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 97

Shock EKG/ECG Academics Stroke 97

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.

Shock 127

Shock Stroke Operations Ultrasounds 127

PulmCCM

DECEMBER 11, 2023

Sepsis, infectious disease Managing septic shock with a restrictive-fluids approach (preferentially using vasopressors after a single liter crystalloid bolus) led to similar outcomes as the usual practice of bolusing large volumes of fluids first. Either approach in severe sepsis with shock seems reasonable.

Sepsis 94

Sepsis Stroke Shock Infectious Diseases 94

RebelEM

SEPTEMBER 18, 2024

Skip the zones of the neck and focus on hard signs of vascular ( Shock w/o another source, Pulsatile bleeding, Expanding hematoma, Audible bruit, Signs of stroke) or aerodigestive (Airway compromise, Bubbling wound, Extensive SubQ air, Stridor, Significant hemoptysis/hematemesis).

Stroke 90

Stroke Shock EMS 90

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

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 88

Stroke Shock Pediatrics Resuscitation 88

JournalFeed

SEPTEMBER 5, 2020

We cover a review of acute ischemic stroke, ACP/AAFP musculoskeletal pain guidelines, antibiotics for cirrhosis with upper GI bleed, early norepinephrine for septic shock, and the best way to tape an ETT so it won’t come out. It’s the JournalFeed Podcast for the week of Aug. 31 - Sept.

Stroke 52

Stroke Shock 52

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

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

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 104

Sepsis Shock Resuscitation Outcomes 104

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 100

Stroke Outcomes Shock Research 100

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 98

Stroke Hyperthermia / Hypothermia Outcomes Shock 98

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

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 136

Stroke Outcomes Hospitals Administration 136

Sensible Medicine

APRIL 29, 2024

Say blueberries and rates of stroke. This came as a shock to me. Specification curve analysis is similar to a multiverse analysis, meaning it’s a way of defining and implementing all plausible and valid analytic approaches to a research question. This time in nutritional epidemiology. In other words: one way.

Stroke 142

Stroke Documentation/Coding Shock Research 142

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 133

EKG/ECG Shock CPR Stroke 133

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.

Shock 91

Shock Seizures Airway Management Stroke 91

Don't Forget the Bubbles

FEBRUARY 5, 2025

In trauma patients, the primary sources of bleeding are external haemorrhage (blood on the floor), chest, abdomen, pelvis, and long bones in paediatrics brain is also included (infants with open sutures can bleed a significant amount intracranially) Shock The most common cause in trauma is haemorrhage.

Fluid Resuscitation 59

Fluid Resuscitation Domestic Violence Head Injuries Sexual Assault 59

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 125

Resuscitation Outcomes EMS Sepsis 125

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

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.

Stroke 109

Stroke Academics Outcomes Shock 109

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

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

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

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 94

Sepsis Research Stroke Academics 94

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.

Burns 52

Burns Stroke Ambulance Services Seizures 52

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 Burns Pediatrics 52

EM Curious

SEPTEMBER 9, 2015

CUTTING EDGE ACUTE ISCHEMIC STROKE CARE [LECTURE]: Dr. Melissa Motta, a neuro-critical care expert breaks down current best practice in acute ischemic stroke in an excellent talk at Maryland CC Project. Rob Orman breaks down this topic on ER Cast to help us better understand the evidence and demystify this issue.

Stroke 52

Stroke Pediatrics Best Practices EMS 52

PulmCCM

NOVEMBER 17, 2023

For any given hemodynamic state, measure or estimate the P ra and CO [or stroke volume, SV] simultaneously and repeatedly after each intervention. The trick, I believe, lies in ‘operating point guided resuscitation’ [OPGR]. What does this mean? Am J Cardiol 1990, 66(4):493-496. Ultrasound J 2022, 14(1):36.

Operations 132

Operations Ultrasounds Resuscitation Blood Transfusions 132

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

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

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

RebelEM

JUNE 8, 2023

They can be associated with side effects such as reflex bradycardia, decreased stroke volume in phenylephrine, tachycardia and hypertension associated with epinephrine. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. 2006;130(4):941–6.

Administration 98

Administration Emergency Department Outcomes Documentation/Coding 98

ACEP Now

OCTOBER 10, 2023

The CT scan reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Symptoms began just prior to presentation.

Outcomes 52

Outcomes Stroke Emergency Department Hospitals 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

Dr. Smith's ECG Blog

JANUARY 9, 2024

Slow VT below the detection rate of the ICD lead to worsening heart failure and low stroke volume. Lowering the back up rate (LRL) of the ICD/pacer allowed for an intrinsic rhythm with physiologic AV conduction and normal AV synchrony with resultant increase in stroke volume and cardiac outpt.

EKG/ECG 119

EKG/ECG Stroke Hospitals Documentation/Coding 119