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-9-1-1 103

E-9-1-1 ALS ED OR 103

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.

E-9-1-1 139

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

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

EMDocs

DECEMBER 1, 2024

A 52-year-old male with a history of essential hypertension presents to your South Texas ED for his second visit this week complaining of indolent fever, shortness of breath, pleuritic chest pain, and a rash on his trunk and extremities. We’ll keep it short, while you keep that EM brain sharp.

EMS 82

EMS E-9-1-1 OR ED 82

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-9-1-1 115

E-9-1-1 Coronary STEMI ALS 115

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 98

E-9-1-1 STEMI ED OR 98

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 ).

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

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 86

EMS E-9-1-1 Epinephrine OR 86

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

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

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

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.

E-9-1-1 105

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

EMDocs

NOVEMBER 13, 2024

Definition: SBP is an infection of the peritoneal ascitic fluid without an intra-abdominal focus of infection. Commonly a monomicrobial infection with gram-negative bacteria like E. Major takeaway: Consider SBP in any patient who comes into the ED with ascites. coli (50-90% of cases). Send fluid for cell count and culture.

E-9-1-1 79

E-9-1-1 ALS OR ED 79

EMDocs

SEPTEMBER 7, 2024

A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. 1 Risk Factors: 1-4 Spontaneous Anticoagulants (Apixaban, Rivaroxaban, etc.)

EMS 74

EMS E-9-1-1 Operating Room OR 74

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

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.

E-9-1-1 98

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

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 100

Coronary E-9-1-1 STEMI ACS 100

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.

Emergency Management 97

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

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].

E-9-1-1 67

E-9-1-1 CAD OR STEMI 67

Don't Forget the Bubbles

JULY 5, 2023

Figure 1: Clinical manifestations and long-term consequences of sickle cell disease Training and education on sickle cell disease: Training and education are crucial to improve morbidity and mortality. with thanks A 15-month-old Kenyan boy presents to ED with right hand swelling. Blood culture is pending.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

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

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 86

Emergency Department E-9-1-1 ALS OR 86

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

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

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.

E-9-1-1 52

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

REBEL EM

OCTOBER 26, 2023

1–4 Antimicrobial resistance is a global health crisis, underscoring the importance of antibiotic stewardship. After consent, children were randomized 1:1 to receive 5 additional days of antibiotics or 5 days of a matching placebo. 933 children did not receive 1 of the accepted antibiotics. 9 excluded after randomization.

E-9-1-1 81

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

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.

E-9-1-1 82

E-9-1-1 ACS STEMI Coronary 82

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

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.

E-9-1-1 72

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

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.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

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.

E-9-1-1 75

E-9-1-1 Emergency Department OR ALS 75

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?

E-9-1-1 81

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

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

Dr. Smith's ECG Blog

SEPTEMBER 27, 2019

. == MY Comment by K EN G RAUER, MD ( 9/27/2019 ): == As suggested by the title of this Blog post — confirmation of the diagnosis in this case was made not by ECG — but instead by chest aorta CT ! For clarity — I’ve put these first 2 tracings together in Figure-1. Figure-1: The first 2 ECGs in this case ( See text ).

E-9-1-1 52

E-9-1-1 OR ED 52

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

E-9-1-1 52

E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

The pattern of STE and STD reminded us of Brugada Type 1 morphology. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. 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 52

E-9-1-1 CAD STEMI OR 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.

E-9-1-1 78

E-9-1-1 STEMI Coronary OR 78

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