By: Chase Hamilton, PGY3
Reviewed by: David Slattery, MD
Acute ST-elevation myocardial infarction is a “must-not-miss” in the world of medicine. Time is myocardium. Along with that adage is the importance of early detection and prevention of myocardial injury and potential infarction. Electrocardiograms (ECGs) are not highly sensitive in detecting early signs of potential ischemia. Also, ECG reading and interpretation is physician dependent and based on experience and education. These two factors make it difficult to reliably detect potential signs of early myocardial damage without infarction or ischemia.
The morphology of the T wave in V1 can be a herring for early left anterior descending (LAD) artery disease in patients with active symptoms. The normal morphology of the T wave in V1 is inverted or flat. An upright T wave with active chest pain should make the physician more seriously consider cardiac etiology and further evaluate and study the ECG and/or ensure serial ECGs are performed2. The upright T wave is considered a type of hyperacute T wave. Specifically, it should be considered hyperacute if the T wave in V1 is larger than the T wave in V6. This is described as loss of precordial T wave balance by Marriott et al. Literature has found that it was present in 36% of subtle LAD occlusion versus 16% of precordial early repolarization1,3.
By: Kelvy Levit, PGY3
Reviewed by: David Slattery, MD
Violence is rising at a concerning rate in emergency departments. According to a national survey by American College of Emergency Physicians’ (ACEP), almost 50% of emergency physicians and nearly 70% of emergency nurses report being physically assaulted at work. A troubling 97% of assailants were patients (1).
With these staggering statistics in mind, it’s important to not only have preventative measures in place, but also a management plan when dealing with agitated, combative, and altered patients.
Dealing with the agitated patient can be distressing to not only the emergency physician but also to the staff involved directly or indirectly. As providers, we are prone to cognitive errors during times of high stress. This blog will discuss the approach to the agitated patient to include verbal de-escalation techniques, options for chemical sedation, and an overview of the current literature supporting practice recommendations.
By Jason David, PGY3, Aaron Johnson, PGY3, and Jerad Eldred, PGY1
Working in a county hospital, we witness healthcare disparities and the consequences of poor access to healthcare every day. Some of our residents shed light on some of the unfortunate consequences of poor healthcare access in our Las Vegas community.
Hernias with loss of domain are often a consequence of poor access to surgical care and require extensive planning and management. Emergency medicine and general surgery communities should collaborate on what constitutes a need for urgent surgical intervention or the need for surgical coordination without primary care acting as an additional step/obstacle.
Read the full article in EM Resident here: https://www.emra.org/emresident/article/scrotal-hernia/
Conquering the Night Shift
By Patrick Wallace, DO PGY3 and Jordana Haber, MD
Night shift is not unique to the specialty of Emergency Medicine, but we are required to remain alert and efficient throughout the entire night. In order to have a successful career in Emergency Medicine, it is imperative that you conquer the night shift as well as the rapid transition from days to nights. What does the science say we should do to prepare for night shift and the accompanying circadian transitions? This article discusses the top ten evidence based practices that you can implement to improve efficiency, alertness, productivity, and transitions for night shifts to include the importance of light, timing of caffeine, timing your pre shift nap, and what foods you should be eating.
Check out Dr. Wallace's full article in EMJ here: https://emj.bmj.com/content/37/9/562
By Perry Lee, MD (PGY-3)
Advanced airway management is a mainstay of an emergency physician’s armamentarium. Many practitioners establish a routine with personal nuances established either by their training or from prior experiences. Here we examine common techniques and their effectiveness.
The studies selected are not meant to drastically change your systematic practice, but give recognition to the variability in routine that can still achieve a successful intubation. In addition to technique, intubation success also relies on muscle memory from repetitive practice, operator confidence from successful mental visualization, and the ability to calmly troubleshoot a difficult airway.
By Perry Lee, MD (PGY-3)
Tranexamic Acid (TXA) is an antifibrinolytic that inhibits the enzymatic breakdown of fibrin by plasmin.[i] It was first developed in 1962 by Japanese wife and husband researchers, hoping to find an effective treatment for post-partum hemorrhage which was a leading cause of maternal death in Japan at that time.[ii] Given its effectiveness and relative cheap cost, TXA has routinely been included on the World Health Organization’s List of Essential Medicines.[iii] Below is a list of uses for TXA commonly encountered in the emergency department (ED) with supporting research.
By Emerson Posadas, MD, MBA PGY-3
The use of thrombolysis in the management of pulmonary embolism is controversial. While many physicians will give thrombolytics in patients with massive pulmonary embolism, I have found that many physicians are much more hesitant to utilize thrombolysis for sub-massive pulmonary embolism. While there has been significant evidence behind the use of thrombolysis in CVA and cardiac ischemia, the evidence behind its use in pulmonary embolism is much less clear. Yet, pulmonary embolism represents a significant disease process that is associated with high morbidity and mortality. The AHA and American Cardiology Association in the past year has advocated for the use of thrombolytics in both massive and sub-massive pulmonary embolism in select patients.1However, ACEP has yet to release a clinical policy regarding the use of thrombolysis in sub-massive pulmonary embolism. In this review, I will discuss the evidence behind the use of thrombolysis in pulmonary embolism, specifically in sub-massive pulmonary embolism.
By Emerson Posadas, MD, MBA (PGY-3)
Thromboelastography (TEG) is a tool that measures in real-time clot development, stability, and dissolution. It not only measures the coagulation cascade, but also shows the interaction of platelets in clot formation. It is a dynamic measurement, that has in recent years, become more readily available in the emergency department. This blog will review the evidence behind its use in the Emergency Department in the setting of shock in both trauma and medical patients.
Pediatric bacterial meningitis: an update on early identification and management.
Recent Publication by Chief Resident Emerson Posadas:
The presentation of bacterial meningitis can overlap with viral meningitis and other conditions, and emergency clinicians must remain vigilant to avoid delaying treatment for a child with bacterial meningitis. Inflammatory markers, such as procalcitonin, in the serum and cerebrospinal fluid may help distinguish between bacterial meningitis and viral meningitis. Appropriate early antibiotic treatment and management for bacterial meningitis is critical for optimal outcomes. Although debated, corticosteroids should be considered in certain cases. This issue provides evidence-based recommendations for the early identification and appropriate management of bacterial meningitis in pediatric patients.
Click For the Full Article:
Pediatric Stroke and its Mimics
By Elizabeth Chen MD PGY-3
Acute Ischemic Stroke (AIS) in the pediatric population is extremely rare, has many mimics, and often presents with signs and symptoms that differ from a typical “adult” stroke. Because the goal for diagnosis and treatment of AIS in adults is 4 hours, these differences often lead to delayed recognition and treatment. In a Canadian study, median interval from time of onset to diagnosis was 22.7 hours. When a stroke occurred in hospital, it still took 12.7 hours to diagnose. When a child had a stroke out of the hospital, it took on average 1.7 hours for patients to present to the hospital, indicating that the time delay to diagnosis was often on the part of the medical staff. Currently, only a handful of large, dedicated pediatric centers have pediatric stroke teams similar to the typical adult “code stroke” teams found in most communities. These pediatric teams are equipped to diagnosis and potentially treat children with AIS quickly but most hospitals are not. The key to improve care for children in the community is for all emergency physicians to be well trained on how to recognize and evaluate children for stroke.
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