2013 and ACS - Paramedicine Now

Elbow Dislocations

REBEL EM

NOVEMBER 6, 2024

PMID: 32644703 Robinson PM, Griffiths E, Watts AC. PMID: 27227986 Glover NM, Black AC, Murphy PB. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Simple elbow dislocation. Shoulder Elbow. 2017 Jul;9(3):195-204. PMID: 28588660 Donohue KW, Mehlhoff TL. Chronic Elbow Dislocation: Evaluation and Management. J Am Acad Orthop Surg.

E-9-1-1

E-9-1-1 ACS OR Emergency Department

SAEM Clinical Images Series: Pediatric Neck Mass

ALiEM

AUGUST 30, 2024

2013 Mar;34(3):115-24; quiz 125. Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM; American Thyroid Association Task Force on Thyroid Hormone Replacement. An ultrasound and thyroid antibodies may also be helpful to confirm diagnosis. Pediatric neck masses.

ACS

ACS Emergency Department ED OR

REBEL Core Cast 123.0 – Posterior Epistaxis

REBEL EM

MAY 29, 2024

VS abnormalities can drive this as well Strongly consider reversal of AC (this will typically come after control) Stopping the Bleeding PPE: these things bleed like stink. Laryngoscope 2013; 123: 2928-9. Posterior epistaxis: clinical features and acute complications. Acad Emerg Med 1995; 25(5): 592-6.

ICU

ICU ALS ACS EMS

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1.

Coronary

Coronary E-9-1-1 STEMI ACS

Tasty Morsels of Critical Care 046 | Abdominal Compartment Syndrome

Emergency Medicine Ireland

JUNE 21, 2021

This week we’re looking at the other ACS, the surgical ACS, the old abdominal compartment syndrome. This week we’re looking at the other ACS, the surgical ACS, the old abdominal compartment syndrome. These are all very nice and should all be reflected upon and followed when appropriate in your ACS.

Critical Care

Critical Care ACS OR

REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. Am J Cardiol 2013. PMID: 23102885 Aykan AC et al. Because the lungs receive 100% of cardiac output, it has been hypothesized that a lower dose of thrombolytic therapy may still be effective with a better safety profile [3][4]. Clin Exp Emerg Med 2023.

ALS

ALS ACS OR CPR

52 in 52 – #41: The CENSER Trial

EMDocs

AUGUST 17, 2023

mL/kg/hr for 2 consecutive hours OR Decrease in serum lactate by more than 10% from initial level Primary outcome – Early norepinephrine group vs. the control group demonstrated higher rates of shock control at 6 hours: 76.1% vs 48.4% (OR 3.4, vs 48.4% (OR 3.4,

Overdose

Overdose ACS Critical Care OR

Fluoroquinolone Use In Children

Pediatric EM Morsels

AUGUST 18, 2023

Etminan 2019) In Belgium between 2010 – 2013, of the 262 children treated with fluroquinolones while hospitalized, only 17% were used for labelled indications. References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. Nearly 400,000 prescriptions were written and 22% were found to be inappropriate based on clinical guidelines.

E-9-1-1

E-9-1-1 ACS OR ALS

Can we rule out appendicitis with a low ALVARADO score?

EM Didactic

OCTOBER 15, 2018

References Meltzer AC, Baumann BM, Chen EH, Shofer FS, Mills AM. 2013 Aug 1;62(2):126-31. If discharging, give strong worsening statements and explain uncertainty about the diagnosis and need for review if symptoms change. Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis. Annals of emergency medicine.

ACS

ACS ED OR

Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation.

E-9-1-1

E-9-1-1 Coronary ACS BLS

Cardiac arrest: even after the angiogram, the diagnosis is not always clear

Dr. Smith's ECG Blog

OCTOBER 28, 2013

Here is an article I wrote: Updates on the ECG in ACS. Was this: 1) ACS with ischemia and spontaneous reperfusion? Also, anterior MI could result from 1) ACS, but also from 2) severe ischemia due to combination of a hemodynamically significant LAD stenosis + severe hypotension during cardiac arrest. References : 1.

Defibrillator

Defibrillator ACS CPR STEMI

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Anything more on history?

ACS

ACS Coronary STEMI ALS

Episode 152 Hemochromatosis: Ironing out the details

This Podcast Will Kill You

SEPTEMBER 24, 2024

2013): 403-412. 2013): 788. ACS omega , 7 (24), pp.20441-20456. New England Journal of Medicine , 387 (23), pp.2159-2170. Barton, James C. “Hemochromatosis and iron overload: from bench to clinic.” ” The American journal of the medical sciences 346.5 Mackenzie, E.L., Iwasaki, K. and Tsuji, Y., Butler, Thomas.

ALS

ALS ACS

Target Acquired

EMS 12-Lead

APRIL 2, 2022

Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. Given such findings, serial ECG’s are prudent to consider, and carry significant impact moving forward, which has been demonstrated in previous posts. 2] Surawicz, B.

ALS

ALS STEMI Coronary OR

How does Acute Total Left Main Coronary occlusion present on the ECG?

Dr. Smith's ECG Blog

AUGUST 9, 2019

But if they do present: The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion , though it might be due to sub total LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. They will add up in varying magnitudes resulting in a variety of ECG presentations.

Coronary

Coronary STEMI ACS ALS

Middle Aged Woman with Asystolic Cardiac Arrest, Resuscitated: Cath Lab?

Dr. Smith's ECG Blog

OCTOBER 20, 2013

Two prehospital 12-lead ECGs looked similar to this ED ECG: This shows diffuse ST depression (I, II, III, aVL, aVF, V3-V6) with reciprocal ST elevation in lead aVR. This ECG is diagnostic of diffuse subendocardial ischemia.

STEMI

STEMI Coronary ACS Emergency Department

Beyond Ketamine: When to use Facilitated Intubation in the ED

EMDocs

SEPTEMBER 25, 2023

References: Heffner AC et al. Resuscitation 2013; 84(11): 1500 – 4. 2013): 71-78. Incidence and factors associated with cardiac arrest complicating emergency airway management. PMID: 23911630 Kim WY et al. actors Associated with the Occurrence of Cardiac Arrest after Emergency Tracheal Intubation in the Emergency Department.

ED

ED Emergency Department ALS Paramedic

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Although this is considered a "STEMI equivalent" and the ACC/AHA guidelines even approve of thrombolytics for ACS with this ECG, the usual criteria used to alert the cath lab team of an inbound Code STEMI are not met by this ECG. For instance: sepsis, bleeding, dehydration, hypoxia, and mild ACS. Circulation 1970;41:623-627 9.

Coronary

Coronary ACS ALS STEMI

Optimizing Hemodynamics Prior to RSI

FOAMfrat

OCTOBER 20, 2023

Heffner AC, Swords DS, Neale MN, Jones AE. 2013 Nov;84(11):1500-4. Epub 2013 Aug 1. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Crit Care Med. 2018 Apr;46(4):532-539. doi: 10.1097/CCM.0000000000002925. 0000000000002925. PMID: 29261566. Resuscitation. doi: 10.1016/j.resuscitation.2013.07.022. 2013.07.022.

E-9-1-1

E-9-1-1 ALS ACS OR

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

Dr. Smith's ECG Blog

DECEMBER 16, 2019

This was formerly an indication for cath lab activation, but was abandoned in the 2013 guidelines because of poor specificity. Here is an algorithm that is very useful in such cases, published by Cai and Sgarbossa in 2013. Excessively discordant STE, as defined by at least 1 mm and with an ST/S ratio of 25% or more.

ED

ED ACS OR ALS

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

Dr. Smith's ECG Blog

DECEMBER 12, 2022

You must understand this and the dynamic nature of ACS to provide excellent care for such patients. One year later: EKG#5 (one year later) Inferior Q waves persist, as do inferior T wave inversions. Learning Points: The ECG can pass through normal or near-normal on its way from occlusion to reperfusion, or vice versa.

OR

OR ACS STEMI Coronary

A man in his 70s with acute chest pain and paced rhythm.

Dr. Smith's ECG Blog

MAY 8, 2023

8 , 9 The most recent American College of Cardiology and American Heart Association ST-elevation myocardial infarction (STEMI) guidelines (2013) give no direction on diagnosing occlusion myocardial infarction in patients with ventricular paced rhythm.

STEMI

STEMI Coronary ED ACS

Right precordial ST depression in a patient with chest pain

Dr. Smith's ECG Blog

AUGUST 3, 2017

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Card 1999; 34:748-753. O'Gara et al. Circulation. mm in ≥ 1 posterior lead and has few false positives. (6)

STEMI

STEMI E-9-1-1 Coronary ALS

How much time are you willing to wait for OMI to become STEMI (if it ever does)?

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

Posterior STEMI" may not even technically exist according to the current (2013) ACC/AHA STEMI guidelines, as it is not described as a "STEMI equivalent" and the only relevant statement in the guidelines is: "In addition, ST depression in 2 precordial leads (V1-V4) may indicate transmural posterior injury."

STEMI

STEMI E-9-1-1 ACS OR

Steroids in preschool wheeze

Don't Forget the Bubbles

JULY 22, 2024

Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, et al. 2013 Jun 4;2013(6):CD004878. Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, et al. Yao TC, Wang JY, Chang SM, Chang YC, Tsai YF, Wu AC, et al. Annals of Emergency Medicine. 2016 May;67(5):593-601.e3. Arch Dis Child.

E-9-1-1

E-9-1-1 ALS ACS ED

ABG Versus VBG in the Emergency Department

EMDocs

FEBRUARY 12, 2024

11) Webb RK, Ralston AC, Runciman WB. 2013 May;14(3):212-7. doi: 10.1136/emermed-2013-202879. Epub 2013 Oct 17. PMID: 11685301. (10) 10) Jubran A. Pulse oximetry. Intensive Care Med. 2004 Nov;30(11):2017-20. doi: 10.1007/s00134-004-2399-x. Epub 2004 Jul 24. PMID: 15278272. (11) Potential errors in pulse oximetry.

Emergency Department

Emergency Department E-9-1-1 ED ICU

emDOCs Revamp – Acute Chest Syndrome

EMDocs

JUNE 27, 2024

Critical Care Medicine 41(12):p A191, December 2013. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. 2013 Jan-Mar;16(1):91-5. Epub 2013 Aug 7. -smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 mg/kg, max 0.4

E-9-1-1

E-9-1-1 ICU ACS EMS

ToxCard: Acute Organophosphate Toxicity

EMDocs

JUNE 7, 2023

2013; 6:524. Published 2013 Dec 9. 12784 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L. Clin Toxicol (Phila) 51: 838, 2013. [PMID: 25031861] Malla G, Basnet B, Vohra R, Lohani SP, Yadav A, Dhungana V. Parenteral organophosphorus poisoning in a rural emergency department: a case report. BMC Res Notes.

E-9-1-1

E-9-1-1 ICU Emergency Department ED

ToxCard: Chronic Organophosphate Toxicity

EMDocs

JUNE 14, 2023

Published 2013 Dec 9. doi:10.1186/1756-0500-6-524 Ross SM, McManus IC, Harrison V, Mason O: Neurobehavioral problems following low-level exposure to organophosphate pesticides: a systematic and meta-analytic Crit Rev Toxicol 43: 21, 2013. Parenteral organophosphorus poisoning in a rural emergency department: a case report. 2013;6:524.

E-9-1-1

E-9-1-1 Emergency Department Plasma ACS

Bubble Wrap PLUS – June 2023

Don't Forget the Bubbles

JUNE 14, 2023

2023 May;182(5):2013-2026 QuantiFERON-TB Gold Plus Performance in Children: A Narrative Review. De Alwis AC, et al. N Engl J Med. 2023 May 11;388(19):1755-1766. Guidelines and best evidence Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view. Mondardini MC, et al.

ALS

ALS ACS ED OR

Antibiotics in the paediatric emergency department

Don't Forget the Bubbles

SEPTEMBER 18, 2023

Davidson L, Foley DA, Clifford P, Blyth CC, Bowen AC, Hazelton B, et al. 2013 Sep 1;88(5):338–40. McMullan BJ, Andresen D, Blyth CC, Avent ML, Bowen AC, Britton PN, et al. References Acute otitis media Csonka P, Palmu S, Heikkilä P, Huhtala H, Korppi M. Outpatient Antibiotic Prescribing for 357,390 Children With Otitis Media.

Emergency Department

Emergency Department E-9-1-1 ALS ACS

Rethinking Fluid Resuscitation in Vaso-Occlusive Crisis: Is Lactated Ringer’s the Superior Choice?

REBEL EM

DECEMBER 23, 2024

saline (NS) solutions are both isotonic crystalloids widely used for intravenous fluid resuscitation across many contexts and disease states ( Myburgh 2013 ). Paper: Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. PMID: 28106307 Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. Lactated Ringer (LR) and 0.9% JAMA Intern Med.

ALS

ALS ED ACS EMR

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

Patients with suspected ACS should be evaluated with echocardiography. Incidence and Prognosis of Pericarditis After ST-Elevation Myocardial Infarction (from the Acute Coronary Syndrome Israeli Survey 2000 to 2013 Registry Database). Perhaps not all readers of this blog are experienced evaluating echo images. References: [1] Lador, A.

STEMI

STEMI ALS OR Coronary

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

Dr. Smith's ECG Blog

MARCH 8, 2025

After completing the ACS algorithm with amiodarone and lidocaine, there are diminishing returns on further treatments. Or was it out of proportion, perhaps worsened by the sympathetic surge? We will never know for certain. In addition to profound acute heart failure, the patient suffered from electrical storm. SanzRuiz, R., Solis, J., &

E-9-1-1

E-9-1-1 OR Defibrillator Coronary

Paramedicine Now

Elbow Dislocations

SAEM Clinical Images Series: Pediatric Neck Mass

Trending Sources

REBEL Core Cast 123.0 – Posterior Epistaxis

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Tasty Morsels of Critical Care 046 | Abdominal Compartment Syndrome

REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

52 in 52 – #41: The CENSER Trial

Fluoroquinolone Use In Children

Can we rule out appendicitis with a low ALVARADO score?

Concerning EKG with a Non-obstructive angiogram. What happened?

Cardiac arrest: even after the angiogram, the diagnosis is not always clear

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Episode 152 Hemochromatosis: Ironing out the details

Target Acquired

How does Acute Total Left Main Coronary occlusion present on the ECG?

Middle Aged Woman with Asystolic Cardiac Arrest, Resuscitated: Cath Lab?

Beyond Ketamine: When to use Facilitated Intubation in the ED

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Optimizing Hemodynamics Prior to RSI

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

A man in his 70s with acute chest pain and paced rhythm.

Right precordial ST depression in a patient with chest pain

How much time are you willing to wait for OMI to become STEMI (if it ever does)?

Steroids in preschool wheeze

ABG Versus VBG in the Emergency Department

emDOCs Revamp – Acute Chest Syndrome

ToxCard: Acute Organophosphate Toxicity

ToxCard: Chronic Organophosphate Toxicity

Bubble Wrap PLUS – June 2023

Antibiotics in the paediatric emergency department

Rethinking Fluid Resuscitation in Vaso-Occlusive Crisis: Is Lactated Ringer’s the Superior Choice?

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Patient is informed of her husband's death: is it OMI or it stress cardiomyopathy?

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