Wellens Syndrome -Remember, there are both Type A and Type B Wellens findings on EKG -Both are extremely high risk for unstable LAD occlusion and reperfusion -Treat like a ACS -Emergent cardiac consultation for catheterization -Beware the Wellens patient that develops chest pain Medical/Trauma Resuscitation Conundrums -Never let an initial impression turn off your medical thinking -If the clinical trajectory isn't making sense, revisit your diagnosis and plan -Ongoing hypoxia and hypotension demands a full reevalution, consider repeating bedside imaging and ultrasound is your best friend -Upright film more sensitive than supine for blood in the chest, US even better -Hemothorax rules: 1500 cc immediately, or 200 cc/hr x 4 hours = OR
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The mnemonic for systematically evaluating a non-contrast head CT is “Blood Can Be Very, Very Bad”. A Reassuring CT: · No Blood is seen · All Cisterns are present and open · Brain is symmetric with normal gray-white differentiation · Ventricles are symmetric without dilation · No hyperdense Vessels are present · No Bone fractures - Only approximately 5% of all headaches that present in the ED are true emergencies - After evaluating for potential emergencies and performing a full neuro exam, pause and consider if any of the following Red Flags are present:
To diagnose migraine, need 5 separate episodes of headache characterized by:
"Migraine” or undifferentiated benign headache, you can treat the same way in the ED Best evidence for acute headache treatment includes the following:
Avoid narcotics and barbiturates out of concern for dependency and rebound effect
Field treatment: don’t make things worse, get to the nearest hospital In the hospital: 1. ABCs 2. Wound assessment and pain control 3. Labs to assess for coagulopathy and rhabdomyolysis 4. Call poison control – should always talk to toxicologist 5. CroFAB vs observation only - Mild/dry bite: no CroFAB, just observation - Moderate/severe: one or more doses as needed based on wound progression CroFAB is only curative treatment currently but VERY expensive; Currently evaluating anti-TNFa agents TNFa pilot study: active now, enrolling nonpregnant healthy adults
Bariatric Patients
Aortic DIssection
Bifascicular Block and Second Degree AV Block1. In asymptomatic individuals, chronic bifascicular block does not usually require cardiac work-up; the prognosis is generally benign 2. The following high-risk features, however, warrant urgent evaluation: a. Bifascicular block and syncope b. Bifascicular block and intermittent second degree AV block c. 1:1 AV conduction at slower sinus rates but higher grade block (i.e., 2:1 AV conduction) at faster sinus rates (“acceleration-dependent AV block”) 3. Evaluation and management of patients with bifascicular block: a. Actively search for nonconducted P waves in the 12-lead ECG b. Always review telemetry strips and actively search for episodes of second degree AV block (blocked P waves) c. In symptomatic patients with bifascicular block who develop acceleration-dependent second degree AV block and a very slow ventricular rate, carotid massage or IV beta blocker can paradoxically restore 1:1 AV conduction d. Patients with bifascicular block and syncope require admission and cardiology consultation for possible pacemaker implantation e. Patients with bifascicular block and intermittent second degree AV block require cardiology consultation for possible pacemaker implantation The Pacemaker ECG1. Ventricular pacing: always try to determine what the atria are doing
2. Sinus P wave in front of each paced QRS complex indicates dual chamber (A-V sequential) pacemaker where the ventricular pacer is tracking sinus rhythm 3. Two pacer spikes about 5 mm apart indicate AV sequential pacing 4. If there are no P waves or 2 pacer spikes, search for the presence of retrograde P waves after the paced QRS complexes; retrograde P waves are sharp negative in the inferior leads (in II, III and aVF) and usually upright in V1 5. If there are no P waves in front of the paced QRS complexes and no retrograde P waves present, always consider the possibility of underlying atrial fibrillation 1. Pediatric Chest Pain - Myocarditis
2. Neuroleptic Malignant Syndrome
1. Foreign Body Ingestion - Think about with wheezing, drooling, stridor OR a good story. A. Esophageal:
2. Pulmonary embolism:
3. Pyloric Stenosis:
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