OMI vs. NOMI: The STEMI/NSTEMI is a failed pardigm!
- many NSTEMI have occlusion
- many STEMI don't have occlusion
- @PendellM at #HRreloaded
- we've tried putting band-aids on STEMI.
- the list of STEMI-equivalents keeps growing!
- unfortunately there's no consistent approach to these (cath lab may refuse to activate)
- @PendellM at #HRreloaded
- STEMI algorithm evolved from prior QWMI/NQWMI pardigm, based on RCTs involving thrombolysis
- STEMI is an improvement on ignoring EKG entirely, but it's deeply flawed
- OMI is the next pardigm
- @PendellM at #HRreloaded
NSTEMI RCTs show that 25% of patients with NSTEMI have complete occlusion! such patients are treated sub-optimally and often do poorly
- @PendellM at #HRreloaded
the STEMI paradigm perpetuates itself due to circular logic. it's difficult to have a "false-negative" STEMI based on the way it is defined.
- @PendellM at #HRreloaded
hyperacute T-waves occur earlier than STE. why can't we identify hyperacute T-waves to use them as a tool to guide early reperfusion? cardiology literature largely ignores hyperacute T-waves, favoring delay until STE occurs 😬
- @PendellM at #HRreloaded
focus on absolute STE and ST segment places blinders on us preventing global understanding of EKGs and patients
- @PendellM at #HRreloaded
woah. OMI pardigm may move away purely focusing on EKG, to integrate with *POCUS* and H&P. 🤯 #ThisIsTheWay
- @PendellM at #HRreloaded
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how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little rough…
🧵 1/6…
stage 1: denial
- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…
stage 2: anger
- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being
this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.
(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)
other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.
I think it's time for a difficult discussion, folks.
Let's talk about CSF lactate 🫣
CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...
a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.
this can lead to unnecessary admissions & antibiotics
some patients are subjected to repeat LPs 😩
a low CSF lactate could avoid all of this, allowing patients to go home from the ED
CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.
(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)