R.E.B.E.L. ECG of the Week #4

29 Nov
November 29, 2013

R.E.B.E.L. EM ECG of the Week #462 year old male with chief complaint of weakness.  Patient had a complicated hospital course including necrotizing fasciitis which required surgical debridement and IV antibiotics.  Patient was discharged home with oral antibiotics and returned to the ED with a chief complaint of weakness, abdominal pain, and 3 weeks of loose bowel movements.

BP: 100/51     HR 93     RR 16     Temp 97.2     O2 Sat 98% on RA

ECG from triage is shown… Read more →

SVT With Aberrancy Versus VT

22 Nov
November 22, 2013

Brugada CriteriaDifferentiating between SVT with aberrancy versus VT can be very difficult. It is crucial to be able to make this distinction as therapeutic decisions are anchored to this differentiation. Brugada et al prospectively analyzed 384 patients with VT and 170 patients with SVT with aberrant conduction to see if it was possible to come up with a simple criteria to help differentiate between the two with high sensitivity and specificity. Read more →

Does a Porcelain Gallbladder Equal Gallbladder Cancer?

21 Nov
November 21, 2013

Does Porcelain Gallbladder Equal Gallbladder Cancer?Gallbladder cancer (GBC) incidence ranges from 12 – 62% when porcelain gallbladder (PGB) is seen.  You ever wonder where these numbers come from?  Well, these are the quoted numbers from two studies done in 1959 and 1966.  These studies also indicated that if porcelain gallbladder was seen, that a prophylactic cholecystectomy should be performed. Is this the best evidence we have?  Is there nothing more recent?  Well, it turns out there is.

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Should we stop prescribing Azithromycin in the ED?

19 Nov
November 19, 2013

azithromycinIn 2011, Azithromycin was the 7th most prescribed (55.3 million prescriptions) medication according to IMS Health.  There have been several publications indicating that the use of macrolide antibiotics, increase risk of serious ventricular arrhythmias and sudden cardiac death (FDA Adverse Event Reporting System). Specifically, 2 recent studies in the NEJM were published looking at the risk of Azithromycin with cardiovascular death and received lots of press. Read more →

R.E.B.E.L. ECG of the Week #3

18 Nov
November 18, 2013

R.E.B.E.L. EM ECG of the Week #3The subject of this ECG of the Week is a 47 y/o hispanic female with a past medical history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and morbid obesity with a chief complaint of weakness.  Per the patient she cleans houses for a living and for the past 2 weeks she gets weak and short of breath earlier in the day while cleaning houses.  She used to be able to clean all day without issues, but for the past 2 weeks this has been getting less and less.  No chest pain, vomiting, diaphoresis, or syncope.  She has never had anything like this before.  She comes to the ER today because this is her only day off.  She has not had any symptoms today.

BP 156/94  HR 68 RR 14 O2 sat 100% on RA   Temp 98.7

ECG from triage is shown…

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R.E.B.E.L. ECG of the Week #2

11 Nov
November 11, 2013

R.E.B.E.L. EM ECG of the Week #258 year old female with chief complaint of chest pain x2hours with PMH of type 2 diabetes mellitus, Hyperlipidemia, and hypertension.    She is brought in via EMS still having active chest pain.

BP: 102/88  HR: 82  RR: 24  O2 Sat on 2L: 99%  Temp 99.0

ECG obtained at arrival is shown…

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R.E.B.E.L. ECG of the Week #1

08 Nov
November 8, 2013

R.E.B.E.L. EM ECG of the Week #168 year old hispanic female with a chief complaint of weakness/syncope.  PMH of type 2 diabetes mellitus and hypertension.  She was brought in via EMS due to the family calling 911 as she had an episode of syncope while at the dinner table.  At the time of arrival:

VS: 96/48   43     18     99% on RA  98.7

ECG obtained at arrival is shown…

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CPR: Hands-on or Hands-off Defibrillation

01 Nov
November 1, 2013

CPRPauses in chest compressions are known to be detrimental to survival in cardiac arrest, so much so that the 2010 American Heart Association (AHA) emphasize high-quality compressions while minimizing interruptions. There have been some studies that now advocate for continuous chest compressions during a defibrillation shock. There have been substantial changes to external defibrillation technology  including:

  • Biphasic shocks with real-time impedance monitoring to reduce peak voltages
  • Paddles being replaced by adhesive pre-gelled electrodes
  • Enhancement in ECG filtering permitting rhythm monitoring during chest compressions.

So the mantra of “hard and fast” may be true when it comes to CPR, but the real question now becomes, should we be continuing CPR during defibrillation?

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Bundle Branch Blocks: 101

01 Nov
November 1, 2013

Electrical Conduction System of the HeartRecently, I have been asked by several students at my home institution (UTHSC at San Antonio) to help them understand bundle branch blocks.  This is different than some of my usual posts because it is meant to be more educational than evidence based.  So here we go.  The normal conduction system of the healthy heart is shown to the right.  If there is a delay or block in the left or right bundle, depolarization will take longer to occur. Therefore we get a widened QRS (>0.12 sec or >3 small boxes).

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The Importance of Reciprocal Changes in aVL

01 Nov
November 1, 2013

Reciprocal Change in aVLECG interpretation is one of the most important skills to master as an emergency  physician, and its interpretation can be very complex and frustrating. ECG manifestations can be very subtle, and sometimes the earliest and only ECG change seen will be reciprocal changes alone. To further complicate this, many patients have the atypical symptoms of nausea/vomiting, weakness, or shortness of breath and not chest pain.

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