Peer Perspective on Addiction, Dr. McMurray:

• Make an effort to attempt to treat those with Opioid Use like you would anyone else, connect with them, ask them about their families, hobbies, things that make them happy Disorder
• Louisville area addiction resources guide to be posted in EXI and able to handout to patients with updated information
• Buprenorphine: partial opioid agonist
  • Subutex: buprenorphine only
  • Suboxone: buprenorphine and naloxone (attempts to decrease misuse or diversion)
  • Ceiling effect for euphoria/pain relief
  • Use caution when other CNS depressants are on board or patient has liver impairment
• X wavier: free, takes 3-4 min to apply, must have DEA number
  • Use link to apply https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner
  • Enter licensing state, medical license number, and DEA number
  • “starting at the 100 patient level” select “no” for both questions
  • Select “I wish to apply for the 30 patient level with exemption”
  • Recheck in ~1 week to make sure your application was approved
• 3 day rule is for those without an x-wavier
• Resources: California Bridge Buprenorphine Pathway, Clinical Pathway on room9er by Dr. Kuzel
• Dot phrase for resources: ,dcaddict
• Prescribe Narcan kit at discharge

Pharmacy- Eclampsia/Pre-E, Josh Senn, PharmD:

• Important to quickly identify and treat these patients in a timely manner
• Hypertensive disorders of pregnancy are one of the leading causes of maternal and perinatal mortality worldwide
• 20-26% of eclampsia cases occur 48h-6weeks postpartum
  • 78% of these patients had no BP issues in pregnancy
• ACE-I and ARBS are contraindicated in pregnancy
• Preeclampsia: new onset hypertension and proteinuria
  • >160 systolic or >110 diastolic x1 or >140 and >90 x2 four hours apart
• Pre-e with severe features: new onset hypertension and signs of end organ dysfunction after 20 weeks gestation and up to 6 weeks postpartum
• Eclampsia: convulsive manifestation
  • Maintain airway, establish IV access, fetal monitoring and assessment, BP control, Mg therapy, obtaining pertinent labs
• Magnesium:
  • Do not wait on labs to initiate treatment with Mag!!
  • MOA possible cerebral vasodilation + blocking Ca entry + entry in neural cells and altering neurotransmission
  • Multiple studies validate use
  • Dosing: 4-6g IV over 15-20 min, repeat 2-4g loading dose PRN
  • Maintenance 1-2g/hr
  • **NO IV ACCESS: 5gm x2 IM in each buttock**
  • Monitoring: respiratory dive, patellar reflexes, for reversal can give Ca Gluconate 1g IV over 5-10 min, +/- 40mg Lasix (renal excretion of Mg)
• Blood pressure control otherwise: no difference in efficacy or safety in hydralazine, labetolol, nifedipine
• Initiate treatment for any SBP >160 or DBP >110
• Refractory HTN: nicardipine gtt (5-15 mg/hr) titrated to goal BP
• Stay up to date on ED protocol

Lightning Lectures:

• HELLP, Dr. Beard:
  • In pregnancy: multiple normal physiologic changes
  • HELLP 0.1-1% of all pregnancies
  • Questionably represents a severe form of pre-e
  • 15-20% do not have antecedent HTN or proteinuria
  • Pathogenesis: inadequate placental perfusion, induces platelet aggregation, endothelial dysfunction & arterial hypertension, fibrin released, microangiopathic hemolytic anemia
  • Risks: previous hx, multiparous women (>50%), COVID
  • Clinical manifestations: HTN, RUQ or epigastric pain, jaundice, nausea/vomiting, headaches, vision changes
  • Haptoglobin, LDH, coags in addition to other labs
  • Maternal stabilization and then prompt delivery if possible
  • Multiple pregnancy related disparities exist: black and Hispanic women are at significantly higher risk for pre-e and HELLP
• PID/TOA, Dr. Kushner:
  • PID: Proportion of cases caused by CT/GC is decreasing
    • Multiple other nontraditional organisms are surfacing and becoming more common
  • Risk factors: multiple partners, <25 yo, prior hx of PID or STI, partner with STI
  • Can occur acutely over several days or over weeks/months
  • S/s: lower abdominal or pelvic pain, pain with intercourse, abnormal uterine bleeding, urinary freq, vaginal discharge
  •  No single historical, physical or lab finding is both sensitive and specific
  • Special population: transgender patients- ask pronouns and ask about patient’s anatomy/organs
    • Very common (21%) for these patients to avoid ED care due to fear of discrimination
    • 4x higher rates of HIV, also higher rates of extreme poverty, sexual assault, sex work
    • Be cognizant of this
  • Maintain low threshold for clinical diagnosis of PID
    • Even mild or asymptomatic cases may be at risk of infertility
    • Presumptive treatment should be initiated for sexually active women: experiencing pelvic or abdominal pain, no other cause for illness can be identified or if one or more of the following criteria are present on pelvic exam: CMT, uterine tenderness, adnexal tenderness
  • Workup: pregnancy test, microscopy of vaginal discharge, HIV, syphilis, UA (in addition to other labs including inflammatory markers, CBC if more severe presentations)
  • Stay up to date on CDC guidelines
  • TOA: inflammatory mass involving fallopian tube, ovary, sometimes other adjacent organs like bowel/bladder
  • Not all are associated with PID
  • Pathophys: ascending lower genital tract infection
  • Not all have fever and acute abdominal pain
    • 23% have normal WBC count
  • CT > US if need to exclude GI tract involvement
  • Need at least 24h of inpatient observation

Research Updates, Dr. Huecker:

• Residents should understand how research is conducted, evaluated, explained to patients, and applied, participate in scholarly activity, have appropriate resources to accomplish these goals
•  ULDEM has a full time PhD faculty member who performs stats and also designs and serves as PI on studies: Dr. Jacob Shreffler

• Think, Do, Write
• Travel to conference is sponsored by the university if you are presenting
• Plan ahead, use available resources, expect delays, something you are passionate about

Suturing 101, Dr. Eisenstat:

• Resource: thelacerationcourse.com, also closing the gap
• “The best suture for a given laceration is the smallest diameter suture, which will adequately counteract static and dynamic tension forces on the skin” -Brian Lin
• Sizes and removal: please always discuss with patient and make sure to document in discharge instructions
• There is a difference between how long an absorbable suture supports the wound vs how long it actually stays in the skin
• Absorbable (fast gut) is completely appropriate for facial sutures in regards to scarring and patient satisfaction
• Utilize undermining when wound edges are too far apart to get good closure
• Vertical mattress sutures are good in high tension wounds: can make a big difference even with 1-2 placed in the middle of the wound
• Elderly, thinner skin: use steri-strips along edges and put sutures through steri strips

Dr.Baker- Knobology

ALARA- As Low As Reasonably Achievable

High Frequency Probe- Good for superficial structures, High Resolution

Low Frequency Probe-Good for deeper structures, Low Resolution

Gain- Brightness

Depth

Zoom

Use these three to make your image clearer

Hyperechoic- Brighter (More echogenicity) than surrounding area

Hypoechoic- Darker (Less echogenicity) than surrounding area

Isoechoic-Same color (Same echogenicity) as surrounding area

Anechoic- Black. No color at all (No echogenicity)

Dr.Neal, PharmD- Sepsis  and Antibiotics

Sepsis- Life threatening organ dysfunction secondary to unregulated host response to infection

SIRS- hypo or hyperthermic, tachypnea, tachycardia, leukocytosis

Septic shock- Infection requiring vasopressors despite adequate fluid resuscitation

Good empiric choice should cover 80% of the bug you’re suspecting, based on local antibiogram

Give bacterial meningitis patients steroids to help reduce risk of side effects of infection (deafness, etc.)

Use source to guide your empiric antibiotic therapy

Dr.Howell, PharmD- Fluids and Vasopressors in Septic Shock

Maintain MAP > 65

30cc/kg bolus of fluids if hypotensive or lactate greater than 4.

Must document why if you give less

If fluids don’t maintain pressure, start vasopressors

Hypotension is due to decrease in systemic vascular resistance, use pressors that increase SVR

Norepinephrine is safe to start peripherally

Norepi is 1^st line for septic shock

Vasopressin is 2^nd line

Epi vs phenylephrine is 3^rd/ 4^th line, depending on scenario

Dr. Senn, PharmD- Rapid Sequence Intubation

Etomidate- GABA receptors, .3mg/kg, onset 30-60secs, duration 5-1min, minimal side effects of hemodynamics, may cause myoclonus. May cause some adrenal suppression but clinical relevance unclear

Propofol- GABA receptors, 1-1.5mg/kg, onset 10-30secs, duration 3-10min, may cause hypotension

Ketamine- NMDA receptors, 1-2mg/kg IV, onset 30-60sec, Duration 5-15min, Sympathomimetic and may cause hypersalivation

Succinylcholine- Depolarizing agent, 1-2mg/kg, onset 45-60secs (look for fasciculations), Duration 10-15min, may cause hypotension, causes hyperkalemia about .5-1 mEq rise transiently, may also cause malignant hyperthermia, use with care in peds due to underlying muscular dystrophy

Rocuronium- Nondepolarizing agent, .6-1.2mg/kg, onset 60-120s, Duration 30-45min

Vecuronium- Nondepolarizing agent,.08-.1mg/kg, onset 2-3min, Duration30-50min, may cause hypothermia

Have post-intubation sedation meds ready when asking for intubation drugs, do not want patient paralyzed but not sedated

Dr. Cook- Room 9 Follow Up

AMS in young person – Concern for toxidrome. But keep wide differential.

Prolonged QTc. Look at T-wave as it related to QRS complexes, if greater than halfway between two QRS complexes, think prolonged.

Serotonin Syndrome- Nystagmus, Sustained Clonus, elevated BP, HR, Respiratory Rate, Hyperthermia, Altered Mental Status, Diaphoresis.

Hunter’s Criteria to help diagnose.

Treatment = Stop offending medication, supportive care, Benzos

In TCA overdose, treatment for EKG changes is bicarb. Serial EKG’s to monitor following bicarb administration.

Dr. Lund- Peds ED

See sicker patients first

Lots of order sets for specific cases (neonatal fever, DKA, Asthma, etc.)

Vaccine status very important

Finish notes within 24 hours

All medical subspecialties aside from heme/onc admit to JFK (medicine)

Newborns eat 2oz every 2 hours on average

1 month oz, 4oz every 4 hours on average

Newborns may poop once a week or multiple times a day

Ibuprofen/Tylenol 10mg/kg every 6 hours, Ibuprofen > 3 months, Tylenol any age

Versed PO dose 1mg/kg, IV .1mg/kg, IN .2-.3mg/kg

Morphine .1mg/kg

Fentanyl 1mcg/kg

Need high dose amox to kill strep pneumo (pneumonia, AOM)

Bolus = 20cc/kg

Sepsis= 60cc/kg in first hour

Dr. Ferko- Shock

Shock = Hypoperfusion

Signs of shock – hypotension, tachycardia, decreased urine output, altered mental status

Types of shock- cardiogenic, obstructive, distributive, hypovolemic

Distributive shock- Example is sepsis. Inappropriate vasodilation.

Use lactic and blood pressure to determine severity of sepsis. Severe sepsis needs 30cc/kg bolus

Norepinephrine is first line. Vasopressin 2^nd line. Then epinephrine or phenylephrine.

Cardiogenic shock- Most likely caused by acute MI. Severe decrease in cardiac output.

Norepinephrine is first line pressor again (pretty much first line for all shocks)

Distributive shock- Another example is distributive shock. Again, inappropriate vasodilation. Also classically involves no appropriate increase in cardiac output

Hypovolemic shock- In trauma, number one cause of shock. Treatment is blood or fluids, depending on cause of hypovolemia

Obstructive shock- Example is cardiac tamponade or tension pneumothorax. Decrease in cardiac output secondary to physical obstruction. Treatment is to relieve the obstruction.

Dr. Danzl- Law and Emergency Medicine

Document everything you do

When in doubt, treat the patient

Be kind and compassionate to your patients

Do everything you can to prevent patients leaving AMA. Give them the best chance to succeed if leaving AMA (give follow up, antibiotics as needed, etc.)

Take x-rays of all foreign bodies

Be sure patient can walk prior to discharge if they can normally walk

Always get a pregnancy test in women of childbearing age

Room 9 Introduction by Dr. Harmon

Interns- Expose patient. ABC handled by upper level this early in year. Don’t cut clothes if you don’t have to

EFAST- Save lots of clips. Ask for help. Diagnostic exams can be pulled into chart. Educational can’t.

Cardiac view first in penetrating trauma. RUQ in blunt trauma.

If you don’t know where stuff is in room 9, ask

PGY2- Do they need a man scan? Vital signs? Open fracture? All reasons to keep in room 9

Stroke- Get last known normal. 10min to get to CT. Expedite neuro exam. Stroke attending will want BP, glucose, hx of stroke, blood thinners.

EMS Introduction / Radio Calls by Dr. Orthober

Types of EMS/EMS providers. EMT (no procedures) vs Paramedic (procedures)

Taking calls – Get Vitals. Decide triage vs room 9 vs see in room 9 and decide

Answering helicopter calls, speaker vs phone call

Be professional on calls

3 types of “death” that must be transported. Hypothermia, Cold water drowning, Electrical

Transfer of Care by Dr. Platt

Happens all the time during a patient’s stay

Be professional

IPASS

When receiving, try to dictate ToC note yourself

Try to avoid doing ICU care to get patient to medical service

Sign out AMR patients

Be aware of patients coming from EPS. If you take call from EPS, you find patient on cerner and put your name on it

Healthcare Disparities by Dr. Eisenstat

Equality vs equity. Similar opportunities vs Similar outcomes.

People come from different walks of life and it affects your healthcare

Most people experiencing homelessness are temporary. 27% are “chronically homeless”

People experiencing homelessness have life expectancy 10-15 years less than their non-homeless counterparts

Tuskegee Experiments went on from the 1930’s until 1972. We knew penicillin could treat at the beginning.

Think about bias in triage patients

Be compassionate

Dr Eisenstat

5/18/22

1.  What we don’t use anymore: Spotlight on ancient vomiting sticks!, Ipecac syrup (no longer in use 2/2 aspiration risk), EWOL tube (large bore gastric tube), Potassium permanganate
2. Activated Charcoal: binds drugs in a 10:1 ratio.  The earlier the better (1-2 hours) and more efficacious with large, less polar molecules; dose 1-2g/kg (come in 50g tubes); CI with caustic ingestion, hydrocarbons, airway compromise, AMS
3. When to give multiple doses of AC
   1. SDAC: single dose AC, used predominately for salicylates
   1. MDAC: multiple doses AC, “gut dialysis”  for drugs to undergo enterohepatic recirculation; single bolus dose (1g/kg) and then q8 hours (.5g/kg); do not use w/ sorbitol (diarrhoea); does not reduce M&M but does reduce drug rate
      1. Carbamazepine
      1. Lamictal
      1. Colchicine
      1. Dapsone
      1. Phenytoin
      1. Phenobarbital
      1. Amatoxin
      1. Quinine (hypothetical with hydroxychloroquine)

•  Whole Bowel Irrigation (1-2L Go Lytly 1-2 hours) best used for things not well absorbed by AC; packers (drug mules), XR preparations.  Eg: Iron, Lithium, XR BB/CCB, bupropion.  Note that this is a cumbersome and messy endeavour.   
• Gastric lavage: used with colchicine or paraquat (pesticide)
• Take homes: AC best in the first 2 hours (but can argue to give beyond this), be familiar with MDAC, WBI for lithium and extended release substances

Lecture Points May 11, 2022

Zach Heppner, MD: Upper GI Bleed

1.  Most common aetiologies: PUD, erosive gastritis, oesophageal varices, malignancy, Mallory Weiss Tears
2. Initial management massive UGIB: ABC (secure airway, obtain access, blood to bedside), medical management (Rocephin, Protonix, Octreotide)
3. Balloon Tamponade
   1. Indications: tamponade that is unresponsive to endoscopic therapy or temporisation before definitive treatment
   1. No contraindications
   1. Complications: oesophageal rupture, rebleeding, aspiration, pain, cardiac arrythmias, pressure necrosis (x>48 hours of placement)
   1. Types of tubes
      1. Blakemore (3 ports)
      1. Minnesota (4 ports)
      1. Linton (2 ports, holds 700cc air)

Samantha Lucrezia, MD: Paediatric Haem/Onc Emergencies

1.  Closely examine: CVL sites, mucosal areas, skin/soft tissue
2. Workup: CBC, CMP, Blood (peripheral cultures are not routinely indicated)/urine cultures, CXR, LP if altered, Stool studies as needed based on symptoms
3. ALL: most common childhood malignancy; common presentation with fevers, lymphadenopathy, peteciae/purpura, hepatosplenomegaly, gingival hyperplasia, bone pain, hyperleukocytosis
4. Hyperleukocytosis: WCC>100k, high risk in infantile leukaemia, T cell ALL, AML, CML.  Manage with hydration (#1) and consider alkalinised fluids without addition of K.  Consider next adding Allopurinol and addition of Rasburicase (do not administer without consultation with haematology); avoid PRBC transfusion (increased risk of hyperviscosity)
5. Sickle Cell Anaemia: If pt presents with temp>35.5C, obtain CBC, blood/urine cultures, CXR, speak with haem/onc, antibiotics and admission of abnormal labs; can consider discharge if normal labs and OK with haem/onc/discussion with family/patient
   1. Acute chest syndrome: SSA, plus chest pain, fever, SOA/hypoxia, new infiltrate on CXR.  It is defined as a life-threatening lung infarction, common in 2-4 year olds, half of cases develop during hospitalisation and not at initial presentation.  It is the second most common cause of hospitalisation in children with SSA. 
      1. Acute management: fluids, antibiotics, transfusion as needed (maintain hgb 9-11g/dL) for anaemia or severe hypoxaemia

Jonathan Boland, MD: Hernias

1.  Reducible: soft, easy to replace; incarcerated: difficult to reduce, but retained blood flow; Strangulated: unable to be reduced, signs of ischaemia
2. Inguinal hernias are most common type of hernias; direct vs indirect
3. Femoral hernias: most common in women
4. Hernia management: if reducible> refer for outpatient management; if not reducible, CT and surgical consult.  USS may be helpful but CT for definitive imaging
5. Tips for reduction, per Dr Eisenstat: pain control, Trendelenburg, ice hernia prior to reduction

Kyle Stucker, MD: Cholecystitis, Cholangitis, Cholelithiasis

1.  Cholecystitis: more common in women, 8% prevalence in men, common with increasing age, bariatric surgery; vast majority asymptomatic
   1. Physical examination findings: Murphy’s sign (65% sens, 87% spec)
   1. Imaging: US modality of choice (81% sens, 83% spec)
   1. Gallstones + sonographic murphy’s sign: high PPV for acute cholecystitis
   1. If cholecystitis goes untreated, then gangrenous cholecystitis/perforation/emphysematous cholecystitis
   1. Treatment: fluids, Abx, pain control, admission, surgical consultation
   1. Acalculous cholecystitis: high occurrence with systemic, life-threatening disease
2. Biliary Colic: recurrent attacks of upper abdominal pain, associated with evening hours, lasts no more than a few hours; caused by stone moving in and out of obstructing position.  Treatment in the ER: pain control, outpatient surgery referral
3. Cholangitis: Charcot triad (fever, RUQ pain, Jaundice), +AMS, shock (Raynaud’s pentad)
   1. Tx with Abx, fluids, surgical consultation; ERCP for definitive management

Skyler Hill-Norby, DO: Hepatitis

1.  Aetiologies: viral, medication-induced, toxin induced, ischaemia
2. Clinical features: malaise, nausea/vomiting, fever, jaundice, hepatomegaly
3. Labs/imaging
   1. CMP: AST/ALT elevation, elevated Bilirubin, alk phos elevation
   1. LFTs: coags (PT/INR reflects synthetic function)
   1. Ammonia level
   1. RUQ US: may show acute liver pathology
   1. CT abdomen/pelvis
4.  Dispo: admission on case by case basis
5. Tylenol Toxicity          
   1. Suggested dose: 4g/day; toxic dose 150mg/kg
   1. Features of toxicity based on duration of ingestion
   1. Acute ingestion: Rumack Nomogram, NAC therapy
   1. Fulminant hepatic failure based on Cr, lactic acid, INR level
6.  Mushroom toxicity
   1. Amanita Phylloides
   1. Eary vs Late onset (early onset suggest benign course)
   1. Tx considerations: NAC, glucose monitoring, possible need for liver transplant
7.  Shock liver: very ill patients, treatment is to treat underlying causes of shock

Jessica Javed, MD: Palliative Care/Hospice Elective Follow Up

1.  Palliative Care: focused on symptom management, MDT, quality of life
2. Hospice: focused on patients who have less than 6 months to live, quality of life, pain management
3. Palliative care is available easily on an outpatient basis and can be arranged without admission
4. Hospice Takeaways: anyone can initiate a referral, inclusion criteria includes multiple ED visits for a chronic, unresolving medical issue, covered by most insurance, Hosparus is one of the only options for hospice in KY. 
5. Tips for breaking bad news
   1. Quiet setting
   1. Create IDT with chaplain/nurses
   1. Sit down if you can
   1. Start by asking what the families know and fill in knowledge from there
   1. Prepare family for bad news if appropriate
   1. Give family/patient time to process
6.  Tips for goals of care discussions
   1. Focus on what the patient would want
   1. Determine POA if patient is not decisional
   1. Do give your recommendations
   1. Don’t refer to full code as “doing everything”; this implies that everything else is not good/worthy
   1. Goals of care can change; be open to this
7.  Kentucky MOST form (Medical Orders for Scope of Treatment)
   1. Makes goals of care more algorithmic
   1. Usually used for hospice/palliative patients
   1. Kept in the home
   1. Can be used as a guide for caregivers/EMS (EMS must have original copy)/healthcare providers to direct what patient wants with regards to their care, especially in end of life situations
   1. Generally reviewed annually or after d/c from healthcare facility

Dr. Dan Fisher and Dr. Mitchell Weeman did an awesome job with their clinical pathway summarising ER management of both upper and lower GI bleeds. See brief lecture summary below and find their clinical pathway uploaded to the site for a more in-depth review.

1.  UGIB more common than LGIB; increased mortality with UGIB
2. GIB mimics: Pepto Bismol, Bismuth, Beets, red food colouring, bleeding from epistaxis/dental bleeding, red meat, iron supplements, vit C, horseradish, methylene blue
3. UGIB (proximal to ligament of Trietz; gastric>duodenal): most common aetioloy is PUD (NSAIDs, ETOH, ASA, Tobacco use), followed by erosive gastritis, oesophageal varices (high mortality) and Mallory Weiss tears; Risk stratification with Glasgow Blatchford Score
4. LGIB (distal to ligament of Treitz): most common aetiology haemorrhoids, diverticulosis/itis, aorto-enteric fistula (herald bleed), colitis, malignancy (ask about type B symptoms, Fhx), Meckels (in paediatric population)
5. ED workup: full history/physical, DRE, CBC, CMP (BUN:CR>36 w/o renal failure), type/screen, coags, guac stool test (if GIB can be pos for up to 2 weeks following), +/-lactic acid (risk stratification), +/- VBG (base deficit in acute setting), EKG (demand ischaemia), CT angio is test modality of choice for vascular cause of bleeding

• Anticoagulation in VTE (Dr. Daugherty, PharmD)
  • Heparin à no renal metabolism (helpful in patients with renal failure)
    • Thrombocytopenia, HIT, heparin resistance, hyperkalemia from aldosterone suppression
    • Half-life 30-60 minutes, immediate onset
    • IV administration for VTE, must be administered inpatient
    • Careful monitoring required
  • Enoxaparin (Lovenox, LMWH)
    • Derived from heparin
    • 3-5 hour onset, no monitoring required, patients may self-administer 
    • Similar outcomes compared to heparin with regards to recurrent VTEs, some data suggest lower bleeding risk
    • Renal clearance, avoid in renal dysfunction 
    • Similar precautions as heparin
    • Lower incidence of HIT, but still contraindicated in patients with HIT
    • Subcutaneous dose for VTE
  • Apixaban (Eliquis)
    • Factor Xa inhibitor
    • Half-life 9-14 hours, BID dosing
    • Renal clearance, caution in renal insufficiency
  • Rivaroxaban (Xarelto)
    • Factor Xa inhibitor
    • Half-life 5-19 hours, daily dosing
    • Must be taken with food to be effective
    • Renal clearance, caution in renal insufficiency
  • Dabigatran (Pradaxa)
    • Direct thrombin inhibitor
    • Half-life 12-14 hours
    • VTE dosing after 5 days of bridging, BID dosing
  • 2020 AHS Guidelines on Management of VTE suggests using DOACs over Warfarin
    • Does not apply to all patients
    • AMPLIFY à Eliquis non-inferior to standard therapy (Warfarin, LMWH), less bleeding complications
    • EINSTEIN DVT/PE à Xarelto non-inferior to standard therapy
    • Does not recommend one DOAC vs. another, recommend using patient specific factors to guide clinical decision making
    • Recommends home treatment for patients with uncomplicated DVT
    • 2020 AHS guidelines recommend considering home treatment for patients with low-risk PE (PESI Score risk stratification), conditional recommendation
  • Extremely important to counsel patients when being discharged on these high-risk medications, ensue follow-up and understanding of risks and return precautions

• Pneumomediastinum (Dr. Alia)
  • Presence of free air in the mediastinum
  • Spontaneous (idiopathic, tobacco use, recreational drug use) vs. secondary (i.e. traumatic, iatrogenic) etiologies
  • 30% have normal chest x-rays à CT Chest is preferred diagnostic modality
    • “Continuous diaphragm sign” on XR
  • Management:
    • Treat underlying cause
    • Supportive care à typically resolves spontaneously in 1-2 weeks
  • Disposition:
    • Primary à discharge with PCP follow-up
    • Secondary à management of underlying cause, typically will require admission

• Lung Abscess, Parapneumonic Effusion, Empyema or (Dr. Edwards)
  • Typically polymicrobial, affected tissue at risk for necrosis and cavitation
  • Diagnosed via CXR vs. CT Chest (also recommended following XR diagnosis)
    • Ultrasound helpful for evaluation of effusions and for procedure guidance
  • Obtain blood and sputum cultures (blood cultures frequently negative in empyema)
  • Treatment à empiric antibiotics with anaerobic coverage
    • Empyema, effusions require drainage
    • VATS for complicated effusions and empyema
  • Thoracentesis provides definitive diagnosis for empyema (distinguishes between effusion and empyema) à body fluid cultures and diagnostics must be obtained

• Pneumonia for EM Residents (Dr. Eisenstat)
  • CAP à everything not HAP or VAP
  • HAP à >48 hours from time of admission, previous admission within 90 days
    • Cover for pseudomonas and MRSA
  • VAP à >48 of intubation time, recent previous intubation  
    • Cover for pseudomonas and MRSA
  • Therapy tailored based on sensitivities and culture results
  • Normal vital signs and normal respiratory examination have good negative predictive value in most patients
  • Procalcitonin à good predictor of blood culture positivity
  • Hypoglycemia, lactate à predictors of 28-30 day mortality
  • 2-view chest XR recommended
  • Flu test patients with CAP during flu season
  • Give antibiotics to all patients clinically suspected to have CAP regardless of procalcitonin
  • Clinical judgement + decision tool is best (PSI > CURB-65)
  • Healthy, outpatient à amoxicillin vs. doxycycline vs. macrolide (if local resistance is <25%)
  • Comorbidities, outpatient à Augmentin vs. cephalosporin (cefpodoxime, cefuroxime) AND macrolide vs. doxycycline
    • Monotherapy with respiratory fluoroquinolone also acceptable, but consider risk factors
  • Inpatient treatment of CAP in adults without risk factors for MRSA or Pseudomonas
    • Combination therapy with Beta-lactam + macrolide or doxycycline
    • Monotherapy with respiratory fluoroquinolone
  • Inpatient treatment of severe CAP
    • Beta-lactam + macrolide (ex. Rocephin + azithromycin)
    • Beta-lactam + respiratory fluoroquinolone
  • Coverage of anaerobic pathogens not necessary in admitted patients who are suspected to have aspiration PNA
  • Inpatient treatment of patients with risk factors for MRSA and Pseudomonas à vancomycin or linezolid for MRSA, Zosyn/cefepime/meropenem for Pseudomonas
  • Corticosteroids are unnecessary unless used in patients persistently hypotensive despite IVF and vasopressors (i.e. surviving sepsis guidelines) but evidence is not conclusive
  • Give Tamiflu to patients with CPA who test positive for flu (regardless of inpatient vs. outpatient or duration of symptoms), give antibiotics regardless of flu positivity
  • Antibiotic treatment duration for outpatient treatment of CAP à 5-7 days
  • No follow-up CXR necessary in adults who are improving following treatment

• Pediatric Respiratory Distress (Dr. Poteh)
  • Bronchiolitis
    • <2 years (>2 years is referred to as WARI)
    • Leading cause of hospitalization in infants in the US
    • Symptoms often worsen on day 3-5 of illness and worse at night
    • Hypoxemia occurs from V/Q mismatch from mucus plugging
    • Pathophysiology à infection causes inflammation of the bronchiolar epithelium
    • Commonly causes by RSV, but also caused by other viruses and bacterial infections
    • Exam tricks:
      • Expose trunk
      • Count RR yourself for at least 30 seconds
      • Note signs of respiratory distress
      • Assess activity level (playful, fatigue, lethargic)
      • Assess hydration status (tears, saliva, capillary refill, wet diapers in 24 hours)
      • Check the ears (occasionally have coinfections)
      • Always do an abdominal examination to assess for hepatosplenomegaly
    • Management:
      • Suction! Suction! Suction!
      • CXR unnecessary unless concern for superinfection or clinical picture not consistent with typical bronchiolitis (prolonged symptoms, high fevers, persistent hypoxia) à atelectasis and peribronchial cuffing on CXR if obtained
      • Viral testing is not always necessary (exception: influenza, COVID-19, RSV <1 month causes apnea)
      • Respiratory support
      • Dexamethasone in patients <1yo with no history of wheezing did not demonstrate benefit
      • Albuterol has not been shown to benefit patients
    • Bronchiolitis Score is helpful with risk stratification
    • Discharge Criteria
      • O2 saturation >90% while awake
      • Adequate PO intake
      • Mild/moderate work of breathing
      • Reliable caretaker
      • Timely pediatrician follow-up in 1-2 days
    • Admission Criteria
      • Hypoxemia
      • Severe respiratory distress
      • Apnea
      • High-risk patients
      • Poor oral intake
      • Parents uncomfortable with discharge
    • Consider intubation if…
      • Recurrent apnea
      • Declining mental status
      • Not improving with respiratory support
  • Asthma Exacerbation    
    • Antibody binds antigen à release of histamine/leukotrienes à inflammation à bronchospasm
    • Pediatric Respiratory Assessment Measure (PRAM) is helpful for risk stratification
    • Timing of medications is key!
    • CXR is not required unless concern for complicating factors
    • Management:
      • Beta-2 agonists 
        • Albuterol à MDI vs. nebulizer
          • Always use a spacer!
          • Short vs. 1-hour long vs. continuous albuterol nebulizer
          • Discharge à take 4 puffs every 4 hours for the next 48 hours, then as needed after that
          • Remember to write for MDI with spacer if discharging with albuterol prescription
        • Terbutaline à IV vs. SQ
      • Corticosteroids à mainstay of treatment considering the pathophysiology
        • Dexamethasone
        • Prednisone/prednisolone
        • Methylprednisolone
      • Ipratropium nebulizer
        • Anticholinergic
        • Often used in conjunction with albuterol nebulizer
      • Magnesium sulfate
        • Smooth-muscle relaxer
        • Can cause smooth-muscle relaxation in the vasculature à hypotension (consider IVF bolus)
      • Epinephrine à anaphylaxis dosing
    • Admission Criteria
      • Requiring >1 1-hour long albuterol
      • Respiratory distress
      • Hypoxemia (O2 <92%)
      • Dehydration
  • Croup (laryngotracheobronchitis à upper airway)
    • Acute subglottic inflammation
      • Morbidity is greatest in 1^st year of life due to narrower subglottic airway
    • Affects children aged 6-36 months
    • Classically caused by parainfluenza virus, but also caused by many other viruses
    • Clinical presentation:
      • Barky cough
      • Inspiratory stridor (more concerning if occurring at rest)
      • Tachypnea
      • Suprasternal retractions (hypoxia, intercostal retractions, abnormal breath sounds, subcostal retractions are uncommon à croup is a disease of the upper airway, if hypoxia is present and lungs are clear to auscultation there should be high concern for impending upper airway compromise)
      • Low-grade fever
    • Management
      • Dexamethasone
      • Racemic epinephrine for resting stridor or respiratory distress (can repeat every 15-20 minutes)
      • Monitor for 3-4 hours prior to discharge if administering racemic epinephrine à admit for refractory stridor or if repeat dosing of racemic epinephrine is required
      • Consider Heliox for severe respiratory distress as it decreases turbulent flow

• Documentation Lecture (Ashley Chesman)
  • Critical Care Documentation
    • 7.2% of all ED visits reported to Medicare in 2019 were reported as critical care
    • Time at bedside, but also time spent engaged in work directly related to the patient’s care:
      • Reviewing test results and imaging studies
      • Consulting services
      • Placing orders
    • Procedures billed separately
    • Billings starts at 30 minutes à critical care time requests <30 minutes may not be compensated  
    • E/M and Critical Care Same Date of Service
      • Can now bill for E/M and Critical Care on the same date/visit
      • Documentation must support decompensation to a state requiring critical care
    • Remember to document critical care time beginning in residency!

• Subclavian Central Venous Lines (Drs. Nichols and Leavitt)
  • Contraindications
    • Overlying infection
    • Anatomic obstruction
    • Fracture of ipsilateral clavicle
    • Relative à coagulopathy (harder to compress and apply pressure to the subclavian site)
  • Complications
    • Arterial injury
    • Pneumothorax
    • Air embolism
    • Cardiac dysrhythmia
    • Infection
    • Bleeding
  • Supra- vs. Infraclavicular Subclavian Access
    • Infraclavicular
      • Utilizes short-axis ultrasound
      • Index finger on the sternal notch and thumb at the midpoint of the clavicle at the angle
      • Make contact with the clavicle and “walk-down” and pass under the clavicle vs. insert needle further laterally to avoid having to “walk-down” the clavicle
      • Ultrasound assisted technique utilizes short-axis
    • Supraclavicular
      • Well-defined landmarks (claviculo-SCM angle)
        • 1 cm superior and 1 cm lateral to the claviculo-SCM angle
        • 5-15 degrees above the coronal plane
        • Don’t advance past 3 cm
        • Ultrasound assisted technique utilizes long-axis as opposed to the short-axes
      • Shorter distance from skin to vein
      • Larger target area
      • Straighter path to the SVC
      • Less proximity to the lung
      • Fewer complications compared to infraclavicular
      • Found to be non-inferior to the infraclavicular approach

04/06/2022

• Lightning Lectures – Pulmonary Cases (Drs. Bishop and Slaven)
  • Tuberculosis
    • TB concern à NAAT + sputum cultures to assist with diagnosis (95% sensitive)
      • Negative pressure room with airborne precautions, PPE precautions for providers, HIV test if TB suspected  
    • Mycobacterium tuberculosis à aerobic rod, highly antigenic à can disseminate systemically if initial granuloma formation fails to contain the infection
    • Immunocompromised population at highest risk (2x)
    • bCG vaccine recipients all have positive TB skin tests (PPD)
    • Interferon test does not distinguish between latent and active TB
    • Active TB àINH, RIF, pyrizanimide, ethambutol x8 weeks à INH/RIF x18 weeks + B6
      • Hepatotoxicity
    • Latent TB à INH x9 months + B6
    • Must contact Public Health Department prior to discharge
  • Spontaneous Pneumothorax
    • Sudden pleuritic chest pain, increased work of breathing, hypoxia
    • DDx with examination + upright CXR
      • CT chest is very sensitive/specific but takes time to obtain
      • Consider US
    • Management:
      • Supplemental O2
      • Unstable à Decompression (treatment for tension PTX)
      • Stable, small à consider observation 4-6 hours, repeat CXR, must ensure follow-up within 24 hours à admit any recurrent or complicated PTX
      • Admit everything else and all PTX caused by comorbidities
• Inhaled Intoxicants (Dr. Eisenstat)
  • Huffing/bagging à toluene is intoxicating substance (higher in gold and silver paints)
    • Can cause NAGMA, renal tubular acidosis, hypokalemia, chronic encephalopathy
    • Sudden sniffing death syndrome à hydrocarbon (huffing) + high levels of catecholamine surge à death
      • Generally not recommended to use epinephrine/norepinephrine in patients suspected of hydrocarbon toxicity
  • Aluminum encephalopathy from black tar heroin use à basal ganglia lesions on MRI
  • High water solubility à chlorine, tear gases, ammonia (mucous membrane effects)
  • Low water solubility à phosgene, chloramine, nitrogen dioxide (delayed pulmonary edema)
  • Phosphine gas/aluminum phosphide à occurs when aluminum phosphide interacts with moisture à can expose providers during ventilation efforts/resuscitation
  • Nitrogen dioxide à silo fillers
  • Phosgene à choking agent, delayed pulmonary edema
  • Tear gases à OC spray AKA pepper spray AKA mace à capsaicin-based tear gas à causes severe burning and irritation, CS (military grade) is more potent
    • Treatment is irritation (consider Morgan lens for eye involvement)
  • Organophosphates à nerve agents àdecontamination, atropine, pralidoxime, supportive care
  • Asphyxiants à methane, propane, argon gas à sudden collapse, helper also collapses, etc.
  • Carbon monoxide à can be high in smokers (COHgb of 10) and large cities
    • Treatment is controversial à begins with O2 therapy (100% FiO2, NRBM)
    • Consider hyperbaric in COHgb levels >25 (15 in pregnant patients due to fetal Hgb affinity for CO) or signs of organ dysfunction (AMS, NSTEMI)
    • The reason for HBO therapy is to reduce long-term symptoms, which are often delayed (up to 6-8 weeks), not life-saving
  • Cyanide à combustion of nitriles in house fires à leads to unconsciousness and CV collapse à elevated lactate (>8 with ingestion, >10 in house fires) with high suspicion
    • Amyl nitrite (induces methemoglobinemia) vs. Hydroxocobalamin/Cyanokit (safer, colors urine organe/red) with levels >8 
  • Hydrogen sulfide à cellular asphyxiant similar to cyanide à rotten-egg smell in low concentrations (odorless in high concentrations), used in chemical suicide

• COPD and Asthma Cases (Dr. French)
  • COPD à titrate goal O2 to 88-92%
  • Patients need PPV
  • Antibiotics for COPD exacerbation à some evidence for reduced rate of readmission/representation
  • Remember to consider breath-stacking/auto-PEEP in MV
  • PRAM Score for asthma exacerbation à follow-up 3 hours with additional PRAM Score, can assist with disposition planning
    • PRAM >12 à marker of impending respiratory failure

• ED Management of Brain Aneurisms (Dr. Ding)
  • Unstable à repair
  • Stable à timely outpatient follow-up
  • 1/3 will die, 1/3 will be self-sufficient at discharge, 1/3 will have poor recovery
  • Surgery (clip) vs. endovascular (coiling)
    • Treatment modality depends on multiple factors à age, medical comorbidities, multiple aneurisms, location, size, symptoms
  • Which aneurisms will rupture à location (anterior communicating, posterior communicating aa. higher risk) vs. size of aneurism vs. risk factors vs. family history vs. connective tissue disease/AAA vs. stress vs. growth of aneurism  
  • Enlarging and symptomatic unruptured aneurisms should be treated
  • Before/after stent-coiling or flow diversion à DAPT
  • Consult NES for incidentally found aneurisms on imaging, both admitted and discharged
  • CTA/MRA for history of aneurism and symptoms
  • Consider SAH in post-coital headache 
  • Don’t forget about LP vs. MRI in patients suspicious for SAH with negative CT/CTA

Interesting paper here, retrospective data pulled from the NEAR registry, a big high quality airway registry.

The take home point was NO difference in desaturations during induction in the ramp vs supine position. They reported DL and VL cohorts separately. Now I like to ramp patients, especially those with low GCS or obesity. So I am going to find the issues with the paper, and try to hold strong in my beliefs.

But seriously, there are some problems. It is retrospective. The patients who were ramped were probably sicker and more obese! It turns out they are:

However, obesity and subjective impression of difficult airway were more common in the ramped cohorts (Table 1) and independently associated with postinduction hypoxemia (Tables 3 and 4).

The paper is in AEM and therefore very well done. They perform adjusted analyses to try to tease out any real effects. But you cannot infer causation with this study. They do cite one paper on ICU intubations that found no benefit and possible adverse effects of ramping. But this study did not control for … wait for it … apneic oxygenation! Remember the post this week on airway success, apneic oxygenation is awesome, do it. But at least in this paper all patients had apneic O2.

Something else left out is how long they were ramped before intubation (i wouldn’t expect 30 seconds of ramping to help), they excluded trauma patients, they didn’t talk about how ramping can prevent vomiting / aspiration, they did mention that perioperative data suggests benefit to ramping : ).

Overall this paper is worth reading and the stats get pretty thick. Maybe a journal club in the future. But we have to be very careful making practice changes or any strong assertions based on a confounded (direct quote: “we are unable to control for unmeasured confounders”) retrospective paper.

Check out this paper in the upcoming Annals of EM. Data from the Videography in Pediatric Resuscitation (VIPER) Collaborative. Not a huge number of patients (494), but a solid N for a pediatric airway paper.

Research Pearl: Never just read the abstract, at least also look at the tables and figures! Then of course when you write a paper (or even an abstract), spend tons of time on your tables and figures, they are often the most efficient way to convey your findings to the reader.

Much of their findings are of course applicable to adult airway. Some interesting stats:

– The first-attempt success rate was 67%

– Median laryngoscopy duration 35 seconds (interquartile range 25 to 40)

– Hypoxemia occurred in 15% of the patients.

– Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia.

– Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts.

***What is happening? Why do we not set up apneic oxygenation on everyone? They had two of the 18 people (11%) with apneic O2 desat, but 18% of those with no apneic O2. Of course 18 is a tiny number and we can’t draw any conclusions, but there is no reason not to throw a nasal cannula (>15L) on every patient you intubate.

Take a look at Table 1 (pasted below), impressive intubation success for EM residents.

Ok that’s probably enough for one post, check out the paper.

Aaron R. Kuzel, D.O., M.B.A

Acute Coronary Syndrome

Acute Coronary Syndrome or ACS is any condition that results in ischemia of the coronary arteries resulting in diminished perfusion of the myocardial tissue. There is a spectrum of cardiac diseases that fall into the designation of ACS including: ST-Elevation Myocardial Infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. This discussion will center around STEMIs as well as introduce some STEMI-equivalents.

Chest pain is the most common presenting symptoms for ACS. However, 20-30% of patients presenting with ACS will present with atypical symptoms. There are associated risk factors for ACS as noted in the table below.

Work-Up and Management

Patients presenting with concern for ACS should receive prompt electrocardiography (ECG) as well as CBC, chest radiograph, electrolytes, serum troponin, and PT/PTT. The 2013 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend serial ECGs in the first hour if there are concerning symptoms and the first ECG is non-diagnostic. The serial ECGs are important as approximately 15-20% of STEMIs are diagnosed on the repeat ECG. Missing a STEMI or myocardial infarction is one of the most common causes of malpractice for the emergency physician. The table below demonstrates the most common causes of losses in malpractice cases related to the cause of chest pain.

Definition of a STEMI

ST-segment elevations are noted with the red arrows. Notice that there are ST-segment elevations in three contiguous leads: II, III, and AVF. There is usually reciprocal ST-segment depression in the opposite leads associated with ST-elevation myocardial infarctions. In this case of an Inferior Myocardial Infarction, there are reciprocal ST-segment depressions in the Septal and Lateral leads. This is denoted with blue arrows.

Wellens Syndrome

Wellens Syndrome refers to angina associated with T wave inversions in the left anterior descending coronary artery or LAD most notably in leads V2 and V3. Wellens Syndrome often presents in a pain-free state, but those patients who did not undergo reperfusion therapy with Wellens Syndrome noted on the ECG fared poorly with 75% developing an anterior wall myocardial infarction due to proximal LAD occlusion. Patients diagnosed with Wellens Syndrome should proceed urgently to cardiac catheterization.

There are two types of Wellens Syndrome:

Type A is a biphasic T wave in V2 and V3 occurring in 25% of cases and Type B are deep, symmetrically inverted T-waves in V2 and V3 occurring in 75% of cases. (Picture from WikEM). In the EKG below from Life in the Fast Lane ECG Library , there are inverted T-waves in V2 and V3 consistent with Type B Wellens Syndrome.

De Winter’s T Waves

De Winter’s T waves were first identified in 2008 and account for 2% of proximal LAD occlusions making it a STEMI-equivalent requiring emergent cardiac catheterization. De Winter’s T waves are tall, peaked T waves in the precordial leads (V1-V6) with ST-segment depression at the J-point. In most cases, ST-segment elevation will be seen in lead aVR, however this is not specific.

In this figure, there are obvious peaked T waves in leads V2, V3, and V4 denoted by the red arrows indicating De Winter’s T waves. There is some ST-segment elevation in aVR consistent with this finding. A patient presenting to the emergency department with this ECG finding should go immediately to cardiac catheterization for likely LAD occlusion.

Left Bundle Branch Block with Myocardial Infarction

Previously, a new Left Bundle Branch Block (LBBB) was considered a STEMI-equivalent, however, recent literature suggests that a new LBBB does not often demonstrate increased risk of acute myocardial infarction. However, in 1996, Dr. Sgarbossa published a study of acute myocardial infarction in the presence of a LBBB with three criteria. Although the Sgarbossa criteria is not very sensitive, the findings were very specific for the finding of acute myocardial infarction.

Dr. Amal Mattu, professor of emergency medicine from the University of Maryland, separates the Sgarbossa criteria into three subsections: Category A, B, and C.

In Sgarbossa A, the QRS complex is deflected in the positive direction (up) and ST-segment elevation is also present or concordance. If this occurs in any lead in the presence of a LBBB this is a STEMI-equivalent and the patient should proceed to cardiac catheterization. In Sgarbossa B, the QRS complex is deflected in the negative direction as well as the ST-Segment depression a shown in the example above in V1. If the ST segment is depressed in V1, V2, or V3 and the QRS complex is deflected downward this is also a STEMI-equivalent indicating acute myocardial infarction in the presence of a LBBB. Finally, in Sgarbossa C if the ST segment elevation is greater than 5 mm (or 5 blocks), this may indicate a STEMI-equivalent, however this is not as specific as criteria A or B. That being said, the finding of Sgarbossa C should prompt the physician to consult Interventional Cardiology as well as consider other signs and symptoms of ischemia.

Sgarbossa A:

In the above example, there is ST elevation concordance with the QRS in the presence of a LBBB in lead aVL indicating a myocardial infarction. Notice, that this is the only lead with ST-elevation >1 mm, but the criteria indicates that concordant ST-segment elevation in any lead with a LBBB is an indication for PCI.

In this example, there is concordant ST-depression in lead V2 in the presence of a LBBB indicating the need for emergent cardiac catherization.

Conclusion:

There are many findings on ECG that could indicate either a STEMI, STEMI-equivalent, or the presence of ischemia. It is important to note that there are a multitude of other ischemic rhythms and this is a brief and limited introduction to ischemic ECGs. Ischemia can be present even in the absence of ECG changes or changes in troponin, so history and physical still remain the most important methods in physician diagnosis of myocardial infarction and ischemia.

For further reading for acute care ECGs, I recommend:

Electrocardiography in Emergency Medicine by Amal Mattu, Jeffrey Tabas, and Robert Barish

ECGs for the Emergency Physician Volume 1 and Volume 2 by Amal Mattu and William Brady

Electrocardiography in Emergency, Acute, and Critical Care by Amal Mattu Jeffrey Tabas and William Brady

References:

AHA ACA – NSTEMI ACS Guidelines 2014

de Winter R, et al. A new ECG sign of proximal LAD occlusion. NEJM. 2008; 359:2071–2073.

de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730-736.

Hennings JR and Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012; 30(6):994–1000.

Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med. 2000 Apr 20;342(16):1187-95.

Maloy KR, Bhat R, Davis J, et al. Sgarbossa Criteria are highly specific for acute myocardial infarction with pacemakers. West J Emerg Med. 2010;11(4):354-357. (Retrospective cohort; 57 patients)

Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffith JL, Selker HP. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000 Apr 20;342(16):1163-70.

Sgarbossa EB, Pinski SL, Barbagelata MD, et al. Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block. NEJM. 1996;334(8)

Thygesen, K et al. Fourth Universal Definition of Myocardial Infarction (2018). 2018 Nov 13;138(20):e618-e651.

Ünlüer EE et al. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens’ Syndrome and Upright T wave in V1. West J Emerg Med. 2012 May; 13(2): 160–162