Ecgs for the emergency physician 1 free download

Discussion Question - Chest Pain Forum. Abdominal Aortic Aneurysm. Read the entire web page. Discussion question: Thoracic Aortic Dissection Forum. Pulmonary Embolus URL. Quiz: Module 3: Lesson 1: Pulmonary Embolus. Discussion Question - Pulmonary Embolus Forum. Crossword Acute coronary syndrome Game. Understand the presentation, diagnostic tests, and ED management of appendicitis Describe the presentation, diagnostic procedures, and ED management of common biliary diseases.

Understand the pathophysiology, presentation, diagnostic tests, and ED management of bowel obstruction Describe the presentation, causes, and ED management of massive GI bleeding.

Describe the causes, presentation, diagnostic tests, and ED management of mesenteric ischemia. Abdominal Pain URL.

Acute Abdomen URL. Please read the entire text. Quiz: Module 3: Lesson 2: Abdominal Pain. Discussion Question - Abdominal Pain Forum. Discussion Question - Gastrointestinal Bleeding Forum. What are some of the most rare causes of gastrointestinal bleeding in your country or region? Quiz: Module 3: Lesson 2: Appendicitis. Discussion Question - Appendicitis Forum. Biliary Disease URL. Quiz: Module 3: Lesson 2: Biliary Disease. Discussion Question - Biliary Disease Forum. Mesenteric Ischemia URL.

Quiz: Module 3: Lesson 2: Mesenteric Ischemia. Discussion Question - Mesenteric Ischemia Forum. Perforated Viscus URL. Quiz: Module 3: Lesson 2: Perforated Viscus.

Discussion Question - Perforated Viscus Forum. Crossword Small Bowel Obstruction Game. Learning objectives Describe common toxidromes and commonly available antidotes or treatments. Understand the pathophysiology of burns. Describe the initial assessment, classification, and ED management principles for burns.

Describe the presentation and potential complications of inhalation injuries. Describe the presentation and ED management for envenomations.

Understand the indications for antivenom. Describe the presentation and differences in diagnosis and ED management of classic and exertional heatstroke. Understand the difference between hypothermia, frostbite, and trench foot. Describe the presentation and ED management of a drowning incident. Understand investigations that may be used in drowning incidents.

Poisonings URL. Quiz: Module 3: Lesson 3: Poisonings. Discussion Question - Poisonings Forum. Envenomation URL. Quiz: Module 3: Lesson 3: Envenomation. Discussion Question - Envenomation Forum.

Discussion Question - Heat Illness Forum. Quiz: Module 3: Lesson 3: Hypothermia. Discussion Question - Hypothermia Forum. Quiz: Module 3: Lesson 3: Drownin. Discussion Question - Drowning Forum. Learning objectives Recognize the breadth of the differential for altered mental status. List emergent causes for altered mental status. Altered Mental Status. Discussion Question - Altered Mental status Forum. Suicidal Patient URL. Quiz: Module 3: Lesson 4: Suicidal Patient.

Cryptex Altered Mental Status Game. Headache URL. Quiz: Module 3: Lesson 5: Headache. Discussion Question - Headache Forum. Learning objectives Describe life-threatening causes, clinical manifestations, and the role of arterial blood gas in respiratory distress.

Understand the presentation, diagnostic tests, and ED management for an acute asthma exacerbation. Understand the use of non-invasive positive pressure ventilation and intubation in severe COPD exacerbation Describe the presentation, microbiology, diagnostic tests, and ED management of pneumonia. Describe the presentation, imaging tests, and ED management of pneumothorax.

Quiz: Module 3: Lesson 6: Respiratory Distress. Discussion Question - Respiratory Distress Forum. Quiz: Module 3: Lesson 6: Asthma. Discussion Question - Asthma Forum. Quiz: Module 3: Lesson 6: Pneumonia. Discussion Question - Pneumonia Forum. What should you do differently when treating an immune-compromised patient for pneumonia?

Quiz: Module 3: Lesson 6: Pneumothorax. Discussion Question - Pneumothorax Forum. Crossword Respiratory Distress Game. Cryptex Asthma Game. Learning objectives Describe the causes classifications and clinical manifestations of shock. Describe the initial evaluation of a trauma patient primary and secondary survey Promote injury control and prevention Describe the screening for intimate partner violence Describe the spectrum of sepsis syndromes and the use of Early Goal Directed Therapy in treating sepsis.

Quiz: Module 3: Lesson 7: Shock. Discussion Question - Shock Forum. Read pages 3 to Quiz: Module 3: Lesson 7: Trauma. Discussion Question - Trauma Forum.

How are you affected emotionally when you are exposed to a trauma patient in the ED? Quiz: Module 3: Lesson 7: Sepsis. Discussion Question - Sepsis Forum.

What is the most typical presentation of sepsis in your ED? Cryptex Trauma Game. Learning objectives Describe the classic presentation, ED investigations, and ED management of diabetic ketoacidosis and hyperosmolar hyperglycemic state Describe the presentation, ECG changes, and ED management of hyperkalemia.

Describe the presentation and ED management of hypoglycemia. Understand the pathophysiology, presentation, diagnostic tests, and ED management of thyroid storm. Hyperglycemia URL. Quiz: Module 3: Lesson 8: Hyperglycemia. Discussion Question - Hyperglycemia Forum. Quiz: Module 3: Lesson 8: Hyperkalemia. Discussion Question - Hyperkalemia Forum. Quiz: Module 3: Lesson 8: Hypoglycemia. Discussion Question - Hypoglycemia Forum. Thyroid Storm URL. Quiz: Module 3: Lesson 8: Thyroid Storm.

Discussion Question - Thyroid Storm Forum. Learning objectives Describe the risk factors, diagnostic tests, and management options for ectopic pregnancy. Describe the presentation, diagnostic tests, and ED management of ovarian torsion.

Describe the presentation and initial ED management of testicular torsion. Ectopic Pregnancy URL. Quiz: Module 3: Lesson 9: Ectopic Pregnancy. Discussion Question - Ectopic Pregnancy Forum. Explore the reasons why smoking is a risk factor for ectopic pregnancy.

Ovarian Torsion URL. Quiz: Module 3: Lesson 9: Ovarian Torsion. Discussion Question - Ovarian Torsion Forum. What is the most difficult or challenging aspect of diagnosing ovarian torsion in the ED?

Testicular Torsion URL. Quiz: Module 3: Lesson 9: Testicular Torsion. Discussion Question - Testicular Torsion Forum. Crossword Ectopic pregnancy Game. Learning objectives Describe the clinical presentation, initial ED investigations, and ED management of acute ischemic stroke. Describe the indications and contraindications for the use of thrombolytic therapy. Describe the presentation and diagnostic tests for intracranial hemorrhage.

Understand the differences between types of intracranial hemorrhage and the interpretation of lumbar puncture in its diagnosis. Describe the presentation, diagnostic tests, and ED management of meningitis and encephalitis.

Describe the work-up and management of first time and recurrent seizures. Understand the definition and ED management of status epilepticus. Ischemic Stroke URL. Quiz: Module 3: Lesson Ischemic Stroke. Discussion Question - Ischemic Stroke Forum. Intracranial Hemorrhage URL.

Quiz: Module 3: Lesson Intracranial Hemorrhage. Discussion Question - Intracranial Hemorrhage Forum. Who would you need to inform of this situation e. Discussion Question - Meningitis Forum. Discussion Question - Status Epilepticus Forum. Competencies covered in this module: Perform the procedures listed in the Data supplement S2 of the Emergency Medicine Clerkship Curriculum.

In addition to proper technique, the focus should be given to recognizing the indications, contraindications, and complications associated with each. The student should be able to discuss aftercare and reasons to return for further evaluation with the patient.

IV access URL. Go through this entire module. Mentored Activity: Perform IV insertions under supervision. Intraosseous Access URL. Review only the sections regarding intraosseous access. Pediatric intraosseous access URL.

Quiz: Module 4: Lesson 1: Intraosseous Access. Read the checklist. Mentored Activity: Central line insertion Assignment. Review Table 1. Discussion Question - Airway Management Forum.

Mentored Activity: Bag-mask ventilation Assignment. Please click the link provided and review the entire page. Oropharyngeal Airway URL. Please watch the entire video. Nasopharyngeal Airway URL. Quiz: Module 4: Lesson 2: Airway Management. Cardiac Monitoring URL.

Review the chart for cardiac monitoring lead placement. Quiz: Module 4: Lesson 3: Cardiac Monitoring. Discussion Question - Cardiac Monitoring Forum. What are the biggest challenges or difficulties you've had in learning to interpret ECGs?

Review section on AEDs. Ventricular Tachycardia URL. Ventricular Fibrillation URL. Review the section on defibrillation. Mentored Activity: Defibrillator Assignment. Quiz: Module 4: Lesson 3: Defibrillator. Mentored Activity: Chest Compressions Assignment. Discussion Question - Chest Compressions Forum. Quiz: Module 4: Lesson What can you do to relieve a patient's discomfort when inserting a nasogastric tube?

Urinary Catheterization URL. Mentored Activity: Catheterization Assignment. Discussion Question - Catheterization Forum. Patient care was at the discretion of the clinician and not mandated by the outcome of the HEART pathway. There were patients studied, with patients in each treatment group.

The primary outcome was the rate of objective cardiac testing stress test, coronary computed tomography angiogram, or invasive coronary angiography within 30 days of presentation. Secondary outcomes were early discharge rate, index length of stay, cardiac-related recurrent ED visits, and nonindex hospitalization at 30 days.

There was no significant difference between the 2 groups for cardiac-related recurrent ED visits or nonindex hospitalization at 30 days. No patients identified for early discharge in either group had a missed major adverse cardiac event MACE during the first day follow-up period. The study was not designed to adequately detect differences in MACE between the 2 study groups. There were patients studied. Billing data were missing for 12 patients from the original study. Cost metrics considered in each group were index visit cost, total cost at 30 days, cardiac-related healthcare cost at 30 days, cardiac and noncardiac diagnostic testing cost, ED cost, inpatient cost for index visit, and outpatient cost.

HEART pathway patients had a significantly lower mean and median cost for both index visit and day follow-up. There was no significant difference between the median and mean costs of the other metrics. Mahler et al in also published a secondary analysis looking at high-sensitivity cardiac troponin I hs-cTnI and high-sensitivity cardiac troponin T hs-cTnT.

The authors recommend further appropriately powered studies to determine small differences in the accuracy of the high-sensitivity troponin assays. The GRACE risk score estimates in-hospital and 6-month mortality for patients with acute coronary syndromes.

Many guidelines recommend more aggressive medical management, or even early-invasive management, for patients with a high mortality risk. A patient with some nonspecific features in the workup eg, history, ECG, troponin can be more objectively risk-stratified for chest pain by quantifying the risk; this can potentially lead to shorter hospital stays, fewer inappropriate interventions, and more appropriate interventions.

GRACE is a large international database from 94 hospitals in 14 countries, which gives it excellent external validity a priori.

Patients included in the study presented with signs or symptoms of acute cardiac ischemia and also had ECG findings consistent with ACS, cardiac biomarker serial increases consistent with ACS, or documented coronary artery disease. The in-hospital mortality status was available in Twenty-two percent of the in-hospital deaths occurred within 24 hours of admission, which suggests that this registry contains a very sick cohort of patients.

GRACE 2. Chest pain is one of the most common complaints bringing patients to the ED for evaluation. Patients in the 0 to 1 point group should be further risk stratified using another risk score or institutional practices, as their risk is not low enough to safely discharge them from the hospital.

Patients were excluded if revascularization was performed within 24 hours or if the patient had a contraindication for anticoagulation.

The primary end points were composite all-cause mortality, myocardial infarction MI , or urgent revascularization within 14 days. By the end of the 14 days, An increase in the TIMI risk score correlated with an increase in all-cause mortality, MI, or urgent revascularization.

The same pattern was seen in the internally validated groups. There have been many external validation studies since the original derivation. Primary end points were death, MI, and recurrent ischemia within 6 weeks and at 1 year. As in the original derivation study and internal validation studies, there was an increase in mortality, MI, and recurrent ischemia with each increase in the TIMI risk score.

This validation is less useful for patients with undifferentiated chest pain seen in the acute care setting of the emergency department ED. Pollack et al externally validated the TIMI risk score in a prospective observational cohort study of adult patients with chest pain in the ED. Whereas the original derivation study looked at adverse outcomes within 14 days, and Scirica et al validated the risk score looking up to 6 weeks and even 1 year, Pollack et al followed up with patients for up to 30 days from presentation for adverse outcomes of death, MI, or revascularization.

As in prior studies, the higher the TIMI risk score, the higher the likelihood of adverse outcome within the measured time period, which was 30 days in this study. However, the patient population was different in that there were more black patients and more female patients. Also, if no cardiac markers were ordered, a score of 0 was assumed and assigned to the category of cardiac enzymes.

Chase et al externally validated the TIMI risk score in a prospective observational study of patient visits in the ED. Whereas Pollack et al included patients with cocaine use, Chase et al excluded patients if cocaine was used in the 7 days prior to presentation. Like Pollack et al, Chase et al assigned a score of 0 to cardiac enzymes if they were not drawn. Chase et al also followed patients for up to 30 days.

Within 30 days, In patients with a TIMI risk score of 0, 1. Although there was a general correlation of an increase in adverse outcome with higher TIMI risk score, this study did not show a similar stepwise increase.

This is likely secondary to having a study population that was dissimilar to the original derivation group or other validation studies, as this study had patients with mostly low TIMI scores and included STEMI patients in the study population. Get a Sample Issue. Date of Original Release: January 1, Date of most recent review: December 10, Termination date: January 1, This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Physicians should claim only the credit commensurate with the extent of their participation in the activity. Term of approval is for one year from this date. Specialty CME: Not applicable.

For more information, please call Customer Service at Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.

Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.

Goals: Upon completion of this activity, you should be able to: 1 demonstrate medical decision-making based on the strongest clinical evidence; 2 cost-effectively diagnose and treat the most critical presentations; and 3 describe the most common medicolegal pitfalls for each topic covered. Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration—approved labeling.

Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities.

All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship.

The information received is as follows: Dr. Jung, Dr. Bord, Dr. Gottlieb, Dr. Shy, Dr. Mishler, Dr. Toscano, Dr. Jagoda, and their related parties report no relevant financial interest or other relationship with the manufacturer s of any commercial product s discussed in this educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.

Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www. This can be dangerous if you get an impulse on the tail end of a T wave, which can result in R on T phenomenon. R on T can cause ventricular tachycardia or Torsade de Pointes which we usually like to avoid. Hardware problem inadequate lead contact or battery, pulse generator or insulation malfunction 2.

Over-sensing incorrectly sensing T waves, sensing an unintended chamber or outside myopotentials Failure to sense or under-sensing 1. Low native voltages Rate — Too Fast 1. Normal response to intrinsic fast heart rate 2. Atrial arrhythmias 3. Pacemaker-mediated tachycardia 4. Sensor-induced tachycardia Rate — Too Slow 1. FTC 2. It is not an exhaustive list. Most pacemaker malfunctions will require a cardiology consult for definitive management, but there are some exceptions. The previous pacemaker essentials post details management of pacemaker-mediated tachycardia and other tachyarrhythmias.

Any time you are concerned for your patient with a malfunctioning pacemaker, it is reasonable to get your cardiology colleagues involved early. In cases of malfunction in an unstable or potentially-unstable patient, you can always try a magnet which should result in asynchronous pacing or use transcutaneous pacing until a transvenous wire is placed, depending on the issue.

LBBBs can make detecting ischemia tricky. We often apply the Sgarbossa criteria 3 or more points is concerning for myocardial infarction in the presence of LBBB [3,4]. We can, but its use is quite limited. Only 17 patients 0. A retrospective study in looked at 57 patients who were ventricular paced and diagnosed with a MI.

The patient is now chest pain free. After you complete your full workup he is discharged home with chest pain NYD. Thanks for reading! This is a great infographic related to rhythm analysis on a paced ECG, providing the key features to look for as well as a differential diagnosis when the rhythm is abnormal. Future areas of exploration might include the approach to identifying ischemia on the ECG if the patient is paced, common issues related to pacemakers and how to address common issues in the ED.

Does this person actually have a pacemaker? Paced spikes are not always obvious. Keep an eye out for special beats: Fusion beats — the native beat and pacemaker beat fuse, causing an odd hybrid QRS complex.

Capture beats — the native beat breaks through and is conducted by the ventricle. It should be narrower and have a different morphology than your paced beats. Figure 1.