Chest pain, RBBB but “STEMI Negative”: Is this a false cath lab activation, or a false cancellation?
A 90 year old with a history of atrial fibrillation presented with two weeks of intermittent retrosternal chest pain lasting minutes. An hour prior to presentation it became constant and more severe, accompanied by nausea and general weakness, and the paramedics brought them to the ED as a code STEMI. Heart rate was in the 50s and other vitals normal. What do you think? There ’s atrial fibrillation, a right bundle branch block, normal axis and normal voltages. RBBB should produce secondary ST depression and T wave inversion in the anterior leads with the RsR’ (as it does in V1). But here in...
Source: Dr. Smith's ECG Blog - July 18, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Quiz post - which of these, if any, are OMI? What is the South African Flag Sign? Will you activate the cath lab? Can you tell the difference on ECG?
Written by Pendell Meyers, additions and edits by Grauer, Smith, McLarenBelow we have 5 cases of adults (ranging from 40-70 years old) who all presented to the ED with acute nontraumatic chest pain that sounded at least somewhat like potential ACS to the provider. You should look at each ECG and decide if it is OMI, not OMI, or something else.Our goal in this post is to compare and contrast OMIs with false positives that mimic them. In this post we will examine the anterolateral distribution that has been described as the " South African Flag Sign. " (SAFS)It is very hard to describe why an ECG expert can easily...
Source: Dr. Smith's ECG Blog - May 11, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Simplifying Opioid Conversions
by Drew Rosielle (@drosielle)A Satirical Monologue in One Act:“Ok, 3rd year resident, let’s talk about rotating opioids. What do I mean by ‘rotating’ opioids? It’s just therapeutically switching one opioid with another. It’s um, like, a turnstile, I guess? Anyway--first let’s look at this equianalgesic table. Do you know what equianalgesia means? No? It is the concept that different opioids have the same analgesic power but at different milligram doses due to different potencies. That is, the idea that, say, 50 mg of oral morphine has the same analgesic power as 10 mg of hydromorphone. So 50 mg of oral morphi...
Source: Pallimed: A Hospice and Palliative Medicine Blog - May 2, 2022 Category: Palliative Care Tags: opioid rosielle Source Type: blogs
A man in his 60s with chest pain. Cardiologist refuses to take to the lab. Obvious STEMI, even with criteria. Yet final diagnosis " NSTEMI " . This happens far too often.
Submitted by Anonymous MD, edits by MeyersA man in his 60s with past medical history of multiple sclerosis and hypertension was brought in by EMS from home for chest pain thatstarted acutely just prior to arrival. He rated the pain at 9/10, describes as pressure, radiates towards the left arm with associated shortness of breath, diaphoresis and had one episode of emesis. He did not have a prior history of CAD or other cardiac disease. His pain improved to 6/10 after EMS gave him 3 sprays of sublingual nitroglycerin and 324 mg of aspirin. Prehospital ECGs:What do you think?Both ECGs are diagnostic of acute LAD OMI...
Source: Dr. Smith's ECG Blog - April 15, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 50s with acute chest pain and history of prior MI
Written by Pendell MeyersA man in his 50s with prior history of anterior MI with LAD stent presented with acute chest pain similar but more intense than his last MI. He presented around midnight with pain that had started around 9pm the night before. He had taken NTG at home with no improvement, and immediately received morphine on arrival at the ED for severe chest pain (a very bad idea if your accuracy for finding OMI on ECG is low, since ongoing pain will be your last chance to identify those with ongoing untreated OMI).Here is his triage ECG at 0012:What do you think? What is the differential of this ECG?There is sinus...
Source: Dr. Smith's ECG Blog - April 13, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
The true story of morphine milligram equivalents
They are the foundation of the CDC’s 2016 opioid guidelines, resulting in legislation limiting opioid prescribing in 36 states. Morphine milligram equivalents, or MMEs, are used to set arbitrary prescribing limits for opioids by physicians since many state legislators fail to understand — and translate into policy and law — the’16 guidelines. If weRead more …The true story of morphine milligram equivalents originally appeared inKevinMD.com. (Source: Kevin, M.D. - Medical Weblog)
Source: Kevin, M.D. - Medical Weblog - March 26, 2022 Category: General Medicine Authors: < span itemprop="author" > < a href="https://www.kevinmd.com/post-author/charles-dinerstein" rel="tag" > Charles Dinerstein, MD, MBA < /a > < /span > Tags: Meds Pain Management Source Type: blogs
Opioid Equianalgesic Tables are Broken
by Drew Rosielle (@drosielle)I am proposing we do away with equianalgesic table (EAT) as a tool to inform clinical decisions about opioid rotations/conversions. Fundamentally, EATs create too many problems, and there are simpler and safer ways to teach clinicians how to convert between different opioids.Part 1: New Data Can ' t Fix the EATA couple HPM fellows every year ask me which table do I prefer to use —the old EAT or the new one? By the old one, they refer to the table most of us used or were at least deeply familiar with for the last 10-20 years. By the new one, they mean the one created by Dr. Mary Lynn McPherson...
Source: Pallimed: A Hospice and Palliative Medicine Blog - March 21, 2022 Category: Palliative Care Tags: opioid pain rosielle Source Type: blogs
False cath lab activation or false cancellation?
Written by Jesse McLarenA 40 year old developed sudden chest pain radiating to the jaw, with diaphoresis and vomiting. What do you think?What do you think? There ’s normal sinus rhythm with normal conduction, normal axis, normal R wave progression and normal voltages. There are hyperacute T wave in I/aVL and possibly V5-6, with reciprocal change in III. There’s also ST depression in V1-3. The computer interpretation labeled this ECG as “nonspecific”, and it does not meet STEMI criteria. But there are ischemic abnormalities in the majority of leads that add up to an ECG diagnostic of posterolateral Occlusion MI...
Source: Dr. Smith's ECG Blog - March 16, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
What's new in midwifery - other research
This study looked at nulliparous women.Ameta analysis looking at side effects in transversus abdominis plane block versus intrathecal morphine following caesarean. A systematic review of randomised trials of theeffects of continuous glucose monitoring on maternal and neonatal outcomes in perinatal women with diabetes. A study from the Netherlands looking at theuse of the Rotterdam Reproductive Risk Reduction checklist to identify risk factors for growth and development in children.A study from Spain looking atmidwives ' experiences of working with women who have been victims of sex trafficking.&...
Source: Browsing - March 11, 2022 Category: Databases & Libraries Tags: midwifery Source Type: blogs
Did the posterior leads help here? Why not just get good at STDmaxV1-V4?
Written by Pendell MeyersA middle aged woman presented with chest pain and dyspnea. Her exam and vitals were within normal limits. Here is her triage ECG:What do you think?There is sinus rhythm with a relatively normal QRS (except for the substantial positive QRS component in V2). There is STD in V2-V4, with no QRS explanation, and downsloping ST morphology in V2 and horizontal morphology in V3-4. Thus, there is posterior OMI until proven otherwise, because of STD maximal in V1-V4. There is also subtle evidence of inferior OMI, with slight STD and TWI in aVL with suspiciously full upright T waves in the III and ...
Source: Dr. Smith's ECG Blog - December 27, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
A man his 50s with chest pain. What happens when you treat with morphine rather than with reperfusion?
Written by Pendell MeyersA man in his late 50s presented to the ED with 3 days of left chest pain radiating into the jaw and neck. He described it as " heartburn. " The pain radiates into his left arm and causes numbness and tingling from time to time. The history does not state what changed on day 3 that made him finally present to the ED; the history has no details as to whether the pain was off and on, or fluctuating, or whether the pain become persistent soon before arrival (these are key details and would help with many important questions we will have below!). Vitals were normal, and his triage ECG is below, at...
Source: Dr. Smith's ECG Blog - December 17, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
Even when the story is obvious, with intractable pain, the STEMI paradigm can cause preventable delays
Written by Pendell MeyersA man in his early 60s presented with acute chest pain rated 10/10 with associated nausea and vomiting with known history of multivessel CAD. He presented at 2300 with onset of symptoms at 2230. He was awoken from sleep by the symptoms, which were identical to prior MI for which he received a stent years ago. On arrival his heart rate was 43 bpm and blood pressure 91/62. Atropine and IV fluid was given.Here was his triage ECG:What do you think? Baseline below for comparison, but try first without it.His baseline ECG was available on file:The presentation ECG shows diagnostic evidence of poste...
Source: Dr. Smith's ECG Blog - December 1, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
poem
Op Note IXI was alone at a research station in Antarctica. No assistants available. No high end equipment. I had gone south in order to experience absolute zero. Foolish. Conceited. But I needed everything to slow down, be still. A place where even piercing screams hung silent in the frozen air. Nothing moves, neither particle nor wave. When the pain came I acted quickly. Knife, iodine, a mirror that kept fogging. You say you could never do it but we cut into ourselves everyday. Claw at the inside of our skulls. Promise enduring ardor and then break the hearts of our very own souls over ...
Source: Buckeye Surgeon - October 31, 2021 Category: Surgery Authors: Jeffrey Parks MD FACS Source Type: blogs
poem
Op Note IXI was alone at a research station in Antarctica. No assistants available. No high end equipment. I had gone south in order to experience absolute zero. Foolish. Conceited. But I needed everything to slow down, be still. A place where even piercing screams hung silent in the frozen air. Nothing moves, neither particle nor wave. When the pain came I acted quickly. Knife, iodine, a mirror that kept fogging. You say you could never do it but we cut into ourselves everyday. Claw at the inside of our skulls. Promise enduring ardor and then break the hearts of our very own souls over ...
Source: Buckeye Surgeon - October 31, 2021 Category: Surgery Authors: Jeffrey Parks MD FACS Source Type: blogs
A man in his 60s woken from sleep by epigastric pain. Would you have been able to correctly diagnose him?
Written by Pendell MeyersA man in his mid 60s with history of CAD and stents experienced sudden onset epigastric abdominal pain radiating up into his chest at home, waking him from sleep. He called EMS who brought him to the ED. He had active chest pain at the time of triage at 0137 at night, with this triage ECG:I sent this ECG, without any text at all, to Dr. Smith, and he replied: " LAD OMI with low certainty. V3 is the one that is convincing. " After his response I sent him the baseline ECG (below), still with no context at all except that this was his prior ECG:Dr. Smith replied: " Now high certainty. By the way,...
Source: Dr. Smith's ECG Blog - October 5, 2021 Category: Cardiology Authors: Pendell Source Type: blogs
