation of the vertebrae due to a pyogenic, fungal or mycobacterial organism. Epidemiology 1 to 2.4 Epidemiology 1 to 2.4 Other pathogens include: E. Often used interchangeably with osteomyelitis.

E-9-1-1 88

E-9-1-1 ALS ED OR 88

EMDocs

MARCH 30, 2024

Comprehensive physical exam is unremarkable, but she does have pain at the T-12/L-1 region of her back. Her patellar reflexes are 1+ bilaterally, no ankle clonus is noted, and she denies any saddle anesthesia or bowel/bladder incontinence. CT of lower spine is ordered and shows the following: 1 What is the diagnosis?

EMS 105

EMS E-9-1-1 Emergency Department Ambulance 105

Don't Forget the Bubbles

JUNE 17, 2024

The lack of consistent definitions in the literature makes it difficult to report its true prevalence and hampers efforts to combat it. Here are ten things to think about: 1. Churruca K, Pavithra A, McMullan R, Urwin R, Tippett S, Cunningham N, Loh E, Westbrook J. 2014 Jun 26;23(12):653-9. 2020 Jan 1;35(1):70-6.

E-9-1-1 105

E-9-1-1 Critical Care CPR ICU 105

EMS 12-Lead

AUGUST 22, 2022

Question 1: What is the rhythm? They are not premature, by definition. 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. The green arrows, however, do show premature complexes.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Don't Forget the Bubbles

DECEMBER 16, 2024

Coverage of the 6-in-1 vaccine measured at 12 months of age in England for Q4 2023 to 2024 Source: ONS under the Open Government License v3.0 Young infants and immunosuppressed individuals are particularly at risk of severe disease, resulting in significant morbidity and associated mortality rates of 1-3 per 1,000 cases.

E-9-1-1 59

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

EMDocs

FEBRUARY 26, 2024

1 While PJP gained significant recognition among HIV-positive adults during the early AIDS epidemic, the growing utilization of immunosuppressants has resulted in an increased incidence of the disease in individuals who are HIV-negative. 9 The signs and symptoms of PJP infection are non-specific. for detecting pulmonary opacities.

E-9-1-1 110

E-9-1-1 ED ALS OR 110

Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. But maybe not. Thelin et al.

E-9-1-1 40

E-9-1-1 STEMI ACS Coronary 40

EMDocs

NOVEMBER 18, 2023

A point of care ultrasound of the liver reveals the following: Image 1: Ultrasound of the liver showing abnormal hepatic artery flow and resistance index 1 Question: What is the diagnosis? Rosh Review Website Link References 1) Karmazyn B, Sağlam D, Rao GS, Jennings SG, Mangus RS. In: Molmenti E, Santibañes M, Santibañes E.

EMS 95

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

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 109

Coronary E-9-1-1 STEMI ACS 109

Don't Forget the Bubbles

AUGUST 28, 2023

A biopsy is often ultimately required for a definitive diagnosis. You contact ICU, anaesthetics, ENT, and oncology with a plan to attempt more definitive imaging in the prone position (which Ginny tells you is much comfier) What’s the evidence for our emergent management? 2014;9(9):S102-S109. 2019;43(1):98-103.doi:10.1097/RCT.0000000000000782

Emergency Management 97

Emergency Management Emergency Manager E-9-1-1 Critical Care 97

EMDocs

MARCH 4, 2024

A wide variety of conditions can result in either type of cholestasis (Figure 1). 1 Extrahepatic obstruction is due to mechanical obstruction occurring downstream of the hepatic ducts such as pancreatic disease, gallstone obstruction of the common bile duct, and cancer. 9 How are cholestatic labs defined?

Emergency Department 105

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

Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pain is described as located in the midsternal area, radiating to the right arm, described as 8-9/10 and worse with deep inspirations. QRS onset is the best location for ST segment comparison, and is the location recommended by Universal Definition of MI. Figure-1: The 4 serial ECGs shown in this case ( See text ).

E-9-1-1 52

E-9-1-1 Coronary OR ACS 52

Dr. Smith's ECG Blog

MAY 30, 2023

We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. 1 mg of Atropine was given and the heart rate increased transiently to 60. Atropine usually works in junctional rhythm with a narrow complex 9. What to do? RVMI explains part of the shock.

E-9-1-1 97

E-9-1-1 STEMI Coronary OR 97

REBEL EM

JULY 3, 2023

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 primary purpose of Table 1 is to provide a summary of baseline characteristics and demographics of the study population, presenting data in a clear and organized manner.

E-9-1-1 91

E-9-1-1 EMR Emergency Department ED 91

Dr. Smith's ECG Blog

JULY 21, 2019

These are reasons why it does not look like OMI: 1. Definitive diagnosis is by MRI. Serial Troponins remained in the 9-11 range, w/o any large rise and/or fall, also atypical for OMI. The ECG was repeated 12 minutes later ( = E CG # 2 ). A 3rd ECG was recorded 2 hours later ( = E CG # 3 ). flat ST segment in V4 2.

E-9-1-1 52

E-9-1-1 OR ED 52

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. This case fits this definition of cardiac memory. == MY Comment , by K EN G RAUER, MD ( 11/9 /2023 ): == I found Dr. What Can Sometimes Be Learned from Intermittent BBB Conduction! link] Shvilkin et al.

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

Dr. Smith's ECG Blog

MARCH 1, 2023

It is unclear to me whether this case could represent 1) simple supply/demand mismatch due to increased demand from epinephrine, 2) Kounis syndrome (usually described as mast cell mediated coronary vasospasm during allergic reaction), 3) brief autolysed left main or LAD ACS with no findings on later echo and CT coronary angio, or 4) something else.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

4 important features that indicate acute right hear strain: 1. 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). They found that only 11% of PE had 1 mm T-wave inversions in both lead III and lead V1, vs. 4.6%

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

Dr. Smith's ECG Blog

SEPTEMBER 9, 2020

== MY Arrhythmia Case by K EN G RAUER, MD ( 9/9/2020 ): == PREFACE: Recognition of the presence ( or absence ) of AV block is a common problem in emergency medicine. The ECG that is shown in Figure-1 was obtained from an elderly patient, who was admitted to the hospital for a fall. Is there AV block?

E-9-1-1 52

E-9-1-1 OR 52

Don't Forget the Bubbles

DECEMBER 13, 2023

It is commonly seen in the first couple of years of life and accounts for 1-5% of paediatric hospital admissions for those under two. Failure to thrive’ has many definitions We use standardized charts to document infant growth. E.g. cleft palat e. 2016 Apr;175(4):573-9. Epub 2015 Dec 9. His birth weight was 2.72

E-9-1-1 98

E-9-1-1 OR 98