TweetED: FOAM For Your Phone

If you’re reading this blog, it’s likely that you already have a good sense of how much valuable information can be found on #FOAMed from day to day. Keeping up with Twitter can be difficult though, especially as the FOAMed movement becomes more popular and the number of related tweets continues to increase. Information overload is an issue we all deal with on a daily basis, and finding mechanisms to get to the information that is most high-yield and relevant is crucial. Twitter provides an easy way to assess the popularity (and in the FOAM world, possibly the clinical utility) of its content through the crowdsourcing functions of retweeting and favoriting tweets.

This reasoning was the inspiration behind TweetED, an iPhone app that aggregates FOAMed from Twitter, helping you to find, share, and save the most useful clinical information.

TweetED brings together multiple FOAM hashtags (#FOAMed, #FOAMped, #FOAMcc, #FOAMtox, #EMBoardReview, #EMConf), as well as the Twitter userlist published in EMA’s February 2014 introduction to FOAM paper. The app provides the ability to sort tweets by time as well as by popularity (the “score” is a composite of the number of retweets and favorites), and lets you boost that score to increase the visibility to other users.

The ephemeral nature of tweets is often at odds with our desire to keep that medical knowledge around for later reference. TweetED is also integrated with Evernote, so you can save tweets to your default notebook for future indexing, tagging, and searching.

Twitter.com and the Twitter iPhone app do offer means of sorting and saving tweets, though these features are designed for all-purpose content from a much broader user base. I think the FOAMed community has something special going on right now, and finding ways to improve on the organization and delivery of our collective and specific knowledge is an inherent part of what we’re about.

Feedback on the app is encouraged, and thanks to all of the contributers to #FOAMed for making it possible in the first place!

The post TweetED: FOAM For Your Phone appeared first on emDocs.

SEMS ASM Wrap

SEMS ASM just wrapped in Changi General Hospital and it was one for the ages. Karim Brohi, Colin Parker, Dan Davis, Aper Cevik and a host of local talent as well - all who shall be illuminated in our forthcoming video releases for the conference in the spirit of FOAM.

The show-stopper was of course SIMWARS and here's a brief perspective from the Turkish contigent who came.

I seminari della Scuola di specializzazione in medicina d’emergenza-urgenza dell’Università di Perugia

di Paolo Balzaretti, redazione blog Simeu

@P_Balzaretti

Non si smette mai di imparare, soprattutto in medicina d’urgenza, che non prevede la routine come carattere fondante. Di solito siamo interessati ad approfondire questioni che emergono dall’introduzione di nuovi farmaci o procedure, ma spesso anche ritornare ad approfondire ambiti che diamo per scontati, che fanno parte del nostro bagaglio culturale da molto tempo è utile e ci permette di guardare alle nostre conoscenze in una luce diversa.

E’ in quest’ottica che iniziamo da oggi la pubblicazione della trasposizione in video dei seminari della Scuola di Specializzazione di Medicina d’Emergenza/Urgenza dell’Università di Perugia, coordinati dal suo Direttore prof. Giancarlo Agnelli, grazie al fantastico lavoro del dottor Federico Germini (su twitter @ciospitter).

I seminari trattano tutti i temi più importanti della nostra disciplina: l’arresto cardiaco, il poli-trauma, l’emogasanalisi, le emergenze aritmologiche e così via e saranno disponibili sul canale YouTube SIMEU.

Iniziamo con il seminario del 3 febbraio, tenuto dal dott. Cibinel, Presidente SIMEU, dal titolo “Le 3 E dell’arresto cardio-respiratorio: ECG, EGA, ECO. Un approccio fisiopatologico”: buona visione!


Anterior STEMI?

The patient presents to the emergency Department with complaints of substernal left-sided chest pain present for 4 days but worse in the last 24 hours.

Here is his ED ECG:

ED ECG
The computerized QTc is 451.  What do you think?  The previous ECG, with interpretation, is below.














Here is the Previous ECG.
My reading was printed on the ECG as "probable benign T-wave inversion."    I had discharged the patient at his previous visit.  His presentation had not been concerning for ACS and his ECG was, to me, a benign variant.




The physicians were appropriately worried about the previous ECG and used the formula (see sidebar Excel applet) and came out with a value above 23.4  (I cannot remember what the value was, but they did use 3 mm for the STE variable).

When I apply the formula, even if I use 3 mm as the ST elevation as 60 ms after the J-point, and use R amplitude in V4 at 22 mm, I get 23.03 (which is less than 23.4 and thus indicates early repol).  Furthermore, the morphology of V4 is nearly diagnostic of "Benign T-wave inversion."

In general, if there is T-wave inversion, I do not recommend using the formula. Patients whose ECGs had T-wave inversion in V2-V5 were excluded from the study because T-wave inversion, as a general rule, should imply MI.  However, if you are familiar with the morphology of Benign T-wave Inversion (BTWI), then you would see that these ECGs manifest probable BTWI and be less worried about the ST Elevation.

As for the formula, when you get a value that is close to 23.4, it is wise to not rely on it too heavily.  The sensitivity and specificity of 23.4 was close to 90%, but I the closer the value is to 23.4, the less sensitive and specific it is.

Appropriately, they ordered a 2nd ED ECG about 20 minutes later:
QTc is 445



They thought there might be more STE in lead V3.  I do not see any significant change.

They were still worried, but instead of activating the cath lab, they appropriately consulted the cardiologist and together decided on an immediate formal echocardiogram.

The echo showed:

--Normal left ventricular size, mild concentric left ventricular hypertrophy and hyperdynamic systolic function.
--The estimated left ventricular ejection fraction is 75 %.
--No left ventricular wall motion abnormality identified.
--Normal right ventricular size and function.

The patient was admitted and ruled out for MI.


Benign T-wave Inversion (this link takes you to many examples)

There are many etiologies of T-wave inversion.  We are most worried about ischemic T-wave inversion.  Wellens' syndrome is particularly dangerous, as it signifies an unstable critical LAD stenosis.  I have several posts on this; here is one that shows the entire evolution.

Another etiology is "Benign T-wave Inversion", which has long been recognized. I first saw it described in Chou's textbook.  It is a normal variant associated with early repolarization.  K. Wang recently studied it.  He reviewed ECGs from all 11,424 patients who had at least one recorded during 2007 at Hennepin County Medical Center (where I work) and set aside the 101 cases of benign T-wave inversion.  97 were black.  3.7% of black men and  1% of black women had this finding.  1 of 5099 white patients had it.  Aside from an 8.8% incidence (9 of 109) black males aged 17-19, it was evenly distributed by age group.

I have reviewed these 101 ECGs, and what strikes me is:

1. There is a relatively short QT interval (QTc < 425ms)  (this case would be an exception!)
2. The leads with T-wave inversion often have very distinct J-waves.
3. The T-wave inversion is usually in leads V3-V6 (in contrast to Wellens' syndrome, in which they are V2-V4)
4. The T-wave inversion does not evolve and is generally stable over time (in contrast to Wellens', which always evolves).
5. The leads with T-wave inversion (left precordial) usually have some ST elevation
6. Right precordial leads often have ST elevation typical of classic early repolarization
7. The T-wave inversion in leads V4-V6 is preceded by minimal S-waves
8. The T-wave inversion in leads V4-V6 is preceded by high R-wave amplitude
9. II, III, and aVF also frequently have T-wave inversion. 

Anterior STEMI?

The patient presents to the emergency Department with complaints of substernal left-sided chest pain present for 4 days but worse in the last 24 hours.

Here is his ED ECG:

ED ECG
The computerized QTc is 451.  What do you think?  The previous ECG, with interpretation, is below.














Here is the Previous ECG.
My reading was printed on the ECG as "probable benign T-wave inversion."    I had discharged the patient at his previous visit.  His presentation had not been concerning for ACS and his ECG was, to me, a benign variant.




The physicians were appropriately worried about the previous ECG and used the formula (see sidebar Excel applet) and came out with a value above 23.4  (I cannot remember what the value was, but they did use 3 mm for the STE variable).

When I apply the formula, even if I use 3 mm as the ST elevation as 60 ms after the J-point, and use R amplitude in V4 at 22 mm, I get 23.03 (which is less than 23.4 and thus indicates early repol).  Furthermore, the morphology of V4 is nearly diagnostic of "Benign T-wave inversion."

In general, if there is T-wave inversion, I do not recommend using the formula. Patients whose ECGs had T-wave inversion in V2-V5 were excluded from the study because T-wave inversion, as a general rule, should imply MI.  However, if you are familiar with the morphology of Benign T-wave Inversion (BTWI), then you would see that these ECGs manifest probable BTWI and be less worried about the ST Elevation.

As for the formula, when you get a value that is close to 23.4, it is wise to not rely on it too heavily.  The sensitivity and specificity of 23.4 was close to 90%, but I the closer the value is to 23.4, the less sensitive and specific it is.

Appropriately, they ordered a 2nd ED ECG about 20 minutes later:
QTc is 445



They thought there might be more STE in lead V3.  I do not see any significant change.

They were still worried, but instead of activating the cath lab, they appropriately consulted the cardiologist and together decided on an immediate formal echocardiogram.

The echo showed:

--Normal left ventricular size, mild concentric left ventricular hypertrophy and hyperdynamic systolic function.
--The estimated left ventricular ejection fraction is 75 %.
--No left ventricular wall motion abnormality identified.
--Normal right ventricular size and function.

The patient was admitted and ruled out for MI.


Benign T-wave Inversion (this link takes you to many examples)

There are many etiologies of T-wave inversion.  We are most worried about ischemic T-wave inversion.  Wellens' syndrome is particularly dangerous, as it signifies an unstable critical LAD stenosis.  I have several posts on this; here is one that shows the entire evolution.

Another etiology is "Benign T-wave Inversion", which has long been recognized. I first saw it described in Chou's textbook.  It is a normal variant associated with early repolarization.  K. Wang recently studied it.  He reviewed ECGs from all 11,424 patients who had at least one recorded during 2007 at Hennepin County Medical Center (where I work) and set aside the 101 cases of benign T-wave inversion.  97 were black.  3.7% of black men and  1% of black women had this finding.  1 of 5099 white patients had it.  Aside from an 8.8% incidence (9 of 109) black males aged 17-19, it was evenly distributed by age group.

I have reviewed these 101 ECGs, and what strikes me is:

1. There is a relatively short QT interval (QTc < 425ms)  (this case would be an exception!)
2. The leads with T-wave inversion often have very distinct J-waves.
3. The T-wave inversion is usually in leads V3-V6 (in contrast to Wellens' syndrome, in which they are V2-V4)
4. The T-wave inversion does not evolve and is generally stable over time (in contrast to Wellens', which always evolves).
5. The leads with T-wave inversion (left precordial) usually have some ST elevation
6. Right precordial leads often have ST elevation typical of classic early repolarization
7. The T-wave inversion in leads V4-V6 is preceded by minimal S-waves
8. The T-wave inversion in leads V4-V6 is preceded by high R-wave amplitude
9. II, III, and aVF also frequently have T-wave inversion. 

Çevik: SEMS2014 ve Simulasyon Savaşları

9-14 Nisan 2014 tarihleri arasında Singapurda düzenlenen SEMS2014′e katıldım ve burada ilk kez olarak düzenledikleri Simulasyon Savaşlarında hakem olarak görev aldım. Oldukça dinamik ve heyecanlı geçen bu aktiviteden arta kalan zamnda da organizasyonun önemli isimlerinden Dr. June, Dr. Ynonne ve kongre başkanı A/Prof. Dr. Goswami ile acilci.net adına görüştüm. İzleyeceğiniz 4 dk’lık bu video söyleşileri ...