"We urge that
@ACEPNow
actively rescind any explicit or implicit endorsement of the 2009 Report on
#ExcitedDelirium
Syndrome.
This position should be communicated to law enforcement and to expert witnesses testifying in civil and criminal litigation."
Don't give CPR to a 🐇 that has just been killed by a cat.
It's a traumatic arrest, CPR doesn't help.
What does help?
Rapid access through the chest to release a tension ptx or drain a tamponade.
Next step...
1/47
Two nights ago I gave a wild baby rabbit CPR w breaths after I took it from my Petey (cat). Today, I’m being admitted to the hospital with signs of “bunny fever” (Tularemia). I’m on 8L oxygen, a cocktail of very expensive antibiotics, anti-diuretics. Need light & love, please!
A recent study found that kids (ages 9-12) often had a very high rise in troponin following an intervention that is *claimed* to be healthy.
The dotted line shows the threshold of troponin that diagnoses a heart attack!
1/3
"Every day you put on a mask, think to yourself, 'I rock. I may be saving 20 people’s moms or dads today alone.'"
This is how I think about
#Zachsmath
. 12/
COVID Update July 25: Right now in this crisis, good or bad is less important than early or late.
If saving lives is important to your mayor & governor, they need to be early to action. 1/
The ECG that radicalized me.
I was a PGY-3.
Middle-aged guy with typical chest pain, early AM.
Both ED attending and cards fellow say this isn't an indication for the cath lab.
Still salty about my attending.
Me: "Hey, calling for a consult, young healthy female, syncope."
Cards: "Uh, do you really need us? Unstable vitals?"
"No"
"ECG concerning?"
"No"
"Don't tell me that you sent a..."
"Actually, troponin is undetectable."
"Then why..."
"There's a plop."
"..."
The same effect can be seen in e.g. competitive swimming! ()
So... should we have kids stop swimming or kicking balls around?
Or maybe should we just be a little more careful when using troponin as an outcome?
😉
3/3
"Sir, it sounds like you had a simple fainting spell. We don't usually have to do much testing, just hold still while the tech gets the ECG."
"Um, please record that."
Performed a tactical intubation last night, minimal noise, silent team communication, moved patient under cover.
Was trying to get my yearly tube without the resident popping up "Hey, I heard there's an intubation!"
@EMPAthy_atrophy
This was just covered in the Risk Management Monthly podcast.
If the patient is not in custody, this could be a HIPAA violation, unless the patient consents to sharing information...
(
@BadHippa
come @ me)
TL;DR on the new AF guidelines.
For acute control of RVR:
- CCB vs BB is a tired discussion
- Don't kill mod-severe CM with CCB tho
- Mag is fetch
- If not hemodynamically unstable, and don't have decomp CHF, it's not an emergency.
#CCR23
: In the DEVICE trial, the use of video laryngoscopy in critically ill patients undergoing intubation in the ED or ICU resulted in a higher incidence of successful intubation on the first attempt than direct laryngoscopy.
Why would someone not see the acute MI on this ECG?
I'm *not* being snide - I'm looking for common cognitive errors, problems with ECG education, etc.
I'll start: The computer said "normal" 😬
The paradox of interpreting the ECG with a RBBB:
- Overt STE may be present, satisfying OMI/STEMI criteria, but it is not appreciated; or conversely
- The widened QRS of a normal RBBB ECG is misinterpreted as suggesting OMI/STEMI, despite normal ST segments.
A 🧵.
1/6
"Keep me away from my wife. I don't want to give this to her"
The last thing my
#COVID19
patient said to me, as I was doffing at his door.
Just saw he didn't make it out of the ICU. Damn
"That's not in ACLS!!"
Working title for ED talk about things we do in resus that we shouldn't; things that we don't that we should; and controversial therapies
Your thoughts?
Examples below:
1/2
@smithECGBlog
@tbouthillet
@critconcepts
@srrezaie
If you care about
#MeToo
Weinstein, Spacey, etc...
Stop telling students to use "Dubin's" to learn ECGs!
He drugged and raped a 16 y.o.
He owned and made child pornography.
There are many, many other good sources to learn ECGs.
#DumpDubin
"We report the case of a 32-year-old male recently diagnosed with type 2 diabetes treated at an urban university emergency department (ED) crowded to 250% over capacity"
@shesinscrubs
@critconcepts
From the nyt story about DHR.
"Some elective procedures" is the buried lede
They want the $$ to keep rolling in.
Vulnerable Border Community Battles Virus on ‘A Straight Up Trajectory’
"Many EDs have increased functional ED capacity by designating ED hallway space (despite the serious privacy and HIPAA issues that creates).
There is no other setting in health care where placing patients in public hallways is considered routinely acceptable. "
@Toaster_Pastry
I've worked in urban EDs for 15 years, and what heartens me is that patients and family are *overwhelmingly* understanding and even empathetic.
While horrible, what you witnessed is an aberration.
... and so rather than fruitlessly aim to educate or correct clinicians, we feel it is better to just accept these "alternative" ECG lead placements.
As a result, what we formally termed "artifact" or "garbage" will now be the standard.
All the stakeholders agreed that ...
3/4
KETAMINE, KIDS, AND DOSING
While legal authorities looked on, two white men injected a young brown-skinned child with a big dose of ketamine.
They then handcuffed him and deliberately shoved his face underwater.
The child lived.
JUST NOW:
@ACEPNow
withdraws approval of the 2009 White Paper on Excited Delirium.
"This means if someone dies while being restrained in custody, people can’t ... point to ACEP’s endorsement of the concept to bolster their case"
@EmergencyDocs
Provocative take:
Dilt or metop for AF with RVR is *not* an urgent intervention.
Little reason for EMS, or EM in the first hour, to do this.
Risk >> possible benefit
#OculoDiltReflex
"A federal judge said New Hampshire has one year to stop holding psychiatric patients in hospital emergency rooms ... also said the state can only hold people in emergency rooms for up to six hours, before transferring ... for treatment."
Both the ECG patterns of early repolarization and of pericarditis can show ST segment elevation.
It may be difficult to tell the difference between these 2 ECG diagnoses.
Herein, a case-🧵 of pericarditis developing on top of a baseline ECG with ER
1/
Older guy, vague history of MI, CVA. Syncope witnessed by wife.
Called cath lab activation.
Was this a good or bad call??
(Everyone play nice this time ya hear, this is the nice corner of Twitter)
I am *not* speaking to any specifics about the ER crew care of Mr. Knotts.
I would highlight, though, that the *moment* our patient comes in our doors, they are, well, our patient.
And we need to anticipate and prevent restraint asphyxia, even when LEOs are "in charge."
1/2
I can’t stress this enough.
If you are reporting on the death of Kenneth Knotts in Texas…you MUST NOT cover it like an isolated event.
He died while being held PRONE (facedown)
AFTER he’d already been handcuffed
1/
Consultants, if you wield any power at all in your workplace, don't let shit like this happen. Working on office-less wards is miserable. The most prescribing errors (and general errors) I ever made on a job was on a ward like this where we just got constantly interrupted.
de Winter pattern was initially defined by *up-sloping* STD in the anterior leads.
But a lot of cases of reports of de Winter show flat or even down-sloping STD.
1/2
yOuNg pEoPlE dOn'T gEt sIcK fRoM cOvId.
This person is, shall we say, old enough to buy beer, but still young enough to get hit with a special add-on fee at Hertz car rental.
And they're only alive because of massive critical-care efforts.
Number of patients I've seen where high BP causes nosebleeds: 0
Number of patients I've seen who have been told their high BP is the cause of their nosebleeds: 10+
Number of patients I've seen where high BP causes headaches: 0
Number of patients I've seen who have been told their high BP is the cause of their headaches: 100+
@SDSheriff
@SDSOSanMarcos
@Up2SD
Ok, some ER doc edits:
"Recently, a
@SDSheriff
Deputy [fainted] and nearly [drowned from a nasal Narcan] overdose. If it wasn't for the quick-thinking of his Field Training Officer in [putting a pillow under his head], that deputy would [have a crick in his neck]"
Reminds me of a case I wrote up for
@smithECGBlog
's blog, also presented at an electrocardiology conference. I was accused by a cardiologist, in public, of wasting their time presenting an EKG with obvious artifact lol
I work with Emily in the Bridgeport ER. I know her very well.
When she comes to me, alerting me to a problem, I believe her, and I respond.
So now *you* have to believe her.
The nurses and doctors, the people, the children in Gaza are being killed and maimed.
Watch this.
Emily Callahan is a nurse with Doctors Without Borders. She shares her experience being in Gaza for 26 days.
I’m genuinely surprised
@CNN
aired her testimony.
The deputy medical examiner has made 9 diagnoses of "excited delirium" in their career.
In 8 of those cases there was "positional restraint" involved.
Further evidence that almost no one dies from "excited delirium" in the absence of aggressive restraint.
56-year-old Oral Nunis was in a mental health crisis. No drugs or alcohol in his system when police arrived. In just 20 minutes, after being placed in a WRAP and a spit sock, Nunis was dead. SD's Med Examiner blamed "excited delirium."
... and so rather than fruitlessly aim to educate clinicians, we feel it is better to just accept these "alternative" ECG lead placements.
As a result, what we formally termed "artifact" or "garbage" will now be the standard.
All the stakeholders agreed that ...
#ECG
3/4
Can we finally quash the garbage of "Women typically present atypically?!"
New ESC guidelines emphasize that we need to be focused on a wide range of symptoms, but especially chest discomfort, in *both* women and men.
@HeartSisters
thoughts?
@psych_biscuits
Yes, it can be quite educational.
It can show those patients that when they show up in the emergency department, they will be the subject of humor, giggling, and derision.
Quite educational for them.
Just published online today.
@PendellM
This is our best and most important work ever.
Another nail in the STEMI/NonSTEMI coffin.
Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute OMI.
Full text:
A rant about defining "posterior" MI
The
@ACCinTouch
put out a pretty good report on evaluating chest pain in the ED this year.
One highlight: A handy chart of "STEMI equivalents," informed by recent EM literature! (and authors! e.g.
@debdiercks
)
But...
1/7
84 yo 👵 hx of Parkinson’s disease with right arm tremor. Incorrectly diagnosed as Torsade de Pointes and given IV magnesium. The key to correct diagnosis is found in lead III i.e. artefact
@ecgrhythms
#Cardiotwitter
#epeeps
Maybe a rare beast?
Middle-aged, hx untreated HTN, no meds, no drugs
Has dizziness and "pounding heart"
No change w/ lIdocaine
Adenosine had transient undocumented effect
Verapamil produced this rhythm change
1/4
What are the potential downsides of getting a URINE TOX in an emergency patient?
Talking with two residents last night, a junior and a senior.
They had not been exposed to this idea.
I gave some thoughts, would love to hear the crowd
@RyanMarino
@clairezagorski
@fakeQrampage