Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. The patient was in clinical shock with a lactate of 8. This confirms inferior, posterior, lateral, and RV MI RV MI often leads to shock and (systolic) hypotension. RVMI explains part of the shock. His prehospital ECG was diagnostic of inferior posterior OMI.

Shock 82

Shock EKG/ECG Academics Stroke 82

Sensible Medicine

MAY 6, 2024

A treatment to reduce stroke is tested in a clinical trial. of patients had a stroke vs 2.9% In the PROTECTED TAVR trial, the confidence intervals went from -1.7% (a lower stroke rate) to 0.5% (a higher rate of stroke). In the treatment group, 2.3% in the control arm. difference is signal or noise. Emphasis mine.)

Stroke 86

Stroke Shock Outcomes 86

EMDocs

JANUARY 13, 2024

sodium chloride) reduced acute kidney injury and improved other outcomes in these pediatric patients with septic shock. Source Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial. Crit Care Med. 2023 Nov 1;51(11):1449-1460. doi: 10.1097/CCM.0000000000005952.

Stroke 62

Stroke Shock Pediatrics Resuscitation 62

Sensible Medicine

JUNE 17, 2024

PFA destroys myocardium with electricity (shocks). Every “application” is actually a shock. Stroke occurred in 7 patients (0.12%). PFA is especially concerning because the shocks in the left atrium create intense microbubbles. Sensible Medicine is a reader-supported publication.

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Shock Stroke Operations Ultrasounds 125

ACEP Now

JULY 7, 2023

However, between four and five percent of cases of VT or VF will be refractory to standard management, with nonperfusing arrhythmia persisting despite repeated shocks. Initial guidelines defined “refractory” as VT or VF occurring despite three shocks from a cardiac defibrillator. amiodarone or lidocaine). References Tsao CW, et al.

Resuscitation 98

Resuscitation Shock Stroke Hospitals 98

Sensible Medicine

AUGUST 26, 2024

Strokes and heart failure are the main complications of AF. And even when drugs suppress AF, trials failed to show that doing so reduces stroke or heart failure. It was a shocking result. In population studies, AF associates with worse outcomes. Plus, many patients have symptoms from AF. Drugs to suppress AF are not the best.

Stroke 80

Stroke Outcomes Shock Research 80

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. The goal of the trial was to see if early vasopressors improved shock control by 6 hours. This resulted in better shock control by 6hrs (76.1% Read more

Sepsis 105

Sepsis Shock Resuscitation Outcomes 105

Pediatric Emergency Playbook

JUNE 1, 2016

Do we recognize shock early enough? World wide, shock is a leading cause of morbidity and mortality in children, mostly for failure to recognize or to treat adequately. So, what is shock? Simply put, shock is the inadequate delivery of oxygen to your tissues. How do we prioritize our interventions? Pericardial Effusion?

Shock 40

Shock Sepsis Pediatrics Ultrasounds 40

The Trauma Pro

APRIL 23, 2024

These indicate a high risk for deeper injury and consist of the following: Vascular signs Refractory shock Pulsatile or difficult-to-control hemorrhage Large or expanding hematoma Audible bruit or palpable thrill (I hardly ever see anyone actually check the neck for these, so brush up your skills!) Hard signs.

Operations 113

Operations Stroke Shock 113

RebelEM

SEPTEMBER 28, 2023

The STREAM-1 trial found that for [2] patients with STEMI presenting within 3 hours of symptom onset and unable to attain PCI within 1 hour of first medical contact, a pharmaco-invasive strategy resulted in similar rates of death, shock, heart failure, or reinfarction compared to primary PCI. Primary PCI: 95.7% Primary PCI: 95.7%

EKG/ECG 138

EKG/ECG Allergic Reactions Shock Stroke 138

Taming the SRU

JANUARY 26, 2024

Morbidity & MOrtality - Mini Lit Blitz - Post-Rosc Care - Qi/KT Morbidity & Mortality WITH Dr. Yates Case 1: Stroke and Stroke Mimics Early diagnosis of stroke improves stroke outcomes, where misdiagnosis is associated with an upwards of 4-time higher likelihood of mortality Missed strokes most often occur with atypical symptoms, in younger (..)

Stroke 59

Stroke EKG/ECG Seizures Outcomes 59

Sensible Medicine

JUNE 5, 2023

For instance, in the FOURIER trial, the super-expensive PCSCK9 inhibitor, evolocumab, reduced a primary composite outcome (CV death, MI, Stroke, unstable angina, coronary revascularization) vs placebo. We call this acute ischemic stroke or AIS. We are shocked at the response this newsletter has achieved. A brief word of thanks.

Stroke 89

Stroke Outcomes Hyperthermia / Hypothermia Shock 89

Ziqitza HealthCare Ltd

JUNE 13, 2024

Difficulty speaking Sudden speech difficulties, weakness, or numbness could be an emergency medical warning sign of a stroke. Major issues like stroke, internal bleeding, low blood sugar levels, and sudden drops in blood pressure could all accompany this warning sign. These also require emergency medical intervention at the earliest.

Stroke 52

Stroke Burns Ambulance Services Seizures 52

PulmCCM

JULY 10, 2023

In the MERCY trial, 607 critically ill patients with sepsis (most with septic shock) at 26 hospitals in Croatia, Italy, Kazakhstan, and Russia were randomized to receive meropenem by either continuous (3 g / 24 hours) or intermittent administration (1 g every 8 hours). However, the practice has not been supported by randomized trials.

Stroke 52

Stroke Sepsis Infectious Diseases Outcomes 52

Don't Forget the Bubbles

NOVEMBER 18, 2024

Neonatal hypotension can result from inadequate cardiac output, low systemic vascular resistance, or a combination of both, which are influenced by: Cardiac Output: Neonates, particularly preterm ones, may have compromised cardiac output due to myocardial immaturity, leading to reduced stroke volume and heart rate. Fernandez, E.

Sepsis 59

Sepsis Shock Hyperthermia / Hypothermia Administration 59

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.

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Shock Seizures Airway Management Stroke 91

Taming the SRU

NOVEMBER 29, 2023

Hemorrhagic shock is the most common etiology of instability in trauma and should always be highest on the differential. Posterior circulation stroke Patients with posterior strokes will likely have a low NIH. Workup with a negative troponin and EKG reliably rules out BCI. Ambulation is key during physical exam.

Stroke 53

Stroke EKG/ECG Resuscitation Shock 53

Taming the SRU

JULY 24, 2024

National campaigns to improve sepsis care, namely the Centers for Medicare and Medicaid Services’ introduction of “Severe Sepsis and Septic Shock Early Management Bundle”, have faced many challenges in physician and provider adherence. Sepsis as a disease process has been difficult to both clearly define and quickly recognize.

Sepsis 89

Sepsis Resuscitation Emergency Department Wellness 89

RebelEM

JANUARY 29, 2024

in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 to 4.0mg/hr typically given in EKOS therapy (See Below).

Stroke 137

Stroke Outcomes Hospitals Administration 137

Dr. Smith's ECG Blog

APRIL 2, 2024

He was unidentified and there were no records available After 7 shocks, he was successfully defibrillated and brought to the ED. No wall motion abnormality Decreased left ventricular systolic performance, severe Left ventricular enlargement, marked Dilated cardiomyopathy severe Est. stroke volume 52 cc at HR 70 = 3.64

EKG/ECG 128

EKG/ECG Shock CPR Stroke 128

Don't Forget the Bubbles

JULY 5, 2023

The Kilifi algorithm includes five clinical situations that are common sickle cell presentations – clinical jaundice, severe anaemia, bone and joint infections, and stroke. Symptoms may be non-specific in the beginning with patients quickly developing septic shock and disseminated intravascular coagulation.

Blood Transfusions 126

Blood Transfusions Stroke Dehydration Sepsis 126

Pediatric EM Morsels

JULY 21, 2023

Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma. Fun fact for animal lovers!- cats and dogs have their own GCS scores [Lapsley 2019, Ash 2018] Moral of the Morsel Modified can make it Merrier! 2008 Apr;39(4):1347-8. doi: 10.1161/STROKEAHA.107.498345.

Head Injuries 246

Head Injuries Pediatrics Outcomes Shock 246

Sensible Medicine

SEPTEMBER 23, 2024

The rate of the composite primary outcome of CV death, MI, unstable angina, stroke or transient attack was 4.29% with asa vs 4.48% with placebo. Update on Sensible Medicine: Vinay, Adam and I remain shocked at the success of this newsletter. The six-year trial was not stopped. Sensible Medicine is a reader-supported publication.

Academics 89

Academics Stroke Outcomes Shock 89

University of Maryland CC Project

JUNE 16, 2023

The first annual Mid-Atlantic Neurocritical Care Symposium will bring together experts from The University of Maryland/Shock Trauma Hospital, Johns Hopkins University, INOVA, Christiana Care, and beyond to discuss the basics of caring for critically ill neurological patients, as well as highlight recent innovations in the field.

Shock 70

Shock Hospitals Wellness Stroke 70

Pediatric Emergency Playbook

AUGUST 1, 2020

Heat illness and heat stroke. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. Jardine DS. Pediatr Rev 2007; 28:249.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Stroke Best Practices Pediatrics 52

RebelEM

FEBRUARY 8, 2024

Background: Patients with shock frequently present with hypotension. Many of these patients are started on vasopressor and inopressor medications to assist in efforts to normalize blood pressure to help improve organ perfusion. In shocky patients, arterial lines are often used to monitor hemodynamic parameters and inform treatment decisions.

Resuscitation 126

Resuscitation Outcomes EMS Sepsis 126

JournalFeed

MARCH 26, 2022

Epi vs. NorEpi Spoon feed: Continuous epinephrine infusion for post-resuscitation shock in out of hospital cardiac arrest (OHCA) was associated with both higher all-cause and cardiovascular specific mortality when compared to norepinephrine. Check out journalfeed.org for details.

Stroke 40

Stroke Documentation/Coding Emergency Department Resuscitation 40

AED Leader

SEPTEMBER 11, 2023

Atrial fibrillation increases the risk of blood clots, strokes, heart failure, and other heart-related complications. It’s essential to note that atrial flutter also carries a potential risk of stroke. Administering an electric shock to the heart in cases of ventricular fibrillation increases the patient’s chance of survival.

Shock 52

Shock Stroke CPR Resuscitation 52

Stop and Think

JANUARY 9, 2022

When someone presents in shock because of AV block and a low heart rate, you place a pacemaker. Anticoagulant drugs given to patients with atrial fibrillation reduce the odds of a future stroke. Same for anticoagulants in AF; if we anticoagulated all patients with AF, we would prevent lots of strokes. You fix it. But…But.

Stroke 52

Stroke Outcomes Shock 52

Taming the SRU

APRIL 17, 2024

Results They studied 1852 patients in the MICU with the most common admission diagnoses being respiratory failure (34 %), sepsis (23 %), and primary CNS disease such as stroke or hemorrhage (23 %). Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49:e1063-e1143.

Sepsis 93

Sepsis Research Academics Stroke 93

The Skeptics' Guide to EM

SEPTEMBER 28, 2019

Case: A 45-year-old female in the emergency department is being admitted to the intensive care unit (ICU) for septic shock secondary to urinary tract infection (UTI). The existing evidence to support vitamin C use in patients with septic shock is weak and has been summarized in a systematic review meta-analysis. .

Sepsis 52

Sepsis Shock Outcomes Stroke 52

Taming the SRU

JULY 31, 2024

Barometric pressure, humidity, and temperature changes may influence stroke and fall incidence (especially in elderly patients with cardiovascular risk factors). Nice people are not more likely to get cancer. Black clouds don’t exist (but I still sort of think they do).

EKG/ECG 52

EKG/ECG Sepsis Documentation/Coding Stroke 52

Stop and Think

MARCH 28, 2023

In the course of investigating this benign condition, the patient suffers a stroke from a coronary angiogram. Had this person never seen a doctor, or had no prevention efforts, she would have avoided a stroke. A person comes in for a yearly physical exam and is found to have an asymptomatic irregular heartbeat.

Stroke 52

Stroke Wellness Shock Hospitals 52

Taming the SRU

SEPTEMBER 1, 2023

for detecting major injuries Abnormal CXR Rapid deceleration mechanism Presence of a distracting injury Chest wall tenderness Sternal/thoracic spine/scapular tenderness There are limited decision-making rules for thoracic spine imaging Yet a study (Inaba et al., 2015) reported a sensitivity of 98.9%

Sepsis 95

Sepsis Documentation/Coding Administration Fractures 95

PulmCCM

MAY 22, 2023

More patients (9% vs 4%) had adverse events in the early mobilization group, including 7 serious events in the early-mobilization group (mostly arrhythmias and one stroke) vs 1 in the usual care group. At least one expert questioned whether the study was adequately powered. In an NHLBI-sponsored trial enrolling 1563 patients at 60 U.S.

Fluid Resuscitation 68

Fluid Resuscitation Resuscitation Hospitals Sepsis 68

ACEP Now

MAY 9, 2024

This should be suspected in patients with intraoperative cardiac arrest or shock. However, only one case—a patient who decompensated during her procedure and suffered a stroke but ultimately survived to hospital discharge—was presumed to be attributable to PFE.

Emergency Department 52

Emergency Department Operations Ultrasounds Hospitals 52

RebelEM

JUNE 26, 2023

Severe acute traumatic coagulopathy = PT >1.5 to 3.33; P = 0.72 NOT STATISTICALLY SIGNIFICANT Also no difference in individual components given Thromboembolic Events: 4F-PCC: 35% Placebo: 24% Absolute Diff: 11%; 95% CI 1 to 21% Relative Risk 1.48; 95% CI 1.04 to 2.10; P = 0.03

Administration 145

Administration Outcomes Resuscitation Radiology 145