Abnormal Presentations of ACS -Always think of this on your differential -Frequently re-evaluate patients -Interpret ECGs in a systematic fashion - and do this every time! RBBB and STEMI - No criteria for STEMI as there are in LBBB - Any ST elevation is abnormal - Read your EKG’s carefully and compare to old - It is never a bad idea to get serial EKG’s if the presentation is unclear ("One ECG Begets Another") De Winter’s Sign - This is an Anterior STEMI Equivalent! - Seen in 2% of acute LAD occlusions - Criteria -Tall prominent symmetric T waves in the precordial leads -Upsloping ST segment depression > 1mm at the J point -No ST elevation in the precordial leads -ST elevation in aVR aVR Sign -Widespread horizontal ST depression, most prominent in I, II, V4-V6 -ST elevation in aVR >1mm -ST elevation in aVR >V1 Hyphen
- Defined as blood in the anterior chamber - Complete a full visual examination - Must evaluate for ruptured globe - Ruptured Globe = Tetanus, antibiotics and emergency consultation Siedel’s Sign - Evaluates for aqueous humor leak secondary to violation of the anterior chamber - Apply topical anesthesia - Paint eye with fluorescein dye - Test is positive if there is a stream of dye emanating from the wound site
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Ovarian Torsion - Ovarian Torsion requires us to be vigilant. It is often misdiagnosed initially by both EM and GYN physicians. - Reconsider your DDx. "Appendicitis" and "Renal Colic" are common mimics of Ovarian Torsion. - Fight diagnostic momentum. - Don’t be fooled by “normal blood flow.” The ovary has two arterial supplies. Diminished venous flow should be alarming even if there is "normal" arterial flow. - See Ovarian Torsion. Perforated Gastric Ulcer - Review your own films! Radiologists are human too. You know what your concern is and may be able to actively see the important abnormality more easily! - Concerning abdominal exam? You don't need to wait for images to call a surgeon. - Think twice before sending to CT, especially with a concerning abdominal exam. - Resuscitate aggressively! Prepare for the patient to become dramatically more ill! - Don’t forget the broad spectrum antibiotics! Ruptured AAA- Resuscitate! (ABCs, Large Bore Access), but be comfortable with permissive hypotension.
- Target SBP ~80-90 mmHg - Do not be in a hurry to intubate the patient if they are breathing on their own. Many arrest after intubation. - IF you must intubate, VENTILATE SLOWLY. Increased intra-thoracic pressure will crush their already tenuous pre-load and cause an arrest. - Cross-matched PRBCs (consider massive transfusion protocol) - Contact your Vascular Surgeon emergently - At CMC, activate “Code Rupture” STEMI vs Pericarditis - Think STEMI if: Reciprical STD (except V1 or aVR), STE in III > II, horizontal or convex upwards STE, new Q waves, check mark sign (T wave takes off directly from S wave, no real ST segment). - Think pericarditis if: PR depression in multiple leads, PR elevation in aVR, Spodick’s sign (downsloping TP segment) Sgarbossa’s Criteria - Concordant ST elevation > 1mm or concordant ST depression >1mm V1-V3 - 90 % specific - Excessively discordant (>5mm discordant ST change or if ST change >25% S wave) – sensitive but not specific! - Only need one lead, do not need two contiguous leads Tick Paralysis - Commonly misdiagnosed as Guillain Barre Syndrome - Most common in females <8 yo with long hair in April-June - Presents with ascending flaccid paralysis, hyporeflexia, sensory sparing - Maternal well-being = fetal well-being… resuscitation the mother!!! - Understand important changes in maternal physiology: - Increased blood volume - Decreased respiratory reserve - Aggressive early management of the ABCs essential - Thoughtful diagnostic testing that still protects mother and baby - Placental abruption a risk following both major and minor trauma Medical Direction
Prehospital Provider Medicolegal Risks
EMTALA with respect to EMS
Air Medical Transport Multiple factors related to air vs. ground transport:
1. Every fever does not require a urine screening test. 2. UTI= pyuria plus >50,000 CFU single organism 3. UTI becomes the diagnosis when the culture is available. We start antibiotics based on the results of the screening UA. Follow up is needed. 4. Choose antibiotics by resistance patterns and not your favorite PEM attending. 5. Renal scars are a long term consequence of pyelonephritis. Whether we can prevent scarring remains uncertain. 1) Three main skin cancers: Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma. 2) Basal cell carcinoma is the most common type at 70-80% of skin cancers. 3) Skin cancers cause emergencies of the airway with obstruction, GI tract with obstruction and perforation, bleeding with carotid blowout syndrome, and pain with bony, nerve, and soft tissue metastases. 4) If you're not a dermatology wizard, use VisualDx to aide you and refer them to a dermatologist.
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