Taming the SRU

FEBRUARY 5, 2024

(1) However, it wasn’t until the 1890s that purposeful, successful, and safe attempts to access this fluid were documented (2). The LP is now a standard procedure and in 2010 well over 135,000 LPs were performed in Emergency Departments throughout the US (3). (And WHY - Why Not?

Infectious Diseases 97

Infectious Diseases Seizures Ultrasounds Sepsis 97

Dr. Smith's ECG Blog

JUNE 17, 2024

There are well preserved R-waves in Wellens waves. Cardiac Ultrasound may be a surprisingly easy way to help make the diagnosis Answer: pulmonary embolism. Now another, with ultrasound. Submitted by a Med Student, with Great Commentary on Bias! Chest pain, SOB, Precordial T-wave inversions, and positive troponin. This is a quiz.

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EKG/ECG Emergency Department Shock Ultrasounds 138

Dr. Smith's ECG Blog

MAY 13, 2024

There are findings concerning for anterolateral OMI including ST elevation and hyperacute T waves in the anterolateral leads most prominent in V2-V5, as well as hyperacute T waves in the inferior leads. On our ultrasound machine, the TEX, normal strain is considered -18 % and higher (more negative).

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EKG/ECG Emergency Department Ultrasounds Documentation/Coding 120

Sensible Medicine

JULY 24, 2023

But there had been two placebo-controlled drug trials that documented a 45-55 second increase in exercise time. A later re-analysis increased the time to 21 seconds, which was still well below statistical significance. You might wonder how they came up with 200 patients? This, too, was brilliant thinking.

Academics 98

Academics Documentation/Coding Ultrasounds Wellness 98

Mind The Bleep

NOVEMBER 21, 2023

” Yes, I have seen clerking look like this and I can confirm, it does not go down well. Unless you’re documenting something hilarious, please keep it brief and to the point. History of Presenting Complaint In this section use SOCRATES to document the pain.

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

He had no previously documented medical problems except polysubstance use. However the patient continued to have chest pain and bedside ultrasound showed hypokinesis of the septum with significantly reduced LVEF. The LCx and OM vessels are not as well visualized. An ECG was obtained shortly after arrival: What do you think?

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EKG/ECG EMS Emergency Department Wellness 107

Taming the SRU

AUGUST 4, 2024

We discussed some practices to push learners outside of their comfort zone and promote learning, based on their level as well as their goals for the shift.

Dislocations 85

Dislocations Emergency Department Documentation/Coding Burns 85

Dr. Smith's ECG Blog

JULY 21, 2024

In both tracings — an exceedingly fast PMVT is documented. In this study — Procainamide was superior to Amiodarone for terminating monomorphic VT, as well as having fewer adverse effects than Amiodarone ( Ortiz et al — Eur Heart J 1;38 (17): 1329-1335, 2017 ). The arrhythmia starts with a PVC having a short coupling interval.

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EKG/ECG Shock Hospitals Sepsis 131

Northwestern EM Blog

MAY 16, 2022

What is your initial imaging test of choice, ultrasound (US) or non-contrast CT, and why? Would you be confident in a point-of-care-ultrasound evaluation or a formal ultrasound? Many patients in the ultrasound groups did get additional imaging, but this was not the majority. How do you proceed? In this study, 40.7%

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Ultrasounds Radiology Radiology Outcomes 52

Emergency Medicine Ireland

DECEMBER 17, 2020

There is a substantial ANZICS document on tracheostomy that forms the structure for this tasty morsel. And this seems to work exceptionally well. I suppose this is somewhat similar to ultrasound for CVCs as plenty of people seem to cope perfectly well without it * no good data to guide a solid recommendation as yet.

Ultrasounds 40

Ultrasounds Documentation/Coding Wellness 40

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

The cut points for what constitute OMI and not OMI as well as confidence levels are calibrated to maximize sensitivity and specificity according to the receiver operating characteristic. The diagonal branches are overlapping one another and not well visualized in this view. The QOH output is a number between 0 and 1.

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EKG/ECG Operations Wellness Ultrasounds 66

Dr. Smith's ECG Blog

OCTOBER 18, 2023

A majority (62.5%) of those presenting with ‘normal’ ECGs had the cath lab activated without any ECG being labeled ‘STEMI’ by automated interpretation – based on signs of Occlusion MI including ECG changes, regional wall motion abnormality on bedside ultrasound, or refractory ischemia.

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EKG/ECG Documentation/Coding Emergency Department Outcomes 119

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Pads were placed with ultrasound guidance, so they were in the correct position. As I discussed and documented in Lesson 1 of My Comment at the bottom of the page in the April 2, 2022 post of Dr. Smith's ECG Blog — certain patients may remain in sustained VT not only for hours — but even for days! However, this is not SVT.

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EKG/ECG Shock Academics Documentation/Coding 138

Dr. Smith's ECG Blog

JUNE 14, 2017

A bedside cardiac ultrasound was normal. It appears to be benign in children as well (see references below). He has a great blog too: ECG Interpretation He is also well known on the Facebook EKG Club page , where you can learn tons about ECGs: Here is his response, with the first ECG labelled: Hello Steve & Avinash.

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EKG/ECG Documentation/Coding Ultrasounds Wellness 52

The Skeptics' Guide to EM

MAY 11, 2019

His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation. His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation. first appeared on The Skeptics Guide to Emergency Medicine.

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Documentation/Coding Operations Academics Ultrasounds 40

Resus Review

FEBRUARY 12, 2015

Use ultrasound to identify an large vessels in the area. Dont forget to document your perc trach procedure well. Skin Incision The neck should be carefully palpated and the anatomy should identified (thyroid cartilage, cricoid cartilage, and 2-3 tracheal rings). Consider labelling the landmarks with a permanent marker.

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Operations Documentation/Coding Ultrasounds Wellness 52

Taming the SRU

MAY 30, 2023

Generally accepted (and some airlines spell it out) that they are assuming the liability even for you helping Documentation: To protect yourself (and the airline), will/should make documentation of what happened. hours earlier and went to OR 3.5 hours earlier and went to OR 3.5 Each airline generally has their own protocol.

OB/GYN 52

OB/GYN Ultrasounds Pediatrics Resuscitation 52

Mind The Bleep

FEBRUARY 29, 2024

This may well seem daunting given how unwell and complex the patients might be but a thorough, well-structured A-E will give you most of the information you need to progress that patient’s care. C Assessment BP and MAP Invasive reading (via an arterial line) or non-invasive (via a BP cuff)?

Documentation/Coding 52

Documentation/Coding Hospitals Wellness Best Practices 52

Dr. Smith's ECG Blog

JUNE 27, 2021

A bedside ultrasound was done, with dozens of clips, and was even done with Speckle Tracking. There was no cough or fever, the CXR looks like pulmonary edema, the ultrasound showed classic pulmonary edema B lines. ECGs were interpreted for OMI, as well as various characteristics of ST depression, blinded to outcomes.

EKG/ECG 40

EKG/ECG Radiology Radiology Ultrasounds 40

EMDocs

JANUARY 11, 2024

Individualize MAP targets based on the patient, as well as treatments (inotropes, vasopressors, and fluids) for hypotensive patients. These conversations should occur frequently and be clearly documented for other health care professionals who are not present during the conversations (96%, 22/23). There are no hard MAP recommendations.

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Seizures Shock Infectious Diseases CPR 97

Pediatric Emergency Playbook

JUNE 1, 2017

This child is at risk for expected complications, as well as overdiagnosis and iatrogenia. These children depend on their preload to run blood passively into the pulmonary circuit; afterload reduction is also important to compensate for a poor left ejection fraction, as well as to avoid the development of pulmonary hypertension.

Pediatrics 52

Pediatrics EKG/ECG Wellness Seizures 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

A bedside cardiac ultrasound was performed with a parasternal long axis view demonstrated below: There is a large pericardial effusion with collapse of the right ventricle during systole. This patient was reported to have distant heart sounds but was not hypotensive and did not have JVD according to documentation.

EKG/ECG 40

EKG/ECG Ultrasounds Documentation/Coding COPD 40

EB Medicine

JUNE 6, 2019

CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Jeff: Next we have everybody’s favorite, the ultrasound. Jeff: Indeed. Sounds familiar.

Ultrasounds 40

Ultrasounds Radiology Radiology Sepsis 40

Dr. Smith's ECG Blog

JUNE 20, 2018

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. The medicine note documents that the patient had worsening pain with lying flat and relief with leaning forward.

EKG/ECG 52

EKG/ECG Documentation/Coding Ultrasounds Wellness 52

Advanced Emergency Nursing from AENJ

FEBRUARY 29, 2016

A natural one, and especially suited for increasing capability without regard to physician residency program output of graduates, and in less-well-served rural areas. Advances in Medical Imaging (CT, MRI, and Ultrasound) facilitating rapid, accurate, diagnosis affording new potential to save additional lives. EDNA->ENA. Sakran, J.

Emergency Nursing 40

Emergency Nursing EMS Resuscitation Military 40

EB Medicine

MARCH 1, 2019

Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. Nachi: Definitely. for pericardial effusion.

Emergency Department 40

Emergency Department EKG/ECG Operations Fractures 40

Downeast Emergency Medicine

APRIL 26, 2021

Trauma patients between the ages of 18-90 years had to have either had one documented episode of hypotension (defined as a systolic BP <90 mmHg) or tachycardia (>100 beats/minute) to be included in the study. If the trauma center performed screening ultrasounds to evaluate for asymptomatic DVTs, they were not included in this study.

Head Injuries 52

Head Injuries Administration Outcomes Seizures 52

EB Medicine

JULY 8, 2019

Jeff: Well that’s kind worrisome. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

EB Medicine

OCTOBER 1, 2018

Jeff : So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis? If it’s possible to establish an IV and initiate fluids without delaying transport, EMS should do that as well. One, lung ultrasound can be really useful to find that occult pneumonia or differentiating pneumonia from CHF.

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Sepsis Shock Fluid Resuscitation Hospitals 40

Dr. Smith's ECG Blog

APRIL 8, 2016

He had significant history of CAD with CABG x5, and repeat CABG x 2 as well as a subsequent PCI of the graft to the RCA (twice) and of the graft to the Diagonal. Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. A late middle-aged man presented with one hour of chest pain.

Resuscitation 52

Resuscitation EKG/ECG Hospitals Administration 52

EB Medicine

AUGUST 1, 2018

It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

EB Medicine

AUGUST 6, 2019

Nachi: Well, I’m sure more of those studies are still coming. Nachi: Well that was a ton of information and background on the DOACs. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. But next we should talk about ultrasound. Jeff: Agree.

Emergency Department 40

Emergency Department Stroke Wellness Resuscitation 40

Dr. Smith's ECG Blog

APRIL 8, 2015

Check : [vitals, SOB, Chest Pain, Ultrasound] If the patient has Abdominal Pain, Chest Pain, Dyspnea or Hypoxemia, Headache, Hypotension , then these should be considered the primary chief complaint (not syncope). Aortic Dissection, Valvular (especially Aortic Stenosis), Tamponade. Vasovagal syncope is generally benign. orthostatic vitals b.

Emergency Department 52

Emergency Department EKG/ECG Outcomes Seizures 52

Emergency Medicine Ireland

OCTOBER 28, 2020

EF does not correlate with particularly well with mortality in sepsis though diastolic dysfunction does * It may be due to under filling and the reduced diastolic filling due to the ubiquitous tachycardia in sepsis. This has relevance to the ICU population in 2 major ares * Sepsis. *

Sepsis 40

Sepsis Documentation/Coding Ultrasounds Wellness 40

EB Medicine

JANUARY 2, 2019

So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. For a threatened abortion, the os would be closed with an IUP seen on ultrasound.

Ultrasounds 40

Ultrasounds Radiology Radiology Infectious Diseases 40

Dr. Smith's ECG Blog

DECEMBER 5, 2019

Thus, Brugada is the likely diagnosis _ A very nice explanation of this is given in the document quoted below on current ECG criteria for Brugada pattern. A bedside cardiac ultrasound revealed grossly normal to hyperdynamic systolic function with no obvious areas of wall motion abnormalities. Bayes de Luna, A et al.

EKG/ECG 52

EKG/ECG Hyperthermia / Hypothermia Seizures Documentation/Coding 52

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. No need for Seidel test if there’s obvious globe rupture.

Fractures 97

Fractures Documentation/Coding Ultrasounds Wellness 97