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Emergency Medicine Pitfalls

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181. Chest Pain and Q-waves in V1 and V2. Is there previous septal MI?

clue to leads too high are the R'-waves in V1 and V2. These are commonly a result of high lead placement. Brooks Walsh ( ) has a great article on this topic, though he does not discuss septal Q-waves as a result: (full text). American Journal of Emergency Medicine 36(5):865-870; May 2018. We placed the leads in the correct position and this was the result: Now the ECG is completely normal She ruled out for MI by troponins. She had a normal echocardiogram, with normal shortening and thickening (...) ): ----------------------------------------------------------- Important post by Dr. Smith regarding recognition of chest lead misplacement of leads V1 and V2 . Two features about this pitfall amaze me: i ) How surprisingly common this technical error is ( In our informal study of internet-published examples supposedly illustrating “proper lead placement” — more than half of these published examples showed faulty lead placement! ); and , ii ) How commonly emergency care providers fail to recognize this form of lead misplacement! The “good news” — is that it is EASY

2018 Dr Smith's ECG Blog

182. Idiopathic Ventricular Tachycardias for the EM Physician

Resources , . Dr. Stephen W. Smith is a faculty physician in the at Hennepin County Medical Center (HCMC) in Minneapolis, MN, and Professor of Emergency Medicine at the . This work is licensed under a . Disclaimer Cases come from all over the world. Patient identifiers have been redacted or patient consent has been obtained. The contents of this site have not been reviewed nor approved by Hennepin County Medical Center and any views or opinions expressed herein do not necessarily reflect the views (...) VT, how could I protect myself when none of the guidelines’ tachycardia algorithms deal with idiopathic VT?” “Cardioversion is safe, effective, and fun.” Option #2: Fancy Pants In this option you adopt a practice in which you act on your experienced suspicion of IVT, but in a way that has been prospectively thought out to avoid the pitfalls and complications in the event that you’re wrong. You’ve thought out exactly when and why you’re going to use each medication. The reasoning includes

2018 Dr Smith's ECG Blog

183. Power Threat Meaning Framework: innovative and important? #PTMFramework

strange that both evidence-based medicine and outdated philosophies such as psychoanalysis and Foucauldian discourse are given the same weight in the Framework. Evidence-based medicine is just that: statistics have shown that it is effective for a high enough percentage of people to be useful. The same sorts of statistics can never be gathered for psychoanalysis. In terms of narratives, I agree that they can be useful. Looking at what happened can be helpful, up to a point. Many of us, however, find (...) Provisional General Patterns which emerge from within the Foundational Pattern. They are not one-to-one replacements for diagnostic clusters, but are based on broad regularities which cut across diagnostic groups, and which arise out of personal, social and cultural meanings. Seven diagnostic clusters, of a type familiar from ICD and DSM, then. This impression is reinforced by their definition: “a pattern refers to associations that seem to occur above chance level” . This is reminiscent of the Maudsley

2018 The Mental Elf

184. Another Cardiac Arrest - Is it OMI this time? Use your skills from the previous post!

that it is downplayed by the STEMI vs. NSTEMI paradigm, and even more downplayed in actual practice by some physicians (EM and cardiology). Look for supplementary evidence of OMI within PVCs. Posted by Pendell at Labels: , , , Reactions: 1 comment: Well written and very informative! Subscribe to: Recommended Resources , . Dr. Stephen W. Smith is a faculty physician in the at Hennepin County Medical Center (HCMC) in Minneapolis, MN, and Professor of Emergency Medicine at the . This work is licensed under (...) bystander CPR, and appropriately timed reperfusion therapy. The patient ultimately died 2 weeks later. The ECG pitfalls in this case are common, especially among the sickest patients with OMI. The STEMI vs. NSTEMI paradigm does not prepare us for cases like this. The STEMI vs. NSTEMI paradigm fails even in those with normal-appearing QRS complex, and fails even more as the QRS complex becomes more and more abnormal. Only advanced ECG interpretation and training will help these patients in the cases when

2018 Dr Smith's ECG Blog

185. #UnderstandingPsychosis?

by on Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+ Share this post: Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+ Share via email Tagged with: , , , , , , , , , , , , , , , , , , Dr Jauhar graduated in Medicine from Glasgow University in 2002, having also completed a degree in Public Health and Epidemiology. His research interests focus on understanding neurobiological causes of psychotic illness, with a focus on the affective psychoses (...) , and treatment of psychotic and affective illnesses. He also has a keen interest in evidence-based medicine and treatments, both pharmacological and non-pharmacological in affective and psychotic illness. He received a Royal College of Physicians, Edinburgh JMAS Sim Fellowship in 2018, enabling him to build on work examining the presynaptic dopamine system in affective psychoses. Clinically, he has worked as a Consultant Psychiatrist in Early Intervention in Psychosis since 2012, throughout South London

2017 The Mental Elf

187. Right precordial ST depression in a patient with chest pain

. . Emergency Medicine Journal 34(2):119. July 2016. 8. Goldwasser D, Senthlikumar A, Bayes de Luna A. Lateral MI Explains the Presence of Prominent R Wave (R ≥ S) in V1. 2015 Nov;20(6):570-7. 9. Anand U, Kulkarni MD, Renee B. Clinical use of posterior electrocardiographic leads: A prospective electrocardiographic analysis during coronary occlusion. Volume 131, Issue 4, Pages 736-741 10. Chia BL, Tan HC, Yip JW. Electrocardiographic patterns in posterior chest leads (V7, V8, V9) in normal subjects. 2000 Apr (...) County Medical Center (HCMC) in Minneapolis, MN, and Professor of Emergency Medicine at the . This work is licensed under a . Disclaimer Cases come from all over the world. Patient identifiers have been redacted or patient consent has been obtained. The contents of this site have not been reviewed nor approved by Hennepin County Medical Center and any views or opinions expressed herein do not necessarily reflect the views or opinions of Hennepin County Medical Center. As of March 10, 2018, I've

2017 Dr Smith's ECG Blog

188. Sudden weakness with bradycaria and bizarre T-waves

of the gate I would say PE?. No. It's AV block. Subscribe to: Recommended Resources , . Dr. Stephen W. Smith is a faculty physician in the at Hennepin County Medical Center (HCMC) in Minneapolis, MN, and Professor of Emergency Medicine at the . This work is licensed under a . Disclaimer Cases come from all over the world. Patient identifiers have been redacted or patient consent has been obtained. The contents of this site have not been reviewed nor approved by Hennepin County Medical Center and any views (...) is working, and then it is only working on every other beat!! Management: Since these patients are at high risk of progressing to complete heart block, especially in the context of acute MI (not applicable here), it is wise to apply the external pacing pads. Get ready for emergent transvenous pacing and get the patient to an electrophysiologist who can place a permanent pacemaker. The electrophysiologist was called. The patient remained stable. Electrolytes, especially K, were normal. Troponin

2017 Dr Smith's ECG Blog

189. Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®): Health Professional Version

Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®): Health Professional Version Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®) - PDQ Cancer Information Summaries - NCBI Bookshelf Warning: The NCBI web site requires JavaScript to function. Search database Search term Search NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. PDQ Cancer (...) and Practice of Pediatric Oncology. 7th ed. Philadelphia, Pa: Lippincott Williams and Wilkins, 2015, pp 463-97. Chessells JM; haemostasis and thrombosis task force, British committee for standards in haematology: Pitfalls in the diagnosis of childhood leukaemia. Br J Haematol 114 (3): 506-11, 2001. [ ] Onciu M: Acute lymphoblastic leukemia. Hematol Oncol Clin North Am 23 (4): 655-74, 2009. [ ] Heerema-McKenney A, Cleary M, Arber D: Pathology and molecular diagnosis of leukemias and lymphomas. In: Pizzo PA

2018 PDQ - NCI's Comprehensive Cancer Database

190. Interventions to Improve the Economic Self-sufficiency and Well-being of Resettled Refugees: A Systematic Review

serve. 11 The Campbell Collaboration | www.campbellcollaboration.org Contemporary programmes have emerged as a result of more recent contexts, and this review therefore focused on studies undertaken or published since 1980, which can be characterised as something of a ‘watershed’ year for the following reasons. The legislation and structure of refugee resettlement in the United States, Australia, Canada, and Europe changed dramatically since the late 1970s. The United States, by far the largest (...) resettlement country, passed the 1980 Refugee Act, which serves as the basis for the mandate and structure of its current programme. Australia’s contemporary approach to refugees emerged in December 1979 when the Community Refugee Resettlement scheme came into force. This scheme included housing, social and employment support (Refugee Council of Australia, 2012). Canada’s current refugee programme is based on the 1976 Immigration Act and further shaped by the 1982 entrenchment of the Canadian Charter

2015 Campbell Collaboration

191. Genetics of Prostate Cancer (PDQ®): Health Professional Version

Genetics of Prostate Cancer (PDQ®): Health Professional Version Genetics of Prostate Cancer (PDQ®) - PDQ Cancer Information Summaries - NCBI Bookshelf Warning: The NCBI web site requires JavaScript to function. Search database Search term Search NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. PDQ Cancer Information Summaries [Internet]. Bethesda (MD (...) to detailed sections below that describe the evidence on each topic. Inheritance and Risk A genetic contribution to prostate cancer risk has been documented, and knowledge about the molecular genetics of the disease is increasing. Clinical management based on knowledge of inherited pathogenic variants is emerging. include the following: 1) multiple affected first-degree relatives (FDRs) with prostate cancer, including three successive generations with prostate cancer in the maternal or paternal lineage; 2

2018 PDQ - NCI's Comprehensive Cancer Database

192. Childhood Cancer Genomics (PDQ®): Health Professional Version

Childhood Cancer Genomics (PDQ®): Health Professional Version Childhood Cancer Genomics (PDQ®) - PDQ Cancer Information Summaries - NCBI Bookshelf Warning: The NCBI web site requires JavaScript to function. Search database Search term Search NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. PDQ Cancer Information Summaries [Internet]. Bethesda (MD (...) advanced by the application of whole-genome and exome sequencing to cohorts of children with cancer. Estimates for rates of pathogenic germline mutations approaching 10% have emerged from studies applying these sequencing methods to childhood cancer cohorts.[ - ] In some cases, the pathogenic germline mutations are clearly contributory to the patient’s cancer (e.g., TP53 mutations arising in the context of Li-Fraumeni syndrome), whereas in other cases the contribution of the germline mutation

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2018 PDQ - NCI's Comprehensive Cancer Database

193. Genetics of Breast and Gynecologic Cancers (PDQ®): Health Professional Version

Genetics of Breast and Gynecologic Cancers (PDQ®): Health Professional Version Genetics of Breast and Gynecologic Cancers (PDQ®) - PDQ Cancer Information Summaries - NCBI Bookshelf Warning: The NCBI web site requires JavaScript to function. Search database Search term Search NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. PDQ Cancer Information

2018 PDQ - NCI's Comprehensive Cancer Database

194. Implementing system wide risk stratification approaches

Emergency Department EHR Electronic Health Record EMR Electronic Medical Record GP General Practitioner HCC Hierarchical Condition Category ICDMP Indiana Chronic Disease Management Program FINDRISC Finnish Diabetes Risk Score FRS Framingham Risk Score JADE Joint Asia Diabetes Evaluation Risk Engine JHUACG Johns Hopkins University Adjusted Clinical Groups KPSC Kaiser Permanente Southern California LACE Length of Stay, Acuity of Admission, Comorbidities, Emergency Department Visits LVH Left Ventricular (...) contribute to reductions in hospital readmissions, health service use and improved patient outcomes. Evidence from evaluation in this area is scattered yet rapidly emerging. We found protocols of four high potential trials of the implementation of risk stratification tools that are due to report within the next 12 months; all of which intend to take a comprehensive, mixed-methods approach to examining a broad range of aspects related to the implementation of risk stratification tools closely aligned

2015 Sax Institute Evidence Check

195. Late Effects of Treatment for Childhood Cancer (PDQ®): Health Professional Version

Late Effects of Treatment for Childhood Cancer (PDQ®): Health Professional Version Late Effects of Treatment for Childhood Cancer (PDQ®) - PDQ Cancer Information Summaries - NCBI Bookshelf Warning: The NCBI web site requires JavaScript to function. Search database Search term Search NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. PDQ Cancer Information (...) CNS tumors, female breast cancer, Hodgkin lymphoma, and leukemia, evidence of excess mortality risk persisted, or re-emerged, more than 10 years after a cancer diagnosis. Conditional relative survival was lowest for adolescent and young adult patients with CNS tumors, although patients aged 15 to 29 years demonstrated a higher survival rate than did patients aged 30 to 39 years at the time of diagnosis of their CNS tumors.[ ] Monitoring for Late Effects Recognition of both acute and late modality

2018 PDQ - NCI's Comprehensive Cancer Database

196. Computed Tomography to Evaluate Children with Suspected Appendicitis

– Age group unclear 6. Thompson AC, Olcott EW, Poullos PD, Jeffrey RB, Thompson MO, Rosenberg J, et al. Predictors of appendicitis on computed tomography among cases with borderline appendix size. Emerg Radiol. 2015 Feb 17. PubMed: PM25687166 7. Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Accuracies of diagnostic methods for acute appendicitis. Am Surg. 2013 Jan;79(1):101-6. PubMed: PM23317620 8. Soyer P, Dohan A, Eveno C, Naneix AL, Pocard M, Pautrat K, et al. Pitfalls and mimickers at 64 (...) -the balance between cost effectiveness and safety remains challenging. Langenbecks Arch Surg. 2014 Apr;399(4):493-501. PubMed: PM24633534 Guidelines and Recommendations – Unclear Methodology 11. Appendicitis/abdominal pain: emergency department clinical practice guideline (CPG) [Internet]. St. Louis (MO): Cardinal Glennon Children’s Medical Center; 2013 [cited 2015 Apr 1]. Available from: http://www.cardinalglennon.com/Documents/emergency- medicine/appendicitis-and-abdominal-pain-clinical-practice

2015 Canadian Agency for Drugs and Technologies in Health - Rapid Review

197. Treatment of Acute Hyperkalaemia in Adults

Wiese – Representative of the College of Emergency Medicine Mrs Brenda Wilson – Representative of Scottish Resuscitation Group Mrs Jacqueline Beatson - Representative of Scottish Resuscitation Group Mrs Lyn Allen – Renal Nurse; Representative of British Renal Society Mrs Mumtaz Goolam – Renal Nurse; Representative of British Renal Nursing Mrs Morag Whittle – Representative of UK Renal Pharmacy Group FINAL VERSION MARCH 2014 2 Final Draft 1.3.14 Please send feedback to Dr Annette Alfonzo (...) Treatment of Acute Hyperkalaemia in Adults FINAL VERSION MARCH 2014 1 CLINICAL PRACTICE GUIDELINES TREATMENT OF ACUTE HYPERKALAEMIA IN ADULTS UK Renal Association 2014 FINAL VERSION - MARCH 2014 Contributors: Dr Annette Alfonzo – Consultant Nephrologist Dr Jasmeet Soar – Consultant in Anaesthesia & Intensive Care Medicine; Immediate Past Chairman of Resuscitation Council (UK) Dr Robert MacTier - Consultant Nephrologist; Former lead of Guidelines Committee of Renal Association Dr Jonathan Fox

2014 Renal Association

198. Electronic Health Records (EHRs)

. Key challenges identified by health practitioners who have implemented EHRs b. Proposed Solutions 10. EHRs: More Research? Background • In 1991, the Institute of Medicine released a landmark report recommending that electronic health records (EHRs) be implemented in health systems within 10 years 1 ; • Almost 20 years later, only a small proportion of health providers have implemented EHRs. 2 3 • A meta-analysis of diffusion rates of EHRs in the U.S. shows that uptake has slowed in recent years (...) it is about successful EHRs that benefit patients, their health practitioners and the health systems within which they operate. 1 Institute of Medicine. The computer-based patient record: an essential technology for health care. Dick RS, Steen EB, eds. Washington DC: National Academy Press, 1991. 2 Erstad TL. Analyzing Computer Based Patient Records: A Review of the Literature. J Healthcare Inf Management 2003; 17(4): 51-57. 3 Kotecha JA, Birtwhistle RV. Use of electronic medical records: Reminders

2014 OHRI Knowledge to Action

199. Long-term Consequences Polycystic Ovary Syndrome

that supports them. Areas lacking evidence are highlighted and annotated as ‘Good Practice Points’. 4. Diagnosis 4.1 How is PCOS diagnosed? PCOS should be diagnosed according to the Rotterdam consensus criteria. The 1990 NIH preliminary consensus definition has now been replaced by a more recent definition by the Rotterdam European Society of Human Reproduction and Embryology (ESHRE)/American Society for Reproductive Medicine (ASRM)-Sponsored PCOS Consensus Workshop Group. 17 The Rotterdam criteria 17 have (...) with diabetes or other high-risk factors with blood pressure greater than 130 mmHg systolic and/or 80 mmHg diastolic may require drug therapy). Women with hypertension who need to start oral contraceptive therapy should be counselled regarding its risks and benefits and should be monitored and treated as per the Joint British Societies’ guidelines. 46 There is emerging evidence that statins improve hyperandrogenaemia and the metabolic profile in women with PCOS. 47,48 However, lipid-lowering treatment

2014 Royal College of Obstetricians and Gynaecologists

200. Henele E’ale: A new antivaccine naturopathic quack (but I repeat myself)

on medicine, quackery, science, and pseudoscience (and anything else that interests him). Henele E’ale: A new antivaccine naturopathic quack (but I repeat myself) One of the most common myths promulgated by die-hard antivaxers is the idea that if you have a healthy immune system you don’t need vaccines because your immune system will protect you against infectious diseases. It’s an idea that’s based on a germ of a legitimate idea, namely that if you are unhealthy or your immune system is suppressed you (...) can certainly be more susceptible to infection. However, antivaxers take that observation to a huge extreme by claiming that a healthy immune system renders vaccines unnecessary. A corollary to this idea is that you can “strengthen” your immune system by using whatever woo the quack believes in, be it supplements, dietary interventions, coffee enemas, or whatever. It’s magical thinking, of course, but it’s magical thinking that permeates much of alternative medicine and antivaccine ideology. I saw

2018 Respectful Insolence

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