REBEL EM

MAY 27, 2024

Clinical Question: Does simultaneously performing the modified valsalva maneuver and administering intravenous adenosine, compared to either treatment alone, have greater success in achieving normal sinus rhythm in patients presenting to the ED with PSVT? Duration of Antiarrhythmic Effect: MVM group: 35.44 seconds (range: 22.5,

OR 137

OR E-9-1-1 ED ALS 137

ALiEM

APRIL 12, 2024

Traditionally large-bore tube thoracostomy has been the standard of care for treating many acute intrathoracic pathologies [1]. Pigtails provide a less invasive and often better tolerated alternative to traditional chest tubes and allow for adequate treatment of pneumothoraces and uncomplicated pleural effusions [1-5]. 1999;3(1):57-61.

E-9-1-1 183

E-9-1-1 ALS Critical Care Emergency Department 183

ALiEM

AUGUST 9, 2023

Technique Positioning and Probe Figure 1: Younger children can sit in their parent’s lap and give a hug for lateral and posterior lung scanning. The patient should be in a position of comfort: supine, sitting, or in parent’s lap (Figure 1). Identify anatomical landmarks on ultrasound (Figure 3, Video 1).

E-9-1-1 246

E-9-1-1 Emergency Department ALS OR 246

ALiEM

MARCH 7, 2024

Ultrasound probes from left to right: linear (nenoates), phased array (infants/younger children), and curvilinear (older children/adolescents) Pro tips for performing renal/bladder POCUS on a child [1] Addressing potential anxiety leads to a more efficient and comfortable examination. Pre-warmed ultrasound gel is helpful when available.

E-9-1-1 177

E-9-1-1 Emergency Department ALS ED 177

REBEL EM

JANUARY 25, 2024

In many emergency departments (ED), US machines are readily available and can be used to rapidly assess and monitor patients with acute dyspnea at the bedside. What They Did: Design: Randomized, controlled, blinded-outcome trial Sites: Three emergency departments in Denmark Duration: October 9, 2019 to May 26, 2021.

ED 128

ED E-9-1-1 Emergency Department ALS 128

ALiEM

MAY 13, 2024

Her symptoms started 1 week ago as a scratch which progressively got more red and painful. Pediatric Soft Tissue POCUS Ultrasound Technique Figure 1. Cellulitis with cobblestoning Video 1. Abscess with irregular borders and surrounding cellulitis E. Superficial abscess with well-circumscribed borders Table 1.

E-9-1-1 161

E-9-1-1 ALS Emergency Department OR 161

Dr. Smith's ECG Blog

OCTOBER 3, 2024

I agree, however: 1) I don't think you can get a good enough ech o without bubble contrast. 3) E cho is another step that takes time. I had only 9 false positives but I missed 2 OMI. This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. I assumed it was a patient with acute chest pain. Real or just fake?"

E-9-1-1 122

E-9-1-1 Coronary ALS ED 122

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. Challenge QUESTION: The relative change in T-QRS-D is not the only thing that changes during period of time that passed between recording of the 2 ECGs shown in Figure-1.

E-9-1-1 126

E-9-1-1 Coronary ACS BLS 126

EMDocs

MARCH 2, 2024

A 58-year-old female with a history of diabetes, hypertension, and chronic back pain presents to the ED with severe headache and nausea. Answer : Pneumocephalus 1-21 Background: Pneumocephalus is defined by the presence of air within the cranial cavity. On arrival, she is awake and alert and in obvious distress.

EMS 120

EMS E-9-1-1 OR ED 120

Don't Forget the Bubbles

AUGUST 30, 2023

The parents of 9-month-old Josie bring her into the Emergency Department with coryzal symptoms and difficulty breathing. Among those who do not always obtain a CXR, one-fifth still routinely obtained them under a certain age (2 weeks to 12 years, median of 1 year). All of these guidelines send a clear message.

E-9-1-1 131

E-9-1-1 Emergency Department ALS OR 131

Broome Docs

SEPTEMBER 3, 2024

In a surprise to no one who reads First10EM, clinical judgment is better than all decision tools for sepsis Knack SKS, Scott N, Driver BE, Prekker ME, Black LP, Hopson C, Maruggi E, Kaus O, Tordsen W, Puskarich MA. Epub 2024 Apr 9. 2024 Mar;27(1):26-29. 2024 Jul 4;391(1):9-20. doi: 10.1016/S0140-6736(24)00700-1.

E-9-1-1 95

E-9-1-1 Emergency Department ICU ALS 95

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 ). Answer : Bedside ultrasound!

E-9-1-1 126

E-9-1-1 Coronary STEMI ALS 126

EMDocs

APRIL 10, 2024

1-5] Since then, many more medications have been developed and deployed. These medications are a vital tool in the care of ED patients, from simple local analgesia for a laceration repair to regional analgesia for painful procedures. 1] CV manifestations include: Bradycardia, tachycardia, ventricular dysrhythmias, cardiac arrest. [1-5]

E-9-1-1 111

E-9-1-1 Plasma Epinephrine Life Support 111

EMDocs

MAY 25, 2024

Massaging the gland causes expression of purulent material. What is the diagnosis?

EMS 98

EMS E-9-1-1 OR ED 98

Don't Forget the Bubbles

SEPTEMBER 20, 2023

Up to 70% of children diagnosed with constipation in the ED have had an AXR. A large retrospective multicentre cohort study involving 282,225 children with constipation across 23 EDs in the USA and Canada reported that AXRs were performed in 65.7% The correlation between the severity of constipation and AXR findings is poor.

E-9-1-1 133

E-9-1-1 Emergency Department ALS ED 133

REBEL EM

AUGUST 30, 2023

Epidemiology 1 to 2.4 cases per 100,000 people ( Zimmerli 2010 ) More common in males with M:F of 3:1 Rate is also increasing due to increased number of spinal procedures Typically affects adults, with most cases occurring in patients over 50 years old. Other pathogens include: E. Often used interchangeably with osteomyelitis.

E-9-1-1 96

E-9-1-1 ALS ED OR 96

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-9-1-1 115

E-9-1-1 Coronary EMS ED 115

EMDocs

NOVEMBER 21, 2023

In ED, repeat potassium level was 2.6 Epidemiology: Prevalence of hypoPP is approximately 1 per 100,000. Permanent weakness usually affects the proximal lower extremities, happens in older patients, and develops late. Diagnosis: Can be made in the ED based on history, exam, lab testing. Could not ambulate.

E-9-1-1 96

E-9-1-1 ALS ED OR 96

Broome Docs

DECEMBER 22, 2024

2024 Oct 9. There were no differences in survival (12% with IO vs 10% with IV) or neurologically intact survival (9% vs 8%). There is a bunch more – so have a listen or watch us on Youtube feed below. You can read all the papers on the links in the show notes right here. doi: 10.1001/jama.2024.20424. 2024.20424. of the IV group).

E-9-1-1 52

E-9-1-1 ACS Paramedic Emergency Department 52

EMDocs

JULY 29, 2023

Other bacterial causes include anaerobic oral flora, Strep viridans, E. Other bacterial causes include anaerobic oral flora, Strep viridans, E. Other bacterial causes include anaerobic oral flora, Strep viridans, E. Other bacterial causes include anaerobic oral flora, Strep viridans, E.

E-9-1-1 97

E-9-1-1 EMS Emergency Department OR 97

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 98

EMS E-9-1-1 Operating Room OR 98

Broome Docs

MAY 31, 2024

Do we need to intubate French drunkards in ED? 2013 Sep;24(9):1848-53. 2023 Nov 28;27(1):465. 2024 Apr 1:e240167. 2023 Sep 8;9(1):73. 117(1) 36–41 DOI: 10.1177/01410768231207260 This is a fascinating read about the history of the humble placebo in science. Psychol Sci. doi: 10.1177/0956797613479386.

E-9-1-1 82

E-9-1-1 ED Critical Care ICU 82

EMDocs

MAY 11, 2024

A 74-year-old female with a past medical history of hypertension, diabetes, recent basilar artery stent placement with a 20 pack-year smoking history presents to the ED via EMS for altered mental status and episodes of apnea. CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis?

EMS 111

EMS E-9-1-1 ALS OR 111

EMS 12-Lead

AUGUST 22, 2022

Question 1: What is the rhythm? 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. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside. Said differently, it’s a mess.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

ACEP Now

NOVEMBER 8, 2024

1 Prehospital endotracheal intubation and EGAs are typically placed without paralytics and are reserved for unconscious, apneic, and out-of-hospital cardiac arrest patients. 9 LMAs use an inflatable mask expanded using a similar technique to the endotracheal tube cuff. In: Cone DC, Brice JH, Delbridge TR, Myers B, eds.

E-9-1-1 40

E-9-1-1 Emergency Medical Services Emergency Medical Technician AEMT 40

EMDocs

OCTOBER 30, 2023

” – Musings of an American ED resident in July 2022 when US healthcare was affected simultaneously by supply chain issues from GE Healthcare (contrast media) and Abbott Laboratories (Similac baby formula). 3 A study of CT use trends in the ED has shown increasing use of CTs by almost 60% from 2005 to 2013. 11 Table 1.

E-9-1-1 102

E-9-1-1 Emergency Department ALS CCT 102

EMDocs

JULY 13, 2024

A 37-year-old G2P2 female with no other past medical history presents to the ED with a 2-day history of intermittent fever and foul-smelling vaginal discharge. We’ll keep it short, while you keep that EM brain sharp. On pelvic exam, she has moderate thick, foul-smelling purulent discharge. What is the diagnosis?

EMS 93

EMS E-9-1-1 Plasma OR 93

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. Here are ten things to think about: 1. Churruca K, Pavithra A, McMullan R, Urwin R, Tippett S, Cunningham N, Loh E, Westbrook J. cognitive rehearsal techniques ). Organizational dynamics. 2020 Aug 20.

E-9-1-1 105

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

REBEL EM

SEPTEMBER 13, 2023

Features Urticaria and pruritis Rapid onset (1-2 hours) IgE Dependent (Type I Hypersensitivity) Reactions An allergen cross-links two or more IgE molecules on mast cells or basophils and initiates a signal cascade leading to degranulation. of people who take NSAIDs ( Nzeako 2010 ). of people who take NSAIDs ( Nzeako 2010 ).

Frozen Plasma 104

Frozen Plasma Allergic Reaction FFP Plasma 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.

E-9-1-1 96

E-9-1-1 EMR Emergency Department ED 96

Dr. Smith's ECG Blog

JULY 14, 2023

A 40-something with persistent Ventricular Fibrillation presented after attempted prehospital resuscitation A 40-something with no previous cardiac history presented to the ED in persistent Ventricular Fibrillation after attempted prehospital resuscitation. Finally, head-up CPR (which was not used here), makes for better resuscitation.

E-9-1-1 98

E-9-1-1 Defibrillator CPR STEMI 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 109

Coronary E-9-1-1 STEMI ACS 109

EMDocs

AUGUST 3, 2023

Patient is asymptomatic. A 4-hour acetaminophen level is obtained and results with a level of 180 mcg/mL. These local protocols vary from the labeled dosing; contacting and using your local poison center’s protocol is recommended.

Overdose 98

Overdose E-9-1-1 OR ED 98

EMDocs

AUGUST 7, 2023

Schnapp, MD, MEd (Associate Program Director, University of Wisconsin) // Reviewed by: Joshua Lowe, MD (EM Attending Physician, USAF), Marina Boushra (EM-CCM, Cleveland Clinic Foundation); Brit Long, MD (@long_brit) Case A 36-year-old pregnant woman at 21 weeks gestation presents to the ED with chest pain. Her lungs are clear to auscultation.

E-9-1-1 97

E-9-1-1 ALS Plasma OR 97

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 Exclusion: Presented with acute anaphylaxis, and their acute anaphylactic symptoms had not yet been treated.

Allergic Reaction 52

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

Don't Forget the Bubbles

AUGUST 28, 2023

The median age at diagnosis was 47 months (range 1-173 months). Depending on the location of the mediastinal mass, lying a child flat or using a rapid sequence induction protocol may cause cardiorespiratory arrest. As clinicians, we need to be prepared. What causes a mediastinal mass? Don’t ignore them!

Emergency Management 97

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

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 97

E-9-1-1 STEMI Coronary OR 97