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On a busy day shift in the emergencydepartment, our seasoned triage nurse comes to me after I finish caring for a hallway patient, “Hey, can you come see this guy in the triage room? This is the essence of emergency medicine. The “bundling” heuristic—if I send a troponin, then an ECG is needed. His vitals are fine…”.
This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. The undergraduate's analysis: This EKG shows J point elevation of about 0.5-1 Edited by Smith He also sent me this great case.
Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the EmergencyDepartment via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage.
All initial ECGs were labeled ‘normal’ or ‘otherwise normal’ by the computer interpretation, and below are the ECGs with the final cardiology interpretation. 1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes.
This was sent by anonymous The patient is a 55-year-old male who presented to the emergencydepartment after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. This ECG was recorded in triage.
Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergencydepartment for evaluation of chest pain. See Ken Grauer's additional comments about this ECG at the end of the post!
male with pertinent past medical history including Atrial fibrillation, atrial flutter, cardiomyopathy, Pulmonary Embolism, and hypertension presented to the EmergencyDepartment via ambulance for respiratory distress and tachycardia. Bedside ultrasound showed volume depletion and no pulmonary edema. SVT with aberrancy?
The photos that Dr. Clarke took from 19781980 provide a glimpse into working in an emergencydepartment in the years the specialty was being established. for a few years working as an emergency physician. Dr. Clarke was then hired as assistant director in the emergencydepartment (ED) at Pomona Valley Hospital, Pomona, Calif.
A submassive PE does not result in hypotension but does result in right ventricular (RV) dysfunction (as evidenced by CT or ECG) and/or signs of myocardial injury, such as elevated B-type natriuretic peptide, elevated troponin, or new ECG changes. 6 The second common catheter-directed approach is mechanical thrombectomy.
This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Our first 12 lead ECG was then recorded at 0926. What do you think?
89% agree that violence in the emergencydepartment has harmed patient care. Scrutinize but don’t overthink (interpret your EKGs with context) Know your splints Be comfortable with OMI EKGs Know your resources & know when to ask for help Be creative
Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergencydepartment with 2 days of heavy substernal chest pain and nausea. These diagnoses were not found in his medical records nor even a baseline ECG. The patient continued having chest pain.
Annals of Emergency Medicine, May 2024 Guest Skeptic: Dr. Casey Parker is a Rural Generalist from Australia who is also an ultrasounder. There are no abnormalities in the blood work, ECG, or chest x-ray. Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis.
Triage EKG: What do you think? A prior ECG was available for comparison. Prior EKG from 2 months ago was available: Let's put the precordial leads from the 2 ECGs side by side: Now you can really see the difference. Immediately after the second ECG was performed, the patient's pain resolved completely.
This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: EmergencyDepartment Diagnosis and Management. Jeff: And it likely goes without saying, but an EKG is a must on all trauma patients with suspicion for blunt cardiac injury in accordance with the EAST guidelines.
He presented to the EmergencyDepartment with a blood pressure of 111/66 and a pulse of 117. He had this ECG recorded. He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6.
If you want to see Justin in the video format and his new Youtube series then click here: [link] If you would like to check out my current ultrasound training project then click here: WACHS Ultrasound Otherwise – enjoy the show and see you in a few weeks. Am J Emerg Med. 2022 Feb;52:85-91. doi: 10.1016/j.ajem.2021.11.030.
Colin is an emergency medicine resident beginning his critical care fellowship in the summer with a strong interest in the role of ECG in critical care and OMI. A patient in their 40s with type 1 diabetes mellitus and hyperlipidemia presented to the emergencydepartment with 5 days of “flu-like” illness.
She arrives in the emergencydepartment (ED) with decreased level of consciousness and shock. The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients.
4 In an emergencydepartment (ED) presentation of cardiac arrest, the diagnosis of PE is challenging without the use of CT angiography. Point-of-Care-Ultrasound (POCUS) is a bedside modality that can assist Emergency Physicians (EPs) in differentiating PE from other causes of cardiac arrest. EKG RV strain.
But this month’s episode is special in its own way - we’ll be tackling Electrical Injuries in the emergencydepartment - from low and high voltage injuries to the more extreme and rare lightning related injuries. Jeff: Let’s move on to evaluation in the emergencydepartment. Jeff: You’re right. Let’s move on to treatment.
Glucose POC ECG: Is this actually sinus tachycardia? Looking at the initial or even repeating the ECG will be helpful here. Unanticipated death after discharge home from the emergencydepartment. Ann Emerg Med. Qualitative factors in patients who die shortly after emergencydepartment discharge.
ULTRASOUND GOODIE BAG ULTRASOUND FOR LATE PREGNANCY [PODCAST]: While not a routine exam we perform other than confirming fetal heart tones, definitely some great pearls on more advanced US topic. Consider an ultrasound guided ulnar nerve block. Part 1 here. US GUIDED ULNAR NERVE BLOCK [BLOG]: Boxer's fracture need a reduction?
ECG, CXR, and troponin are negative. A medical student reports a murmur, not documented by either the emergency physician or the cardiologist. Troponins #1 and #2 are borderline and ECG is non-specific. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. ECG, CXR, and troponin are all normal.
to teach you and your learner something new on shift skin adhesives WITH dr. hill Dermabond is a polymer (octyl cyanoacrylate) that can be used to repair lacerations in the EmergencyDepartment faster than sutures, allowing the ED physician to be more efficient.
In the emergencydepartment (ED), physicians face the challenge of making rapid decisions that can significantly impact patient outcomes. Collaborating with one of my ultrasound faculty, we conducted a bedside echocardiogram to explore potential cardiac anomalies. Our workup started with an ultrasound and EKG.
ULTRASOUND IN CHEST PAIN: [BLOG]: It is never a bad idea to throw an ultrasound probe on your patient with chest pain. ECG PATTERN RECOGNITION CARDIAC ARREST AND ST ELEVATION: [BLOG]: Dr. Smith features a brief cardiac arrest case with an ECG pattern that you must know and be able to recognize! Check out his post here.
This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on EmergencyDepartment Management of Patients With Complications of Bariatric Surgery. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. Jeff: Next up is ultrasound.
If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation? But you can make a diagnosis here, and Pendell and I do this all the time when reading ECGs from databases. The patient had this ECG recorded at 7 minutes after registration at triage as a walk-in (not by EMS): What do you think?
Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergencydepartment with substernal chest pain for 3 hours prior to arrival. The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Epub 2021 Nov 15.
Semin Ultrasound CT MR. 2013 Apr;34(2):131-41. Available from: [link] American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Use of Intravenous tPA for Ischemic Stroke:; Brown MD, Burton JH, Nazarian DJ, Promes SB. Ann Emerg Med. Erratum in: Ann Emerg Med. doi: 10.1053/j.sult.2013.01.004.
He had this ECG at time 0 What do you think? There was an old ECG for comparison: Very normal Interpretation: There is serious widespread ST elevation that could easily by due to a wraparound LAD with anterior and inferior MI. Another ECG was recorded at 1.5 ng/mL Another ECG was recorded at 3.5 Learning Points: 1.
Clinical pathologic case presentation - r1 diagnostics/therapeutics: Lumbar punctures - AIRWAY GROUND ROUNDS- r4 capstone - r3 taming the sru - ultrasound grand rounds Clinical pathologic case presentation WITH Drs. Consider starting more goals of care discussions in the emergencydepartment, not just for patients who are actively dying.
Here is his ECG: There is atrial fibrillation at a rate of 95. If detected early by ultrasound, the patient can be saved. Our own Dave Plummer of HCMC reported on survival of 2 of 6 patients with free wall myocardial rupture diagnosed by bedside ultrasound in the ED.(3) This was the 12-lead ECG. There was some SOB.
Here is his ECG: What is your interpretation? This was the 12-lead ECG. This remains consistent with PIRP, as was the first ECG. If detected early by ultrasound, the patient can be saved. He found 2 ECG patterns of atypical T-wave development in PIRP: 1) persistently positive (upright) T-waves 48 hours after AMI onset.
She was unable to be defibrillated but was cannulated and placed on ECMO in our EmergencyDepartment (ECLS - extracorporeal life support). A followup ECG was recorded 2 days later: No definite evidence of infarction. Smith — “ S hark F in” m orphology was noted on the initial monitoring strip, and initial 12-lead ECG.
He had the following EKG recorded: Low voltage, suggests effusion. A bedside cardiac ultrasound was normal, with no effusion. He was started on Extracorporeal Life Support ("VA ECMO") Here is the ECG on ECMO: Very low voltage On Day 3, the EF recovered (that seems quick!) He was moderately hypoxic.
Every 30 minutes, a range of topics draws new participants to discuss everything from mastering ultrasound techniques to finding career mentorship. Get a personal financial plan, immerse yourself in hands-on training, brush up on your ultrasound and more. EmergencyUltrasound Management Course: (Sept. 28: 10 a.m.–5
What is your ECG interpretation and what would you do next? This ECG shows a normal sinus rhythm with a normal conduction pattern (normal PR, normal QRS, and normal QTc), normal axis, late R wave progression (and misplaced V2), normal voltages, ST-elevation in aVR and global ST-depressions. BP was 110 and oxygen saturation was normal.
A retrospective evaluation of phenobarbital versus benzodiazepines for the treatment of alcohol withdrawal in a regional Canadian emergencydepartment Link: [link] Bottom Line: This study in a small regional ED showed a QI project rolling out a Phenobarbital or Diazepam for Alchohol withdrawal syndrome. and NPV(50%).
Beware of using it to reverse your prior opinion that the ECG represents LAD occlusion. I recommend using it when you are worried that an ECG with apparent normal ST Elevation might be LAD occlusion. Case 3 I was reading a stack of ECGs yesterday, and saw this one, with no clinical information. Sensitivity is not perfect.
Written by Destiny Folk MD, with edits by Meyers, peer reviewed by Smith and Grauer A woman in her late 20s with a past medical history of cervical cancer status post chemotherapy and radiation therapy presented to the emergencydepartment for shortness of breath, chest tightness, and two episodes of syncope. Her pulse is 125.
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. Sounds familiar. Jeff: We sure did!
Ultrasound can be used to troubleshoot when needed. Regardless of the exposure, obtain an ECG and look for bundle branch block, heart block, and dysrhythmias , since those will change disposition. Discharge patients with low-voltage injury, no symptoms, and a normal ECG. Mattu M, Swadron SP (eds). Phiadelphia.
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