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

Taming the SRU

MARCH 30, 2023

Diastolic shock index and clinical outcomes in patients with septic shock. O: There was an association between increased diastolic shock index score and mortality at 90 days and performed similarly to more advanced measures of morbidity and mortality in septic shock including lactate levels and SOFA scores.

Shock 52

Shock Outcomes Sepsis Resuscitation 52

EM Ottawa

APRIL 18, 2024

In this Prehospital Journal Club Recap, let us take a deep dive into the use of blood products, as well as the adjunct use of automated controlled elevation in CPR.

CPR 115

CPR Resuscitation Shock Wellness 115

Sensible Medicine

APRIL 1, 2024

In the same session, Jacob Eifer Møller, MD, PhD, from Odense University in Denmark, will present the results of the DanGer-Shock trial. I rank this trial—of the Impella ventricular assist device in patients with cardiogenic shock—as one of the most important trials of this decade.

Shock 128

Shock Wellness Outcomes 128

Dr. Smith's ECG Blog

FEBRUARY 22, 2024

She did well and stabilized after dialysis. Here is her ECG the next day with normal potassium level: She did well. Physician also reads it as normal) Severe shock, obtunded, and a diagnostic prehospital ECG. ST elevation in aVL with reciprocal ST depression in the inferior leads Shock, bradycardia, ST Elevation in V1 and V2.

EKG/ECG 142

EKG/ECG EMS Shock Wellness 142

RebelEM

MAY 25, 2023

I recently gave a talk on the initial management of trauma patients with hemorrhagic shock. Clinical Take Home Point: In patients with TBI and hypovolemic shock, target a SBP or MAP ≥90mmHg, but know this is based on limited evidence. vs SBP target <90mmHg which resulted in a mortality of 33.4% NEJM 1994. [2]

Resuscitation 145

Resuscitation Fluid Resuscitation Head Injuries Shock 145

The Trauma Pro

AUGUST 22, 2023

The EMS report indicates that your incoming patient is in shock. The patient is doing well but has an unexplained pressure dip. A simple one is the use of any of your blood refrigerator products or emergency release blood , or a calculated score such as the ABC score or shock index (SI). And it happens again.

Shock 100

Shock Wellness EMS 100

RebelEM

FEBRUARY 15, 2024

Additionally, intubation can risk hemodynamic instability as well as hypoxemia from the procedure itself. It is unclear, though, if the risks of intubation (including ventilator associated pneumonia) outweighs the benefits. of the risk of pneumonia by not intubating patients (NNT = 13) Additionally there was an absolute reduction of 12.2%

Poisoning 137

Poisoning Airway Management Seizures Shock 137

Dr. Smith's ECG Blog

OCTOBER 20, 2024

Figure B At this point, with the ECG changing from diffuse ST depression to widespread ST elevation and the patient presenting in cardiogenic shock, left main coronary artery (LMCA) occlusion is the likely diagnosis. Complete LMCA occlusion is associated with clinical shock and/or cardiac arrest. This is an ominous sign.

EKG/ECG 131

EKG/ECG Shock Emergency Department Ambulance Services 131

Thinking Critical Care

DECEMBER 8, 2024

Every resus doc needs to have a holistic approach to shock – MAP and forward flow simply isn’t enough. Here, Matt and I chat a bit about recent things we’ve heard in the world around us, as well as how we use and see the use of the interface concept. Don’t forget to come up your game at #HR25!!!

Shock 90

Shock Wellness 90

The Trauma Pro

JUNE 18, 2024

Objective MTP activation criteria have been developed and are well-supported by the literature. The ABC score and the shock index are two of the more common methods. The Shock Index (SI) uses the initial vital signs to perform a quick and dirty calculation by dividing the heart rate by the systolic blood pressure.

Pediatrics 113

Pediatrics Blood Transfusions Resuscitation Shock 113

The Trauma Pro

APRIL 26, 2024

A multi-center trial published in 2015 showed an astounding 32% mortality rate for patients with shock from pelvic fracture. Years ago, we tried to pack the pelvis from the inside (peritoneal cavity), but it never worked very well. As I continue to preach, going anywhere but the OR is dangerous for the patient.

Fractures 147

Fractures Head Injuries Radiology Radiology 147

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 95

Sepsis Shock Resuscitation Outcomes 95

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 135

EKG/ECG Allergic Reactions Shock Stroke 135

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

JUNE 17, 2024

PFA destroys myocardium with electricity (shocks). Every “application” is actually a shock. Europeans do PFA ablation in well under an hour. PFA is especially concerning because the shocks in the left atrium create intense microbubbles. Sensible Medicine is a reader-supported publication.

Shock 117

Shock Stroke Operations Ultrasounds 117

PulmCCM

OCTOBER 14, 2024

How well does it work? In this way albumin produces most of the vascular system’s oncotic pressure—the force tending to retain fluid in blood vessels without its leaking into the extravascular space. This increases mean arterial pressure.

Resuscitation 52

Resuscitation Shock Wellness 52

Taming the SRU

MARCH 10, 2024

critical AS, ASD, HCM) Arrhythmogenic right ventricular cardiomyopathy Pulmonary embolism Thoracic aortic dissection Transient occult shock Sepsis Hemorrhagic shock (ex. Can’t miss ED diagnosis for syncope Brady/tachy dysrhythmia, arrhythmias such as ARVC, channelopathy (Brugada) Acute MI Structural heart disease (ex.

EKG/ECG 96

EKG/ECG Shock Wellness EMS 96

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock. Well, don't we see diffuse ST Elevation in Myo-pericarditis (with STD in aVR)? Referring to Figure-1 — this 53-year old woman who presented in extremis with cardiogenic shock and an initial pH = 6.9, This was sent by a reader.

Shock 52

Shock Hyperthermia / Hypothermia EKG/ECG Hospitals 52

EMDocs

JANUARY 23, 2024

Episode 93: BRASH syndrome Background: Brash syndrome has 5 components: bradycardia, renal failure, AV nodal blocker, shock, hyperkalemia. BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia. BRASH syndrome: Bradycardia, Renal failure, Av blocker, Shock, and Hyperkalemia. J Emerg Med. 2020.05.001.

Shock 98

Shock Dehydration Sepsis EKG/ECG 98

EM Literature of Note

JANUARY 27, 2024

A brief post collating a few bits of my various work published across the interwebs … The Annals of Emergency Medicine Podcast continues to summarise the meatiest articles from each month, featuring a cycle of new co-hosts, as well: Apple Podcasts Google Podcasts Soundcloud Naturally, there are continuing Journal Club features, covering the (..)

Resuscitation 96

Resuscitation Emergency Department Shock Wellness 96

EMDocs

OCTOBER 8, 2024

Tachycardia may be present both from many medications or drugs, as well as withdrawal. Additional resuscitation Have we addressed all potential sources of shock for the patient in front of us? Does the patient require blood, a procedure to address obstructive shock, or other source control? Do they have edema? Sinus Tachycardia.

Shock 103

Shock Emergency Department Pediatrics EKG/ECG 103

RebelEM

DECEMBER 17, 2024

You order antibiotics, an initial fluid bolus as well as blood cultures. A large observational study of > 2000 patients found an association with fever at presentation and ICU survival for patients with severe sepsis or septic shock ( Sunden-Culberg 2017 ). Vitals are BP 114/42, HR 138, T 102.1, Sat 93% on RA.

Sepsis 68

Sepsis Shock EMS Emergency Department 68

Dr. Smith's ECG Blog

DECEMBER 15, 2015

No shock was ever delivered. He was in profound shock. There is no pericardial fluid to account for shock. Fifth: the ultrasound in RV MI can look identical to that of PE: there can be both McConnell's sign and "D" sign, as well as enlarged RV with poor function. Sixth: Severe shock (e.g., He was intubated.

Shock 40

Shock Ultrasounds EKG/ECG Wellness 40

The Skeptics' Guide to EM

FEBRUARY 24, 2018

Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. He writes an […] The post SGEM#208: It Makes No Difference – Glucocorticoids for the Treatment of Septic Shock first appeared on The Skeptics Guide to Emergency Medicine. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. NEJM January 2018.

Shock 40

Shock Sepsis Emergency Department Resuscitation 40

Ken Grauer, MD

SEPTEMBER 28, 2024

The ECG in Figure-1 — was obtained from a 45-year old man with diabetes, who was being treated for septic shock. PEARL # 2: The reason today's tracing is so challenging — is that every 3rd P wave is so well hidden within the T waves of every odd-numbered beat. QUESTIONS: How would YOU interpret the ECG in Figure-1 ? What is the rhythm?

EKG/ECG 262

EKG/ECG Shock Wellness 262

EMDocs

NOVEMBER 6, 2023

Venoarterial extracorporeal membrane oxygenation can be lifesaving for patients with cardiogenic shock or dysrhythmias that are refractory to other treatment measure s. The usefulness of administering methylene blue for refractory vasodilatory shock due to CCB poisoning is uncertain. COR 2a, LOE C-LD. COR 2a, LOE C-LD.

Poisoning 106

Poisoning Hyperthermia / Hypothermia Seizures Administration 106

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

Dr. Smith's ECG Blog

JUNE 9, 2024

There are no P-waves (this can also happen in hyperkalemia due to sino-ventricular rhythm), but here is it slow and even wider than 9 minutes later: The patient eventually did well and fully recovered. A middle aged man with unwitnessed cardiac arrest Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?

EKG/ECG 103

EKG/ECG Resuscitation Shock Wellness 103

Ken Grauer, MD

OCTOBER 21, 2023

P EARL # 2: As noted above — ECG #1 is remarkable for the presence of diffuse ST depression ( in more than 7 leads! ) — with ST elevation in lead aVR ( as well as in lead V1 ). Figure-2: I've labeled some findings from Figure-1.

EKG/ECG 245

EKG/ECG Shock Wellness 245

RebelEM

JANUARY 18, 2024

It is well-established that earlier recognition and treatment can lead to better outcome for these patients . septic shock) earlier antibiotics most likely makes a difference in morbidity and mortality, however earlier antibiotics in all patients who meet SIRS criteria may not be a good thing and potentially cause more harms than good.

Sepsis 129

Sepsis Hospitals Administration Outcomes 129

Sensible Medicine

AUGUST 7, 2023

It is shocking. Also shocking was the secondary findings. And I am happy to show you science done well. These were all eye-opening trials. But today I present an even more surprising one. It’s called REVIVED-BCIS. First some background. Their primary outcome was death or hospitalization for heart failure. Look at that.

Shock 98

Shock Outcomes Hospitals Wellness 98

Pediatric EM Morsels

NOVEMBER 3, 2023

With concern for malaria, it is very important to identify who is non-immune and semi-immune as this can affect both the timeframe for illness after departure from the endemic country as well as severity of illness. falciparum parasitemia , and no other defined cause of AMS (WHO 2023). Third times the charm!

Seizures 278

Seizures Pediatrics CDC Infectious Diseases 278

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

Taming the SRU

DECEMBER 17, 2024

Out of 18 patients receiving ORT, 4 failed to respond well and were escalated to IV therapy. Other contraindications include those who are unable to drink liquid (respiratory problems or impaired unconsciousness) and patients in shock, persistent vomiting, or with an ileus. AtherlyJohn et al. A systematic review by Freedman et al.

Dehydration 83

Dehydration Fluid Resuscitation Administration Resuscitation 83

Dr. Smith's ECG Blog

AUGUST 28, 2020

Now appears to be in cardiogenic shock." However, cardiogenic shock usually takes some time to develop, so it is probably subacute." A fixed stenosis in that other artery, especially in the context of hypotension from the occlusion of the first coronary artery, can lead to ischemia and very poor LV function and worsening shock.

Shock 40

Shock EKG/ECG Wellness Outcomes 40

Stop and Think

AUGUST 28, 2024

There is surely placebo effect as well. RITA-2 shocks me. But that difference was diminished at 2 years and gone by 3 years. And, of course, this was an unblinded trial. So one group got a procedure and the other did not. Here is that the authors concluded in the prominent journal Lancet in 1997—the dawn of coronary stenting.

Outcomes 120

Outcomes Shock Hospitals Wellness 120