Ken Grauer, MD

MAY 20, 2023

The ECG in Figure-1 — was obtained from an older woman with persistent CP ( C hest P ain ) over the previous day. Her symptoms lessened after Nitroglycerin — so the decision was made not to activate the cath lab. Do YOU agree with this decision? Figure-1: The initial ECG in today's case. MY Thoughts on the ECG in Figure-1: In a patient with CP that had been persistent over the previous day ( until Nitroglycerin was given ) — the initial ECG shown in Figure-1 is extremely worrisome.

EKG/ECG 363

EKG/ECG Wellness 363

The Trauma Pro

MAY 19, 2023

The serial hemoglobin (Hgb) determination. We’ve all done them. Not only trauma professionals, but other in-hospital clinical services as well. But my considered opinion is that they are not of much use. They inflict pain. They wake patients up at inconvenient hours. And they are difficult to interpret. So why do them? I’m reposting this mini-series on serial hemoglobin draws in light of a new paper that was published in the Journal of Trauma Nursing.

Fractures 130

Fractures Hospitals Wellness 130

Pediatric EM Morsels

MAY 12, 2023

We all know that Gravity Works ! While this fact can adversely affect anyone, it offers the greatest challenge for those who cannot protect themselves , like children less than 3 months of age ! We last pondered this in 2011 Morsel , just a couple years after PECARN head injury data was published. Since that time there have been several studies externally validating the PECARN rule in all age groups and in multiple different countries.

Head Injuries 130

Head Injuries Fractures Pediatrics EMS 130

RebelEM

MAY 29, 2023

Background: Sepsis can induce numerous physiologic derangements. At the most severe end, this includes endothelial dysfunction leading to increased vascular permeability, abnormal nitric oxide metabolism, and vasodilation (i.e. septic shock). Judicious fluid resuscitation is indicated in patients with signs of hypo perfusion but is often inadequate necessitating the administration of vasoactive medications.

Shock 145

Shock Fluid Resuscitation Sepsis Resuscitation 145

Greater Sydney Area HEMS

MAY 30, 2023

In the first in this series, HEMS physician and podcast host Dr Samuel Bulford interviews senior staff specialist Dr Cliff Reid who describes a case that changed his life and set his approach to mission preparation and training on a new trajectory.

Leadership 137

Leadership 137

Don't Forget the Bubbles

MAY 31, 2023

What’s the relationship between COVID-19 and diabetes? May saw the e-publication of the DIMPLES study. Let’s take a deep dive into this paper and its implications for PEM internationally. Ponmani C, Nijman RG, Roland D, Barrett M, Hulse T, Whittle V, Lyttle MD on behalf of PERUKI. Children presenting with diabetes and diabetic ketoacidosis to Emergency Departments during the COVID-19 pandemic in the UK and Ireland: an international retrospective observational study.

Emergency Department 135

Emergency Department Research Documentation/Coding Outcomes 135

Ken Grauer, MD

MAY 26, 2023

The ECG in Figure-1 was obtained from a 60-ish year old man with a history of coronary disease ( including prior CABG ) — who presented to the ED ( E mergency D epartment ) with new CP ( C hest P ain ) of 3 hours duration , diaphoresis and nausea/vomiting. The patient was hypotensive at the time his initial ECG in Figure-1 was obtained. The decision was made not to immediately perform cardiac cath — because there is no ST elevation in Figure-1 — and because the initial troponin was negative.

EKG/ECG 195

EKG/ECG Wellness Resuscitation 195

Pediatric EM Morsels

MAY 5, 2023

Our world has become inundated with the newest food and diet crazes. It seems like every social media persona provides “expert” opinions on the best way to nourish our bodies. Adults are one thing, but how does that translate to our growing, developing pediatric patients? Today we are focusing on vegan diets in children , and which nutritional deficiencies we need to remain vigilant to spot!

Pediatrics 130

Pediatrics Documentation/Coding EMS 130

RebelEM

MAY 25, 2023

I recently gave a talk on the initial management of trauma patients with hemorrhagic shock. In the initial management of trauma resuscitation there are 4 key principles that should be followed: Control bleeding Restore tissue perfusion Minimize iatrogenic injury from resuscitation itself Promote hemostasis In this blog post I will summarize the lecture and the evidence for each of these principles… MINIMIZE IATROGENIC INJURY PERMISSIVE HYPOTENSION Maintaining a lower blood pressure than physiol

Resuscitation 145

Resuscitation Fluid Resuscitation Head Injuries Shock 145

Science Based Medicine

MAY 21, 2023

British consulting cardiologist Dr. Aseem Malhotra has become the latest darling of the COVID-19 minimization and antivaccine movement in the UK. Previously known for anti-statin views and advocacy of the Pioppi diet who pivoted to more dangerous misinformation during the pandemic. The post Unsafe and Ineffective: Aseem Malhotra first appeared on Science-Based Medicine.

107

107

EMCrit

MAY 4, 2023

My attempt to model my empirical experience with Burnout EMCrit Project by Scott Weingart, MD FCCM.

133

133

Ken Grauer, MD

MAY 12, 2023

I was sent the rhythm strip shown in Figure-1 — obtained from telemetry monitoring. I did not know the history. Can YOU explain what happens after beat #4? Figure-1: Multi-lead rhythm strip obtained from telemetry monitoring. MY Thoughts on the Rhythm Strip in Figure-1: The first 4 beats in this 11-beat rhythm strip are sinus — as determined by the presence of regular upright P waves , with a constant PR interval in lead II ( RED arrows in Figure-2 ).

EKG/ECG 195

EKG/ECG Wellness 195

The Trauma Pro

MAY 9, 2023

For years, I’ve taught my residents participating in trauma activations, “Your patient is bleeding to death until proven otherwise.” This concept served as the basis of the [poorly documented] “Golden Hour” and for decades has directed our efforts at getting patients to a center with an immediately available OR as quickly as possible.

Head Injuries 130

Head Injuries Operations Documentation/Coding Outcomes 130

Don't Forget the Bubbles

MAY 24, 2023

A 5-year-old boy with a past medical history of Crouzon syndrome presents in the Pediatric ED. He is febrile and tachypnoeic, with low blood pressure and a capillary refill time of 4 seconds. His oxygen saturations are 86% in air, and he has a GCS of 8/15. His notes suggest that he was a difficult intubation in the neonatal intensive care unit. While you prepare the difficult airway cart, a young trainee asks about cannot intubate cannot oxygenate scenarios.

Airway Management 98

Airway Management Teamwork Pediatrics Emergency Department 98

RebelEM

MAY 18, 2023

Background: IV fluids are part of the standard resuscitation bundle in septic shock, however it is unclear if they provide a significant benefit. 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).

Sepsis 105

Sepsis Shock Resuscitation Outcomes 105

ALiEM

MAY 29, 2023

Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.

Blood Transfusions 98

Blood Transfusions Emergency Department Shock Hospitals 98

SheMD

MAY 23, 2023

To all the 4th year medical students out there CONGRATULATIONS! We know Match Day was not exactly how you pictured in this post-COVID19 world, but it is still a huge accomplishment and you should be so proud! While the world is a little different right now than we thought it would be, we know that you all are both excited and anxious to begin your residency.

OB/GYN 98

OB/GYN Hospitals Administration Wellness 98

Ken Grauer, MD

MAY 6, 2023

The ECG in Figure-1 — was obtained from an older woman with chest pain. How would YOU interpret this tracing? What kind of AV block is present? — OR — Is there no clear evidence of any AV block? Figure-1: The initial ECG in today’s case. ( To improve visualization — I've digitized the original ECG using PMcardio ). MY Thoughts on the ECG in Figure-1: This tracing is challenging to interpret because of the changing QRS morphology — and because of the uncertainty regarding atrial activity.

EKG/ECG 195

EKG/ECG 195

PEMBlog

MAY 15, 2023

Syncope is described as a brief loss of consciousness and postural tone caused by transient global cerebral hypoperfusion. It is followed by a complete recovery. An estimated 80% of pediatric syncope is due to autonomic (vasovagal or neurocardiogenic) syncope. Our role as providers is to identify the patients who have a life-threatening etiology to their syncope.

Pediatrics 97

Pediatrics EKG/ECG Emergency Department Burns 97

Don't Forget the Bubbles

MAY 22, 2023

You’ve just started working in the Children’s Emergency Department (CED). The triage nurse comes to let you know about Robin. He is eight years old, with a background of cerebral palsy and severe scoliosis. He has come in today because he has noisy breathing with rattly secretions that seem to be getting worse. The community physiotherapist (who has been visiting daily for the last 4 days) told Mum that Robin’s oxygen saturations were low.

Radiology 98

Radiology Radiology Hospitals Wellness 98

RebelEM

MAY 24, 2023

Take Home Points The Parkland formula can be used to be a guide for initial fluid resuscitation. This is based on second- and third-degree burns (not first-degree). Utilize response to treatment as a guide to continue fluid resuscitation. Patients in fires in closed spaces for a prolonged time are at risk for airway edema and need for intubation. History of fire is very important and please monitor patient condition, patients’ voice, and repeat physical exam.

Burns 98

Burns Fluid Resuscitation Resuscitation EMS 98

ALiEM

MAY 19, 2023

A heavy alcohol drinker, who is well known to your Emergency Department, presents with altered mental status, except that he looks different this time. He looks really bad, stating that he has been vomiting blood. He is hypotensive. He then vomits a copious amount of blood right in front of you. You intubate the patient and initiate the massive transfusion protocol, but everything you pour into him seemingly comes right back out.

Emergency Department 98

Emergency Department Ultrasounds Wellness EMS 98

Thinking Critical Care

MAY 20, 2023

Super excited for this. No issues with travel this year, the H&R family all keen on getting together again, the lineup is awesome, most of the OGs able to make it, lots of new additions, and the programme is looking really sweet. Am totally amped to have Katie Wiskar as the Chair of The Hospitalist as she’s putting together a great group with sharp lectures and super interesting workshops.

Airway Management 97

Airway Management Resuscitation EKG/ECG CPR 97

EM Ottawa

MAY 18, 2023

Welcome Back to BHP Corner For those who are new to this segment of the EMOttawa Blog, here’s a little refresher. In the Base Hospital Program (BHP) Corner, we aim to review interesting and evolving topics, as they pertain to the prehospital/paramedicine world. Advances, reviews, and changes to Ontario and local practices, you name […] The post BHP Corner – Out of Hospital Discharge: Pearls and Pitfalls appeared first on EMOttawa Blog.

Hospitals 97

Hospitals EMS 97

PDC Healthcare

MAY 1, 2023

Patient tracking during large-scale events is a challenge. Patients may be passed between first responders, ground transport, air transport, and then transferred from one facility to another. For routine calls with individual patients, it’s feasible to track who transported the patient and where they ended up. But in mass-casualty incidents and large-scale hazards, chaotic scenes […] The post PDC Partners with Pulsara to Streamline Communication Between EMS, Hospital Personnel, and Emergen

Mass Casualty Incidents 97

Mass Casualty Incidents EMS Hospitals Patient Safety 97

Don't Forget the Bubbles

MAY 29, 2023

You are working with your colleagues to assist an 8-year-old with multiple injuries following a high-impact traffic collision. You’re thinking about the next steps and voicing the options; you hear an impatient voice saying, “Are up for this? Should I do it?” from one of the team. What does incivility look like? Whilst not a new concept, incivility is still a widely reported concern within healthcare.

Leadership 98

Leadership Patient Safety Academics Research 98

RebelEM

MAY 15, 2023

You are working in a rural ED, and an older woman from a local assisted care facility arrives via ambulance in obvious respiratory distress. EMS is able to tell you that she is currently being treated for pneumonia. The patient is on a nonrebreather mask, and vital signs on arrival are BP 110/50 mm Hg, HR 120 bpm, RR 40/min, T 98.6°F (37°C), and SpO2 86%.

EMS 98

EMS Documentation/Coding Resuscitation 98

Medagadget

MAY 23, 2023

Researchers at the University of Göttingen in Germany have developed a cell culture chamber that lets them culture tissue samples, mimic the mechanical conditions that tissues experience in various disease states, and closely monitor tissue reactions. The technology could be particularly useful for pre-clinical drug testing, allowing researchers to test the effects of various drug candidates on tissues without the need to use experimental animals.

Research 95

Research Academics Wellness 95

PEMBlog

MAY 31, 2023

When we think of managing agitated patients we think of medicines – but that shouldn’t be our first option. However, medications can be adjuncts to non-pharmacologic means to help keep agitated children safe from harm. This podcast episode hosted by Brad Sobolewski ( @PEMTweets ) and co-authored by Dennis Ren ( @DennisRenMD ) is all about age-appropriate pharmacologic management strategies for agitated children.

Psychiatric 93

Psychiatric Emergency Department Pediatrics Administration 93

ALiEM

MAY 24, 2023

A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick. Background The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip.

Pediatrics 93

Pediatrics 93

St. Emlyn

MAY 22, 2023

St.Emlyn's - Emergency Medicine #FOAMed On Thursday 18th May the National Institute for Health and Care Excellence (NICE) released the updated head injury guidelines: assessment and early management [NG232] There have been three head injury … NICE Head Injury Guidelines 2023: Now who do we scan? Read More » The post NICE Head Injury Guidelines 2023: Now who do we scan?

Head Injuries 92

Head Injuries 92

Dr. Smith's ECG Blog

MAY 23, 2023

Written by Pendell Meyers A man in his early 40s experienced acute onset chest pain. The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. EMS arrived and recorded this ECG: What do you think? See same ECG below with computer automated interpretation, using the Glasgow ECG algorithm which apparently is used by many different providers and devices Amazing that

EKG/ECG 92

EKG/ECG Wellness Emergency Department EMS 92

RebelEM

MAY 11, 2023

Background: The emergency department is frequently visited by patients suffering from symptomatic alcohol withdrawal, and the traditional management has been dominated by repeated doses of benzodiazepines. 1, 2 Phenobarbital has been studied as an alternative or adjunct to benzodiazepines with encouraging results, but primarily among inpatient services. 3, 4 Much of the appeal of phenobarbital lies in its ability to stave off severe alcohol withdrawal symptoms days after administration, without

Emergency Department 98

Emergency Department Administration Hospitals Academics 98

Medagadget

MAY 26, 2023

Researchers at the Hubrecht Institute in the Netherlands have developed a biobank of cancer organoids using tissue samples obtained from head and neck cancer patients. So far, the team used the biobank to validate tumor biomarkers. Excitingly, they also correlated patient treatment responses with organoid treatment responses, suggesting that the organoids provide a good proxy for testing new treatments and for designing a personalized treatment plan for individual patients.

Outcomes 93

Outcomes Research 93

Don't Forget the Bubbles

MAY 10, 2023

In May 2022, Holly and Joe, two students on the joint QMUL and DFTB PEM MSc , created video presentations on human factors. We’ve incorporated some of our favourite elements from their presentations in this blog post. You’re in the paediatric emergency department, typing some notes for the child you’ve just discharged. You’re just about aware of the tannoy in the background.

Emergency Department 91

Emergency Department Resuscitation Documentation/Coding Teamwork 91

Sensible Medicine

MAY 21, 2023

It’s my pleasure to introduce today’s guest post by Dave Allely. Although Mr. Allely is a medical student— his analysis of the RSV vaccine for pregnant women is superior to the FDAs. He notes a bizarre moment in the recent VRBPAC meeting where Peter Marks asked Pfizer to make a closing statement— seemingly in an effort to get the vote he wanted.

Outcomes 88

Outcomes Hospitals Research 88

EMCrit

MAY 27, 2023

My dear pulmonologists, I have some bad news. Santa Claus isn't real. Neither is “ARDS.” “ARDS” has traditionally been conflated with a specific histopathological form of lung injury: diffuse alveolar damage (DAD). Lectures, chapters, and articles typically juxtapose these two entities, promoting the concept that they're one and the same.

88

88