Chest Pain: Can we do 2-hour rule outs?

26 Jan
January 26, 2014

Chest Pain and TimeHospital admissions for chest pain often incur costly and resource-intensive workups for ACS. Is there a way to identify a low risk group who can be discharged home in a timely manner, without further workup, and without short-term adverse events from ACS? Read more →

Chest Pain: Coronary CT Angiography in the ED

26 Jan
January 26, 2014

chest pain and CCTAIt is well known that taking a good history and physical, getting a non-ischemic EKG, and serial cardiac biomarkers, results in a risk of death/AMI of <5% in 30 days. Patients, in whom you still suspect have CAD, should undergo provocative testing within the next 72 hours based on the AHA/ACC guidelines. Their guidelines deem provocative testing as including:

  • Exercise treadmill stress test,
  • Myocardial perfusion scan,
  • Stress echocardiography, and/or
  • Coronary CT angiography (CCTA).   Read more →

Three Predictors of Success in Cardiac Arrest

25 Jan
January 25, 2014

DefibrillationThe goal of resuscitation in cardiac arrest is to respond in a timely, effective manner that leads to good patient outcomes.  Resuscitation is not taking an ACLS and BLS course and going through the motions of a code. There have been several studies looking at the quality of intubation and CPR, and their association with good patient outcomes. Read more →

The HEART Score: A New ED Chest Pain Risk Stratification Score

10 Jan
January 10, 2014

Chest PainChest pain is a common presentation complaint to the emergency department (ED) and has a wide range of etiologies including urgent diagnoses (i.e. acute coronary syndrome (ACS), pulmonary embolism, aortic dissection) and non-urgent diagnoses (i.e. musculoskeletal pain, gastroesophageal reflux disease (GERD), pericarditis). The challenge in the ED is to not only to identify high risk patients but also to identify patients who can be safely discharged home. Specifically, when dealing with ACS, dynamic ECG changes or positive cardiac biomarkers is pretty much a slam dunk admission in most cases, but a lack of these does not completely rule out ACS. Currently, most guidelines and risk stratification scores focus on the identification of high risk ACS patients that would benefit from early aggressive therapies, but what about all the other chest pain patients that don’t have ACS… are they accounted for? Read more →

R.E.B.E.L. ECG of the Week #6

12 Dec
December 12, 2013

R.E.B.E.L. EM ECG of the Week #6The case from this week is from one of the PGY-1 residents at University of Texas Health Science Center at San Antonio (UTHSCSA).  Several of the details of the case have been changed to keep patient information confidential.

53 year old female with a past medical history of hypertension, hyperlipidemia, coronary artery disease, and 3 anterior myocardial infarctions s/p 4-vessel CABG (LIMA-LAD, RIMA-RCA, SVG-D1-OM1 sequentially) 9 months ago who presents with intermittent 10/10 chest pain that radiates to his left arm for the past 6 months. The chest pain is associated with nausea and shortness of breath but denies diaphoresis or syncope. Patient reports that the pain is the same as his index chest pain and is both exertional and non-exertional and will often wake him up from sleep. The pain can last 5-10 minutes and is always relieved by rest. The patient reports good medication compliance (on metoprolol, atorvastatin, enalapril, amlodipine, aspirin). He presented with similar symptoms 3 months ago but left against medical advice before a work-up could be performed. Now he presents with increasing frequency of chest pain.

BP 152/105  HR 86 RR 16 O2 sat 99% on RA   Temp 98.0

ECG from triage is shown… Read more →

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