A 55 year old male was brought to the Emergency Department (ED) by paramedics complaining of weakness and chest discomfort. His past medical history was notable for coronary artery disease with bypass grafting, diabetes mellitus, and end stage renal disease. He reported being non-compliant with his last 2 scheduled hemodialysis sessions. Paramedics noted pallor and recorded a blood pressure of 80/palpated and a heart rate of 44. Upon arrival to the ED, a 12 lead ECG was obtained.
The recognition of ST-segment elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult and frustrating to both emergency medicine physicians and cardiologists. According to the 2004 STEMI guidelines, emergent reperfusion therapy was recommended to patients with suspected ischemia and new LBBB however, the new 2013 STEMI guidelines made a drastic change by removing this recommendation. Several papers have recently been published discussing a modified Sgarbossa’s criteria and a new algorithm to help decrease false cath lab activation and/or fibrinolytic therapy, but are they ready for primetime? (more…)
As 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.
Acute pulmonary embolism (PE) is a common condition that can be both severe and difficult to diagnose. Half of all acute PE cases are diagnosed in the emergency department, and acute PE follows acute coronary syndrome as the second most common cause of sudden unexpected death in outpatients. Also, right ventricular dysfunction is a consequence of massive/submassive acute pulmonary embolism and correlates with a poor prognosis and high mortality rate. Although an ECG lacks both sensitivity and specificity for acute PE, there are some clues that can help in determining the size of an acute PE.
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).
There are several algorithms that are currently used to help distinguish Supraventricular Tachycardia (SVT) with aberrancy and Ventricular Tachycardia (VT). Many of these algorithms lack specificity, and let’s face it, who can remember if the absence of an RS complex in the precordial leads is VT or SVT with aberrancy. So what if there was a criterion that had a good sensitivity (SN), specificity (SP), and was one simple step?
Due to the overwhelming popularity of Dr. Salim Rezaie‘s recent post discussing the Brugada criteria for SVT with aberrancy vs VT, Dr. Jason West (@JWestEM, an EM resident from Jacobi/Montefiore) kindly helped to co-author and package this information into a PV card for quick reference. To use this sequential, four-question approach, if at any time you answer YES to the question, it is ventricular tachycardia.