The Skeptics' Guide to EM

SEPTEMBER 21, 2024

He currently practices emergency medicine in New Mexico in the ED, in the field with EMS and with the UNM Lifeguard Air Emergency Services. Before attending medical school, he was a New York City Paramedic. Chris completed his emergency medicine residency and EMS fellowship at UNM.

Naloxone 260

Naloxone NARCAN Overdose CPR 260

Core EM

JANUARY 25, 2024

One week prior to ED arrival, the patient was becoming progressively despondent, less interactive with peers, exhibiting slow speech and movements, and was not eating. In Diagnostic and statistical manual of mental disorders (5th ed.). Catatonia: a case report by Brown Emergency Medicine. Burrow JP, Spurling BC, Marwaha R.

MICU 246

MICU Emergency Department ED OR 246

Core EM

JANUARY 25, 2024

The Case A 41-year-old male presents to the ED with constant palpitations for one day. Differentiating between the two is difficult as multiple proposed diagnostic criteria have yet to demonstrate sufficient sensitivity or specificity for a definitive diagnosis. Discussion Fascicular VT is a distinct subgroup of idiopathic VT.

Coronary 246

Coronary Emergency Department ED OR 246

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. The patient had no chest symptoms until he had been in the ED for many hours and had been undergoing management of his DKA. The patient was under the care of another ED physician. Another ECG was recorded: What do you think?

ED 119

ED Coronary CAD STEMI 119

Pediatric EM Morsels

AUGUST 23, 2024

Concussion – Presentation [ Silverberg, 2023 ] There is no definitive test to diagnose concussion in the ED. Mild traumatic brain injury also includes a larger group of injuries that may have evidence of structural injury.

Emergency Department 281

Emergency Department OR ED EMS 281

Broome Docs

JANUARY 27, 2025

These results are not definitive, but considering the rarity of demyelination, and the magnitude of the mortality results, this should probably influence clinical practice until we get the proper RCTs. The protocol used the ADD score, a POCUS echo protocol and D-dimer to try and exclude AAS in the ED. Did they pick a heap of PEs?

ED 101

ED OR ACS Critical Care 101

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 104

EMS E-9-1-1 OR ED 104

Pediatric EM Morsels

SEPTEMBER 22, 2023

Definition A series of hemodynamic changes related to autonomic denervation and loss of sympathetic tone. Tenenbein M, Macias CG, Sharieff GQ, et al, eds. Tenenbein M, Macias CG, Sharieff GQ, et al, eds. Main symptoms include hypotension and bradycardia. They may even need atropine and/or pacing for persistent bradycardia.

E-9-1-1 304

E-9-1-1 Epinephrine ALS EMS 304

EMDocs

FEBRUARY 26, 2024

The ED clinician should inquire about a relevant history of HIV infection, malignancy, high-dose corticosteroid use, chemotherapy, organ transplant, or use of immunosuppressive drugs for other indications. She reports occasional central chest pain exacerbated by coughing. Int J STD AIDS. 2019;30(2):188-193. Am J Emerg Med. 2013;31(2):401-405.

E-9-1-1 110

E-9-1-1 ED ALS OR 110

EMDocs

SEPTEMBER 25, 2023

Also known as Facilitated intubation (FI), the use of intubating with only a sedative was an accepted alternative intubation technique prior to those definitive studies in the late 1990s but quickly was abandoned for RSI in all emergent endotracheal intubations (ETI) (8,9). To date, ketamine has been the agent of choice (12).

ED 91

ED Emergency Department ALS Paramedic 91

EMergucate

MAY 30, 2016

Definition Transient LOC and loss of posture secondary to insufficient cerebral perfusion. Common – >25% lifetime incidence, 1% ED presentations … Continue reading →

EMS 100

EMS ED 100

The FllightBridge ED

SEPTEMBER 11, 2023

Since the 2012 Berlin Definition of the Acute Respiratory Distress Syndrome (ARDS), several developments have supported the need for an expansion of the definition, including…

40

40

Core EM

OCTOBER 16, 2024

Author: Natalie Bertrand, MD Editor: Naillid Felipe, MD Background: Definition: adverse reaction to blood product administration Incidence: more common in children than adults, except for delayed hemolytic transfusion reactions Allergic (non-anaphylaxis) – Platelets 1-3%; RBCs 0.1-0.3% In: Marx J, ed. In: Wolfson A, ed.

Allergic Reaction 188

Allergic Reaction Plasma ED Epinephrine 188

Dr. Smith's ECG Blog

JANUARY 27, 2024

Figure-1: I've labeled the initial ECG in the ED. KEY Point: All patients who present to the ED for new CP should promptly have a triage ECG recorded, that is then immediately interpreted by the ED physician. For clarity — I've labeled this initial ECG in Figure-1.

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

MARCH 31, 2024

I simply texted back: "Definite posterior OMI." The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration.

STEMI 111

STEMI ACS ED 111

The Skeptics' Guide to EM

JULY 25, 2020

The bottom line from that episode on skin glue for peripheral intravenous lines was: “Skin glue does appear to decrease the failure rate of IVs in patients admitted to hospital from the ED at 48 hours. It was great that it started with a definition of evidence-based medicine (EBM).

ED 130

ED ALS OR 130

Dr. Smith's ECG Blog

MAY 3, 2024

But this time the Queen gets it wrong (thinks it is not OMI): There were runs of VT: Tha patient arrived in profound shock and had an ED ECG: Now there is some evolution to include the ST elevation (rather than ST depression) in V4-V6. Figure-1: I've labeled the initial EMS ECG and the 1st 12-lead tracing done on arrival in the ED.

ACS 127

ACS ED Coronary EMS 127

EMS 12-Lead

APRIL 2, 2022

1, 2] The most clinically useful definition to account for this entire constellation is intraventricular conduction delay. You will see that they were initially ischemic, by definition, because of the subsequent voltage attenuation. Chou’s Electrocardiography in Clinical Practice, 6th ed. second as the beginning of “wide”?

ALS 130

ALS STEMI Coronary OR 130

Pulsara

AUGUST 1, 2024

They've created a new protocol that allows them to bypass the ED and take qualified patients directly to definitive care. Teams in Arkansas are finding new ways to improve outcomes for pediatric behavioral health patients.

ED 100

ED 100

Don't Forget the Bubbles

MAY 31, 2023

The DIMPLES study by PERUKI sought to investigate the incidence of new-onset diabetes in the paediatric population across the UK and Ireland, as well as the characteristics of these ED presentations, and to determine if SARS-CoV2 infection was involved. This meant 2746 ED presentations by 2618 individuals. Which patients were involved?

Emergency Department 135

Emergency Department ED OR ALS 135

ACEP Now

DECEMBER 6, 2024

By some definitions, you could call former Maryland state legislator Dan Morhaim, MD, FACEP, a retired emergency physician. His health care focus included hospital efficiency, physician and patient satisfaction, and emergency department (ED) wait times, as well as a host of nonhealth issues. He thinks of it as re-deployed.

Emergency Department 98

Emergency Department ED Ambulance OR 98

EMDocs

NOVEMBER 1, 2023

A 39-year-old male with history of achalasia with recent endoscopic dilation 24 hours prior presents to the ED for progressively worsening chest pain with radiation to his left shoulder. If there will be a delay in definitive management and there is evidence of intra-thoracic gastric contents, consider chest tube placement.

Critical Care 93

Critical Care ED EMS OR 93

REBEL EM

FEBRUARY 15, 2024

Background: Patients with decreased level of consciousness due to alcohol, drugs, or medications commonly present to the ED. These patients can be at risk of vomiting and aspiration and often prompts clinicians to pursue definitive airway management to avoid pneumonia and other complications.

ICU 139

ICU ALS ED OR 139

EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. A 12 Lead ECG was captured on her arrival.

Coronary 130

Coronary ACS CAD ED 130

Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? Then the ED doc would be dependent on that first ECG. It must have re-occluded between the ED and the cath lab) --Lesion was stented. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.) Or had not had a prehospital ECG on the ambulance.

STEMI 96

STEMI Coronary Ambulance ED 96

ACEP Now

NOVEMBER 8, 2024

9 Here are some of the key conditions that are considered neurodivergent and that emergency physicians are likely to encounter: Autism Spectrum Disorder (ASD): Although the definition of autism has changed over time, in general, it refers to a group of complex developmental brain disorders. How to assess children with complex needs in the ED.

Emergency Department 52

Emergency Department ED OR ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated. Long term outcome is unavailable.

STEMI 121

STEMI EMS ACS ED 121

EMS 12-Lead

MAY 8, 2022

They are definitely high in amplitude and, intermittently, appear to disproportionately tower over the respective QRS. This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2]

STEMI 130

STEMI ED EMS Firefighter 130

Critical Care Scenarios

JULY 11, 2021

pneumatically), then definitively addressed by Orthopedics at their convenience. Traction splinting is usually not done in the ED. Ultrasound (eFAST) and plain x-rays (chest and pelvis) are useful tools for rapid evaluation in the ED. Orthopedic injuries should be manually reduced and perfusion ensured, splinted (e.g.

Operating Room 100

Operating Room ICU ED OR 100

Dr. Smith's ECG Blog

OCTOBER 30, 2023

Here is the first prehospital ECG (time 0, after one hour of pain): I do not see evidence of OMI, and neither did the Queen of Hearts Here is the 2nd prehospital ECG (time 10 minutes, after 70 minutes of pain): No change On arrival, the first ED ECG was recorded 20 minutes after the last one (90 minutes after pain onset): What do you think?

STEMI 123

STEMI ED ALS OR 123

EMDocs

OCTOBER 19, 2024

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] Labs and x-ray can be nonspecific, and definitive diagnosis is made with direct visualization. ampicillin-sulbactam).

EMS 110

EMS E-9-1-1 Epinephrine OR 110

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Initial ED ECG: What do you think? Definitive diagnosis that ECG #1 is in fact VT is more than academic. That said — We can definitively diagnose AV dissociation in today's tracing! Once I knew that at least 1 definite underlying P wave was present — I diligently looked for more. Why did I say that?

Coronary 139

Coronary OR EMS ED 139

EMDocs

APRIL 2, 2024

Check the pulse RSI= Resuscitation Sequence Intubation Hypoxia, Hypotension, and Acidosis are the reason patients code during/post intubation These patients are super high risk for all 4 Optimize first pass success – Induction agent + paralytic Unconscious patients will still have muscle tone Induction Ketamine or Etomidate at half doses (i.e.,

CPR 115

CPR STEMI Epinephrine ICU 115

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

When the patient arrived in the ED, he was still hypotensive in 70s, slowly improving with EMS fluids. Here is the ED ECG (a photo of the paper printout) What do you think? The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event.

EMS 114

EMS CPR ED Coronary 114

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Both were awake and alert with normal vital signs.

OR 125

OR STEMI EMS ED 125

EMDocs

NOVEMBER 13, 2024

Definition: SBP is an infection of the peritoneal ascitic fluid without an intra-abdominal focus of infection. Major takeaway: Consider SBP in any patient who comes into the ED with ascites. Primary spontaneous bacterial peritonitis (SBP) is one of the most common infections in those with cirrhosis and ascites.

E-9-1-1 105

E-9-1-1 ALS OR ED 105

Dr. Smith's ECG Blog

MARCH 13, 2023

An ED ECG, if recorded with pain, should show LAD OMI. So this ECG was immediately recorded: Indeed, as predicted, a patient with previous Wellens' waves who now definitely has chest pain has acute Occlusion, with new ST elevation in I, aVL, V2-V5. The Cath lab was activated.

ED 52

ED ACS Coronary Paramedic 52