The Hugest of the Huge Hematomas
Welcome to our new series, “Guts and Gore.” That title should serve as a warning that some of the videos we will use as teaching tools may be controversial and not for weak stomachs. We hope, however, that part of why you became an emergency provider was to handle sticky situations like the ones we will present. People like us have the ability to ignore blood and copious discharge, and instead focus on saving and improving the lives of our patients. Rarely are you thanked for this ability, and we hope this series on guts and gore will improve your technique, even when the going gets tough.
The Approach
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Source: The Procedural Pause - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Look at II, III, aVF in this case, and the outcome.....
I just posted this case:Isolated "Inferior" ST Segment Depression: Not a Sign of Inferior IschemiaToday I post another case that nicely demonstrates the significance of inferior ST depression.A middle-aged female presented to the ED with chest pain. It had been intermittent all day.Here was her first ED ECG with active pain:There are abnormal ST segments in "inferior" leads, and very subtle STE in aVL, with T-wave inversion. There are "down-up" T-waves in the inferior leads, which are almost always due to ischemia. (Up-down T-waves are sometimes due to hypokalemia - the upright "T" wave is actually a U-wave...
Source: Dr. Smith's ECG Blog - May 24, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs
Coronary Stents
Coronary stents are tiny spring like structures implanted in coronary arteries to maintain their lumen after balloon angioplasty. They help to prevent immediate recoil and closure of the vessel after angioplasty. Sometimes when there is a tear in the layers of the vessel known as dissection, the stents help to seal off the tear. Use of stents allow us to achieve better luminal diameter than plain old balloon angioplasty (POBA).
Coronary stents are made up of various materials. The popular bare metal stents are the stainless steel stents and cobalt chromium stents. Cobalt chromium stents are superior to stainless steel ste...
Source: Cardiophile MD - May 6, 2015 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Angiography and Interventions Coronary Interventions Source Type: blogs
Research and Reviews in the Fastlane 081
This article reviewed 17,583 adult ED intubations over 10 years at 13 different centers. The study found 95% of intubations were performed by ED physicians with good results: 99% of intubations were successful within 3 attempts.Orotracheal intubation with RSI was, of course, the most common technique, with 85% first pass success rate with this technique. And first pass success rates increased over time during the 10 year period, showing that we are continuing to get better!Interestingly, senior residents had 85% first pass rate, compared to just 72% for attendings.For drugs, etomidate was overwhelmingly the most commonly u...
Source: Life in the Fast Lane - April 30, 2015 Category: Emergency Medicine Authors: Anand Swaminathan Tags: R&R in the FASTLANE critical care Education Emergency Medicine Intensive Care literature recommendations research and reviews Source Type: blogs
Ventricular Fibrillation, Resuscitation, and Hyperacute T-waves: What does the Angiogram show?
An elderly person collapsed and was found to be pulseless. He had immediate bystander CPR. An AED was placed and one shock was given within 5 minutes of arrest. He immediately awoke. EMS arrived and recorded these ECGs:Time = 0Sinus rhythm. Inferior and lateral ST elevation, with hyperacute T-waves in V4-V6.1 min laterNo definite difference.He was stable en route to the ED. On arrival, he was awake and complained of only mild aching left chest pain. He stated that prior to his collapse, he had been walking briskly and was feeling short of breath, but not having any chest pain. He does ha...
Source: Dr. Smith's ECG Blog - April 19, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs
From Scott Weingart EMCrit Interview: Who needs the Cath Lab now??
Who Needs the Cath Lab/Cards Consult?Here is the podcast of Scott's Interview with me . (some of this gets distorted in MS internet explorer)FirstActivate the Lab for unambiguous STEMI (only clear STEMIs have a 90 minute CMS mandate)Get Cardiology or Interventional Consultation for more complicated cases: difficult ECGs, subtle ST elevation, ST depression with ongoing symptoms, STEMI "Equivalents.This requires a systematic approach, with buy-in from Cardiology, that they will respond immmediately to such requests for help. What do they get out of it? Fewer false positive activations and more activatio...
Source: Dr. Smith's ECG Blog - March 29, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs
Interesting Left Main Occlusion....
Many believe that left main occlusion results in diffuse ST depression with ST elevation in aVR. This is not true, as I write about in this post: The difference between left main occlusion and left main insufficiency. This patient presented with ischemic symptoms:There is diffuse ST depression, with ST elevation in aVR.This is consistent with coronary insufficiency, but not coronary occlusion.It could be a tight left main, or a tight LAD, especially with 3-vessel disease.Such patients have about a 50% chance of needing CABG, as shown in an article referenced and described in this post. Therefore, Plav...
Source: Dr. Smith's ECG Blog - February 25, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs
Medications After a Heart Attack
From: www.secondscount.orgYour heart attack recovery will include medications. Taking these medications exactly as prescribed is one of the best tools at your disposal for avoiding death in the months following a heart attack. According to an article published in Circulation, the journal of the American Heart Association, heart attack patients who had not filled any of their prescriptions within 120 days of being discharged from the hospital had 80 percent greater odds of death than those who filled all of their prescriptions.Medications you are likely to be prescribed after a heart attack fall int...
Source: Dr Portnay - January 23, 2015 Category: Cardiology Authors: Dr Portnay Source Type: blogs
Subtle Anterior STEMI Superimposed on Anterior LV Aneurysm Morphology
A male in his early 30s was playing soccer when the ball hit him in the chest. At some point after this, he began having chest pain. The pain radiated into the L arm, and was 8/10 in severity. The pain was similar to pain he had with a previous STEMI, for which he received a bare metal stent in the LAD a couple years prior. He was on no medications. BP was 160/100. Here was his first ED ECG with 8/10 pain:There is sinus rhythm. There is minimal ST Elevation in anterior leads. There is a QS-wave in V2, due to the old anterior MI. The T-wave is taller than expected for old MI. &...
Source: Dr. Smith's ECG Blog - January 22, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs
LITFL Review #165
Welcome to the 165th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.The Most Fair Dinkum Ripper Beauts of the WeekDo you re-spike IV fluid bags? The case of Ruby Chen from gravelessons.com should make us all re-think this. [SO] The Best of #FOAMed Emergency MedicineExcellent discussion of everything you need to know about AFib from EM Cases featuring Ian St...
Source: Life in the Fast Lane - January 19, 2015 Category: Emergency Medicine Authors: Marjorie Lazoff, MD Tags: Education LITFL review Source Type: blogs
LITFL Review 165
Welcome to the 165th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.The Most Fair Dinkum Ripper Beauts of the WeekDo you re-spike IV fluid bags? The case of Ruby Chen from gravelessons.com should make us all re-think this. [SO]The Best of #FOAMed Emergency MedicineExcellent discussion of everything you need to know about AFib from EM Cases featuring Ian Stiell. ...
Source: Life in the Fast Lane - January 19, 2015 Category: Emergency Medicine Authors: Marjorie Lazoff, MD Tags: Education LITFL review Source Type: blogs
Subtle LAD Occlusion with Pseudonormalization of Wellens' Waves.
Here is another patient I saw a few weeks ago He is in his 30's and presented with many hours of chest pain. Here is his initial ECG:The computerized QTc is 361. There is ST elevation in V2-V4. Is it normal ST elevation? Normal ST elevation should have good R-waves and V2 and V3 have Q-waves. So this is not normal ST elevation.STEMI criteria: 2 consecutive leads with ST elevation, defined as 1 mm in V1 and V4-V6, and, for a 35 year old, 2.5 mm in V2 and V3 (at the J-point relative to the PQ junction). This ECG has at most 1 mm in V2, 1.5-2.0 in V3, and 1.5 in V4, so it does not me...
Source: Dr. Smith's ECG Blog - December 17, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
It is Far too Early for a Requiem for Unstable Angina
Dr. Braunwald declared that high sensitivity troponins will make Unstable Angina a thing of the past. That very well may be true, but in the United States we are not yet in the era of high sensitivity troponins. And we do not know what their effect will be.Here are many more cases of Unstable Angina.Unstable AnginaA male in his 50's with no past history presented with new intermittent burning left chest pain, lasting 10 minutes at a time, radiating to the left arm, for 24 hours. He had chest pain just prior to arrival in the ED, but it resolved prior to physician evaluation. He did use cocaine a few...
Source: Dr. Smith's ECG Blog - December 15, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Transient ST elevation, rules out for MI, what is it?
A 70 year old diabetic complained of 6/10 epigastric pain. Here is his initial ECG:There is diffuse ST elevation: II, III, aVF and V3-V6. There is reciprocal ST depression in aVL. This is diagnostic of inferolateral STEMIThe emergency physician activated the cath lab and gave appropriate antiplatelet and antithrombotic therapy.The PCI team came to talk to the patient, and while they were talking, the patient vomited and was pain free thereafter and said he felt much better. They recorded another ECG:The ST elevation is resolved. There can be no other explanation than the patient spontaneously reperf...
Source: Dr. Smith's ECG Blog - December 5, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Dual antiplatelet therapy: More the better?
Dual antiplatelet therapy with aspirin and a thienopyridine (clopidogrel, prasugrel etc) is currently recommended for at least 12 months after implantation of a drug eluting stent (DES) following a percutaneous coronary intervention (PCI). But there have been instances of late stent thrombosis and very late stent thrombosis after DES implantation. Hence the DAPT study (Dual Antiplatelet Therapy) sponsored by the Harvard Clinical Research Institute sought to look at benefits of dual antiplatelet study at 30 months after implantation of a drug eluting stent and bare metal stent. The study results were presented at the Ameri...
Source: Cardiophile MD - November 30, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology Source Type: blogs
