Ken Grauer, MD

MARCH 7, 2023

As a result — cardiac cath ( and reperfusion of an acutely occluded LCx [ = L eft C ircumfle x ] ) artery — was delayed for 9 hours , until markedly elevated troponin values finally brought attention to this case. comparison of RED vs BLUE lines in these leads ). ECG Blog #294 — How to tell IF the "culprit" artery has reperfused.

EKG/ECG 195

EKG/ECG Wellness 195

Ken Grauer, MD

OCTOBER 29, 2023

The talk will be recorded and posted on-line. Figure-5: KEY points in the recognition of isolated posterior MI ( This figure is taken from ECG Blog #193 — in which I review the "Basics" for predicting the "culprit" artery ). = NOTE: These are my "slides" for November 2, 2023 — for my M edALL p resentation.

EKG/ECG 195

EKG/ECG 195

EMDocs

FEBRUARY 12, 2024

Because the RT responsible for drawing arterial blood gases is busy caring for these patients, ABGs will be delayed. ABG and VBG Correlation The correlation between venous and arterial blood gases is well-documented for standard differences (Table 1), and the data obtained from the VBG can be acted on as if it were an ABG (1, 3-6).

Emergency Department 93

Emergency Department Resuscitation COPD Shock 93

The Trauma Pro

MAY 12, 2023

Bottom line: This study is interesting because it gives us a glimpse of the time course of leukocytosis in patients with injured spleens. Splenic artery? I suspect that the WBC count in main splenic artery embolization may behave much like splenectomy in terms of leukocytosis. Superselective? Selective?

130

130

Ken Grauer, MD

MAY 26, 2023

BOTTOM Line: The normal initial troponin — and lack of ST elevation are not reasons for not performing cardiac catheterization. Was the LMain coronary artery the "culprit" ? ECG Blog #80 — What's the Culprit Artery ( and the Mirror Test ). ECG Blog #82 — What’s the Culprit Artery? ECG Blog #316 — The patient died.

EKG/ECG 195

EKG/ECG Wellness Resuscitation 195

Mount Sinai EM

NOVEMBER 14, 2022

Where should I place my Arterial line and pulse ox? In a peripherally cannulated VA ECMO circuit, a right radial arterial line and pulse-ox on the right hand should be placed. Therefore placement of the right radial arterial line and pulse-ox allows for detection of both coronary and cerebral hypoxemia.

Shock 130

Shock Wellness 130

Ken Grauer, MD

OCTOBER 21, 2023

There is ST elevation in lead aVR > V1 ( dotted RED lines in leads in Figure-2 ). BOTTOM Line: Because the situation described above in today's case is clearly unstable — prompt cardiac cath was immediately indicated ( and given the history — prompt cath was indicated as soon as the initial ECG was recorded ).

EKG/ECG 239

EKG/ECG Shock Wellness 239

Ken Grauer, MD

JANUARY 20, 2024

BOTTOM Line: Since many of the P waves in this long lead II rhythm strip occur at points within the R-R interval where they appear to have more than ample opportunity to conduct — yet still fail to do so — some form of 2nd-degree ( if not, 3rd-degree ) AV block is present, in association with marked bradycardia.

EKG/ECG 231

EKG/ECG 231

ACEP Now

MAY 10, 2024

The genicular nerves are named based on their corresponding quadrant of the knee joint (superolateral, superomedial, inferomedial, and inferolateral) and run immediately adjacent to the bone, following the course of the genicular arteries. The probe is placed longitudinally and color Doppler can be used to identify the genicular artery.

Ultrasounds 92

Ultrasounds Emergency Department Hospitals Wellness 92

EB Medicine

JUNE 1, 2023

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the June 2023 Emergency Medicine Practice article, Hypertensive Emergencies: Guidelines and Best Practice Recommendations Epidemiology Etiology Differential diagnosis Prehospital care History and physical Diagnostics Treatment Acute decompensated heart failure Acute ischemic stroke Acute (..)

Best Practices 52

Best Practices Stroke Risk Management 52

EMDocs

APRIL 2, 2024

Check the pulse RSI= Resuscitation Sequence Intubation Hypoxia, Hypotension, and Acidosis are the reason patients code during/post intubation These patients are super high risk for all 4 Optimize first pass success – Induction agent + paralytic Unconscious patients will still have muscle tone Induction Ketamine or Etomidate at half doses (i.e.,

Documentation/Coding 90

Documentation/Coding CPR EKG/ECG Sepsis 90

The Trauma Pro

MARCH 25, 2024

Bottom line: First, use generative AI responsibly. Reference: Successful management of an Iatrogenic portal vein and hepatic artery injury in a 4-month-old female patient: A case report and literature review. And it’s now in the wild for everyone to see. The big question is, how reliable is the rest of the text?

Research 258

Research Radiology Radiology Academics 258

Ken Grauer, MD

MARCH 18, 2023

For example, in Figure-1 — My “eye” was drawn first to the inferior leads ( II,III,aVF ) — each of which show ST segment coving , followed by symmetric T wave inversion ( BLUE lines that I've added to these leads in Figure-2 ). The RCA was confirmed as the culprit artery — and PCI was promptly performed with good result.

EKG/ECG 195

EKG/ECG Wellness 195

Ken Grauer, MD

APRIL 18, 2023

QUESTIONS: There are at least 3 principal findings on this ECG — some of which deal with a possible “culprit” artery and / or the location of whatever is going on. My favorite on-line “Quick GO-TO” reference for the most common types of lead misplacement comes from LITFL ( = L ife- I n- T he- F ast- L ane ). HINT: Is the rhythm sinus

EKG/ECG 195

EKG/ECG Wellness 195

Ken Grauer, MD

JANUARY 26, 2023

Note how the interpolated PVC ( = beat #4 ) slightly prolongs the PR interval of the next sinus-conducted beat ( ie, slight increase in the inclination of the slanted BLUE line in the AV nodal tier ). and , ii ) What is the likely " culprit " artery? ECG Blog #294 — Reviews how to tell IF the "culprit" artery has reperfused.

EKG/ECG 195

EKG/ECG Wellness 195

Taming the SRU

FEBRUARY 23, 2024

Broadstock and Ramachandran Nerve blocks should be a part of your multimodal analgesia toolbox in the ED Basic Equipment: antiseptic cleaner barrier protection needle (EchoBlock needs are specifically designed for regional anesthesia and available in our ED) anesthetic typically 0.5%

Pediatrics 68

Pediatrics Ultrasounds Wellness Fractures 68

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

In comparison with the first ECG, I would guess that the artery is reperfusing. Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Detailed coronary artery evaluation not performed.

EKG/ECG 92

EKG/ECG Ultrasounds Wellness Stroke 92

Sensible Medicine

MAY 25, 2023

The authors continued, “Calcium deposits in breast arteries can indicate a problem.” “The Centers for Medicare and Medicaid Services should make establishing payment codes for products involving women’s heart disease a priority to prompt private insurers to cover new service lines.”

Documentation/Coding 62

Documentation/Coding Academics Wellness 62

RebelEM

JUNE 14, 2023

to 0.5mg (1mg/mL) IV Bolus: 5 to 20mcg (10mcg/mL) IV Infusion: 1 to 20mcg/min If Poor Response to Conventional Therapy Consider Epinephrine 100mcg IV bolus Norepinephrine infusion 0.1mcg/kg/min Vasopressin 0.01

Shock 131

Shock Allergic Reactions Resuscitation EMS 131

EMDocs

NOVEMBER 18, 2023

A point of care ultrasound of the liver reveals the following: Image 1: Ultrasound of the liver showing abnormal hepatic artery flow and resistance index 1 Question: What is the diagnosis? Answer : Hepatic artery thrombosis. What are the complications of liver transplant that we see in the ED?

EMS 67

EMS Ultrasounds Emergency Department Outcomes 67

EMDocs

MARCH 25, 2024

7 Video 2: X minus 7 approach If the gallbladder is still unable to be identified, attempting a coronal approach where Morison’s pouch and the right kidney is identified, with the probe marker facing cranial, and then moving anterior on the patient, approaching the anterior axillary line, until biliary anatomy comes into view.

Ultrasounds 85

Ultrasounds Radiology Radiology Operations 85

PulmCCM

APRIL 1, 2024

All patients received arterial lines to measure PaO2 precisely. Read in JAMA One in 33 central-line placements results in major complications? ” But less than half of the included studies used ultrasound guidance during central line placements.

Ultrasounds 40

Ultrasounds Operations Outcomes Research 40

RebelEM

FEBRUARY 22, 2023

1 st line med: Timolol (beta blocker) Topical meds can be given simultaneously except for pilocarpine, which is given after IOP is < 40 mmHg. Giant Cell Arteritis (arteritic anterior ischemic neuropathy) ( Bagheri 2015 , Hayreh 2009 ) Pathophysiology Giant cell arteritis(GCA) affects that medium-sized and large arteries.

Emergency Department 52

Emergency Department EMS Wellness 52

Ken Grauer, MD

MAY 20, 2023

Based on the ECGs in Figure-5 — Did PCI succeed in opening the "culprit" artery? ECG Blog #294 — How to tell IF the "culprit" artery has reperfused. ECG Blog #194 — AIVR as a sign that the "culprit" artery has reperfused. Bottom Line: The clinical setting in this Blog #380 is certainly consistent with ischemia.

EKG/ECG 328

EKG/ECG Wellness 328

Mount Sinai EM

AUGUST 13, 2023

Hip innervation Indications Intertrochanteric fractures Femoral neck fractures Acetabular fractures Pubic ramus fractures Hip dislocations The PENG block is not effective for injuries below the IT line ; for this go for a block instead. FA: femoral artery. The formal head looks like a rounded hyperechogenic structure.

Fractures 100

Fractures Dislocations Operations Ultrasounds 100

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. However, it still serves as evidence of a patient’s elevated risk for underlying coronary artery disease or cardiomyopathy. Her ECG is shown below.

EKG/ECG 108

EKG/ECG Emergency Department Academics Operations 108

EMDocs

JANUARY 16, 2024

Cardiac surgery is immediately paged for consideration of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for active rewarming. A right femoral arterial line and triple lumen catheter are placed. This is a good time to utilize an arterial line or use the ultrasound to find a central pulse.

Hyperthermia / Hypothermia 83

Hyperthermia / Hypothermia Resuscitation CPR EMS 83

Don't Forget the Bubbles

JUNE 26, 2023

This is often done by combining the pulmonary artery and aorta to create a neo-aorta. Appropriate pulmonary blood flow There should be a permanent pathway for mixed oxygenated/deoxygenated blood to flow from a relatively high-pressure system (either the systemic arterial circulation or the right ventricle) to the pulmonary arteries.

Operations 128

Operations Research Hyperthermia / Hypothermia Hospitals 128

Emergency Medicine Journal

SEPTEMBER 27, 2023

We identified the five most interesting and relevant papers (decided by consensus) and highlight the main findings, key limitations and clinical bottom line for each paper. We used a multimodal search strategy, drawing on free open-access medical education resources and literature searches. Head turner—new concepts.

EKG/ECG 40

EKG/ECG Outcomes 40

Taming the SRU

MAY 13, 2024

Figure 1: CT abd/pelvis demonstrating blind ending structure arising from cecum (arrows) with diffuse fat stranding consistent with acute stump appendicitis Computed Tomography (CT) Abdomen and Pelvis: A 3 cm long blind-ending structure with staple line at the tip arises from the cecum. Notable diagnostics CBC : WBC 19.2,

Ultrasounds 87

Ultrasounds Emergency Department Wellness Operations 87

Taming the SRU

JULY 26, 2023

vancomycin + piperacillin-tazobactam) Not all aspiration needs antibiotic coverage- especially patients suspected to have aspiration pneumonitis

EMS 68

EMS Wellness Research Hospitals 68

Broome Docs

OCTOBER 31, 2022

Bottom line: Although this RCT demonstrates a 7 day mortality benefit of using ketamine over etomidate, the level of certainty in the results is low. PMID: 36103415 Bottom line: Less is more when it comes to intravenous fluids. Tips for radial artery art lines Imbrìaco G, Monesi A, Spencer TR. N Engl J Med. 2022.101096.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Fluid Resuscitation Seizures Emergency Department 52

PulmCCM

JANUARY 29, 2024

Epinephrine remains the drug of choice during CPR Epinephrine remains the first-line therapy for cardiac arrest due to non-shockable rhythms (i.e., Amiodarone and/or lidocaine continue to be endorsed (weakly) as second-line therapies for shockable rhythms, should multiple defibrillation efforts fail. Results are expected in 2025.

Seizures 115

Seizures CPR Documentation/Coding Hyperthermia / Hypothermia 115

EMDocs

SEPTEMBER 6, 2023

Central line placed to continue vasopressors. Arterial line started. Considerations when patients continue to decompensate despite resuscitation and vasopressors: acidosis, endocrine issues like adrenal insufficiency or hypothyroidism, hypocalcemia, anaphylaxis, hemorrhage, multiple causes of shock, ingestion.

Anaphylaxis 69

Anaphylaxis Shock Sepsis Stroke 69

Taming the SRU

AUGUST 6, 2023

Kletsel Pustular psoriasis Psoriasis is characterized by discrete plaques of erythema, scales, and fissures of the extremities It is associated with significant morbidity & treatment consists of topical steroids, along with referral to establish with dermatology Use caution with systemic steroids as they can potentially worsen flares While rare, (..)

Infectious Diseases 74

Infectious Diseases Pediatrics Fractures Wellness 74

Dr. Smith's ECG Blog

JANUARY 5, 2024

Finally , troponin rises more slowly in patients with a persistently occluded artery. What the "BOTTOM Line" Should Be: Providers should appreciate that persistent ischemic CP is among recommended indications for prompt cardiac cath. The troponin is trapped in the myocardium that is not being perfused. DOI:10.1161/CIRCINTERVENTIONS.118.007305),

EKG/ECG 95

EKG/ECG Burns Urgent Care Documentation/Coding 95

Sensible Medicine

MARCH 27, 2024

” He begins the chapter by describing a strong history of premature coronary artery disease (CAD) in his family: 3 uncles had heart attacks in their 40s and his father underwent coronary stenting. The cumulative exposure of an artery to LDL-C over years remains a principal determinant of disease initiation and progression 14.

Research 93

Research Documentation/Coding Wellness 93