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 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 120

OR STEMI EMS ED 120

The Skeptics' Guide to EM

DECEMBER 21, 2019

Outside of his academic duties, he works clinically in the adult ED at Spectrum Health in Grand Rapids, Michigan, the tertiary care center for Western Michigan. Only then would there be definitive evidence for the efficacy of parachutes. Date: December 17th, 2019 Reference: Reeves and Reynolds. It would be a cross over trial.

OR 100

OR ALS ED 100

EMDocs

NOVEMBER 6, 2023

This post will focus on the key parts of the guideline that affect ED evaluation and management. Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association 2023 Guideline for managing cardiac arrest or life-threatening toxicity due to poisoning was recently released. COR Harm, LOE B-R.

Naloxone 94

Naloxone OR Overdose BLS 94

REBEL EM

FEBRUARY 7, 2024

Take Home Points Infections are a leading cause of maternal mortality worldwide. Prompt recognition is critical in management. Most infectious processes will require admission and close observation for improvement or decompensation. References: Abbrescia, K. Sheridan (2003). “Complications of second and third trimester pregnancies.”

ED 104

ED ALS OR EMS 104

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

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. Refers to the Spinal Cord Function and Reflexes, not specifically hemodynamic issues. Moral of the Morsel Anatomy Matters!

E-9-1-1 300

E-9-1-1 Epinephrine ALS EMS 300

EMDocs

SEPTEMBER 16, 2024

Author: Joshua Lowe, MD (EM Attending Physician, San Antonio, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Manpreet Singh, MD (@MPrizzleER); Brit Long, MD (@long_brit) The fluorescent lights above cast a clinical pallor over the bustling ED. Stay Calm Under Pressure: The ED can be chaotic, and emotions can run high.

Heart Attack 68

Heart Attack ED OR Emergency Department 68

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. In inferior aneurysm, we usually see QR-waves, whereas for anterior aneurysm, we see QS-waves (no R- or r-wave at all!).

STEMI 105

STEMI Coronary ACS ED 105

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. A 25-year-old man presents to the ED via EMS after he sustained a gunshot wound to the left flank.

EMS 75

EMS E-9-1-1 Operating Room OR 75

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

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 95

STEMI EMS ACS ED 95

EMDocs

DECEMBER 31, 2023

Without further ado, here is our list of top posts from 2023 based on viewership from you, the readers: Neurogenic Shock: Definition, Identification, and Management in the ED We start off the list with a clinical post from Kira Brayan and Jenny Beck-Esmay on diagnosing and managing neurogenic shock! This post from Mary E.

ED 74

ED EMS OR 74

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. This series provides evidence-based updates to previous posts so you can stay current with what you need to know.

Critical Care 67

Critical Care ED EMS OR 67

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 108

EMS CPR ED Coronary 108

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

There is definite reperfusion. After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time." There was definite evolution of the ECG. He had been smoking an opiate and suddenly collapsed.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

JULY 25, 2024

The patient was brought to the ED and had this ECG recorded: What do you think? Confirmation of sinus tachycardia should be easy to verify when the heart rate slows a little bit ( as the patient's condition improves ) — allowing clearer definition between the T and P waves. After 1 mg of epinephrine they achieved ROSC.

Defibrillator 114

Defibrillator Coronary Epinephrine ACS 114

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

Keep in mind the presenting History ( ie, a 50yo presenting to a rural ED with a 1-hour history of CP radiating to the back and jaw — and an initial ECG labeled as "normal" by the computer interpretation ). This is diagnostic of Occlusion MI of the high lateral wall, either from circumflex or first diagonal.

OR 131

OR STEMI Coronary Emergency Department 131

Critical Care Scenarios

JULY 11, 2021

pneumatically), then definitively addressed by Orthopedics at their convenience. 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.

Operating Room 100

Operating Room ICU ED OR 100

EMDocs

JUNE 6, 2023

Literature suggests we should avoid evaluating ocular pressure, though there are no case reports or peer reviewed data documenting extrusion of ocular contents from ocular pressure evaluation in the ED setting. Visible fluorescein flow under Woods lamp or cobalt blue light = OGI. No need for Seidel test if there’s obvious globe rupture.

ED 75

ED OR 75

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

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. The initiation of empiric antibiotics in hemodynamically stable, neurologically intact patients should be done on a case-by-case basis.

E-9-1-1 103

E-9-1-1 ALS ED OR 103

Dr. Smith's ECG Blog

DECEMBER 16, 2018

The case An older woman presented to the ED with dyspnea, diaphoresis, and chest pressure. This ECG supports that the wide-complex tachycardia seen in the ED was 2:1 atrial flutter with QRS widening due to use-dependent toxicity, and not due to VT. Wide-complex tachycardia: VT or aberrant, or "other?" So was this VT after all?

OR 52

OR ED CAD Overdose 52

Dr. Smith's ECG Blog

APRIL 17, 2023

One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. Full case details and outcomes are below. Case 1: Case 2: Case 1: What do you think? QOH: "Not OMI, High confidence." In this case it is OMI.

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

JUNE 27, 2024

By Sofiya Diurba MD, reviewed by Meyers, Grauer A woman in her 50s with PMH known RBBB and prior syncopal events presents to the ED for five syncopal events over the last 24 hours. This is her first ECG in the ED: What do you see? Each event is associated with a prodrome of mild substernal CP, SOB, and “brain fog.”

ED 122

ED OR Emergency Department Emergency Manager 122

Dr. Smith's ECG Blog

DECEMBER 24, 2023

If I saw this patient in the ED, I would electrically cardiovert back to sinus rhythm. The atrial flutter rate is approximately 200 bpm, with 2:1 AV conduction resulting in ventricular rate almost exactly 100 bpm. This could be a beta blocker such as metoprolol, or a calcium channel blocker such as diltiazem.

ED 128

ED OR Emergency Manager Emergency Management 128

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 92

CPR STEMI Epinephrine ICU 92

REBEL EM

JUNE 22, 2023

However, the medical community is only just starting to understand long-COVID (WHO Definition: the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation). Alpha dominant: 7.9% Delta dominant 8.3% Omicron dominant: 8.4%

ALS 145

ALS OR EMS ED 145

Dr. Smith's ECG Blog

MAY 25, 2024

Previous echo 4 months ago (confirmed with ED bedside echo): The estimated left ventricular ejection fraction is 30%. Was it definitely VT? An elderly dialysis patient presented with chest pain. She has poor LV function. Severely decreased LV function. It could be slow VT or some SVT with RBBB and LPFB. Electrically cardiovert!

OR 123

OR ED 123

The Skeptics' Guide to EM

NOVEMBER 1, 2022

AEM October 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 19-year-old man presents to the emergency department (ED) with his first time anterior should dislocation after trying to recreate one of his favourite scenes in the movie Lethal Weapon.

ALS 152

ALS Emergency Department OR ED 152

REBEL EM

DECEMBER 13, 2023

REBEL Core Cast 114.0 – Carbon Monoxide Toxicity [“[link] Click here for Direct Download of the Podcast Definition and Physiology Carbon monoxide is absorbed via inhalation from the incomplete combustion of any carbon containing substance. Toxicity is mediated through multiple mechanisms.

OR 104

OR EMS ED 104

Handtevy

SEPTEMBER 20, 2022

Case Report: The study discusses the case of a 17-year-old female who arrived at a community emergency department (ED) following a motor vehicle collision. Initially refusing emergency medical services, she was brought to the ED via a private vehicle. The patient experienced a complete neurologic recovery. What are the key takeaways?

Operating Room 52

Operating Room Emergency Medical Services ED Emergency Department 52

ACEP Now

MAY 9, 2024

It has been well over a year since the controversial publication of the Agency for Healthcare Research and Quality (AHRQ) report on diagnostic errors in the emergency department (ED). percent of ED visits resulted in preventable death as result of diagnostic error. 1 The striking conclusions of this report included estimates that 0.1

Emergency Department 52

Emergency Department ICU ALS ACS 52

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. A b rief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality. This was shown to me with no clinical information and I said "It is VT until proven otherwise."

Coronary 139

Coronary OR EMS ED 139

High Performance EMS

MARCH 1, 2022

As we begin to wind down on the pandemic-level of constant 911 calls and the endless hours waiting on a room in the ED, we find ourselves in a time to reflect a little before our next call. Like so many services, we have a new influx of eager young professionals. Stand strong and keep mentoring!

AEMT 100

AEMT EMS ED OR 100

ACEP Now

JANUARY 13, 2024

ED E/M RVUs Remain Stable CMS did not make changes to the Work RVUs for the ED E/M codes, but there were a few small changes to the Practice Expense and Professional Liability Insurance RVUs at the second decimal place. However, ACEP is lobbying Congress to step in with new funding to prevent or lessen these cuts. Click to enlarge.

Critical Care 52

Critical Care ED OR 52

REBEL EM

APRIL 17, 2023

Clinical evaluation may prove difficult since many PTA and peritonsillar cellulitis symptoms overlap. Physical examination is approximately 75% sensitive and 50% specific for identifying PTA. CT and aspiration or drainage are considered the gold standard for diagnosis. Article: Kim DJ et al. Acad Emerg Med. 2023 Jan 10. Epub ahead of print.

OR 128

OR ALS ED EMS 128