Recently, 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).
ECG 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.
- Carotid pulse only = SBP 60 – 70 mmHg
- Carotid & Femoral pulse only = SBP 70 – 80 mmHg
- Radial pulse present = SBP >80 mmHg
Nasogastric 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?
Every 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.