Author Archive for: srrezaie

Five ECG Patterns You Must Know

04 Feb
February 4, 2016

ECG PatternsBackground: The electrocardiogram (ECG) is one of the most useful diagnostic studies for identification of acute coronary syndrome (ACS) and acute myocardial infarction (AMI). The classic teaching is ST-segment elevation myocardial infarction (STEMI) is defined as symptoms consistent with acute coronary syndrome (ACS) + new ST-segment elevation at the J point in at least 2 anatomically contiguous leads of at least 2mm (0.2mV) in men or at least 1.5mm in women in leads V2 – V3 and/or at least 1mm (0.1mV) in other contiguous leads or the limb leads, in the absence of a left bundle branch block, left ventricular hypertrophy, or other non-acute MI ST-segment elevation presentations. Unfortunately, the ECG may be non-diagnostic in nearly half of all patients who initially present with AMI. There are also STEMI equivalent patterns that are caused by occlusion of the coronary arteries that place a significant portion of the left ventricle at jeopardy and result in poor outcomes. This review article focused on 5 under recognized high-risk ECG patterns in the ACS patient that result in poor outcomes including malignant dysrhythmias, higher rates of cardiogenic shock, and death. Read more →

Cardiocerebral Resuscitation: Hands-Only CPR

21 Jan
January 21, 2016

Cardiocerebral ResuscitationOne of the major reasons contributing to dismal survival rates in out-of-hospital cardiac arrest (OHCA) is the lack of bystander initiated cardiopulmonary resuscitation (CPR). Even though the majority of OHCA is witnessed, only 1 in 5 patients will receive bystander initiated CPR [1].  Survey studies have shown that bystanders are not wanting to do mouth-to-mouth resuscitation on strangers. Outside of early defibrillation, only early bystander initiated CPR has consistently been shown to improve neurologically intact survival in OHCA. So what about  Cardiocerebral Resuscitation, also known as “Hands-Only” CPR? Read more →

Modified Sgarbossa Criteria: Part Deux

11 Jan
January 11, 2016

Modified Sgarbossa CriteriaBackground: Left Bundle Branch Block (LBBB) on the ECG makes accurate recognition of ST-Elevation Myocardial Infarction (STEMI) rather difficult. The 1996 and 2004 American College of Cardiology/American Heart Association (ACC/AHA) STEMI guidelines recommended immediate reperfusion therapy for patients with potentially ischemic symptoms and new, or presumed new, LBBB. In 2013, this recommendation was removed from the guidelines. Historically, reperfusion decisions in LBBB have been determined by the original Sgarbossa criteria published in 1996, but there are three key limitations to the original study by Sgarbossa et al:

  1. The original Sgarbossa criteria (i.e. the “weighted” Sgarbossa criteria) depends on a point system that rely on 3 findings, only 2 of which would provide enough points (i.e. 3) to make the diagnosis of AMI. Using the Sgarbossa criteria without the point system (i.e. the “unweighted” Sgarbossa criteria) increases sensitivity but decreases specificity.
  2. Sgarbossa et al diagnosed AMI by creatine kinase MB (CK-MB) elevations instead of angiographic evidence of acute coronary occlusion (ACO), which limits the sensitivity of the rule because it combines NSTEMI and STEMI patients in the outcome definition
  3. Finally, Sgarbossa et al used an absolute criterion (5mm) rather than a proportional criterion for excessively discordant ST elevation lowering the sensitivity of the criteria.

The modified Sgarbossa criteria replaces the absolute 5mm discordant ST elevation with a proportion (ST elevation/S-wave amplitude ≤ -0.25). In other words, the modified Sgarbossa criteria only changes the last of the original Sgarbossa criteria with the first two criteria staying intact. Now, if any of these criteria are met, the cardiac catheterization lab should be activated. We have written on REBEL EM before about the modified Sgarbossa criteria and one of our conclusions was this rule looked very promising, but needed an external validation study. Well that study is now here and for full disclosure I am one of the authors on the paper. Read more →

Does a Normal Head CT Within 6 Hours of Onset of Headache Rule Out SAH?

07 Jan
January 7, 2016

SAHBackground: The traditional standard workup for ruling out subarachnoid hemorrhage (SAH) has been a non-contrast head CT and, if negative, a lumbar puncture. The thought behind this is that the sensitivity of head CT to rule out SAH is not 100% and declines over time and missing a SAH is potentially devastating. There has been a series of studies published in the past few years looking at the value of a negative head CT scan performed within 6 hours of headache onset in ruling out SAH. I have heard many say that if they have a negative Head CT at 6 hours or less in a neurologically intact patient they would not perform a lumbar puncture. Read more →

December 2015 All Cardiology REBELCast

10 Dec
December 10, 2015

REBELCastWelcome to the December 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Cardiology and Critical Care. First of all, we all know that the optimal treatment for STEMI is getting the patient to the cardiac catheterization lab, and time is muscle, but does it help to get patients to the catheterization lab even faster than 90 minutes? Or does speeding up the time have bad outcomes? Secondly, it has been drilled into our heads that high-quality CPR with minimal to no interruptions is key in OHCA.  This gives our patients the best chance of neurologically intact survival.  But a new study just published might beg to differ. So with that introduction today we are going to specifically tackle:

Topic #1: Reducing Door to Balloon (D2B) Times to <90 Minutes in STEMI
Topic #2: Continuous vs Interrupted CPR in OHCA Read more →

Is This an Inferior STEMI or Pericarditis?

30 Nov
November 30, 2015

Inferior STEMIBackground: As emergency providers we must be smarter than our ECG machines. Many times subtle findings on ECGs are not read by the machine, but we must be the experts at making the distinction between findings that require emergent treatment versus more benign etiologies. One specific set of diagnoses that can be very difficult to distinguish from each other is inferior STEMI vs Pericarditis. ECG experts discuss strategies such as looking at morphology of ST-segments (i.e. concavity or convexity), but this is not always accurate. Another, frustrating fact is that ST-elevation in the inferior leads (II, III, aVF) is typically seen with inferior STEMI and pericarditis. We therefore need a finding that has both a high sensitivity and specificity for MI. Read more →

Does My Patient with Chest Pain Have Acute Coronary Syndrome?

23 Nov
November 23, 2015

Acute Coronary SyndromeBackground: We have already discussed the value of a good history in assessing patients with chest pain on REBEL EM. What is known about chest pain is that it is a common complaint presenting to EDs all over the world, but only a small percentage of these patients will be ultimately diagnosed with Acute Coronary Syndrome (ACS). This complaint leads to prolonged ED length of stays, provocative testing, potentially invasive testing, and stress for the patient and the physician. For simplicity sake, we will say that, looking at the ECG can make the diagnosis of STEMI. What becomes more difficult is making a distinction between non-ST-Elevation ACS (NSTEMI/UA) vs non-cardiac chest pain. ED physicians have different levels of tolerance for missing ACS with many surveys showing that a miss rate of <1% is the acceptable miss rate, but some have an even lower threshold, as low as a 0% miss rate. Over testing however, can lead to false positives, which can lead to increased harms for patients. In November 2015, a new systematic review was published reviewing what factors could help accurately estimate the probability of ACS. Read more →

November 2015 REBELCast: All Vascular Access Episode

12 Nov
November 12, 2015

Vascular AccessWelcome to the November 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Vascular Access. Peripheral intravenous (PIV) access is one of the most common procedures we perform in the emergency department (ED) and central venous catheter (CVC), although decreasing in frequency, has some very real complications associated with it. It is always good to question clinical practice, especially in procedures that we perform on a daily basis.  IV access is important to patient care for things that we may take for granted such as lab work and initiation of treatment. So with that introduction today we are going to specifically tackle:

Topic #1: Intravascular Complications of Central Venous Catheter (CVC) Access
Topic #2: US vs Landmark Technique for Peripheral IV Access

Read more →

Ischemic Stroke Treatment Archive

09 Nov
November 9, 2015

Ischemic Stroke Treatment ArchiveI recently returned from the American College of Emergency Physicians (ACEP) Conference which took place from Oct. 26th – 29th, 2015 in Boston, MA.  There were really a lot of amazing talks by so many amazing speakers but one lecture in particular by David Newman, of SMART EM and The NNT fame, made me realize that there is just so much research on treatment of ischemic stroke, that I can’t even keep them straight.  So what I thought I would do is create an archive of all that research and continue to add to the list as more research is released.  I don’t know about you, but I find myself spending lots of time looking this information up every time I need it.  Read more →

Diabetic Ketoacidosis (DKA) Myths

02 Nov
November 2, 2015

DKARecently, I was asked to give a lecture to both my residents and nurses at the University of Texas Health Science Center at San Antonio (UTHSCSA) on some common DKA myths. Now this topic was originally covered by my good friend Anand Swaminathan on multiple platforms and I did ask his permission to create this blogpost with the idea of improving patient care and wanted to express full disclosure of that fact. I specifically covered four common myths that I still see people doing in regards to DKA management:

  1. We should get ABGs instead of VBGs
  2. After Intravenous Fluids (IVF), Insulin is the Next Step
  3. Once pH <7.1, Patients Need Bicarbonate Therapy
  4. We Should Bolus Insulin before starting the infusion

Read more →

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