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.

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EMDocs

JULY 17, 2023

1 While less common than small bowel obstruction (SBO), obstruction of the large bowel is more likely to be a surgical emergency and is often associated with a serious underlying condition. 1 The most common causes of non-cancer-related LBO are cecal and sigmoid volvulus. This also serves as a tool for surgical planning.

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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?

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Don't Forget the Bubbles

OCTOBER 4, 2023

The NEJM published the PREDICT trial, concluding that prophylaxis is ‘statistically’ effective in preventing the first UTI in neonates (albeit a small effect, and it comes at the cost of an increased occurrence of non– E coli organisms and antibiotic resistance). Determining the Best Definition for a Positive Urine Culture in Young Children.

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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 80

EMS E-9-1-1 OR ED 80

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.

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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.

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EMDocs

FEBRUARY 12, 2024

Introduction Arterial blood gas (ABG) or venous blood gas (VBG) testing is used to assess the pH and systemic carbon dioxide tension in patients, and, therefore, provide a more complete picture of their acid-base status than an isolated basic metabolic panel (BMP) (1). However, ABGs have many drawbacks compared to VBGs.

Emergency Department 94

Emergency Department E-9-1-1 ED ICU 94

ACEP Now

JANUARY 9, 2024

FIGURE 1: Abdominal X-ray showing particulate radiopaque foreign bodies involving the stool. 1 Children are particularly vulnerable. 9 Lead exerts its toxic effects by interfering with various organ functions, primarily targeting the nervous system and hematopoietic system, as well as impairing liver and kidney functions.

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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?

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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.

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ACEP Now

MARCH 14, 2024

Tracheo-innominate fistula (TIF) is an unusual and frequently lethal complication of such definitive airway placement. 1 percent of tracheostomies. 9 There may be no time in which to perform a CT scan, and as noted above, CTA and laryngoscopy may show no remarkable findings of fistula. 2005;128: 3906-9. 2021;4(30):1-4.

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EMDocs

JULY 3, 2023

9 Delayed NCHCT is less sensitive due to decreased visibility of blood collection secondary to red blood cell (RBC) degradation. Once SAH has been identified, management should be focused on preventing hematoma expansion, preventing re-bleed, limiting delayed ischemia, reducing intracranial pressure, and preparing for definitive management.

ED 85

ED E-9-1-1 ALS OR 85

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

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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. Hyperacute T waves do not yet have a formal research definition, but are likely defined best by an increased ratio of area under the curve compared to their QRS complex.

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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 69

EMS E-9-1-1 ALS Emergency Department 69

Don't Forget the Bubbles

FEBRUARY 26, 2024

2007 Jan 1;25(1):6-9. Start low and increase for the comfort/tolerance of the patient and talk to the patient throughout the process. Beers SL, Abramo TJ, Bracken A, Wiebe RA. Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics. The American journal of emergency medicine. Frontiers in Pediatrics.

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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.

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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.

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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.

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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 ).

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Don't Forget the Bubbles

MAY 6, 2024

Article 1: Positive urine cultures without pyuria Wang ME, Jones VG, Kane M, et al. Clinical Course of Children 1 to 24 Months Old With Positive Urine Cultures Without Pyuria. 2024;24(1):111-118. Giannoni, E., doi:10.1016/S2213-2600(24)00041-9 What’s it about? Acad Pediatr. doi:10.1016/j.acap.2023.06.023

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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 87

Emergency Department E-9-1-1 ALS OR 87

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.

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Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. As you take another LOOK at ECG #1 — What is the relevance of the findings that I've labeled in Figure-1 ?

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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

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Don't Forget the Bubbles

JANUARY 10, 2024

A definitive trial was needed to help establish the best transfusion practices to prevent child mortality in LMICs. The study asked TWO questions: 1. Immediate vs delayed transfusion In uncomplicated severe anaemia, immediate blood transfusion did not alter mortality at 1- or six months compared to controls.

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Dr. Smith's ECG Blog

JULY 30, 2023

Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). I knew nothing else about the case ( For clarity — I've reproduced today's initial tracing in Figure-1 ). == Figure-1: I have reproduced the initial ECG in today’s case. Easy for anyone.

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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.

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Don't Forget the Bubbles

OCTOBER 19, 2023

Babie Junior, or Bee for short, was the definition of a cute, delightful baby. The bottom line is: Early high-flow nasal cannula oxygen started in the ED resulted in a longer length of hospital stay than standard oxygen therapy in children aged 1 – 4 with respiratory failure. days compared to 1.50 Watch this space.

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Dr. Smith's ECG Blog

JANUARY 19, 2020

Another ECG was obtained during pacing: Mostly paced rhythm with PVCs (#3, #6, #9, #12). Consider thrombolytics for OMI when PCI is not an option. == MY Comment by K EN G RAUER, MD ( 1/19/2020 ): == There is a LOT to talk about regarding the series of tracings in this unfortunate case. mm STE with 9.5

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Dr. Smith's ECG Blog

JANUARY 10, 2020

I was relieved to see this MRI result: MRI IMPRESSION 1) Mildly decreased LV function with no focal wall motion abnormalities. Learning Points: 1. Pericarditis" strikes again == MY Comment by K EN G RAUER, MD ( 1/10/2020 ): == I like this case because it proves what we know = Medicine is not 100%. Pericarditis?

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REBEL EM

AUGUST 21, 2023

In response to this critical issue, the TAME Cardiac Arrest Trial has been launched as a definitive phase III multi-center randomized controlled trial for resuscitated cardiac arrest patients. Figure 2 : Extended Glasgow Outcome Scale (GOS-E) (credit: Doc_HG ) Secondary Modified Rankin Score Secondary outcomes included death within 6 months.

Critical Care 97

Critical Care E-9-1-1 CPR ALS 97

Dr. Smith's ECG Blog

OCTOBER 23, 2022

If you use something like the HEART score: 1. E EKG: a negative ECG (score = 0) 3. Here are a couple shots with strain, or "speckle tracking" on ED Echo: hyperacute T-waves speckle 1 x4 from Stephen Smith on Vimeo. Learning Points : 1. CHALLENGE: Take Another LOOK at the serial chest leads in Figure-1.

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Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Right atrial diastolic collapse is the earliest sign, but the patient needs to have right atrial collapse for at least 1/3 of the cardiac cycle which can be difficult to identify with ultrasound. Beck’s triad only happens all 3 together in approximately 1/3rd of patients. 2013 Sep;26(9):965-1012.e15. J Am Soc Echocardiogr.

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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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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.

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