The Skeptics' Guide to EM

OCTOBER 5, 2019

Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomized, sham-controlled, blinded, phase 3 trial. His 12-lead ECG shows a normal sinus rhythm without ST abnormality or ectopy. This episode will not debate the use of tPA for acute ischemic stroke.

Stroke 52

Stroke Hospitals EMS Administration 52

Taming the SRU

AUGUST 7, 2023

The patient needs a transvaginal ultrasound w/ doppler with gynecology consult and possible laparotomy TVUS is not just for torsion, it can also be used for ectopic pregnancies or pregnancy of unknown location Acute Ischemic Stroke Updates WITH Drs. hours increased the NNT for a good outcome to 20. The expanded window of 3-4.5

Stroke 93

Stroke Outcomes EKG/ECG Research 93

ACEP Now

OCTOBER 29, 2024

Does that normal troponin and ECG obviate the need for cardiology consultation for my patient with a concerning story for acute coronary syndrome? 4 However, emergency physicians rely on gestalt to predict outcomes well. The “bundling” heuristic—if I send a troponin, then an ECG is needed.

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

Dr. Smith's ECG Blog

APRIL 2, 2024

Here is the initial ED ECG. Other thought this was due to hyperkalemia, but the ECG does not have the appearance of hyperkalemia but does have the appearance of severe cardiomyopathy -- LBBB with very wide QRS) 3. Another ECG was recorded 12 minutes later: Paced rhythm, probable Pacemaker-Mediated Tachycardia ?

EKG/ECG 133

EKG/ECG Shock CPR Stroke 133

Dr. Smith's ECG Blog

MAY 30, 2023

His prehospital ECG was diagnostic of inferior posterior OMI. Here is his ED ECG: There is bradycardia with a junctional escape. We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. The patient was in clinical shock with a lactate of 8.

Shock 97

Shock EKG/ECG Academics Stroke 97

Sensible Medicine

AUGUST 28, 2023

Some background: In patients with certain risk factors, AF increases the risk of having a stroke. The increase in risk parallels the presence of risk factors, such as age, high blood pressure, diabetes, coronary disease, and previous stroke. Net benefit means stroke reduction > bleeding increase. We call this clinical AF.

Stroke 98

Stroke Wellness EKG/ECG Outcomes 98

Taming the SRU

OCTOBER 5, 2023

morbidity and mortality - quality improvement - research grand rounds - r1 clinical knowledge: pres/rcvs - r4 case follow-up: compartment syndrome Morbidity and Mortality WITH dr. finney Takotsubo Cardiomyopathy with COVID-19 Increasing incidence of Takotsubo Cardiomyopathy with the COVID-19 pandemic Morbidity and mortality is similar to that of ACS (..)

Stroke 91

Stroke EKG/ECG Seizures CPR 91

The Skeptics' Guide to EM

MARCH 2, 2024

His vital signs are all normal and the ECG done at triage does not show an occlusive myocardial infarction. Symptoms may include more severe chest pain radiating to the back, loss of consciousness, or symptoms of stroke if the blood supply to the brain is affected. It is described as a ripping sensation that radiates to his back.

Emergency Department 131

Emergency Department Stroke Operations Hospitals 131

Sensible Medicine

FEBRUARY 13, 2024

In brief, the trial compared apixaban vs aspirin in patients who had had a stroke of unknown source and evidence of atrial cardiopathy. Recurrent stroke (the primary endpoint) occurred in 40 patients in each group. Apixaban did not reduce the rate of recurrent stroke over aspirin in these patients. The hazard ratio was 1.00.

Stroke 76

Stroke Outcomes Wellness EKG/ECG 76

Taming the SRU

JANUARY 26, 2024

Wosiski-Kuhn and Stothers BP cuff sizing: Using a cuff too large results in lower SBP, using too small results in higher BP VTE risk with hormonal contraception and NSAIDS Isolated use + and contraception leads to IRR of 7.2 10 or greater days and high or moderate risk hormonal contraception amplifies risk to IRR of 44.8

Stroke 59

Stroke EKG/ECG Seizures Outcomes 59

ACEP Now

JULY 7, 2023

2,3 In general, patients who develop cardiac arrest with an initial rhythm of VT or VF tend to have favorable outcomes compared to patients who develop cardiac arrest from either asystole or pulseless electrical activity. Heart disease and stroke statistics-2022 update: A report from the American Heart Association. Circulation.

Resuscitation 98

Resuscitation Shock Stroke Hospitals 98

Dr. Smith's ECG Blog

DECEMBER 26, 2020

An ECG was recorded quickly on return to the ED: (sorry for poor quality, cannot get originals) What do you think? They called their transfer center cardiologist on call, who reviewed the case on the phone with them, as well as the ECG. In my opinion this makes the flutter waves slightly easier to recognize in this ECG.

EKG/ECG 52

EKG/ECG Stroke Administration Seizures 52

Dr. Smith's ECG Blog

NOVEMBER 18, 2019

Here is the ECG: The computer reads a long QT at 449 ms, and a Hodges QTc of 506 ms. Case outcome The Na was 109. From EMCrit: Taking control of severe hyponatremia with DDAVP An ECG recorded 2 days later with a K of 4.1: Figure-1: Both ECGs that were done in this case ( See text ). What do you think?

EKG/ECG 52

EKG/ECG Seizures Stroke Wellness 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

She has no previous cardiac history of which she is aware 911 was called and here is her Prehospital ECG: What do you think? link] Case continued She arrived in the ED and here is the first ED ECG. In comparison with the first ECG, I would guess that the artery is reperfusing. Stroke-volume:50 ml. Normal wall thickness.

EKG/ECG 109

EKG/ECG Ultrasounds Wellness Stroke 109

RebelEM

MARCH 22, 2023

Differential to Consider (for Regular, Narrow Complex Tachydysrhythmias) Sinus Tachycardia AVNRT Orthodromic Atrioventricular Reentrant Tachycardia (AVRT) Atrial Flutter with 2:1 block Common EKG Findings Narrow-complex, regular rhythm with a rate that often exceeds the theoretical maximal heart rate (220 – age) for that patient.

EKG/ECG 52

EKG/ECG EMS Pediatrics Stroke 52

Stop and Think

FEBRUARY 19, 2023

In LOOP, more than 6000 older patients (age 75) without atrial fibrillation—but with high-stroke-risk features--were randomized to having an implantable loop recorder (ILR) vs standard Danish primary care. Except that after five years the rate of strokes and major bleeding did not significantly differ in the two groups.

Stroke 52

Stroke EKG/ECG Outcomes Hospitals 52

Dr. Smith's ECG Blog

MARCH 6, 2019

This ECG was recorded on arrival: What do you think? Proof that all STE and hyperacute T-waves in the presentation ECG are new. They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG shows persistent Occlusion MI but does not meet STEMI criteria.

EKG/ECG 52

EKG/ECG Outcomes Hospitals Wellness 52

Taming the SRU

JUNE 3, 2024

Susan Wilcox Increasing regionalization due to: Growth of specialty centers Increasing development of healthcare systems Hub-and-spoke models Development of ECMO, trauma, transplant, and stroke centers The higher the acuity of the centers, the higher the acuity of the patient that needs to get there. Benefits of transport are evidenced based.

Shock 91

Shock Seizures Airway Management Stroke 91

EMDocs

MAY 15, 2024

ECG: Evaluate for ischemia, right heart strain. Causes and outcomes of the acute chest syndrome in sickle cell disease. Infectious: bacterial or viral pneumonia ( M. pneumoniae, C. Based on light absorption from blood flow at the sensor site (using HbA, not HbS) Underestimates alveolar hypoxemia. Am J Emerg Med. 2022 Aug;58:235-244.

Blood Transfusions 103

Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 103

Taming the SRU

DECEMBER 6, 2023

Calcium is also now carried in the prehospital setting and should be used when EKGs show signs of hyperkalemia, cardiac arrest with concern for hyperkalemia, and those who have crush injuries. With rare exception, patients with sICH should be admitted to a specialized stroke unit (NSICU).

Leadership 57

Leadership Stroke Airway Management EMS 57

The Skeptics' Guide to EM

SEPTEMBER 19, 2020

The SGEM Bottom Line was that for some patients presenting with chest pain who are chest pain free and have normal/non-specific ECG findings could potentially be safely removed from cardiac monitoring using the Ottawa CPCM Rule. TXA also seems to improve patient-oriented outcomes in epistaxis ( SGEM#53 and SGEM#210 ).

Academics 52

Academics Resuscitation EMS Stroke 52

Dr. Smith's ECG Blog

JULY 3, 2018

Here is his initial ECG: 00:04 What do you think? With no other information other than the first ECG above, I texted this to Dr. Smith and he responded: ST elevation in lead V2 and terminal QRS distortion in V3. Therefore, this ECG would not have met the criteria for ACO by this formula. LAD occlusion. Great case.

EKG/ECG 52

EKG/ECG Documentation/Coding Administration Outcomes 52

EMDocs

MAY 28, 2024

ECG: Evaluate for ischemia, right heart strain. Causes and outcomes of the acute chest syndrome in sickle cell disease. Infectious: bacterial or viral pneumonia ( M. pneumoniae, C. Based on light absorption from blood flow at the sensor site (using HbA, not HbS). Underestimates alveolar hypoxemia. Am J Emerg Med. 2022 Aug;58:235-244.

Blood Transfusions 97

Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 97

Dr. Smith's ECG Blog

MAY 16, 2023

Here is his triage ECG: What do you think? No prior ECG was available. Other outcome information is not available. Pretest probability is crucial in ECG diagnosis of OMI or ECG diagnosis of OMI mimic. For clarity in Figure-1 — I’ve reproduced the only ECG in today’s case. Figure-1: Today's ECG. (

EKG/ECG 52

EKG/ECG Stroke Documentation/Coding Outcomes 52

Dr. Smith's ECG Blog

AUGUST 23, 2017

Here is his 12-lead ECG: The computer reads supraventricular tachycardia. Same stroke precautions as atrial fib A 40-something presented with palpitations and had a regular pulse at 170. What is it? It is atrial flutter with 2:1 conduction. It is not PSVT and not sinus. There are clear flutter waves in lead II across the bottom.

Stroke 52

Stroke Sepsis Emergency Department EMS 52

Taming the SRU

APRIL 13, 2023

stent, percutaneous nephrostomy) by urology or IR Hypokalemia evaluate for EKG changes assess for underlying cause and factors that may influence ability to replete (i.e. stent, percutaneous nephrostomy) by urology or IR Hypokalemia evaluate for EKG changes assess for underlying cause and factors that may influence ability to replete (i.e.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Poisoning EKG/ECG Seizures 52

ACEP Now

APRIL 5, 2024

1 However, many clinical features are common: more than 60 percent of patients present with a degree of neurological involvement, ranging from confusion to stroke and coma. 1 25 percent of patients may present with evidence of myocardial ischemia, including abnormal ECGs and elevated troponin levels.

Domestic Violence 40

Domestic Violence Emergency Department Outcomes EKG/ECG 40

Mind The Bleep

NOVEMBER 21, 2023

An ECG will also help with anaesthetic planning Bloods: CRP, U&E, FBC, LFTs, INR (if on warfarin), VBG (for lactate, pH and glucose), amylase Group and save: not all surgical procedures need group and saves- these are expensive and in many cases, unnecessary- check first!

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

Taming the SRU

MAY 1, 2023

Patients must have EKG findings and meet one of a few other criteria (ie family history of sudden death, VF or VT episode, syncope, nocturnal agonal respirations) Most common in patients of Southeast Asian descent and the mean age of death from arrhythmia if untreated is in the 4th decade of life.

Poisoning 52

Poisoning Hyperthermia / Hypothermia Seizures Emergency Department 52

EB Medicine

AUGUST 1, 2018

First up is the link between cannabis use and stroke or TIA. times higher risk of stroke or TIA. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. times higher risk of stroke or TIA. Cannabis users who smoked at least once weekly had a 3.3

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

Dr. Smith's ECG Blog

APRIL 8, 2015

Cardiac Syncope ("True Syncope") Independent Predictors of Adverse Outcomes condensed from multiple studies 1. Abnormal ECG – looks for cardiac syncope. Abnormal Electrocardiogram (ECG): Defined (San Fran syncope rule) as any new changes when compared to the last ECG or presence of non-sinus rhythm.

Emergency Department 52

Emergency Department EKG/ECG Outcomes Seizures 52

EMDocs

DECEMBER 16, 2023

A 12-lead EKG shows sinus tachycardia but is otherwise normal. Both can result in heat exhaustion and heat stroke and have many overlapping symptoms. Patients with heat stroke have hot, dry skin and altered mental status (e.g., C, and heat stroke occurs at a core temperature > 40°C. Temps greater than 41.5C

Hyperthermia / Hypothermia 94

Hyperthermia / Hypothermia EMS Stroke Seizures 94

The Skeptics' Guide to EM

APRIL 9, 2022

Included in this differential is transient epileptic amnesia, transient ischemic attack, stroke, metabolic disorders, psychogenic disorders, and post traumatic amnesia. The workup can include laboratory testing, EEGs, ECGs, echocardiogram and advanced neuroimaging.

Head Injuries 52

Head Injuries Emergency Department Seizures Stroke 52

EMDocs

NOVEMBER 4, 2024

Pain can be associated with a friction rub on cardiac auscultation, a pericardial effusion on a bedside echocardiogram, or diffuse ST elevations on an EKG. A comprehensive, patient-centered approach to pain management ensures effective treatment across these diverse pain syndromes, ultimately improving patient outcomes. Am J Emerg Med.

Emergency Department 105

Emergency Department Fractures Burns EMS 105

Taming the SRU

AUGUST 25, 2023

bicarb <18mEq/L) ketosis (preferably serum beta-hydroxybutyrate >3mmol/L) Risk factors SGLT2 inhibitor use fasting state ketogenic diet intra-abdominal pathology (AGE, pancreatitis, etc.) to 1 mcg/kg/hour procedural sedation loading dose: 0.5-1 1 mcg/kg over 10 minutes followed by continuous infusion: 0.2

Seizures 75

Seizures Fractures EKG/ECG Resuscitation 75

Taming the SRU

JUNE 6, 2023

then need further evaluation Usually with CTA imaging If normal physical exam & ABI>0.9, then need further evaluation Usually with CTA imaging If normal physical exam & ABI>0.9,

Documentation/Coding 64

Documentation/Coding Seizures Psychiatric Wellness 64

Sensible Medicine

JANUARY 20, 2025

After initiation of stroke prevention regimens—often with oral anticoagulation.) The first primary endpoint was a composite of CV death, stroke, hospitalization for heart failure or acute coronary syndrome. They transmitted single-lead ECGs twice per week or when symptomatic. Stroke was even lower at 0.6%

Stroke 60

Stroke Outcomes Hospitals Shock 60