Ken Grauer, MD

JULY 4, 2024

I was sent the ECG in Figure-1 — but without the benefit of any history. QUESTIONS: How would YOU interpret this tracing? WHY do I say there is, "A 2-Part Answer?" Figure-1: The initial ECG in today's case. ( To improve visualization — I've digitized the original ECG using PMcardio ). MY Thoughts on Today's CASE: As important as providing a brief, relevant history is for optimal clinical ECG interpretation — Cases like the one today often prove even more educational, because we are not given any

EKG/ECG 388

EKG/ECG Wellness 388

Pediatric EM Morsels

JULY 19, 2024

Previously, we covered Post-Tonsillectomy Hemorrhage and how we hope that “all bleeding eventually stops: ideally, by means that we have imposed rather than by exhaustion of the patient’s RBC resources.” Since the original morsel ( way back in 2012 ), the literature has shown that there are a few extra ingredients that we can add to our morsel recipe when we care for children with post-tonsillectomy hemorrhage.

Airway Management 290

Airway Management Pediatrics Wellness Operations 290

The Trauma Pro

JULY 30, 2024

There’s a lot of dogma in trauma care, as well as in the field of medicine generally. The knee dislocation dogma is that the incidence of vascular injury is high (around 50%) with posterior dislocation and somewhat lower with non-posterior dislocation. At least, that’s what I learned way back when. After recently finding myself spouting off those numbers, I wondered if it was really true.

Dislocations 264

Dislocations Wellness 264

Sensible Medicine

JULY 22, 2024

I call it therapeutic fashion. Practice patterns. Beliefs. Ways of doing things. Examples: patients with new heart failure get coronary angiography; patients with chest pain without evidence of heart attack get stress tests; certain drugs and devices become favored over generics. The curious thing about many therapeutic fashions is their lack of evidentiary support.

Research 144

Research 144

Speaker: Simran Kaur, Co-founder & CEO at Tattva.Health

AI is transforming clinical trials—accelerating drug discovery, optimizing patient recruitment, and improving data analysis. But its impact goes far beyond research. As AI-driven innovation reshapes the clinical trial process, it’s also influencing broader healthcare trends, from personalized medicine to patient outcomes. Join this new webinar featuring Simran Kaur for an insightful discussion on what all of this means for the future of healthcare!

Outcomes

St. Emlyn

JULY 9, 2024

St.Emlyn's - Emergency Medicine #FOAMed A podcast with Steve Smith ECG educator extraordinaire where we discuss occlusive myocardial infarction and the future of AI and ECG interpretation. The post Podcast – Occlusive Myocardial Infarction, ECGs and Artificial Intelligence with Steve Smith appeared first on St.Emlyn's.

EKG/ECG 140

EKG/ECG 140

RebelEM

JULY 1, 2024

Background: Non-invasive positive pressure ventilation (NIPPV) is an effective treatment modality for patients with both hypoxemic or hypercapnic respiratory failure and has been shown to decrease the need for intubation [2]. Continuous positive airway pressure (CPAP) provides a constant positive pressure support throughout the breathing cycle, while bilevel positive airway pressure (BPAP) provides different levels of positive airway pressure during inspiration and expiration.

COPD 132

COPD Emergency Department Outcomes EMS 132

Pediatric EM Morsels

JULY 26, 2024

We have discussed many causes of encephalitis and encephalopathy previously (ex, Eastern Equine Encephalitis , Posterior Reversible Encephalopathy , FIRES , Reye’s Syndrome ) and have highlighted the fact that they can be challenging to diagnose early. An irritated brain can lead to such a wide array of symptoms. It is even more challenging when the initial symptoms seem to align with what we perceive as psychiatric concerns.

Psychiatric 271

Psychiatric Seizures Outcomes Pediatrics 271

The Trauma Pro

JULY 23, 2024

Although very few things in medicine are new, I love it when I learn about something I’ve never heard of before. Recently, while reading an autopsy report, I ran across the term “hinge fracture of the skull.” What? Maybe if I were a neurosurgeon, I would have recognized the term. This was the perfect excuse to hit the books (or, more accurately, the internet).

Fractures 264

Fractures 264

Sensible Medicine

JULY 28, 2024

In a recent post on Sensible Medicine, written on my phone while traveling, I criticized a randomized trial of masking in the BMJ that found Norweigans told to wear masks for 2 weeks had a lower self-reported rate of cold symptoms from 12% to 9%. A reduction of 3%. In a follow up post , Adam Cifu, my friend and colleague, took me to task. Let me highlight his criticism, and why he is wrong both about the trial, and my Kurt Cobain shirt.

Research 138

Research Wellness 138

St. Emlyn

JULY 14, 2024

St.Emlyn's - Emergency Medicine #FOAMed Background – What do we already know about REBOA? In 2023, Dr Zaf Qasim reviewed the UK REBOA trial for us on St Emlyn’s (The UK-REBOA trial – Has the […] The post JC: Prehospital Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Exsanguinating Subdiaphragmatic Hemorrhage appeared first on St.Emlyn's.

Resuscitation 135

Resuscitation Research 135

Dr. Smith's ECG Blog

JULY 21, 2024

Written By Magnus Nossen — with edits by Ken Grauer and Smith. The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. The below ECG was recorded. The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion.

EKG/ECG 131

EKG/ECG Shock Hospitals Sepsis 131

The Skeptics' Guide to EM

JULY 20, 2024

Reference: Gibbs et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation (The PREOXI trial). NEJM June 2024. Date: July 17, 2024 Guest Skeptic: Dr. Aine Yore is an Emergency Physician, practicing in the Seattle, Washington area for over twenty years. She is the former president of the Washington chapter of ACEP and her career focus outside of clinical practice has been largely devoted to health care policy.

COPD 121

COPD Patient Safety Emergency Department Administration 121

Pediatric EM Morsels

JULY 5, 2024

It seems like just yesterday ( or maybe ~ a month ago ) when we served up a tasty morsel on the PECARN decision rule for intra-abdominal traumatic injuries in children. Our friends at the PECARN injury group have remained busy this spring with generating more externally validated clinical decision rules. In addition to the recently published low risk intra-abdominal injury validation, we have another new tool to use this summer as school breaks, underdeveloped frontal lobes, and high speeds leav

Pediatrics 164

Pediatrics Head Injuries Dislocations Research 164

The Trauma Pro

JULY 9, 2024

Cervical spine injury presents a host of problems, but one of the least appreciated ones is dysphagia. Many clinicians don’t even think of it, but it is a relatively common problem, especially in the elderly. Swallowing difficulties may arise for several reasons: Prevertebral soft tissue swelling may occur with high cervical spine injuries, leading to changes in the architecture of the posterior pharynx Rigid cervical collars , such as the Miami J and Aspen, and halo vests all force the neck int

Head Injuries 264

Head Injuries Fractures Hospitals Wellness 264

Sensible Medicine

JULY 12, 2024

Autonomy is important to me. Maybe it’s because I am a Gen X-er. Some say we were raised by wolves. I do know that we were raised knowing we had the freedom to explore but also the freedom to fail. Our autonomy taught us resilience. With autonomy comes responsibility. I need to do the adulting task of scheduling my annual doctor’s visit.

129

129

St. Emlyn

JULY 11, 2024

St.Emlyn's - Emergency Medicine #FOAMed The Faculty of Forensic & Legal Medicine's guidelines for managing non-fatal strangulation (NFS). These guidelines advocate a trauma-informed, multidisciplinary approach to improve outcomes for patients who have experienced NFS. @stemlyns #FOAMed The post Non-fatal strangulation appeared first on St.Emlyn's.

Forensics 135

Forensics Outcomes 135

Dr. Smith's ECG Blog

JULY 25, 2024

This patient was witnessed by bystanders to collapse. They started CPR. EMS arrived and found him in Ventricular Fibrillation (VF). He was defibrillated into VT. He then underwent dual sequential defibrillation into asystole. After 1 mg of epinephrine they achieved ROSC. Total prehospital meds were epinephrine 1 mg x 3, amiodarone 300 mg and 100 mL of 8.4% sodium bicarbonate.

Resuscitation 124

Resuscitation EKG/ECG CPR Shock 124

The Bottom Line

JULY 19, 2024

In critically ill patients undergoing tracheal intubation does pre-oxygenation with non-invasive ventilation compared with pre-oxygenation with an oxygen mask reduce the incidence of hypoxemia during intubation?

120

120

ETM Course

JULY 31, 2024

In this episode of the ETM Course Podcast we talk to Dr Chris Partyka, Emergency Physician and Prehospital and Retrieval Specialist from Sydney and lead author for the recently published SABRE trial which compared Serratus Anterior Plane Blocks to a standard analgesia package for patients with rib fractures. Also available on Apple Spotify YouTube iHeart Podchaser PlayerFM This was a really well designed and executed study, and the results will be practice changing for anyone who treats trauma p

Fractures 119

Fractures Wellness 119

The Trauma Pro

JULY 16, 2024

Every trauma center is required to have two specific committees: a multidisciplinary trauma performance improvement committee (PI) and a trauma operations committee (ops). However, a common question is, “How often do my committees need to meet?” Let’s start with your PI committee. The answer, of course, is “it depends.” There is no cookie-cutter, one-size-fits-all answer.

Operations 147

Operations Documentation/Coding Pediatrics 147

Sensible Medicine

JULY 27, 2024

When a friend makes a mistake, it is your responsibility to let him know. In the words of the Ad Council and the US Department of Transportation, “friends don’t let friends drive drunk.” They also “don’t let friends misinterpret the medical literature because they have been blinded by their priors.” Friends do this even if the results of the paper in question should change nobody’s behavior and if calling them out will invite the wrath of Sensible Medici

Wellness 126

Wellness Hospitals 126

St. Emlyn

JULY 30, 2024

St.Emlyn's - Emergency Medicine #FOAMed Listen to the podcast recorded live at the Premier Conference 2024. The post Podcast – Button Battery Ingestion appeared first on St.Emlyn's.

113

113

Dr. Smith's ECG Blog

JULY 9, 2024

Written by Pendell Meyers A man in his 50s was found by his family in cardiac arrest of unknown duration. His family started CPR and called EMS, who arrived to find him in ventricular fibrillation. 15 minutes after EMS arrival, after at least 6 defibrillations, the patient achieved sustained ROSC. He arrived to the ED with severe hypotension, heart rate in the 70s, unable to follow commands but moving all extremities requiring restraint and sedation, respiratory rate around 24/min being supporte

EKG/ECG 116

EKG/ECG Resuscitation Shock CPR 116

The Bottom Line

JULY 11, 2024

Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation (REVISE) D. Cook. NEJM 2024. DOI: 10.1056/NEJMoa2404245 Clinical Question In mechanically ventilated adults, does stress ulcer prophylaxis with intravenous pantoprazole (40 mg daily), compared with placebo (0.9% saline), reduce the occurrence of clinically important upper gastrointestinal bleeding at 90 days?

113

113

First 10 EM

JULY 29, 2024

Gestalt for sepsis? This paper hits two of my biggest pet peeves in medicine. 1) The endless emphasis on rushing to hit treatment targets in sepsis or otherwise and 2) the assumption that decision instruments must be better than basic clinical judgment. I am aware, therefore, that my interpretation is more likely to be biased, […] The post Gestalt is better than decision tools for identifying sepsis appeared first on First10EM.

Sepsis 109

Sepsis 109

The Trauma Pro

JULY 19, 2024

In my last post, I discussed how often your multidisciplinary trauma performance improvement committee (PI) should meet. As you know, one other mandatory committee is required of all trauma centers, the Trauma Operations Committee (Ops). In this post, I will: describe how often your operations committee should meet help you determine whether your two committees should meet on the same day or separately How Often?

Operations 113

Operations Documentation/Coding Administration 113

Sensible Medicine

JULY 15, 2024

The GLP1 agonists (glucagon-like-peptide-1-receptor agonist) may be the biggest medical development of this century. The success of Western society has resulted in widespread obesity—and obesity-related diseases, such as diabetes, high blood pressure, heart failure and vascular disease. Obesity is clearly not a good thing for human health. The statistics on obesity—especially in children—are staggering.

Stroke 124

Stroke Research Outcomes 124

St. Emlyn

JULY 22, 2024

St.Emlyn's - Emergency Medicine #FOAMed Background As I think I have mentioned before, I spend some of my time as a major trauma consultant on the major trauma ward (MTW). You may be shocked to […] The post JC: Evaluation of Lidocaine Patches for Elderly Patients with Rib Fractures: A Feasibility Study appeared first on St.Emlyn's.

Fractures 108

Fractures Shock 108

Dr. Smith's ECG Blog

JULY 23, 2024

I was working at triage when the medics brought this patient who is 65 yo and has had chest pain for 12 hours. They recorded a prehospital ECG at 2112 and said that it was “normal”. It had already been crumpled up and put in the waste basket. So I uncrumpled it: What do you think? You need to click on it to enlarge it to view it well I was suspicious for inferior and posterior OMI (Large T-wave in aVF, slight STE in lead III with inverted T-wave in aVL, and a slightly downsloping ST with negativ

EKG/ECG 115

EKG/ECG Wellness EMS Hospitals 115

Emergency Medicine Cases

JULY 8, 2024

In this episode: recognition, risk stratification, decision tools, indications for lumbar puncture in the febrile pediatric patient, tips and trick on performing LPs in children, and ED management of pediatric meningitis. We answer such questions as: what are the test characteristics of the various clinical features of meningitis across various ages?

Pediatrics 109

Pediatrics EMS Wellness Seizures 109

EMDocs

JULY 25, 2024

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits , a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here. Stories of med mal lawsuits can save lives.

Documentation/Coding 104

Documentation/Coding Hospitals Patient Safety Emergency Department 104

The Trauma Pro

JULY 5, 2024

#7. Inappropriate prescribing Most trauma professionals worry about over-prescribing pain medication. But under-prescribing can create problems as well. Uncontrolled pain is a huge patient dissatisfier, and can lead to unwelcome complications as well (think pneumonia after rib fractures). Always do the math and make sure you are sending the right drug in the right amount home with your patient.

Documentation/Coding 113

Documentation/Coding Fractures Emergency Department Wellness 113

Sensible Medicine

JULY 29, 2024

Let’s think today about one of evidence-based medicine’s biggest blind spots: the study of policies. Drugs, devices and treatment strategies often face the challenge of randomized trials. Yet policies mostly escape this challenge. It seems all a policy needs is a strong champion and plausibility. Yet the failure of the hospital readmission penalty policy and sepsis protocols expose the risks of implementing a policy because it sounds good.

Outcomes 118

Outcomes Research Sepsis Emergency Department 118

St. Emlyn

JULY 2, 2024

St.Emlyn's - Emergency Medicine #FOAMed Learn about how to look after patients with eating disorders in the Emergency Department. Listen to this podcast recorded live at the Premier Conference 2024. The post Podcast – Eating Disorders in the Emergency Department appeared first on St.Emlyn's.

Emergency Department 106

Emergency Department 106

Dr. Smith's ECG Blog

JULY 11, 2024

This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech. How is it possible that a kid who has not even started medical school can know so much about EKGs and cardiology? Because: 1) He has been reading this blog for a long time. 2) He is curious This is how Pendell got started. Case A 43 year old male with a history of DM II, hyperlipidemia, and a family history of myocardial infarction presented to a family clinic with two days of epigastric pain

EKG/ECG 113

EKG/ECG Outcomes Hospitals Wellness 113

Emergency Medicine Cases

JULY 30, 2024

In this month's EM Quick Hits podcast: Andrew Petrosoniak on the role of vasopressors in the hemorrhaging trauma patient, Megan Landes on providing HIV PEP and PrEP in the ED, Justin Morgenstern & George Kovacs on the PREOXI trial and evidence for pre-oxygenation with NIPPV before intubation in RSI, Brit Long on recognition and management of blast crisis in the ED, and Leah Flanagan & Liam Loughrey on the rise of nitrous oxide toxicity.

Poisoning 103

Poisoning EMS Resuscitation 103