Dr. Smith's ECG Blog

MAY 26, 2023

A 20-something presented after a huge verapamil overdose in cardiogenic shock. He was admitted to the ICU and was unstable, in shock, overnight. Thus, since high dose insulin's (HDI) primary beneficial effect on calcium channel overdose is to as a positive inotrope, it does not work well for dihydropyridine overdose.

Shock 91

Shock EKG/ECG Documentation/Coding Resuscitation 91

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

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 141

EKG/ECG EMS Shock Wellness 141

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 141

Poisoning Airway Management Seizures Shock 141

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 112

CPR Resuscitation Shock Wellness 112

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 129

Shock Wellness Outcomes 129

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 92

Shock Wellness 92

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 86

Shock EKG/ECG Academics Stroke 86

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

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

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

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 132

EKG/ECG Shock Emergency Department Ambulance Services 132

Greater Sydney Area HEMS

FEBRUARY 20, 2024

Obtaining access in shocked trauma patients can be notoriously difficult due to circulatory collapse. Those who are shocked, shut down with limited or no other options for peripheral access require central access. The evidence for improved safety and quality with the use of ultrasound for CVC implementation is well established [i].

Ultrasounds 98

Ultrasounds Shock Research Operations 98

PulmCCM

NOVEMBER 11, 2024

Since the vast majority of mortality from cardiogenic shock occurs in the first 30 days, why would the survival benefit of an Impella be so delayed? The control arm had 59% mortality at 6 months—higher than other trials enrolling cardiogenic shock patients at a similar severity of illness. Patients in the Impella arm had 2.8

Shock 98

Shock Sepsis Outcomes Research 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% Liberal: 14.9%

Sepsis 105

Sepsis Shock Resuscitation Outcomes 105

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

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 130

Shock Stroke Operations Ultrasounds 130

Mount Sinai EM

NOVEMBER 14, 2022

I included several resources including a link to “One pager ICU” which is where my drawing is derived from as well as several podcasts recommended by Dr. Pesyna. Contact Dr. Greg Serrao (917) – 756 – 6852 or 1-833-MH-SHOCK (1-833-647-4625) 2.) How can I activate ECMO at Mount Sinai vs Elmhurst? Mount Sinai VA ECMO: 1.)

Shock 130

Shock Wellness 130

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Shocked x 2 without effect. Warning: if this is VT, a calcium channel blocker can result in shock and death. Today's case is insightful in many ways — especially since despite prompt electrical cardioversion, we are told that this patient "was shocked X 2 without effect". However, this is not SVT. What to do now? K returned 3.6

EKG/ECG 141

EKG/ECG Shock Documentation/Coding Academics 141

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 94

Resuscitation Emergency Department Shock Wellness 94

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

He was admitted on oxygen and was doing fairly well with saturations of 100% on 2 L nasal cannula. He underwent CPR, and regained a pulse after epinephrine, with an organized narrow complex rhythm at 140, but still with severe shock. Assessment was severe sudden cardiogenic shock. He remained hypotensive and in shock.

Shock 52

Shock EKG/ECG Outcomes Hospitals 52

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

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

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

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 87

Shock Dehydration Sepsis EKG/ECG 87

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 132

Sepsis Hospitals Administration Outcomes 132

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 266

EKG/ECG Shock Wellness 266

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 55

Sepsis Shock EMS Emergency Department 55

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 104

EKG/ECG Resuscitation Shock Wellness 104

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 95

Shock Emergency Department Pediatrics EKG/ECG 95

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 248

EKG/ECG Shock Wellness 248

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

PEMBlog

OCTOBER 18, 2023

The night prior to presentation, mom noticed he was not feeding as well and seemed fussy. Initially in the emergency department he was generally well-appearing with normal vital signs. Neonatal Toxic Shock Syndrome C. Neonatal Toxic Shock Syndrome-Like Exanthematous Disease E. Overnight, she had to wake him to feed.

Infectious Diseases 59

Infectious Diseases Shock Pediatrics Wellness 59