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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Is ATLS wrong about palpable blood pressure estimates?

01 Nov
November 1, 2013
ATLSIn Advanced Trauma Life Support (ATLS), we learned that a carotid, femoral, and radial pulse correlates to a certain systolic blood pressure (SBP) in hypotensive trauma patients.  Specifically ATLS stated:
  •  Carotid pulse only = SBP 60 – 70 mmHg
  •  Carotid & Femoral pulse only = SBP 70 – 80 mmHg
  •  Radial pulse present = SBP >80 mmHg

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NG Lavage: Indicated or Outdated?

01 Nov
November 1, 2013

NG Lavage in Gastrointestinal HemorrhageNasogastric lavage (NGL) seems to be a logical procedure in the evaluation of patients with suspected upper GI bleeding, but does the evidence support the logic? Most studies state that endoscopy should occur within 24 hours of presentation, but the optimal timing within the first 24 hours is unclear.  Rebleeding is the greatest predictor of mortality, and these patients benefit from aggressive, early endoscopic hemostatic therapy and/or surgery. So what are the arguments for and against NGL?

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Chest Pain: What is the Value of a Good History?

01 Nov
November 1, 2013

Chest Pain HistoryEvery year there are 6 million visits to the Emergency Department (ED) for chest pain, and approximately 2 million hospital admissions each year.  This is approximately about 10% of ED visits and 25% of hospital admissions with 85% of these admissions receiving a diagnosis of a non-ischemic etiology to their chest pain (CP).  This over triage has enormous economic implications for the US health care system estimated at $8 billion in annual costs.

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Welcome to REBEL EM

30 Oct
October 30, 2013

REBEL EMAs a physician and newcomer to FOAM, I am finding that I have learned a lot of myths and pearls that are not true as I matriculated through school. This has taught me that learning from textbooks may be great for board exams, but  more importantly it is not optimal for patient care and has made me question a lot of different practices. We all want to know clinically relevant information that is evidence based and up to date that will make a difference in our care of patients. The purpose and goal of REBEL is to create a sustained change in beliefs, attitudes, and behavior through review of the best evidence available.

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