Ahead of Print: Demystifying the Pediatric ECG
  Emergency physicians are able to quickly decode the ciphers of ECGs into meaningful clinical data, at least until they are faced with a pediatric ECG. It breaks their pattern recognition, and they are forced to use the slow part of their brain (recommended reading: Daniel Kahneman’s Thinking, Fast and Slow). Even though the pediatric ECG looks vaguely similar to all of the other ECGs seen during a shift, this one turns into a mystery and confidence drains. It doesn’t look normal based on an adult tracing, but they are unsure if it’s normal for the child. The best ECG readers can resort to folding ...
Source: Spontaneous Circulation - August 3, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Ahead of Print: Demystifying the Pediatric ECG
  Emergency physicians are able to quickly decode the ciphers of ECGs into meaningful clinical data, at least until they are faced with a pediatric ECG. It breaks their pattern recognition, and they are forced to use the slow part of their brain (recommended reading: Daniel Kahneman’s Thinking, Fast and Slow). Even though the pediatric ECG looks vaguely similar to all of the other ECGs seen during a shift, this one turns into a mystery and confidence drains. It doesn’t look normal based on an adult tracing, but they are unsure if it’s normal for the child. The best ECG readers can resort to folding t...
Source: Spontaneous Circulation - August 3, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Demystifying the Pediatric ECG
  Emergency physicians are able to quickly decode the ciphers of ECGs into meaningful clinical data, at least until they are faced with a pediatric ECG. It breaks their pattern recognition, and they are forced to use the slow part of their brain (recommended reading: Daniel Kahneman’s Thinking, Fast and Slow). Even though the pediatric ECG looks vaguely similar to all of the other ECGs seen during a shift, this one turns into a mystery and confidence drains. It doesn’t look normal based on an adult tracing, but they are unsure if it’s normal for the child. The best ECG readers can resort to folding t...
Source: Spontaneous Circulation - August 3, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Patient's Lie Masks the Cause of Chest Pain
A man in his 30s comes to your emergency department at 3 a.m. profoundly diaphoretic and reporting severe 10/10 chest pain. He has been at a party all night, and the chest pain started about 30 minutes earlier. He had a previous heart attack, but cannot remember many of the details. He reports no medication or drug use. No doubt this is a concerning presentation, and you immediately order an ECG, blood work, and an aspirin.   While this is in process, you review the electronic medical information, which reveals that the previous “heart attack” was actually observation for chest pain rule-out. The ECG sho...
Source: Spontaneous Circulation - July 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Patient's Lie Masks the Cause of Chest Pain
A man in his 30s comes to your emergency department at 3 a.m. profoundly diaphoretic and reporting severe 10/10 chest pain. He has been at a party all night, and the chest pain started about 30 minutes earlier. He had a previous heart attack, but cannot remember many of the details. He reports no medication or drug use. No doubt this is a concerning presentation, and you immediately order an ECG, blood work, and an aspirin.   While this is in process, you review the electronic medical information, which reveals that the previous “heart attack” was actually observation for chest pain rule-out. The ECG showe...
Source: Spontaneous Circulation - July 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Forty-Year Struggle for Openness
In 1977, while I was busy with Star Wars and action figures, Andreas Gruentzig was using his kitchen-made balloon catheter to dilate and open a highly stenotic LAD coronary artery. Fixing atherosclerotic disease of the coronary arteries had previously required open heart bypass surgery, a procedure only 10 years old at the time. He had taken coronary catheterization, which until then had only been used for diagnostics and surgical planning, and became the first to perform transluminal interventional therapy. Unfortunately, it turned out that the coronary artery would often close either immediately or over the following day...
Source: Spontaneous Circulation - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Forty-Year Struggle for Openness
In 1977, while I was busy with Star Wars and action figures, Andreas Gruentzig was using his kitchen-made balloon catheter to dilate and open a highly stenotic LAD coronary artery. Fixing atherosclerotic disease of the coronary arteries had previously required open heart bypass surgery, a procedure only 10 years old at the time. He had taken coronary catheterization, which until then had only been used for diagnostics and surgical planning, and became the first to perform transluminal interventional therapy. Unfortunately, it turned out that the coronary artery would often close either immediately or over the following day...
Source: Spontaneous Circulation - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Leading Cause of Failure
Pacemaker and implantable cardioverter defibrillator development has revolutionized the treatment of many kinds of cardiac diseases. The technology advancements have been tremendous, and once-large external batteries are now replaced by gumstick-sized modules as sophisticated as any computer. Unfortunately, the leads that provide sensing, pacing, and defibrillation represent a vulnerable part of the system, and have short- and long-term failure modes. Failure modes can cause a spectrum of issues from minor annoyances to catastrophic failure and death. Failure usually requires replacement of the generator, leads, or both, w...
Source: Spontaneous Circulation - May 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Leading Cause of Failure
Pacemaker and implantable cardioverter defibrillator development has revolutionized the treatment of many kinds of cardiac diseases. The technology advancements have been tremendous, and once-large external batteries are now replaced by gumstick-sized modules as sophisticated as any computer. Unfortunately, the leads that provide sensing, pacing, and defibrillation represent a vulnerable part of the system, and have short- and long-term failure modes. Failure modes can cause a spectrum of issues from minor annoyances to catastrophic failure and death. Failure usually requires replacement of the generator, leads, or both, w...
Source: Spontaneous Circulation - May 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A History of General Refrigeration
Ancient societies figured out that hypothermia was useful for hemorrhage control, but it was Hippocrates who realized that body heat could be a diagnostic tool. He caked his patients in mud, deducing that warmer areas dried first.   Typhoid fever, the plague of Athens in 400 BC and the demise of the Jamestown Colony in the early 1600s, led Robert Boyle to attempt to cure it around 1650 by dunking patients in ice-cold brine. This is likely the first application of therapeutic hypothermia, but it failed to lower the 30 to 40 percent mortality rate. One hundred years later, James Currie tried to treat fevers by applyin...
Source: Spontaneous Circulation - March 31, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A History of General Refrigeration
Ancient societies figured out that hypothermia was useful for hemorrhage control, but it was Hippocrates who realized that body heat could be a diagnostic tool. He caked his patients in mud, deducing that warmer areas dried first.   Typhoid fever, the plague of Athens in 400 BC and the demise of the Jamestown Colony in the early 1600s, led Robert Boyle to attempt to cure it around 1650 by dunking patients in ice-cold brine. This is likely the first application of therapeutic hypothermia, but it failed to lower the 30 to 40 percent mortality rate. One hundred years later, James Currie tried to treat fevers by applying ...
Source: Spontaneous Circulation - March 31, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Curious Consequences of the Lessor Metals
The vagaries of any list or group are that invariably some members are far more popular than others. Hyperkalemia gets all of the attention when we talk about the cardiac effects of electrolyte abnormalities. It is certainly important (read: life-threatening), and we have multiple life-saving treatments that lend themselves well to testing.   We are well versed in hyperkalemia, though one of its treatments has become controversial (I am looking at you, kayexalate). But other electrolyte abnormalities beyond hyperkalemia also deserve attention.   Hypokalemia: The potassium level in the body is closely regulate...
Source: Spontaneous Circulation - March 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Curious Consequences of the Lessor Metals
The vagaries of any list or group are that invariably some members are far more popular than others. Hyperkalemia gets all of the attention when we talk about the cardiac effects of electrolyte abnormalities. It is certainly important (read: life-threatening), and we have multiple life-saving treatments that lend themselves well to testing.   We are well versed in hyperkalemia, though one of its treatments has become controversial (I am looking at you, kayexalate). But other electrolyte abnormalities beyond hyperkalemia also deserve attention.   Hypokalemia: The potassium level in the body is closely regulated, b...
Source: Spontaneous Circulation - March 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Maleficent Troponins
We physicians are obsessed with classifying, sorting, and differentiating in a quest for never-ending precision. We gather all manner of “facts” from our patients. Sights, smells, reactions to pushing or pulling. We divine sounds with antiquated stethoscopes or peer underneath the skin with ultrasound. We subject them to tests of blood, urine, and fluids from any place our needles can reach.     All of this is to arrive at an exact diagnosis that is often frustrated by the secondary nature of the data. Our disappointment has driven us mad, but the promise of exactness from biomarkers leaves us gidd...
Source: Spontaneous Circulation - February 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Maleficent Troponins
We physicians are obsessed with classifying, sorting, and differentiating in a quest for never-ending precision. We gather all manner of “facts” from our patients. Sights, smells, reactions to pushing or pulling. We divine sounds with antiquated stethoscopes or peer underneath the skin with ultrasound. We subject them to tests of blood, urine, and fluids from any place our needles can reach.     All of this is to arrive at an exact diagnosis that is often frustrated by the secondary nature of the data. Our disappointment has driven us mad, but the promise of exactness from biomarkers leaves us giddy. ...
Source: Spontaneous Circulation - January 30, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Wire
Nursing home staff became concerned about a patient because he was “floppy.” He was a 59-year-old man with stage 3 chronic kidney disease, right ventricular heart failure, hypertension, cirrhosis, and insulin-dependent type 2 diabetes mellitus. He had been sleeping all day, according to his nurse, but he was not responding when she checked on him in the evening, and she could “drop his arm and it would just hit his face.”   He was hypotensive (90/50 mm Hg) and bradycardic (about 30 beats/min) in the ED. Respirations were slow and shallow. He was protecting his airway, but was hypoxic (SpO2 82...
Source: Spontaneous Circulation - December 9, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Wire
Nursing home staff became concerned about a patient because he was “floppy.” He was a 59-year-old man with stage 3 chronic kidney disease, right ventricular heart failure, hypertension, cirrhosis, and insulin-dependent type 2 diabetes mellitus. He had been sleeping all day, according to his nurse, but he was not responding when she checked on him in the evening, and she could “drop his arm and it would just hit his face.”   He was hypotensive (90/50 mm Hg) and bradycardic (about 30 beats/min) in the ED. Respirations were slow and shallow. He was protecting his airway, but was hypoxic (SpO2 82%)...
Source: Spontaneous Circulation - December 9, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Techniques that May Actually Save Your V-Fib Patient
Winning teams have depth, and games are often won from the bench or deep in the batting order. That is certainly true when competing against ventricular fibrillation, and a few tools you might not know can help these patients.   A 55-year-old man with severe coronary heart disease and previous four-vessel coronary artery bypass surgery collapsed at a mall. He also had an unprotected left main atherosclerotic plaque. Bystanders immediately began chest compressions, and the available AED, unfortunately, advised no shock. Paramedics started bag-valve-mask ventilation and high-quality mechanical compressions with a Luc...
Source: Spontaneous Circulation - October 1, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Techniques that May Actually Save Your V-Fib Patient
Winning teams have depth, and games are often won from the bench or deep in the batting order. That is certainly true when competing against ventricular fibrillation, and a few tools you might not know can help these patients.   A 55-year-old man with severe coronary heart disease and previous four-vessel coronary artery bypass surgery collapsed at a mall. He also had an unprotected left main atherosclerotic plaque. Bystanders immediately began chest compressions, and the available AED, unfortunately, advised no shock. Paramedics started bag-valve-mask ventilation and high-quality mechanical compressions with a Lucas ...
Source: Spontaneous Circulation - October 1, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Secrets Behind the Curtain
“Doc to the radio phone,” went the call over the PA. This is often just medics notifying about a diabetic refusing transport or stopping a futile code, though like most of emergency medicine, it can be anything. Then we heard, “STEMI. Activating prehospital.” EMS had been called to the house of a 54-year-old man. He had been experiencing chest pain on and off for several weeks. The most recent episode began about 30 minutes prior to ED arrival. He described 8/10 retrosternal pressure that radiated down his arms. He was tachypneic, but denied shortness of breath and was not hypoxic. Other vital sig...
Source: Spontaneous Circulation - September 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Secrets Behind the Curtain
“Doc to the radio phone,” went the call over the PA. This is often just medics notifying about a diabetic refusing transport or stopping a futile code, though like most of emergency medicine, it can be anything. Then we heard, “STEMI. Activating prehospital.” EMS had been called to the house of a 54-year-old man. He had been experiencing chest pain on and off for several weeks. The most recent episode began about 30 minutes prior to ED arrival. He described 8/10 retrosternal pressure that radiated down his arms. He was tachypneic, but denied shortness of breath and was not hypoxic. Other vital signs...
Source: Spontaneous Circulation - September 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Pains of Separation
When a patient arrives to your ED fresh from karate class still in her uniform, you get a feeling about where the case is heading. This patient was 49, and reported that she always had some aches after karate. This evening, though, her pain was very different — and much more concerning. The pain had started about an hour into her class and worsened over the next 30 minutes. It was a severe achy pain over her left chest that radiated to her neck and was associated with pronounced diaphoresis. This prompted an expedited cardiac workup.   The ECG showed a sinus tachycardia with ST-elevation in V2-V3, I, aVR, aVL,...
Source: Spontaneous Circulation - August 5, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Pains of Separation
When a patient arrives to your ED fresh from karate class still in her uniform, you get a feeling about where the case is heading. This patient was 49, and reported that she always had some aches after karate. This evening, though, her pain was very different — and much more concerning. The pain had started about an hour into her class and worsened over the next 30 minutes. It was a severe achy pain over her left chest that radiated to her neck and was associated with pronounced diaphoresis. This prompted an expedited cardiac workup.   The ECG showed a sinus tachycardia with ST-elevation in V2-V3, I, aVR, aVL, w...
Source: Spontaneous Circulation - August 5, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Out of the Routine
Our patient was having an uneventful and ordinary day. He got his children off to school, and spent the morning at the office completing paperwork. By noon he had eaten lunch, and went to the company workout center. It was Wednesday, so it was arms day. He started as he always did with 20 minutes of cardio on the elliptical machine, then shoulders, biceps, triceps, forearms — big muscle to small muscle. It was at the end of his first rep of triceps that things changed.   He felt some dizziness, and the nausea began within 30 seconds or so. He couldn't hold himself upright, and slouched sideways off the bench o...
Source: Spontaneous Circulation - July 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Out of the Routine
Our patient was having an uneventful and ordinary day. He got his children off to school, and spent the morning at the office completing paperwork. By noon he had eaten lunch, and went to the company workout center. It was Wednesday, so it was arms day. He started as he always did with 20 minutes of cardio on the elliptical machine, then shoulders, biceps, triceps, forearms — big muscle to small muscle. It was at the end of his first rep of triceps that things changed.   He felt some dizziness, and the nausea began within 30 seconds or so. He couldn't hold himself upright, and slouched sideways off the bench ont...
Source: Spontaneous Circulation - July 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Unexpected Turns
She watched the Camry coming straight at her, obeying the laws that Newton laid out: a body in motion stays in motion until an external force intercedes.   Her husband, daughter, and the TV weatherman had told her not to go out. Ice had descended on the city earlier in the day, making even the walk to the garage precarious. But she needed milk to make a cake for the next day’s party, and the store was only three blocks away. Her plan was simple: store, milk, home. That might have worked if not for the Camry that became a hockey puck on the ice.   The next couple of hours were a blur but proceeded as rea...
Source: Spontaneous Circulation - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Unexpected Turns
She watched the Camry coming straight at her, obeying the laws that Newton laid out: a body in motion stays in motion until an external force intercedes.   Her husband, daughter, and the TV weatherman had told her not to go out. Ice had descended on the city earlier in the day, making even the walk to the garage precarious. But she needed milk to make a cake for the next day’s party, and the store was only three blocks away. Her plan was simple: store, milk, home. That might have worked if not for the Camry that became a hockey puck on the ice.   The next couple of hours were a blur but proceeded as readers...
Source: Spontaneous Circulation - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Upstream Problems
He had been through this before. The patient, a 57-year-old man, had come through the doors of this emergency department many times. He had a favorite seat in triage. He knew what questions the nurse would ask him once he was in a room, and that the doctor would repeat those same questions. Then tests and labs, then moved upstairs for a couple of days before going home, hopefully feeling better. He knew all of this. Today, though, everything he thought he knew was wrong. He had once considered himself lucky. He even survived a gunshot to the chest as a young man. But that notion had faded long ago. His health had been get...
Source: Spontaneous Circulation - May 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Upstream Problems
He had been through this before. The patient, a 57-year-old man, had come through the doors of this emergency department many times. He had a favorite seat in triage. He knew what questions the nurse would ask him once he was in a room, and that the doctor would repeat those same questions. Then tests and labs, then moved upstairs for a couple of days before going home, hopefully feeling better. He knew all of this. Today, though, everything he thought he knew was wrong. He had once considered himself lucky. He even survived a gunshot to the chest as a young man. But that notion had faded long ago. His health had been gett...
Source: Spontaneous Circulation - May 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Narrow Gate
The patient first felt winded one night after doing the dishes. She was breathing so hard by morning that she was barely able to get out of bed. And a cough had started. “The flu” went through her mind. She stayed home from work to rest, but all day she just couldn’t catch her breath. The cough got worse and was making her chest hurt, and she felt her heart racing. She was exhausted by evening, but knew she wasn’t going to be able to sleep. The temperature was below 0°F outside, but she bundled up and drove herself the three miles to the emergency department. Barely able to speak by the time she...
Source: Spontaneous Circulation - April 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Narrow Gate
The patient first felt winded one night after doing the dishes. She was breathing so hard by morning that she was barely able to get out of bed. And a cough had started. “The flu” went through her mind. She stayed home from work to rest, but all day she just couldn’t catch her breath. The cough got worse and was making her chest hurt, and she felt her heart racing. She was exhausted by evening, but knew she wasn’t going to be able to sleep. The temperature was below 0°F outside, but she bundled up and drove herself the three miles to the emergency department. Barely able to speak by the time she...
Source: Spontaneous Circulation - April 7, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Stressing Situation
A 64-year-old woman presented to the emergency department with two days of severe nausea, numerous episodes of vomiting, and progressively worsening right upper quadrant/epigastric abdominal pain. She was continuously spitting clear secretions into an emesis bag on arrival in triage. Her 8/10 dull ”ripping” pain originated in the right upper quadrant and radiated in a band-like pattern to her epigastrium. She was not experiencing any chest pain or shortness of breath. Her medical history included hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery d...
Source: Spontaneous Circulation - March 10, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Stressing Situation
A 64-year-old woman presented to the emergency department with two days of severe nausea, numerous episodes of vomiting, and progressively worsening right upper quadrant/epigastric abdominal pain. She was continuously spitting clear secretions into an emesis bag on arrival in triage. Her 8/10 dull ”ripping” pain originated in the right upper quadrant and radiated in a band-like pattern to her epigastrium. She was not experiencing any chest pain or shortness of breath. Her medical history included hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery d...
Source: Spontaneous Circulation - March 10, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

More Than a Number
A 68-year-old woman with a history of schizophrenia, severe coronary artery disease, hypertension, and type 2 diabetes mellitus was found in her bed minimally responsive by staff at the group home where she lived. She had been discharged from the hospital two days earlier with a diagnosis of segmental pulmonary embolism and on Coumadin anticoagulation. Lower extremity Doppler ultrasounds were negative for deep vein thrombosis during that hospitalization.   EMS brought her to the emergency department, and had intubated for airway protection. She was febrile, tachycardic, and hypotensive, and had a hemoglobin of 4 g/d...
Source: Spontaneous Circulation - February 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

More Than a Number
A 68-year-old woman with a history of schizophrenia, severe coronary artery disease, hypertension, and type 2 diabetes mellitus was found in her bed minimally responsive by staff at the group home where she lived. She had been discharged from the hospital two days earlier with a diagnosis of segmental pulmonary embolism and on Coumadin anticoagulation. Lower extremity Doppler ultrasounds were negative for deep vein thrombosis during that hospitalization.   EMS brought her to the emergency department, and had intubated for airway protection. She was febrile, tachycardic, and hypotensive, and had a hemoglobin of 4 g/dL....
Source: Spontaneous Circulation - February 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Constricting Diagnosis
The heart, vasculature, and blood (pump, pipes, and fluid) work together to meet the metabolic demands of the body. End organs and tissue are not adequately perfused when the system fails, leading to injury and deranged physiology. Understanding the hemodynamic relations in normal cardiovascular physiology and how it changes in pathologic conditions helps us make the correct diagnosis and implement the right treatment.   Physical examination can provide indirect clues to hemodynamics, though invasive evaluation has been the traditional gold standard. This can include arterial and central venous pressure measurements...
Source: Spontaneous Circulation - December 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Constricting Diagnosis
The heart, vasculature, and blood (pump, pipes, and fluid) work together to meet the metabolic demands of the body. End organs and tissue are not adequately perfused when the system fails, leading to injury and deranged physiology. Understanding the hemodynamic relations in normal cardiovascular physiology and how it changes in pathologic conditions helps us make the correct diagnosis and implement the right treatment.   Physical examination can provide indirect clues to hemodynamics, though invasive evaluation has been the traditional gold standard. This can include arterial and central venous pressure measurements, ...
Source: Spontaneous Circulation - December 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Sweet Wide Complex Tachycardia
A 29-year-old man with history of type 1 diabetes mellitus presents with two weeks of feeling ill that became worse over the previous two days. This included a productive cough, subjective fevers, and frequent vomiting. He reports no headache, chest pain, or abdominal pain. He has had financial problems after losing his job about a month earlier, and is currently living in a local motel. His brother brought him to the emergency department for evaluation after finding him in bed confused, with vomit on the floor.   He appeared ill, and was oriented only to self. Vital signs were blood pressure 78/43 mm Hg, pulse 146 ...
Source: Spontaneous Circulation - November 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Sweet Wide Complex Tachycardia
A 29-year-old man with history of type 1 diabetes mellitus presents with two weeks of feeling ill that became worse over the previous two days. This included a productive cough, subjective fevers, and frequent vomiting. He reports no headache, chest pain, or abdominal pain. He has had financial problems after losing his job about a month earlier, and is currently living in a local motel. His brother brought him to the emergency department for evaluation after finding him in bed confused, with vomit on the floor.   He appeared ill, and was oriented only to self. Vital signs were blood pressure 78/43 mm Hg, pulse 146 bp...
Source: Spontaneous Circulation - November 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Take Me Out to the Ballgame
A 31-year-old man presented to the ED with syncope. He was previously healthy, takes no medications, and had run a marathon the day before. He was riding the light rail home from a baseball game when he developed vague 4/10 epigastric abdominal pain associated with nausea and diaphoresis. He remembers feeling lightheaded and flushed before momentarily passing out. His wife said he became quite pale immediately beforehand. He did not have any headache, chest pain, or shortness of breath before or after the syncopal episode. He has a significant family history of premature coronary artery disease. He had normal vital s...
Source: Spontaneous Circulation - October 11, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Take Me Out to the Ballgame
A 31-year-old man presented to the ED with syncope. He was previously healthy, takes no medications, and had run a marathon the day before. He was riding the light rail home from a baseball game when he developed vague 4/10 epigastric abdominal pain associated with nausea and diaphoresis. He remembers feeling lightheaded and flushed before momentarily passing out. His wife said he became quite pale immediately beforehand. He did not have any headache, chest pain, or shortness of breath before or after the syncopal episode. He has a significant family history of premature coronary artery disease. He had normal vital si...
Source: Spontaneous Circulation - October 11, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Arrhythmia Masquerading as Cardiac Ischemia
A 45-year-old woman with a history of medication-controlled essential hypertension, stage 2 chronic kidney disease, type 2 diabetes mellitus, and a pack-a-day cigarette habit presented less than 60 minutes after acute onset of severe shortness of breath that awoke her from sleep. She had felt well the previous day, and went to bed with no complaints.   Around 4 a.m., she woke up from sleep very dyspneic, with moderate chest “discomfort” over her left chest that radiated to her back and was unchanged by position or respirations. She denied other symptoms such as fever, cough, nausea, vomiting, numbness, o...
Source: Spontaneous Circulation - September 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Arrhythmia Masquerading as Cardiac Ischemia
A 45-year-old woman with a history of medication-controlled essential hypertension, stage 2 chronic kidney disease, type 2 diabetes mellitus, and a pack-a-day cigarette habit presented less than 60 minutes after acute onset of severe shortness of breath that awoke her from sleep. She had felt well the previous day, and went to bed with no complaints.   Around 4 a.m., she woke up from sleep very dyspneic, with moderate chest “discomfort” over her left chest that radiated to her back and was unchanged by position or respirations. She denied other symptoms such as fever, cough, nausea, vomiting, numbness, or ...
Source: Spontaneous Circulation - September 12, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Myocardial Infarction with Dual Culprit Lesions
A 59-year-old man without prior cardiac history presented with three hours of severe upper sternal chest pressure that radiated to his throat, which he described as “strangulating.” An ECG was obtained, and is shown here. It demonstrates a sinus rhythm at rate of approximately 75 bpm. The PR and QT intervals are normal. There is concerning 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3, suggestive of a posterior myocardial infarction. The initial ECG was concerning for 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3. This is suggestive of a posterior my...
Source: Spontaneous Circulation - July 18, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Myocardial Infarction with Dual Culprit Lesions
A 59-year-old man without prior cardiac history presented with three hours of severe upper sternal chest pressure that radiated to his throat, which he described as “strangulating.” An ECG was obtained, and is shown here. It demonstrates a sinus rhythm at rate of approximately 75 bpm. The PR and QT intervals are normal. There is concerning 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3, suggestive of a posterior myocardial infarction. The initial ECG was concerning for 1 mm of ST-elevation in V5 and V6 with ST-segment depression in V2 and V3. This is suggestive of a posterior myocar...
Source: Spontaneous Circulation - July 18, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs