EM@3AM: Brainstem Strokes
EMDocs
MAY 11, 2024
Answer : Brainstem stroke specifically in the pons resulting in locked in syndrome. CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis?
EKG/ECG Outcomes Stroke 
How important are old ECGs in Non-obvious cases of potential OMI?
Dr. Smith's ECG Blog
NOVEMBER 14, 2023
In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). Here is that last post: A 90-something with acute stroke.
EKG/ECG 
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Journal Feed Weekly Wrap-Up
EMDocs
MAY 4, 2024
. #1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.
Friday Reflection 41: Sometimes I Just Need to Complain
Sensible Medicine
JUNE 28, 2024
She is admitted with suspected stroke. There were no personal crises or untoward patient outcomes. Case 1: Excess An elderly woman is admitted to a community hospital with a minor stroke. The plan was that she would get a two-week, continuous EKG monitor placed and have a sleep study at this hospital. I love my job.
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SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients?
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.
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Grand Rounds Recap 8.2.23
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
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Putting Clinical Gestalt to Work in the Emergency Department
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.
Ventricular Fibrillation, ICD, LBBB, QRS of 210 ms, Positive Smith Modified Sgarbossa Criteria, and Pacemaker-Mediated Tachycardia
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 ?
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Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?
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.
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Grand Rounds Recap 10.4.23
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 (..)
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A Note On Criticism Of Yesterday's Study of the Week
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.
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Updates in the Management of Refractory Ventricular Tachycardia or Ventricular Fibrillation Arrest
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.
A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!
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.
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Status epilepticus. What is this ECG pathognomonic of?
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?
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What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?
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.
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REBEL Core Cast 98.0 – AVNRT
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.
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Grand Rounds Recap 5.22.24
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.
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Watch what happens when "pericarditis" and morphine cloud your judgment
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.
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A man in his late 30s with acute chest pain and ST elevation
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. (
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Grand Rounds Recap 4.5.23
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.
SGEM#455: Harmony 5000 – Prehospital Detection of Large Vessel Occlusion Strokes
The Skeptics' Guide to EM
OCTOBER 5, 2024
Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study. The SGEM has covered LVO strokes several times (SGEM#137, SGEM#292, SGEM#333 and SGEM#349). Date: October 2, 2024 Reference: Paxton et al. Reference: Paxton et al.
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A Comprehensive Guide to Surgical Clerking
Mind The Bleep
FEBRUARY 2, 2025
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!
STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?
RebelEM
SEPTEMBER 28, 2023
ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% neoplasm, aneurysm, intracranial or spinal surgery) or recent trauma to head or cranium (i.e. Primary PCI: 95.7%
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EM@3AM: Hyperthermia
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
The NOAH Study Provides Evidence That Aids Decision-Making in Atrial Fibrillation
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.
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SGEM#432: SPEED, Give Me What I Need – To Diagnose Acute Aortic Dissections
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.
Grand Rounds Recap 1.24.24
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
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emDOCs Podcast – Episode 100: Acute Chest Syndrome Part 1
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.
emDOCs Podcast – Episode 101: Acute Chest Syndrome Part 2
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.
Grand Rounds Recap 12.6.23
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).
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Modernity and Health
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.
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What happens when you give adenosine to a patient with this rhythm?
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.
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What will you do for this patient transferred to you who is now asymptomatic?
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.
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SGEM#301: You Can’t Stop GI Bleeds with TXA
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
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Recognition and Treatment of Thrombotic Thrombocytopenic Purpura
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.
A Comprehensive Guide to Surgical Clerking
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!
SGEM#364: Don’t You Forget About Me – DW:MRI Sensitivity for Transient Global Amnesia
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.
Grand Rounds Recap 4.19.23
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.
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Episode 19 - Cannabinoids: Emerging Evidence in Use and Abuse
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
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Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.
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.
Pain Management of Common Chief Complaints in the ED
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.
Diagnostics: Intractable Hiccups
Taming the SRU
NOVEMBER 18, 2024
Other causes include gastritis, gastric malignancy, pancreatitis, hiatal hernia, SBO, large meal, spicy foods, and carbonated drinks Neurologic Stroke, space occupying lesion, epilepsy, CNS infection, demyelinating and neurodegenerative disorders such as multiple sclerosis and Parkinson’s disease are causes of intractable hiccups. BMC Cancer.
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Systemic Lupus Erythematosus: ED presentations, evaluation, and management
EMDocs
FEBRUARY 3, 2025
These complications affect both the central and peripheral nervous systems and encompass a wide range of conditions, including transient ischemic attacks (TIA), stroke, headaches, mood disorders, seizures, psychosis, neuropathy, and cognitive dysfunction (1,6,7). Khan A, Shamim R, Wagan AA, Khan SM, Nazeer Ahmed S, Haroon M. Egypt Rheumatol.
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The Pros and Cons of Studying Strategies with RCTs - EAST AFNET 4
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%
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