EM@3AM: Brainstem Strokes
EMDocs
MAY 11, 2024
Answer : Brainstem stroke specifically in the pons resulting in locked in syndrome. CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis?
Classic heat stroke
EM SIM Cases
NOVEMBER 20, 2023
WHY IT MATTERS Classic heat stroke is a potentially deadly diagnosis that effects some of the most vulnerable of our populations. There are some key differences between exertional and classic heat stroke management and this case gives the opportunity to practice and discuss these skills.
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EM@3AM: Cerebellar Stroke
EMDocs
JUNE 3, 2023
Answer : Cerebellar Stroke Epidemiology: 1-4% of cerebrovascular accidents occur in the cerebellum. 2 In the United States, approximately 795,000 people suffer from strokes every year. 3 Cerebellar strokes are associated with high morbidity and mortality. CT head without contrast 1 reveals the following: What is the diagnosis?
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A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?
Dr. Smith's ECG Blog
NOVEMBER 11, 2023
A 90-something year old woman presented with an acute mild stroke. She had a routine ECG as part of her workup: What do you think? Peak trop 62 ng/L (would be very low for acute OMI) Next AM ECG: Still with very ischemic looking T-waves. Always look at old ECGs, even if you think the diagnosis is obvious.
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The Study of the Week Is a Beautiful Example of Science Done Well
Sensible Medicine
FEBRUARY 12, 2024
Neurologist Hooman Kamel from the Weil Cornell Medical Center in NY had an idea about atrial fibrillation and stroke. Stroke came when these clots moved northward to the brain. One of the big issues with this theory was that studies had failed to show a strong relationship in time between the stroke and the irregular rhythm. (For
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Journal Feed Weekly Wrap-Up
EMDocs
MAY 4, 2024
. #1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.
How important are old ECGs in Non-obvious cases of potential OMI?
Dr. Smith's ECG Blog
NOVEMBER 14, 2023
In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). Here is that last post: A 90-something with acute stroke.
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Grand Rounds Recap 1.24.24
Taming the SRU
JANUARY 26, 2024
Morbidity & MOrtality - Mini Lit Blitz - Post-Rosc Care - Qi/KT Morbidity & Mortality WITH Dr. Yates Case 1: Stroke and Stroke Mimics Early diagnosis of stroke improves stroke outcomes, where misdiagnosis is associated with an upwards of 4-time higher likelihood of mortality Missed strokes most often occur with atypical symptoms, in younger (..)
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STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?
RebelEM
SEPTEMBER 28, 2023
ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% The upper range of this time was 120 minutes from diagnostic ECG in the majority of patients.
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SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients?
The Skeptics' Guide to EM
OCTOBER 5, 2019
Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomized, sham-controlled, blinded, phase 3 trial. His 12-lead ECG shows a normal sinus rhythm without ST abnormality or ectopy. This episode will not debate the use of tPA for acute ischemic stroke.
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AF Duration? Another Big Story from 2023
Stop and Think
DECEMBER 29, 2023
For an older patient with stroke risk factors and 3 hours of AF on a cardiac device, pre-2023 thinking would have us leaning toward anticoagulation. Edoxaban reduced the primary endpoint of stroke, systemic embolism, and cardiovascular death by 19% (HR, 0.81; 95% CI, 0.60-1.08; The doctor would do an ECG and that would diagnose AF.
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SAEM Clinical Images Series: Seeing Double
ALiEM
MARCH 22, 2024
Laboratory Data CBC , CMP , EKG , and Troponins were normal. The two main causes of internuclear ophthalmoplegia are demyelination of the medial longitudinal fasciculus (MLF) from multiple sclerosis (MS) and ischemic cranial nerve damage from stroke. There were no oligoclonal bands.
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A Note On Criticism Of Yesterday's Study of the Week
Sensible Medicine
FEBRUARY 13, 2024
In brief, the trial compared apixaban vs aspirin in patients who had had a stroke of unknown source and evidence of atrial cardiopathy. Recurrent stroke (the primary endpoint) occurred in 40 patients in each group. Apixaban did not reduce the rate of recurrent stroke over aspirin in these patients. The hazard ratio was 1.00.
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Continuous prolonged generalized weakness, lightheadedness, and presyncope. What might you suspect from the ECG?
Dr. Smith's ECG Blog
OCTOBER 28, 2023
Here is his ECG. See this articles: Heart Failure with Preserved Ejection Fraction (NEJM review) One etiology of LVH on the ECG is Hypertrophic Cardiolmyopathy (HOCM), and sometimes ECGs in patients with HOCM are specific for HOCM. But this ECG is NOT specific for HOCM. Figure-1: The ECG in today's case.
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Ventricular Fibrillation, ICD, LBBB, QRS of 210 ms, Positive Smith Modified Sgarbossa Criteria, and Pacemaker-Mediated Tachycardia
Dr. Smith's ECG Blog
APRIL 2, 2024
Here is the initial ED ECG. Other thought this was due to hyperkalemia, but the ECG does not have the appearance of hyperkalemia but does have the appearance of severe cardiomyopathy -- LBBB with very wide QRS) 3. Another ECG was recorded 12 minutes later: Paced rhythm, probable Pacemaker-Mediated Tachycardia ?
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The NOAH Study Provides Evidence That Aids Decision-Making in Atrial Fibrillation
Sensible Medicine
AUGUST 28, 2023
Some background: In patients with certain risk factors, AF increases the risk of having a stroke. The increase in risk parallels the presence of risk factors, such as age, high blood pressure, diabetes, coronary disease, and previous stroke. Net benefit means stroke reduction > bleeding increase. We call this clinical AF.
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Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?
Dr. Smith's ECG Blog
MAY 30, 2023
His prehospital ECG was diagnostic of inferior posterior OMI. Here is his ED ECG: There is bradycardia with a junctional escape. We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. The patient was in clinical shock with a lactate of 8.
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What do you think of this "Ventricular Bigeminy"?
Dr. Smith's ECG Blog
NOVEMBER 19, 2022
Written by Bobby Nicholson MD, with edits by Meyers A woman in her 50s with past medical history of heart failure, prior stroke, atrial fibrillation on Eliquis, lung cancer in remission, and CKD, presented to the emergency department for evaluation of cough and shortness of breath. EKG was obtained in triage and read as ventricular bigeminy.
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A young woman with epigastric pain. ECG Crochetage sign? What is the significance?
Dr. Smith's ECG Blog
JANUARY 8, 2020
A former resident texted me this ECG, done for epigastric pain in an 18 year old. I put it on Facebook EKG club and this is the response: No one knew for certain what that was, but Ken Grauer suspected artifact (due to lead placement over an artery) or a Crochetage sign, which is strongly associated with atrial septal defect.
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A young woman with palpitations. What med is she on? With what medication is she non-compliant? What management?
Dr. Smith's ECG Blog
DECEMBER 24, 2023
Here is her triage ECG: What do you think? And so was an appropriate anti-coagulant, since atrial flutter, like fibrillation, can result in thromboembolism and stroke. For clarity and ease of comparison, I've put together in Figure-1 — the 3 serial ECGs in today's case. Atrial flutter with 2:1 conduction.
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OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.
Dr. Smith's ECG Blog
DECEMBER 5, 2023
Written by Kirsten Morrissey, MD with edits by Bracey, Grauer, Meyers, and Smith An older teen was transferred from an outside hospital with elevated serum troponin and and ECG demonstrating ST elevations. Acute coronary syndrome in a pediatric patient? He denied drug or alcohol use. He did have a family history notable for early CAD.
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Grand Rounds Recap 8.2.23
Taming the SRU
AUGUST 7, 2023
The patient needs a transvaginal ultrasound w/ doppler with gynecology consult and possible laparotomy TVUS is not just for torsion, it can also be used for ectopic pregnancies or pregnancy of unknown location Acute Ischemic Stroke Updates WITH Drs. The expanded window of 3-4.5 hours increased the NNT for a good outcome to 20.
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Comprehending Cardiovascular Disease: Causes, Signs, and Prevention
Ziqitza HealthCare Ltd
APRIL 29, 2024
Some common types of cardiovascular disease are coronary heart disease, stroke, hypertension, arrhythmia, aortic disease, valve disease, heart failure, and peripheral artery disease. Hypertension can cause types of cardiovascular diseas e , causing effects like heart attack and stroke. Cardiovascular diseases are common.
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Grand Rounds Recap 10.4.23
Taming the SRU
OCTOBER 5, 2023
morbidity and mortality - quality improvement - research grand rounds - r1 clinical knowledge: pres/rcvs - r4 case follow-up: compartment syndrome Morbidity and Mortality WITH dr. finney Takotsubo Cardiomyopathy with COVID-19 Increasing incidence of Takotsubo Cardiomyopathy with the COVID-19 pandemic Morbidity and mortality is similar to that of ACS (..)
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A Pathognomonic ECG. What is it?
Dr. Smith's ECG Blog
MARCH 19, 2019
This patient presented with weakness, decreased urine output, and vomiting: What is the ECG diagnosis? Here was a repeat ECG: QTc 523. The value of recognizing this particular ECG pattern — is that it may expedite your clinical diagnosis even before laboratory results return. This is pathognomonic for hypocalcemia.
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How To Avoid Missing an Aortic Dissection
ACEP Now
JUNE 6, 2023
ECG, CXR, and troponin are negative. Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. ECG, CXR, and troponin are all normal.
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Grand Rounds Recap 11.29.23
Taming the SRU
NOVEMBER 29, 2023
Workup with a negative troponin and EKG reliably rules out BCI. Posterior circulation stroke Patients with posterior strokes will likely have a low NIH. Involve the stroke team if posterior circulation stroke is suspected, as they may be a candidate for TNK, or more rarely, EVT.
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Case Report: Pancreatitis Mimics STEMI
ACEP Now
DECEMBER 11, 2023
The Case FIGURE 1: Initial EKG were notable for a leukocytosis of 23.19 A repeat ECG completed shortly after epigastric pain was controlled showed dynamic STE in aVL, V1 and aVR with diffuse ST depressions (see Figure 2). During the initial work-up, her ECG revealed STE measuring approximately 1 mm in V1, V2.
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Central retinal artery/vein occlusion
Mind The Bleep
FEBRUARY 1, 2024
Suspected work-up for CRAO should prompt echo, ECG and carotid doppler. Referral to the stroke team is also required in this instance Treatment Specific options for CRAO: The mainstay of treatment is to perform a full stroke workup and treat this accordingly.
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SGEM#432: SPEED, Give Me What I Need – To Diagnose Acute Aortic Dissections
The Skeptics' Guide to EM
MARCH 2, 2024
His vital signs are all normal and the ECG done at triage does not show an occlusive myocardial infarction. Symptoms may include more severe chest pain radiating to the back, loss of consciousness, or symptoms of stroke if the blood supply to the brain is affected. It is described as a ripping sensation that radiates to his back.
REBEL Core Cast 98.0 – AVNRT
RebelEM
MARCH 22, 2023
Differential to Consider (for Regular, Narrow Complex Tachydysrhythmias) Sinus Tachycardia AVNRT Orthodromic Atrioventricular Reentrant Tachycardia (AVRT) Atrial Flutter with 2:1 block Common EKG Findings Narrow-complex, regular rhythm with a rate that often exceeds the theoretical maximal heart rate (220 – age) for that patient.
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Modernity and Health
Stop and Think
FEBRUARY 19, 2023
In LOOP, more than 6000 older patients (age 75) without atrial fibrillation—but with high-stroke-risk features--were randomized to having an implantable loop recorder (ILR) vs standard Danish primary care. Except that after five years the rate of strokes and major bleeding did not significantly differ in the two groups.
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An Unusual Bradycardia
Dr. Smith's ECG Blog
MAY 5, 2023
Dr. Smith was reading ECGs — and he sent myself and Dr. Meyers the tracing shown in Figure-1. Figure-1: The initial ECG in today's case. Our Initial Thoughts on the ECG in Figure-1: Dr. Meyers said the following: "I see 2 different atrial foci — one sinus and one ectopic. Figure-3: The repeat ECG in today's case.
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What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?
Dr. Smith's ECG Blog
NOVEMBER 15, 2023
She has no previous cardiac history of which she is aware 911 was called and here is her Prehospital ECG: What do you think? link] Case continued She arrived in the ED and here is the first ED ECG. In comparison with the first ECG, I would guess that the artery is reperfusing. Stroke-volume:50 ml. Normal wall thickness.
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Why Attribution Bias Might be the Costliest Bias
Sensible Medicine
JULY 5, 2023
” “… but you could have a stroke or heart failure if you don’t get to the right place, so let’s get an EKG to confirm.” I was ecstatic to tell her the good news, “You do not have a rheumatologic condition!”
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What is strange about this paroxysmal atrial fibrillation in an otherwise healthy patient? And what happened after giving ibutilide?
Dr. Smith's ECG Blog
MARCH 15, 2023
Here is her EKG: What is unusual about this? Here is the ECG after ibutilide: What do you notice? Here is the post-cardioversion ECG: Sinus rhythm, still with the longer QT interval. For more on SSS — See My Comment at the bottom of the page in the July 5, 2018 post in Dr. Smith’s ECG Blog. She was on no medications.
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Grand Rounds Recap 12.6.23
Taming the SRU
DECEMBER 6, 2023
Calcium is also now carried in the prehospital setting and should be used when EKGs show signs of hyperkalemia, cardiac arrest with concern for hyperkalemia, and those who have crush injuries. With rare exception, patients with sICH should be admitted to a specialized stroke unit (NSICU).
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emDOCs Podcast – Episode 86 Tricky Cases Part 2
EMDocs
SEPTEMBER 19, 2023
Also think about NCSE in patients with prior cerebral pathology (ie, ischemic stroke); a patient who was seizing, was treated, and is not coming out of their post ictal state; and in patients with unexplained altered mental status with no other cause. Official diagnosis requires EEG, which is not something we can typically obtain in the ED.
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Nausea and Vomiting. This ECG is loaded with information.
Dr. Smith's ECG Blog
FEBRUARY 29, 2016
In accordance with the last case (in which the patient presented only with vomiting and diarrhea), an ECG was recorded : (Figure 1) Someone thought this was slow VT with a "northwest" axis (towards aVR, or -135 degrees), but there are definite P-waves (with a long PR interval). But in the above ECG, V5 and V6 only have a Q-wave.
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The Importance Of Cardiac Ambulance
Ziqitza HealthCare Ltd
JULY 14, 2023
Often, the blood vessels of such patients become narrow or blocked, leading to chest pain, heart attacks, or strokes, eventually resulting in death. These diseases affect the patient’s circulatory system, blood vessels, heart muscle, valves, or rhythm.
Grand Rounds Recap 8.9.23
Taming the SRU
AUGUST 25, 2023
bicarb <18mEq/L) ketosis (preferably serum beta-hydroxybutyrate >3mmol/L) Risk factors SGLT2 inhibitor use fasting state ketogenic diet intra-abdominal pathology (AGE, pancreatitis, etc.) to 1 mcg/kg/hour procedural sedation loading dose: 0.5-1 1 mcg/kg over 10 minutes followed by continuous infusion: 0.2
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A 40-Something male with a "Seizure," Hypotension, and Bradycardia
Dr. Smith's ECG Blog
OCTOBER 7, 2019
When the paramedics arrived, they obtained a 12 lead ECG and confirmed the unstable vital signs. EKG is pictured below: What do you think? Although the shock is no doubt partly a result of poor pump function, with low stroke volume, especially of the RV, it should be compensated for by tachycardia. Why is the patient in shock?
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Heat related illness
EM SIM Cases
NOVEMBER 3, 2023
Heat Related Illness Download ECG Curtesy of Life in the Fast Lane, ECG Library for sinus tachycardia. CASE SUMMARY In this case of exertional heatstroke, the team must identify hyperthermia and actively cool the patient while working the patient up for other causes. Link can be found here.
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