M is for morphine

Remember MONA (morphine, oxygen, nitro, aspirin) from med school? Well, she may be just “A” now…. Over the years, all of these treatments (except for good old aspirin) have become somewhat controversial in the treatment of ACS. Let’s focus on morphine today. Morphine’s obvious benefit is its ability to control pain and therefore decrease sympatheticRead more

How Safe is Mechanical CPR?

Question – How safe is mechanical CPR compared to manual CPR? There are two devices used for mechanical CPR – the AutoPulse and LUCAS – neither of which has been demonstrated to show a survival benefit over manual CPR in recent studies (CIRC, LINC, PARAMEDIC). Could these devices be causing more injuries compared to manualRead more

What Patients Require Emergent Cath Lab Activation?

Question – STEMI criteria are insensitive for all cases of acute coronary artery occlusion. Among patients with chest pain, what are the other criteria for cath lab activation? Let’s talk more ACS. Patients that need emergent reperfusion therapy are those that have an acute coronary occlusion. ECG findings of ST-elevation will not catch all cases ofRead more

The Echo in ACS

Case – 70 year old male mhx of HTN, IDDM presents with 2 hours of exertional chest pain. His ECG in triage is unremarkable for any ischemic changes. He appears uncomfortable and over the next 30 minutes requires escalating doses of nitroglycerin for chest pain. A repeat ECG is unchanged. You decide to echo himRead more

A Young Man Presents with Syncope

Case – 26M with no medical history presents with chest pain and palpitations. He states that he passed out while walking. He denies associated symptoms or family history of sudden cardiac death. ECG: Question – What are the ECG abnormalities noted here? Diagnosis and Workup? ________________________________________________________ Answer – Arrhythmogenic RV Dysplasia. This is the second mostRead more

Presentation of acute aortic dissections

A 91 yo female presents with sudden onset right arm pain with decreased pulses. Since arrival to the ED, her mental status has also progressively decreased. Her blood pressure is 170/60, HR 60, T97.8, RR20, sats 100% RA. You suspect she has had an aortic dissection and indeed a CTA of her chest / abdomenRead more


74 yo F with hx of CAD, afib, HLD, severe LV dysfunction is brought in by EMS as a notification for a STEMI. A 12-lead EKG in your ED shows the same as the EMS EKG. Should you activate the CATH lab?   Answer: Check an old EKG. An old EKG 3 months before showedRead more

The 52 in 52 Review: A Comparison of Coronary Angioplasty to Fibrinolytic Therapy in Acute Myocardial Infarction (Do I lyse or do I transfer?)

Article Citation: Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, et al; DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003 Aug 21;349(8):733-42. PMID: 12930925   What we already know about the topic:  Globally, ischemic heart disease is the leading cause of death amongst adults. TheRead more


Let’s wait for the chest x-ray they said….let’s try them on BiPAP first they said.   But were they correct? REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in the Emergency Department of Acute Heart Failure) was recently published in the Journal of the American College of Cardiology.  It is a prospective, multicenter, observation cohortRead more

Hypothermia ECG

For our clinical pearl today I thought I thought I would do some basic ECG teaching. This is a real case that I saw with Carlo at Elmhurst in the cardiac room. As always, we will start with a clinical scenario. A middle-aged male with unknown medical history was brought to the emergency department byRead more