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. The RV is supplied during systole as well as diastole.

Shock 97

Shock EKG/ECG Academics Stroke 97

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

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% Liberal: 14.9%

Sepsis 104

Sepsis Shock Resuscitation Outcomes 104

ACEP Now

JULY 7, 2023

1 Ventricular tachycardia (VT) and ventricular fibrillation (VF) represent the most common initial rhythms for patients presenting to the ED in out-of-hospital cardiac arrest, as well as for patients who develop cardiac arrest while in the ED. 6 What Can I Do Outside of Repeated Shocks and Standard ACLS? amiodarone or lidocaine).

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. What we want to know is whether that reduction in AF produces a placebo-resistant effect of improved well being.

Stroke 100

Stroke Outcomes Shock Research 100

Sensible Medicine

APRIL 29, 2024

You can assess how well (or poorly) a practicing cardiologist did analyzing a paper in the Journal of Clinical Epidemiology. Say blueberries and rates of stroke. This came as a shock to me. It’s the Methods ! Allow me an experiment this week. I will write about a fascinating paper. This time in nutritional epidemiology.

Stroke 142

Stroke Documentation/Coding Shock Research 142

Taming the SRU

JULY 24, 2024

Ann Emerg Med 2024 Background Sepsis remains an increasingly common emergency department condition that is tied to higher morbidity and mortality across the United States as well as the rest of the world. They then tested the LASSO model using the remaining 20% of data to see how well it could detect sepsis at the same time points.

Sepsis 89

Sepsis Resuscitation Emergency Department Wellness 89

RebelEM

JUNE 26, 2023

4F-PCC contains factors II, VII, IX, X as well as Proteins S and C. Some clinicians have advocated for early administration of 4-factor prothrombin complex concentrate (4F-PCC) based on limited observational data. High-quality studies are needed to determine the utility of this intervention. Severe acute traumatic coagulopathy = PT >1.5

Administration 143

Administration Outcomes Resuscitation Radiology 143

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. Well more than a million views per month far exceeds are expectations.

Stroke 109

Stroke Academics Outcomes Shock 109

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

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

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

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). This was because of a well-known critical care physician Dr. Paul Marik.

Sepsis 52

Sepsis Shock Outcomes Stroke 52

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

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

Stop and Think

MARCH 28, 2023

This comment from my friend Dr. David Albert captures the idea: Martha, as you well know, we have a sick care system not a well care system that doesn't make $ from wellness but from caring for the sick. If only we could invest as much in making people well, we would save money, goes the thinking.

Stroke 52

Stroke Wellness Shock Hospitals 52

PulmCCM

DECEMBER 11, 2024

An excellent review article titled “Sepsis and Septic Shock” was published 4 December 2024 in the New England Journal of Medicine. It’s a wonderful contribution to the literature and well worth reading. These are nonfalsifiable claims that illustrate the problem well.

Sepsis 45

Sepsis Shock Research Wellness 45

Pediatric Emergency Playbook

APRIL 1, 2016

Less common causes of troponemia are: Kawasaki disease, pediatric stroke, or neuromuscular disease. Brain natriuretic peptide (BNP) In adults, we typically think of a BNP Luckily, we have data in children with congenital heart disease as well. There are two main reasons for an elevated lactate: the stress state and the shock state.

Pediatrics 52

Pediatrics Sepsis Shock Outcomes 52

Pediatric Emergency Playbook

NOVEMBER 1, 2015

Etomidate is perfectly acceptable, but ketamine is actually a superior drug to etomidate in the rapid sequence intubation of children in septic shock. Ketamine is reasonable as well: there is no contraindication to ketamine except for known hydrocephalus. We often have limited information in critical situations. Relax, it’s a myth.

Shock 40

Shock Sepsis Airway Management Pediatrics 40

Dr. Smith's ECG Blog

OCTOBER 7, 2019

When the physicians approached him, he was ashen, diaphoretic, and appeared in shock. Why is the patient in shock? He was in profound cardiogenic shock. Although the shock is no doubt partly a result of poor pump function, with low stroke volume, especially of the RV, it should be compensated for by tachycardia.

Seizures 40

Seizures EKG/ECG Shock EMS 40

Downeast Emergency Medicine

APRIL 26, 2021

MI or stroke). When looking at the subgroups with severe shock, there was an 18.5% When stratifying TXA administration time after injury and qualifying shock incidence, there appeared to be a lower 30 d mortality if TXA was given within 1 hour of the incident. DOES TXA IMPROVE OUTCOMES IN PATIENTS WITH TBI?

Head Injuries 52

Head Injuries Administration Outcomes Seizures 52

Dr. Smith's ECG Blog

AUGUST 13, 2020

Because of the tachcardia, I would expect her to be very poor left ventricular function and maybe Cardiogenic shock. It looks like he has an old anterior lateral MI as well. He had a h/o ischemic cardiomyopathy and right MCA stroke. Still Irregular Blood pressure during these rhythms was adequate; there was no shock.

EKG/ECG 52

EKG/ECG Shock Stroke Seizures 52

PulmCCM

JANUARY 4, 2022

For example, should a fluid challenge fail to raise stroke volume [SV], a state of physiological preload intolerance exists and additional volume is arguably harmful ; further attempts to increase tissue perfusion might then be best achieved with vasoactives. For what are intravenous fluids diagnostic? ED50] and in 90% [i.e.,

Wellness 40

Wellness Outcomes Sepsis Stroke 40

ACEP Now

SEPTEMBER 13, 2023

We wanted to reach emergency physicians, nurses and others working in trauma as well as those at Health and Human Services and the Centers for Disease Control. as well as working closely on behalf of the association on projects with the White House and the Departments of Veterans Affairs, Defense, and Health and Human Services.

EMS 45

EMS Research Academics Military 45

Taming the SRU

MAY 3, 2023

During the admission, she completed a course of broad-spectrum antibiotics and as the underlying shock state improved, she was also weaned off all vasopressor support. She was noted to have improvement in her underlying respiratory status as well and was extubated approximately three weeks later.

Wellness 52

Wellness Hospitals Shock Outcomes 52

EB Medicine

AUGUST 6, 2019

Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Nachi: Well, I’m sure more of those studies are still coming. Show More v Jeff: Fair enough, we’ll take what we can get. Jeff: Agree.

Emergency Department 40

Emergency Department Stroke Wellness Outcomes 40

EB Medicine

NOVEMBER 1, 2018

Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Jeff: Vascular injuries include coagulation necrosis as well as thrombosis.

Emergency Department 40

Emergency Department Burns EKG/ECG Shock 40

Stop and Think

OCTOBER 2, 2024

It is actually simple: you use an online calculator to get your 10-year risk of a heart attack or stroke. Well known is the fact that procedures put out a much stronger placebo effect than tablets. Statin Use and the New Risk Calculator People overthink statin drugs. If not, you don’t take the pill.

Stroke 44

Stroke Academics Shock Ultrasounds 44

Mind The Bleep

FEBRUARY 7, 2024

After a red cell transfusion they have some adult Hb which shifts the curve to the right and you then need a high partial pressure of oxygen to saturate well. Well, a baby in a prone position can better equally inflate both lungs, overall compliance of the chest wall is better and the alveoli are better inflated.

Wellness 52

Wellness Sepsis Stroke Shock 52

Dr. Smith's ECG Blog

MARCH 15, 2023

But when you see this, you should suspect that the AV node is not well. We designed a step-up protocol in which shocks at 50, 100, 200, 300, and 360 J were used for transthoracic cardioversion. I do not know why she did not have a rapid rate.

EKG/ECG 52

EKG/ECG Dehydration Stroke Shock 52

Pediatric Emergency Playbook

JUNE 1, 2017

This child is at risk for expected complications, as well as overdiagnosis and iatrogenia. These children depend on their preload to run blood passively into the pulmonary circuit; afterload reduction is also important to compensate for a poor left ejection fraction, as well as to avoid the development of pulmonary hypertension.

Pediatrics 52

Pediatrics EKG/ECG Wellness Seizures 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

speci fi city of the General Electric (GE) algorithm for AF, but they excluded cases with ventricular paced rhythm (VPR), in which the underlying atrial rhythm was frequently AF;we did not exclude VPR, as accurate identi fi cation of AF in VPR is important for determination of stroke risk [ 22 ]. Poon et al. sensitivity and 98.9%

EKG/ECG 52

EKG/ECG COPD Wellness Sepsis 52

Taming the SRU

MAY 1, 2023

Exertional Hyperthermia Patients with heat stroke will present with Temp > 104, AMS, or seizures. EMS was bagging him on arrival Primary notable for Compromised Airway Protection, bilateral Breath sounds, strong pulses,GCS 3 CT images of Head, Chest, Abdomen, Pelvis, and Spine No acute findings pH of 6.75

Poisoning 52

Poisoning Hyperthermia / Hypothermia Seizures Emergency Department 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. Vaishnav Hyperthermia: abnormally high body temperature due to thermoregulatory failure Severe hyperthermia: temp greater than 40.5C

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Poisoning EKG/ECG Seizures 52

EB Medicine

AUGUST 1, 2018

Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 First up is the link between cannabis use and stroke or TIA. times higher risk of stroke or TIA. Jeff: And the etiology of CHS is not well understood. million, and cocaine at 1.9

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

EB Medicine

SEPTEMBER 1, 2018

You may have heard of the recommendations for incision / excision, use of venom extraction devices, tourniquets, chill methods and even electroshock therapy – well these methods are all OUT. In severe cases this can lead to systemic bleeding and even hemorrhagic shock. Nachi: Let’s move on to diagnostic studies.

Emergency Department 40

Emergency Department Poisoning Anaphylaxis Allergic Reactions 40

Taming the SRU

AUGUST 30, 2023

As the name would suggest, inflammatory markers are biological markers of, well, inflammation. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. They are used clinically to detect pathological inflammation or measure response to treatment [1-2]. Intensive Care Med. Epub 2021 Oct 2.

Infectious Diseases 89

Infectious Diseases Sepsis Emergency Department Point-of-Care Testing 89