Ken Grauer, MD

APRIL 20, 2024

The ECG in Figure-1 — was obtained from a 70-ish year old man with episodic CP ( C hest P ain ) over the previous 2-3 days , being awakened from sleep now for a more severe CP episode. QUESTIONS: In view of this history — How would YOU interpret this ECG? Should you activate the cath lab? Figure-1: The initial ECG in today's case. MY Initial Thoughts on Today's CASE: Although it is difficult from the brief history we are given, to determine the true onset of whatever might be happening — the pat

EKG/ECG 432

EKG/ECG Wellness 432

Pediatric EM Morsels

APRIL 19, 2024

Trauma season is at hand and like all other pediatric emergency departments in the country, we find our ED breaking ( pun intended ) at the seams with orthopedic injuries. We see all different flavors of upper extremity injuries. Yes, we’re talking about your clavicular , proximal humeral, supracondylar, lateral condylar , scaphoid and metacarpal fractures.

Fractures 286

Fractures Pediatrics Best Practices Outcomes 286

The Trauma Pro

APRIL 19, 2024

In my previous post, I described the early days of penetrating neck injury management and introduced a paper suggesting that this concept should be revised. Today, I will summarize a paper by Siletz and Inaba that is currently in press and outlines what the contemporary way of treating these injuries should be. Step 1. If present, rapidly control external hemorrhage and airway compromise.

Operations 240

Operations EMS 240

Sensible Medicine

APRIL 14, 2024

Last week, the US FDA held a meeting to decide if a new surrogate endpoint (Minimal Residual Disease or MRD negativity) could be used to give more & faster drug approvals for patients with newly diagnosed multiple myeloma. Multiple myeloma drugs can cost $600,000 per year of treatment, but if MRD is permitted for drug approval, I suspect we will see a deluge of uncertain drugs added to the roster, and the costs per year per patient will swell to a million dollars or more.

Patient Safety 143

Patient Safety Academics Outcomes Wellness 143

First 10 EM

APRIL 2, 2024

Give your patients a break. Nobody is a perfect diagnostician. Not even the best trained physician can determine, with 100% accuracy, which patients have serious pathology. Even with advanced testing, we aren’t close to perfect. However, if you listen to the subtext of breakroom complaints, it seems like we expect patients to be better diagnosticians […] The post Are you a perfect diagnostician?

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141

Emergency Medicine Cases

APRIL 2, 2024

In this part 2 of our 2-part podcast on asthma with Dr. Sameer Mal and Dr. Leeor Sommer, we dig into the recognition and management of life-threatening asthma. We answer such questions as: what are the key elements in recognition of threatening asthma? What are the most time-sensitive interventions required to break the vicious cycle of asthma? What are the best options for dosing and administering magnesium sulphate, epinephrine, fentanyl and ketamine in the management of the crashing asthmatic

EMS 137

EMS Airway Management Resuscitation 137

Ken Grauer, MD

APRIL 26, 2024

The ECG in Figure-1 — was obtained on the scene by EMS ( E mergency M edical S ervices ). The patient was a man in his 90s, who ~1 hour earlier, noted the onset of severe CP ( C hest P ain ). He was hemodynamically stable — but clearly distressed with a sense of “impending doom” at the time ECG #1 was recorded. Despite the patient’s age — he was independent, lived alone, had good mental function — and had family support.

EKG/ECG 395

EKG/ECG Resuscitation EMS Wellness 395

The Trauma Pro

APRIL 9, 2024

“When the facts change, I change my mind. What do you do, sir?” This is a famous quote from John Maynard Keynes. (Or is it? There is some debate over its authenticity, but you get the idea it tries to convey.) Our knowledge base continually changes, so we must be willing to change our minds (and practices) based on new, reliable information.

Operations 218

Operations Shock 218

Sensible Medicine

APRIL 25, 2024

The US FDA is under tremendous political pressure to approve drugs, and indeed they tout the number of approved drugs as a measure of the quality of their work. Unfortunately, you can approve bad drugs. Selenexor is a toxic poison that does not increase survival. Belantumab causes eye damage and had to be pulled from the US market Idelalisib, copanlisib, duvelisib— the entire P13k inhibitor class —may have resulted in increased deaths.

Poisoning 131

Poisoning Outcomes 131

First 10 EM

APRIL 22, 2024

As mentioned in my most recent review, publication bias has been a major concern when trying to decide whether to prescribe paxlovid. Pfizer rushed to publish their positive study (EPIC-HR), but refused to release the results of a second simultaneous study (EPIC-SR) that was stopped (due to futility) at the exact same time. With the […] The post EPIC-SR: The negative paxlovid data Pfizer has been sitting on appeared first on First10EM.

EMS 137

EMS 137

Dr. Smith's ECG Blog

APRIL 2, 2024

An elderly man collapsed. There was no bystander CPR. Medics found him in ventricular fibrillation. He was defibrillated, but they also noticed that he was being internally defibrillated and then found that he had an implantable ICD. He was unidentified and there were no records available After 7 shocks, he was successfully defibrillated and brought to the ED.

EKG/ECG 130

EKG/ECG Shock CPR Stroke 130

Ken Grauer, MD

APRIL 13, 2024

I was sent the ECG in Figure-1 — told only that the patient was 70 years old, and had a history of an ASD ( A trial S eptal D efect ). Serum K+ was normal. The patient was hemodynamically stable with ECG #1. QUESTIONS: How would YOU interpret the rhythm in Figure-1 ? Are there P waves? Figure-1: The initial ECG in today's case. MY Initial Thoughts on Today's CASE: Knowing that today's patient has a history of an ASD ( A trial S eptal D efect ) — is relevant to the interpretation of today's inter

EKG/ECG 296

EKG/ECG Wellness 296

EM Ottawa

APRIL 11, 2024

Patients living with functional neurologic disorders (FND) have been deeply stigmatized by the medical system. In a patient survey by FND Hope (an international organization for the research and advocacy around FND) 82% of patient respondents felt they had been treated poorly due to stigma relating to their FND diagnosis, primarily by emergency physicians [1] […] The post Functional Neurologic Disorders appeared first on EMOttawa Blog.

Research 128

Research 128

The Trauma Pro

APRIL 26, 2024

In this series, I will review the two major techniques for addressing troublesome bleeding from pelvic fractures. This post will review the evolution of packing techniques and more fully describe the concept of preperitoneal packing. Next, I’ll review an early paper that compared the snippets of information we had to angioembolization. In the last post in the series, I’ll discuss a paper in press that compares the efficacy and hospital charges of the two techniques.

Fractures 147

Fractures Head Injuries Radiology Radiology 147

Sensible Medicine

APRIL 24, 2024

On Friday, the New York Times ran this story. The article begins by explaining that mammograms don’t find all breast tumors — of course they don’t! Even MRI and ultrasound do not. In fact, no imaging modality does. The only way to find all the tumors would be to remove the breast and have a pathologist examine every tiny bit of it.

Ultrasounds 131

Ultrasounds Outcomes 131

RebelEM

APRIL 3, 2024

REBEL Cast – EMTALA + Reproductive Health Click here for Direct Download of the Podcast. Dr. Dara Kass is a practicing emergency medicine physician who was most recently as the Regional Director of Region 2 for the US Department of Health and Human Services. She currently works with organizations and institutions to advance and implement policies that affect the care of individuals in this new healthcare landscape, most specially related to all forms of reproductive health care from contra

Emergency Department 129

Emergency Department EMS Research Hospitals 129

First 10 EM

APRIL 15, 2024

One of the biggest headaches in modern medicine is the apparent requirement to call busy specialists just to confirm what seems like an obvious treatment plan. In emergency medicine, this often happens when a patient needs to be admitted under one service, but with a medical problem related to another speciality. We get stuck in […] The post The Brain Injury Guidelines: Can we avoid talking to neurosurgeons?

EMS 127

EMS 127

Ken Grauer, MD

APRIL 5, 2024

The ECG in Figure-1 was obtained from a middle-aged woman — who presented with low back pain, shortness of breath and marked hypertension — but no CP ( C hest P ain ). QUESTIONS: In view of this history — How would YOU interpret this ECG? Are the large, peaked T waves ( especially in lead V2 ) — likely to indicate hyperacute deWinter T waves? Figure-1: The initial ECG in today's case.

EKG/ECG 238

EKG/ECG EMS Hospitals 238

Emergency Medicine Cases

APRIL 2, 2024

In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chest pain. They explain complementary diagnostic insights into pericardial effusion and cardiac tamponade, occlusion MI and RV strain. The post ECG Cases 49 – ECG and POCUS for Dyspnea and Chest Pain appeared first on Emergency Medicine Cases.

EKG/ECG 122

EKG/ECG Emergency Department EMS 122

The Trauma Pro

APRIL 2, 2024

Extraperitoneal rectal injury repair has evolved considerably over the past 40 years. Way back when, this injury automatically triggered exploration, diverting colostomy with washout of the distal colon, and presacral drain insertion (remember those?). We eventually backed off on the presacral drains (pun intended), which didn’t make a lot of sense anyway.

Wellness 147

Wellness 147

Sensible Medicine

APRIL 1, 2024

First of all, Happy April Fools day. I thought about writing a fake-trial post. But thought the better of it. I normally tell you about a single study on Monday. This week, I want to alert you to the potential bigness of next weekend, when the American College of Cardiology meets in Atlanta. Sunday is an especially important day, as we will hear the results of three clinical trials—each of which could change cardiology in major ways.

Shock 125

Shock Wellness Outcomes 125

Dr. Smith's ECG Blog

APRIL 24, 2024

Quiz The PM Cardio Queen of Hearts AI model for ECG interpretation from Powerful Medical is still in its early days. Do you think you can outperform the toddler version of the AI model? Version 2.0 will soon be available with four times the training data. The QoH groups ECGs into OMI and NOT OMI. Each category is subdivided into three levels of confidence.

EKG/ECG 121

EKG/ECG 121

St. Emlyn

APRIL 27, 2024

St.Emlyn's - Emergency Medicine #FOAMed What you don’t do, determines what you can do Tim Ferris One of the most powerful personal lessons I have learned in recent years is every time I say YES […] The post Choosing with Intention. Liz Crowe appeared first on St.Emlyn's.

EMS 116

EMS 116

First 10 EM

APRIL 29, 2024

Although it made a bit of a splash when published, this article really didn’t interest me. Obviously, GCS 8 doesn’t mean intubate. I didn’t think anyone was simplistic enough to practice medicine based on a jingle. Clearly trajectory matters. If a patient’s GCS hit 8 and they are on a clinical course where you expect […] The post GCS 8 obviously doesn’t mean intubate (in tox or otherwise) appeared first on First10EM.

EMS 118

EMS 118

Science Based Medicine

APRIL 14, 2024

Trying to limit pediatric COVID was literally the pandemic's worst sin for pro-infection doctors, warranting severe punishment. This is how desperately they wanted them infected. The post Dr. Vinay Prasad: It’s “Good” That Parents Who Want To Vaccinate Their Kids Against COVID Get Reported To Child Protective Services first appeared on Science-Based Medicine.

Pediatrics 115

Pediatrics 115

The Skeptics' Guide to EM

APRIL 13, 2024

Reference: Albers GW et al. TIMELESS Investigators. Tenecteplase for Stroke at 4.5 to 24 Hours with Perfusion-Imaging Selection. NEJM Feb 2024 Date: April 12, 2024 Guest Skeptic: Dr. Vasisht Srinivasan is an Emergency Medicine physician and neurointensivist at the University of Washington and Harborview Medical Center in Seattle, WA. He is an assistant professor in Emergency […] The post SGEM#436: For the Longest Time – To Give TNK for an Acute Ischemic Stroke first appeared on The Skeptics Guid

Stroke 112

Stroke Documentation/Coding Emergency Department EMS 112

Sensible Medicine

APRIL 30, 2024

Gosh was this a great conversation about her recent paper on specification curve analysis of nutritional observational studies. Here is Dr. Zeraatkar’s bio: Dena Zeraatkar, PhD is an Assistant Professor in the Departments of Anesthesia and Health Research Methods, Evidence, and Impact (HEI) at McMaster University. She earned her doctoral degree at McMaster University in the Health Research Methodology graduate program.

Research 111

Research Wellness 111

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. The pain recurred at rest 90 minutes prior to presentation, felt like the patient’s prior MIs, and was not relieved by 6 sprays of nitro.

EKG/ECG 119

EKG/ECG Documentation/Coding Fractures Emergency Department 119

St. Emlyn

APRIL 19, 2024

St.Emlyn's - Emergency Medicine #FOAMed This was a really powerful session that took us on a journey from the past, to the present and left us with a feeling of hope for the future. I’ll […] The post R-A-C-E session at RCEM CPD conference. St Emlyn’s appeared first on St.Emlyn's.

Teamwork 113

Teamwork 113

EMCrit

APRIL 15, 2024

A razor is a rule of thumb that is helpful, although it isn't always correct. In medicine we're familiar with Occam's razor (the rule of parsimony). The cutoff razor states: if a continuous variable is dichotomized using a cutoff, then values near the cutoff provide little information. A simple illustration of the cutoff razor is […] EMCrit Project by Josh Farkas.

111

111

Science Based Medicine

APRIL 28, 2024

Is potential death worse than real death? The post Once a Doctor Has Minimized Literal Death for Young People, Should We Value Their Opinion on Any Topic Less Consequential Than Literal Death? first appeared on Science-Based Medicine.

113

113

EM Ottawa

APRIL 18, 2024

In this Prehospital Journal Club Recap, let us take a deep dive into the use of blood products, as well as the adjunct use of automated controlled elevation in CPR. Resuscitation with blood products in patients with trauma-related hemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomized, controlled, phase 3 trial Background The use […] The post PTM Journal Club: Blood Product and ACE-CPR use Prehospital appeared first on EMOttawa Blog.

CPR 110

CPR Resuscitation Shock Wellness 110

Emergency Medicine Cases

APRIL 23, 2024

In this month's EM Quick Hits podcast: Justin Morgenstern on the first RCT of high dose nitroglycerin in SCAPE, Andrew Neill on Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) indications and evidence, Brit Long on indications for CT in suspected diverticulitis, Tahara Bhate on Central Retinal Artery Occlusion (CRAO) and diagnostic error, Matthew McArthur on penicillin allergy labels, myths and penicillin challenges, and Susan Lu on how ED physician personality influences patie

EMS 106

EMS Resuscitation Outcomes Allergic Reactions 106

Dr. Smith's ECG Blog

APRIL 22, 2024

A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chest pain that is worse with exertion, which takes many minutes to resolve after resting and never occurs at rest. It is a ssociated with mild dyspnea on exertion. At times the pain does go to his left neck. It was present on arrival at triage but then resolved before bed placement in the ED.

EKG/ECG 117

EKG/ECG Outcomes Ultrasounds Hospitals 117

St. Emlyn

APRIL 25, 2024

St.Emlyn's - Emergency Medicine #FOAMed Part 2 of our podcast on top papers from 2023/24 with @EMManchester and @docb #FOAMed @stemlyns The post Top papers podcast 2023/24. Part 2. St Emlyn’s appeared first on St.Emlyn's.

110

110

RebelEM

APRIL 29, 2024

Critically ill patients requiring resuscitation often present with many challenges including the ability to secure safe, sterile, fast, and reliable intravenous (IV) access. Over the years emergency and critical care physicians have tried many ways to establish IV access in emergencies including the “crash” or “dirty” central line. If you are not familiar with this term, it’s the act of rapidly trying to place a central line (usually femoral), placing the needle for access over strict sterile pr

Resuscitation 105

Resuscitation Administration Emergency Department Hospitals 105

Science Based Medicine

APRIL 7, 2024

Dr. Jay Bhattacharya March 2020: "If it’s true that the novel coronavirus would kill millions without shelter-in-place orders and quarantines, then the extraordinary measures being carried out in cities and states around the country are surely justified." The post Every Time Dr. Jay Bhattacharya Talks About COVID, He Proves He Was Totally Wrong About COVID first appeared on Science-Based Medicine.

108

108