September, 2023

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Neurogenic Shock in Children

Pediatric EM Morsels

To celebrate the end of trauma season ( is it ever really over? ), we here at the Ped EM Morsels Bakery have cooked up a morsel to remind you that pediatric trauma can be even more difficult than you think. Never fear. As our fearless leader likes to say: “children are not aliens, but they are a special population with unique anatomy and physiology.” Children compensate for blood and volume loss very well… until they don’t.

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ECG Blog #396 — Why the Flat Line?

Ken Grauer, MD

The ECG in Figure-1 — was obtained from a middle-aged man with palpitations and shortness of breath. He was hemodynamically stable at the time this tracing was recorded. How would YOU interpret the ECG in Figure-1 ? Is there evidence of a recent or ongoing acute MI? What might you do first? Figure-1: The initial ECG in today's case. ( To improve visualization — I've digitized the original ECG using PMcardio ).

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How Much Fetal Radiation Exposure In Imaging Studies?

The Trauma Pro

I periodically publish a chart that shows how much radiation exposure our patients get from various trauma imaging studies. For reference, here it is: Test Dose (mSv) Equivalent background radiation Chest x-ray 0.1 10 days Pelvis x-ray 0.1 10 days CT head 2 8 months CT cervical spine 3 1 year Plain c-spine 0.2 3 weeks CT chest 7 2 years CT abdomen/pelvis 10 3 years CT T&L spine 7 2 years Plain T&L spine 3 1 year Millimeter wave scanner (that hands in the air TSA thing at the airport) 0.0

Radiology 288
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When Did “Herd Immunity” Become a Taboo Phrase?

Science Based Medicine

Doctors who repeatedly predicted herd immunity in 2020 and 2021, mocking and berating those who disagreed, now treat herd immunity as a taboo phrase. The post When Did “Herd Immunity” Become a Taboo Phrase? first appeared on Science-Based Medicine.

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Massive hemorrhage: a very deep dive

First 10 EM

Transfusion seems like the simplest intervention in medicine. The patient is losing blood, so let’s put some back in. Not much more complicated than an oil change. Sure, you need to use a specific brand, but as long as the system is topped up, everything should run just fine. Therefore, when someone (to be left […] The post Massive hemorrhage: a very deep dive appeared first on First10EM.

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If you are sick, do not test for COVID19; If your child is mildly sick, do not test & send them to school

Sensible Medicine

In this essay, I will build the case that if you are sick, you should not test for COVID19. If your child is sick, you should not test them, and you should send them to school if they are mildly ill. This is the only logical position, and that of the UK. How do I and the UK experts arrive at this position? Let’s agree to some facts. First, nearly no one is currently being hospitalized with ARDS caused by COVID19; Instead, we have a sea of incidental hospitalizations.

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ECG Blog #394 — Is QRS Morphology Disguised?

Ken Grauer, MD

The ECG in Figure-1 — was obtained from an older man with a history of prior infarction and coronary bypass surgery. How would you interpret this tracing? Clinical implications? Figure-1: The ECG in today's case. ( To improve visualization — I've digitized the original ECG using PMcardio ). MY Thoughts on the ECG in Figure-1: The rhythm in ECG #1 is sinus at ~65/minute — with an upright P wave in lead II, and a constant and normal PR interval (ie, not more than 0.21 second in duration ).

EKG/ECG 288
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The Decision To Stop In Geriatric Trauma – Part 2

The Trauma Pro

In my previous post, I reviewed a recent paper analyzing which geriatric patients were more likely to have care withdrawn after serious injury. The authors noted that those with significant limitations to daily living activities, increasing age and/or frailty, and ventilator dependence were major factors. Today’s paper was written by a multi-institutional group from several Ohio trauma centers.

Hospitals 198
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Dr. Vinay Prasad fully embraces the antivax message of “do not comply”

Science Based Medicine

COVID-19 "contrarians" like Dr. Vinay Prasad have long complained about being labelled "antivaccine," which they view as unfair. Why, then, do they embrace antivax messages like "do not comply," even if they don't use the exact words? The post Dr. Vinay Prasad fully embraces the antivax message of “do not comply” first appeared on Science-Based Medicine.

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Traumatic Cardiac Arrests

EM Ottawa

According to WHO and CDC: more than nine people die every minute from injuries or violence, and 5.8 million people die every year. It is the leading cause of death in people 1-44 years of age in developed countries (unintentional injuries, homicide, suicide). The most common cardiac rhythm in Traumatic Cardiac Arrest (TCA) is pulseless electrical […] The post Traumatic Cardiac Arrests appeared first on EMOttawa Blog.

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Clinical Conundrum: Should a Troponin Routinely be Ordered in Patients with SVT?

RebelEM

Bottom Line Up Top: Troponins should not be routinely sent in patients presenting with SVT. Rarely, they may be necessary if the patient has concerning ischemic symptoms that persist after conversion to sinus rhythm. Clinical Scenario: A 44-year-old man presents with palpitations that started 45 minutes ago. He has no medical problems and denies any prior similar symptoms.

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Will A.I take over the World?!

Critical Care North Hampton

In this video, my great friend and fellow editor Dr Marcus Peck, talks us through the world of A.I in POCUS! Let’s face it, our kids are using it to write essays, the military uses it and you can’t seem to be able to speak to a human being on the phone as companies are.

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ECG Blog #393 — Why So Many Shapes?

Ken Grauer, MD

The interesting rhythm shown in Figure-1 was obtained after Adenosine was given for a regular SVT ( S upra V entricular T achycardia ). How would YOU interpret this rhythm in Figure-1 ? Why are there so many shapes for the QRS complex in the long lead II rhythm strip? Figure-1: 12-lead ECG and long lead II rhythm strip obtained after Adenosine was given for a regular SVT rhythm.

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Delayed sequence intubation: An RCT

First 10 EM

Introduced to the world by our friend Scott Weingart, delayed sequence intubation (DSI) is often summarized as procedural sedation for the procedure of preoxygenation. (Weingart 2011, Weingart 2015) It is a brilliant concept, makes a ton of sense on paper, and anecdotally has seemed to help a number of my patients. However, any long time […] The post Delayed sequence intubation: An RCT appeared first on First10EM.

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Part 1: “Don’t Minimize Myocarditis From The Vaccine”, By the Author of “Don’t Fear Literal Death From COVID”.

Science Based Medicine

Once a doctor has minimized *literal death*, how can we take them seriously when they scold us for minimizing something not as severe as say, *literal death*? The post Part 1: “Don’t Minimize Myocarditis From The Vaccine”, By the Author of “Don’t Fear Literal Death From COVID”. first appeared on Science-Based Medicine.

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A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?

Dr. Smith's ECG Blog

Case submitted by anonymous. Written by Smith. Ken's piece at the bottom is excellent. A 50-something presented with s udden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued. Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest.

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STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?

RebelEM

Background: Primary PCI is the recommended reperfusion strategy in patients with STEMI and should be initiated within 2 hours after first medical contact. In non-PCI-capable hospitals this goal is not always achievable due to delays in transfer. In these cases, thrombolysis is recommended to improve morbidity and mortality. 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 phar

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Let’s Natriurese not diurese!

Critical Care North Hampton

We obsess with diuresis in our critically ill patients with positive fluid balances. But are we doing a dis-service? The focus should perhaps be on natriuresis…but how? The evidence is out there suggesting a positive fluid balance is detrimental to overall outcomes in ICU.

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ECG Blog #397 — An Unusually Long Cycle?

Ken Grauer, MD

You are asked to interpret the ECG in Figure-1. What is the rhythm in ECG #1 ? Figure-1: You are asked to interpret this tracing. What is the rhythm? MY Thoughts on the ECG in Figure-1: I routinely begin assessment of each 12-lead ECG I encounter — with interpretation of the rhythm. To do this — I apply the P s, Q s, 3 R Approach ( See ECG Blog #185 — for review of my system ).

EKG/ECG 242
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Life in Art

Don't Forget the Bubbles

This talk, from Joe Brumm, was given at our 2022 DFTB conference. “Bluey” is an iconic Australian children’s animated television series. It follows the adventures of a Blue Heeler puppy named Bluey and her family, including her father, Bandit, her mother, Chilli, and her younger sister, Bingo. [link] There is a profound connection between art and life.

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Doctors on Measles: “NEVER Listen to the Anti-Vax Cult When They Say This ‘Natural’ Disease is Harmless”. Doctors on COVID: ?

Science Based Medicine

Measles and COVID are different, of course, but they are not categorically different. With both viruses, unvaccinated children suffer the most. Yet, doctors who rightly said "measles can be a devastating childhood illness" also said it was "breathless fear-mongering" to acknowledge that COVID can also be a devastating childhood illness. The post Doctors on Measles: “NEVER Listen to the Anti-Vax Cult When They Say This ‘Natural’ Disease is Harmless”.

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Don’t Use Lytics in Mild Stroke, Part 3

EM Literature of Note

Well, PRISMS demonstrated unfavorable results. MARISS tried to ascertain predictors of poor outcome in mild stroke, and intravenous thrombolysis was not associated with an effect on the primary outcome. Now, again, we examine thrombolysis in “mild” stroke, in this case, NIHSS ≤3 – and fail. Like MARISS, this is a retrospective dredge of patients selected by the treating clinicians to receive either intravenous thrombolysis or, in this case, dual-antiplatelet therapy with clopidogrel

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Emergency Physician Climbs the Seven Summits

ACEP Now

Ben Mattingly, MD, tries to live by the adage, “One should be adventurous and daring, but not reckless.” The challenge is that the line between adventurous and reckless is often paper-thin. Take, for example, his recent expedition to Nepal to summit Mount Everest. When he arrived at the base camp, he found out three rope-fixing sherpas had just been killed in the famously dangerous Khumbu Icefall.

Wellness 126
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Health disparities research is full of low quality work

Sensible Medicine

Recently, I saw a tweet from World Lung Conference. A presenter lamented differences in Lung cancer screening rates by race. Black and Hispanic patients had lower rates of lung cancer CT screening than whites, and the speaker argued that we needed targeted efforts to improve this disparity. But lung cancer screening doesn't work, as I described in a prior post.

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A 50-something with chest pain.

Dr. Smith's ECG Blog

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant. More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior.

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You don’t need X-Rays to tell if a child is constipated

PEMBlog

This is a blog post designed to disseminate the important work of Choosing Wisely , an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not. The Choosing Wisely Pediatric Emergency Medicine Recommendations The Choosing Wisely Campaign Toolkit Expert Contributors Kelly Levasseur, DO Children’s Hospital of Michigan Detr

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The Grand Debunk of the antivaxxer book “Turtles All the Way Down” (part 5/10)

Science Based Medicine

The fifth installment in the grand debunk the antivaxxer book “Turtles All the Way Down”: Chapter 5. The post The Grand Debunk of the antivaxxer book “Turtles All the Way Down” (part 5/10) first appeared on Science-Based Medicine.

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Virtual Reality Headset Takes EEG Measurements

Medagadget

Researchers at the University of Texas at Austin have developed an electroencephalogram (EEG) sensor that is incorporated into a virtual reality headset. The technology can measure brain activity while someone is undergoing an immersive virtual reality experience. The device may assist in enhancing medical virtual reality interventions, such as those used to treat post-traumatic stress disorder or phobias, by revealing brain activity during different tasks or experiences that help clinicians to

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Which Sepsis Alert is the Biggest Loser?

EM Literature of Note

It’s a trick question – in the end, all of us have already lost. This is a short retrospective report evaluating, primarily, the Epic Sepsis Prediction Model, and the mode in which is deployed. The Epic SPM generates a “prediction of sepsis score”, calculated at 15 minute intervals, providing a continuous risk score for the development of sepsis.

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Journals That Ban Replications--Are They Serious Scholarly Outlets At All?

Sensible Medicine

We are living in a time of growing distrust in science and scientific institutions. According to a 2022 Pew surve y, “Trust in scientists and medical scientists, once seemingly buoyed by their central role in addressing the coronavirus outbreak, is now below pre-pandemic levels. Overall, 29% of U.S. adults say they have a great deal of confidence in medical scientists to act in the best interests of the public, down from 40% who said this in November 2020.” Subscribe now At the same

Research 122
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A 60-year-old diabetic with chest pain, cath lab activated

Dr. Smith's ECG Blog

I came to work one day and one of my partners said, "Hey, Steve, we had a STEMI this afternoon!" I said, "Cool, can I see the ECG?' Of course he said: "Yes, it was a 60 year old diabetic with Chest pain." So he showed me the ECG recorded in triage: What did I say? "That is not a STEMI. That is Arterial Pulse Tapping Artifact (APTA)." He said: "What?

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