The Skeptics' Guide to EM

APRIL 3, 2021

mg/kg) was beneficial for unknown onset stroke above a certain core size. Stroke 2021 Case: A 74-year-old man presents to the emergency department after waking up with left sided weakness. He was last seen well when going to bed at 10pm the night before. A SRMA was published by Mistry et al Stroke 2017.

Stroke 52

Stroke Research Outcomes Hospitals 52

EMDocs

JULY 3, 2023

National Institutes of Health Stroke Scale (NIHSS) is 13; vital signs include pulse 86 beats/minute (bpm), blood pressure 164/94 mmHg, and saturation of 98% on room air. 14 The American Stroke Association (ASA) and American Heart Association (AHA) recommend SBP <160 mmHg until definitive management of the bleed is completed.

Seizures 85

Seizures Stroke Outcomes EMS 85

Taming the SRU

APRIL 22, 2023

If untreated, atrial fibrillation can increase clot formation and lead to an increased risk for heart attack and stroke as well as development of congestive heart failure. For treatment, the American Heart Association’s 2019 guidelines recommend limiting use of non-dihydropyridiine CCB due to potential for negative inotropic effects.

Outcomes 52

Outcomes Documentation/Coding Stroke Fractures 52

The Skeptics' Guide to EM

APRIL 6, 2019

Date: April 5th, 2019 Reference: Connolly et al. NEJM 2019 Guest Skeptic: Dr. Ryan Radecki is an Emergency Physician at Kaiser Permanente NW, co-host of the Annals of Emergency Medicine podcast and Journal Club section editor. Date: April 5th, 2019 Reference: Connolly et al. You order a non-contrast CT to rule out hemorrhage.

Stroke 52

Stroke Administration EMS Wellness 52

RebelEM

MAY 18, 2023

These patients can have a vasodilated vascular bed and the initial use of fluids is hypothesized to serve two purposes: Augmenting the macrovascular system (stroke volume and cardiac output) and augmenting the microvascular perfusion (capillary blood flow). Liberal: 14.9% Estimated Difference: -0.9%; 95% CI 04.4 Liberal: 14.9% Read more

Sepsis 100

Sepsis Shock Resuscitation Outcomes 100

PulmCCM

JANUARY 22, 2024

In 2019, the HYPERION trial (NEJM, n=584) found neurologic benefits of cooling to 33°C during the first 24 hours (compared to maintenance at 37°C). Also in 2019, the PRINCESS trial showed no improvement in neurologic outcome with nasal-evaporative cooling after cardiac arrest among 677 patients.

Hyperthermia / Hypothermia 80

Hyperthermia / Hypothermia Outcomes Research Hospitals 80

Pediatric Education

SEPTEMBER 3, 2023

He had no concerns and he was doing well in school and with his friends. He had a sprained ankle the previous year that he says was well-healed. A 2019 systematic review of SCT found that there is a risk for pulmonary embolism, proteinuria and chronic kidney disease (high-strength evidence).

Dehydration 40

Dehydration Hyperthermia / Hypothermia Pediatrics Military 40

Don't Forget the Bubbles

JUNE 30, 2023

Again, there was no increase in thrombotic stroke in the TXA group – TXA looks safe. Well, one study in Kornelson’s systematic review and meta-analysis is interesting. 2019 Nov 9;394(10210):1713-1723. Epub 2019 Oct 14. 2019 Nov 9;394(10210):1712. in the TXA group vs 53.7% in the placebo group).

Head Injuries 145

Head Injuries Seizures Outcomes Pediatrics 145

PulmCCM

JANUARY 24, 2024

In 2019, the HYPERION trial (NEJM, n=584) found neurologic benefits of cooling to 33°C during the first 24 hours (compared to maintenance at 37°C). Also in 2019, the PRINCESS trial showed no improvement in neurologic outcome with nasal-evaporative cooling after cardiac arrest among 677 patients.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Outcomes Hospitals Stroke 52

Dr. Smith's ECG Blog

DECEMBER 24, 2023

And so was an appropriate anti-coagulant, since atrial flutter, like fibrillation, can result in thromboembolism and stroke. She did well. That said — today's case highlights how use of antiarrhythmic medication may account for AFlutter presenting with an atrial rate well under the "expected" 300/minute.

EKG/ECG 128

EKG/ECG Stroke Wellness Administration 128

Pediatric EM Morsels

JULY 21, 2023

cats and dogs have their own GCS scores [Lapsley 2019, Ash 2018] Moral of the Morsel Modified can make it Merrier! 2019 Jul;20(7):660-666. 2019 Sep;241:112-118. Epub 2019 Apr 22. 2019 Jul;20(7):682-683. Systematic review showed 85% of studies with substantial reliability with kappa statistic >0.6 J Surg Res.

Head Injuries 246

Head Injuries Pediatrics Outcomes Shock 246

Dr. Smith's ECG Blog

MARCH 15, 2023

But when you see this, you should suspect that the AV node is not well. IF the Patient is Younger and Athletic: The mechanism of AFib in younger, athletic individuals is often heavily influenced by increased vagal tone ( Rao and Shipon — ACC, 2019 — and — Calvo et al — Br J Sports Med, 2012 ).

EKG/ECG 52

EKG/ECG Dehydration Stroke Wellness 52

Dr. Smith's ECG Blog

MARCH 19, 2019

Although the QT is very long, long QT due to hypocalcemia is rarely associated with Torsades de Pointes. == Comment by K EN G RAUER, MD ( 3/19/2019 ): == There are a number of ECG patterns that should immediately suggest a clinical diagnosis. Here was a repeat ECG: QTc 523. Long ST segment remains. This is one of them!

EKG/ECG 52

EKG/ECG Seizures Stroke Operations 52

Taming the SRU

MARCH 31, 2023

of emergency medicine residents report 1 or more dimensions of burnout (Lin Annals Emerg Med 2019) Moral Injury with COVID “We pushed aside our fear and frustration to focus on saving the patients in front of us; we kept our eyes open, and our feelings closed.

Allergic Reactions 40

Allergic Reactions Seizures Anaphylaxis Leadership 40

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Over some time and the pain moved into her other arm as well as her jaw. Stroke-volume:50 ml. Over the course of the next hour, this pain turned into a pressure in her chest. She said this was midsternal and felt like a tightness. This originally radiated into her left arm. She also had some shortness of breath. Normal wall thickness.

EKG/ECG 103

EKG/ECG Ultrasounds Wellness Stroke 103

Downeast Emergency Medicine

APRIL 26, 2021

Lancet 2019; Vol 394, Iss 10210, P 1713-1723[ Full Text ]. MI or stroke). The primary outcome was 30-day mortality with secondary outcomes of 1-year functional neurological outcome based on GCS as well as hospital length of stay. TXA does not increase the incidence of thromboembolic events such as DVT/PE, stroke, or MI.

Head Injuries 52

Head Injuries Administration Outcomes Seizures 52

EB Medicine

AUGUST 1, 2018

Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests. First up is the link between cannabis use and stroke or TIA.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

PulmCCM

APRIL 8, 2024

Yes, anticoagulate: Post-discharge recurrence of atrial fibrillation detected during sepsis is high (~40% at one year), and stroke risk might be similar as patients with AF identified otherwise. Observational data don’t clearly show DOACs prescribed at discharge after new-onset AF during sepsis actually prevent stroke.

Sepsis 40

Sepsis Stroke Hospitals Wellness 40

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Although the shock is no doubt partly a result of poor pump function, with low stroke volume, especially of the RV, it should be compensated for by tachycardia. Cardiac output is stroke volume x rate, so this patient needs a higher heart rate. He was discharged neurologically intact and did very well. Learning Points : 1.

Seizures 52

Seizures EKG/ECG Shock EMS 52

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

Regarding my Systematic assessment of ECG #1: There is significant baseline artifact , as well as baseline wander. Keep in mind that your interpretation of the ECGs of your patients is part of the medical record. Over the years, I have found recall of a short LIST of Causes of QT Prolongation to be of invaluable assistance.

Seizures 106

Seizures EKG/ECG EMS Documentation/Coding 106

Taming the SRU

AUGUST 30, 2023

As the name would suggest, inflammatory markers are biological markers of, well, inflammation. A 2019 French multi-center prospective RCT involving 370 ED patients published in Annals of Emergency Medicine similarly found no difference in antibiotic exposure between PCT-guided versus usual care groups [50]. 2019 Feb;34(2S):S187-S195.

Infectious Diseases 86

Infectious Diseases Sepsis Emergency Department Point-of-Care Testing 86

The Skeptics' Guide to EM

SEPTEMBER 28, 2019

Date: September 11th, 2019 Reference: Putzu et al. Date: September 11th, 2019 Reference: Putzu et al. This was because of a well-known critical care physician Dr. Paul Marik. The Effect of Vitamin C on Clinical Outcome in Critically Ill Patients: A Systematic Review with Meta-Analysis of Randomized Controlled Trials.

Sepsis 52

Sepsis Shock Outcomes Stroke 52

RebelEM

JUNE 26, 2023

4F-PCC contains factors II, VII, IX, X as well as Proteins S and C. J Trauma Acute Care Surg 2019. Some clinicians have advocated for early administration of 4-factor prothrombin complex concentrate (4F-PCC) based on limited observational data. High-quality studies are needed to determine the utility of this intervention.

Administration 144

Administration Outcomes Resuscitation Radiology 144

RebelEM

JUNE 8, 2023

They can be associated with side effects such as reflex bradycardia, decreased stroke volume in phenylephrine, tachycardia and hypertension associated with epinephrine. Epub 2019 Jul 3. However, peripherally dosed push dose pressors, (PDPs), are beginning to be administered more frequently for management of acute hypotension.

Administration 98

Administration Emergency Department Outcomes Documentation/Coding 98

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Trostel and Meyers — the QTc in markedly prolonged in today's case. The quick and easy way to tell at a glance if the Q Tc is likely to be prolonged is the "eyeball" method. PEARL #5: Over the years, I have found recall of a short LIST of Causes of QT Prolongation to be of invaluable assistance. Which of the 3 Causes in the above LIST are Likely?

EKG/ECG 115

EKG/ECG Seizures Hospitals Stroke 115

Taming the SRU

NOVEMBER 3, 2023

Broad strokes In this prospective, non-randomized study published by Kring et al in January 2022 out of Maine Medical Center, researchers compared mean pain scores at rest and during incentive spirometry before, at 15 minutes after, and then 60 minutes after treatment with a serratus anterior plane block. Ultrasound Med. 41, 2695–2701 (2022).

Fractures 97

Fractures Ultrasounds Outcomes Research 97

RebelEM

FEBRUARY 29, 2024

3, 6 Among patients with stroke or traumatic brain injury (TBI), the risk may be as high as 28%-76% and 23%-60%, respectively. Patient data anonymized when presented to adjudication committee to avoid detection bias Well-balanced patient characteristics between groups. Post-stroke infection: a systematic review and meta-analysis.

CDC 113

CDC Outcomes Radiology Radiology 113

Dr. Smith's ECG Blog

MARCH 6, 2019

There is a new Q-wave in aVL, with STE and large T-wave as well. She requires maximal medical management per all current guidelines (including heparin and P2Y12 inhibitor per cardiology), as well as consideration for emergent cath in the case of persistent ischemia. The patient did well. V2 still has STE and hyperacute T-waves.

EKG/ECG 52

EKG/ECG Outcomes Hospitals Wellness 52

Dr. Smith's ECG Blog

JANUARY 16, 2020

An elderly woman with h/o stroke and aphasia seemed different to her daughter, and was pointing all over her body as if in pain. Also a h/o LV aneurysm with thrombus, on anticoagulation, as well as a dual chamber pacemaker. (not When I didn’t — I went back to the August 9, 2019 Post that Dr. Smith references in his comments above.

EKG/ECG 52

EKG/ECG Stroke Wellness 52

Don't Forget the Bubbles

JULY 5, 2023

SCD, therefore, is not only a mechanical disease but there are also many other cellular and plasma factors as well as endothelial interaction that generate chronic inflammation. Recent studies have shown that low-dose ketamine can reduce pain in acute painful crises of sickle cell patients as well as being an opioid-sparing drug.

Blood Transfusions 126

Blood Transfusions Stroke Dehydration Sepsis 126

EMDocs

NOVEMBER 13, 2023

2 Outcomes of patients presenting with ischemic stroke who received MRI as initial imaging modality have demonstrated similar outcomes to those with initial CTA, with Kim et al. Stroke Authors’ Recommendation: CTA head/neck should be acquired in patients with stroke symptoms presenting within 24 hours of symptom onset.

Stroke 87

Stroke Radiology Radiology Emergency Department 87

Don't Forget the Bubbles

AUGUST 21, 2023

The baby’s parents tell you that the baby hasn’t been feeding well for a few days and today has been very sleepy. Stimulation of baroreceptors results in a catecholamine-mediated increase in heart rate , stroke volume, contractility, and systemic vascular resistance (SVR). What are your differentials? Bad bronchiolitis ?

Pediatrics 98

Pediatrics Outcomes Research Sepsis 98

EMDocs

OCTOBER 30, 2023

Some institutions developed a tier-based system for outpatient imaging as well which was updated in real-time. Published online 2019. doi:10.1155/2019/2350948 Salameh S, Antopolsky M, Simanovsky N, Arami E, Hiller N. 3 A study of CT use trends in the ED has shown increasing use of CTs by almost 60% from 2005 to 2013.

Radiology 73

Radiology Radiology Emergency Department Hospitals 73

The Skeptics' Guide to EM

MAY 30, 2020

It seems to work for epistaxis ( SGEM#53 and SGEM#210 ), failed to demonstrate a decrease in all-cause mortality in post-partum hemorrhage ( SGEM#214 ), and did not result in an improved neurologic outcome in hemorrhagic strokes ( SGEM#236 ). It is unclear if it provides a benefit for gastrointestinal bleeds (GIB). TXA vs. 19.8%

Head Injuries 52

Head Injuries Academics Outcomes EMS 52

Northwestern EM Blog

MAY 16, 2022

The above study was well summarized and bears repeating that, in this multicenter randomized study assessing CT vs POCUS vs radiology performed US in patients with suspected renal colic in the ED setting, initial US reduced radiation exposure without adversely affecting patient-centered outcomes. J Urol 2019. Thanks again toDr.’s

Ultrasounds 52

Ultrasounds Radiology Radiology Outcomes 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

IJC Heart and Vasculature 25(2019). speci fi city of the General Electric (GE) algorithm for AF, but they excluded cases with ventricular paced rhythm (VPR), in which the underlying atrial rhythm was frequently AF;we did not exclude VPR, as accurate identi fi cation of AF in VPR is important for determination of stroke risk [ 22 ].

EKG/ECG 52

EKG/ECG COPD Wellness Sepsis 52

EB Medicine

FEBRUARY 1, 2019

Gabrielle Procopio, a PharmD, have done a fantastic job parsing through the literature, which included over 500 abstracts, 89 full text articles, guidelines from ACEP and the American Academy of Neurology, as well as canadian and european neurology guidelines, to summarize the best evidence based recommendations for you all.

Emergency Department 40

Emergency Department Stroke Outcomes Wellness 40