EMDocs

FEBRUARY 12, 2024

As the only respiratory therapist in the ED has been paged and is starting BiPAP for this patient, an overhead call for two incoming trauma alerts from a multivehicle collision sounds. Importantly, the comparison between an ABG and VBG is site-specific, as illustrated below (Table 1) (1, 3-6).

Emergency Department 94

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

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

NOVEMBER 14, 2023

Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL. 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 ).

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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). Arch Dis Child Fetal Neonatal Ed. 2023 Sep 1:113720. 2023 Sep 13.

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ACEP Now

JANUARY 9, 2024

A 3-year-old male was brought to the emergency department (ED) by his mother, who reported the sudden onset of a rash (hives) covering his entire body, with no rash on his palms and soles. FIGURE 1: Abdominal X-ray showing particulate radiopaque foreign bodies involving the stool. 1 Children are particularly vulnerable.

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Dr. Smith's ECG Blog

MARCH 1, 2023

Sent by anonymous, written by Pendell Meyers A man in his late 40s presented to the ED with concern for allergic reaction after accidentally eating a potential allergen, then developing an itchy full body rash and diarrhea. In the ED he received methylprednisolone, diphenhydramine, and epinephrine for possible anaphylaxis.

Allergic Reaction 52

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

EMDocs

NOVEMBER 18, 2023

A 32-year-old female with a history of hypertension and autoimmune hepatitis status post liver transplant 6 weeks prior on tacrolimus and mycophenolate presents to the ED with abdominal discomfort. What are the complications of liver transplant that we see in the ED? We’ll keep it short, while you keep that EM brain sharp.

EMS 69

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

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. IMPRESSION: 1. We know that most type 1 acute MI due to plaque rupture and thrombosis occurs in lesions that are less than 50% (see Libby reference). I don't know if her pain was getting better or not. The Queen no longer thinks it is OMI.

Coronary 104

Coronary E-9-1-1 STEMI ACS 104

REBEL EM

JULY 3, 2023

Background: Atrial fibrillation and atrial flutter with rapid ventricular rate (AF/AFL with RVR) are the most common subtypes of SVT, comprising a large number of ED visits in aging populations. Investigators enrollend 660 patients in 9 years in 5 EDs; or approximately 6 patients per month; or 1 patient per /month for each ED.

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E-9-1-1 EMR Emergency Department ED 98

EMDocs

MARCH 4, 2024

Case: A 45-year-old woman presents to the emergency department (ED) with itching to bilateral palms. A wide variety of conditions can result in either type of cholestasis (Figure 1). 9 How are cholestatic labs defined? 1 In cholestatic injury, increased reflux of bile salts into hepatocytes causes increased translation of ALP.

Emergency Department 87

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

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. Arch Dis Child Educ Pract Ed.

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Emergency Management Emergency Manager E-9-1-1 Critical Care 96

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. Arch Dis Child Fetal Neonatal Ed. Giannoni, E., Acad Pediatr. doi:10.1016/j.acap.2023.06.023 Epub ahead of print.

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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

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.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Don't Forget the Bubbles

FEBRUARY 26, 2024

A 6-year-old known asthmatic presents to ED with a two-day history of cough and coryza, worsening wheeze and work of breathing over the last day. 2007 Jan 1;25(1):6-9. Non-invasive BiPAP can be a successful ventilation strategy for status asthmaticus, removing the need for intubation and the complications associated with this.

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E-9-1-1 Critical Care OR ALS 72

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. Setting – large, academic, suburban ED. Figure-1: The initial ECG in today's case.

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E-9-1-1 ACS STEMI Coronary 82

Dr. Smith's ECG Blog

JULY 30, 2023

The ED physician read this as "Normal sinus rhythm. Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). In Figure-1 — The ST-T wave abnormality in lead V2 of ECG #1 is obvious. Here is her triage ECG during active symptoms: What do you think?

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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. You, however, are working an ED shift, and when you see the name “Barbie Junior” on your computer screen, your heart does a flutter. It can be in started in the ED, and many of us are already using it. What were Barbie and Ken to do?

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E-9-1-1 OR ED Emergency Department 81

Dr. Smith's ECG Blog

JANUARY 19, 2020

On arrival in the ED, she was profoundly hypotensive, nearly obtunded, and bradycardic. Another ECG was obtained during pacing: Mostly paced rhythm with PVCs (#3, #6, #9, #12). The ED team again pointed out the evidence of inferoposterior OMI, this time by the modified Sgarbossa criteria. mm STE with 9.5 mm STE with 9.5

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E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. 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. He appeared gray in color, with cool skin.

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Dr. Smith's ECG Blog

JANUARY 10, 2020

He presented to the ED because he developed sudden severe, sharp, pleuritic (but not positional), substernal and left mid to lower chest pain. 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?

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

Dr. Smith's ECG Blog

OCTOBER 23, 2022

The patient arrived in the ED. The pain completely resolved after nitroglycerine Moments later, the this ECG was recorded in the ED when she had been pain free for moments only: Computer read: Normal ECG. If you use something like the HEART score: 1. E EKG: a negative ECG (score = 0) 3. Learning Points : 1.

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E-9-1-1 STEMI ED EMS 52

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.

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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. She has already had syncope.

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E-9-1-1 OR ED Emergency Department 52

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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E-9-1-1 OR Coronary ACS 120

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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Don't Forget the Bubbles

JULY 22, 2024

Pre-school wheezers remain a poorly understood cohort of children despite seeing them every day in paediatric EDs. However, there was no difference in LOS (83 minutes for placebo vs 79 minutes for prednisolone) in participants who were discharged straight from the ED ( 32% ). study from 200 9. months to 40.9

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E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

JULY 22, 2023

An ECG was performed in the ED at 1554: Original image unavailable, this is the only recorded scanned ECG available. 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. per year incidence of SCD in this cohort [1].

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E-9-1-1 CAD OR STEMI 70

REBEL EM

JANUARY 23, 2023

Patients were randomized in a 1:1 ratio. 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 Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. 2005 Sep;116(3):643-9.

Allergic Reaction 52

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

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. All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. A PEM Adventure Ranulf is a 14-year-old explorer.

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Don't Forget the Bubbles

JUNE 17, 2024

The Importance of Civility in Critical Care Resuscitation A 3-year-old patient with diabetic ketoacidosis arrives at your ED. 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. 2014 Jun 26;23(12):653-9.

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ACEP Now

NOVEMBER 14, 2023

One of the most hair-raising presentations to the emergency department (ED) can be massive hemoptysis with respiratory failure. The definition of massive hemoptysis is variable across publications with expectorated blood volumes ranging from 100 to 1,000 mL per 24 hours, as these volumes are difficult to estimate for any given patient.

E-9-1-1 52

E-9-1-1 ALS Emergency Department OR 52

EMDocs

MAY 29, 2023

Louis); Marina Boushra (EM-CCM, Cleveland Clinic Foundation); Brit Long, MD (@long_brit) Case A 54-year-old female with a past medical history of rheumatoid arthritis presents to the emergency department (ED) with generalized fatigue. In the ED her vitals are T 99.6°F, What Are ESR and CRP?

ED 53

ED E-9-1-1 Emergency Department OR 53

Dr. Smith's ECG Blog

APRIL 22, 2022

But these cases show the potential dangers of delayed recognition and treatment of inferior reperfusion Take away 1. ECG’s can be labeled as ‘normal’ by the computer (and confirmed by cardiology) even with diagnostic signs of occlusion or reperfusion References 1. JAMA Intern Med 2019 9. Am J Med [Internet] 2017;130(9):1076–83.e1.

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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.

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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.

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Dr. Smith's ECG Blog

MAY 5, 2022

Submitted and written by Destiny Folk MD , peer reviewed by Meyers, Smith, Grauer, McLaren A man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. On arrival in the ED, he was hypotensive with a systolic blood pressure in the 70s. What is it?

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