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. Fortunately, that is exactly what happened.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

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 52

Critical Care ACS OR 52

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. Upon arrival he was found alert and oriented, and without gross distress. He denied difficulty breathing, epigastric pain, or chest discomfort. He denied any chest discomfort, or difficulty breathing.

ALS 130

ALS STEMI Coronary OR 130

EM Didactic

OCTOBER 15, 2018

References Meltzer AC, Baumann BM, Chen EH, Shofer FS, Mills AM. 2013 Aug 1;62(2):126-31. Abdominal pain is a common ED presentation and one of the top differential for RLQ pain is Acute Appendicitis. Early in the course, examination findings are often subtle and bloods may not show a raised WCC or CRP. Annals of emergency medicine.

ACS 52

ACS ED OR 52

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. See image with lines below).

Defibrillator 52

Defibrillator ACS CPR STEMI 52

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?

Coronary 52

Coronary ACS STEMI ALS 52

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. 2 The astute paramedic recognized this possibility and announced a CODE STEMI.

Coronary 40

Coronary ACS ALS STEMI 40

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. 1 mm of concordant STE or 2. 1 mm of concordant STD in V1, V2, or V3 3.

ED 52

ED ACS OR ALS 52

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. The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI!

STEMI 52

STEMI E-9-1-1 Coronary ALS 52

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." J ACC 61(4):e78-140; page e83.

STEMI 52

STEMI E-9-1-1 ACS OR 52

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: 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]. REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

ALS 136

ALS ACS OR CPR 136

Don't Forget the Bubbles

JULY 22, 2024

Since the PREVIEW trial, there have been more negative trials. One such trial was the WASP trial , which involved 477 children in New Zealand. This trial showed no difference in PRAM score or LOS in the prednisolone group compared to placebo. An IPD approach is a collaborative exercise including the authors of included studies and stakeholders.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

EMDocs

SEPTEMBER 25, 2023

Notable Physical Exam: General: Tripoding, severe respiratory distress. However, emergency physicians have recently faced a multitude of patients requiring ETI with anatomically and physiologically difficult airways; these patients increase the risk of a can’t intubate/can’t oxygenate scenario or significant hypoxemia, hypercarbia, or acidemia.

ED 92

ED Emergency Department ALS Paramedic 92

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. Total LM occlusion can present with STE or STD in aVR. D1 ( STE I, aVL, V5, V6 ) and 2b.

Coronary 52

Coronary STEMI ACS ALS 52

FOAMfrat

OCTOBER 20, 2023

Of note, in the paper by Russotto et al., the patients had to have an oxygen saturation greater than 80%, a blood pressure of 90 SYS/MAP 65 or higher, and not have required intubation due to cardiac arrest prior to the intubation procedure for inclusion. How Do I Predict Physiologically Difficult Airways? Recommendations : 1. are at high risk.

E-9-1-1 52

E-9-1-1 ALS ACS OR 52

Dr. Smith's ECG Blog

OCTOBER 20, 2013

BP gradually rose. She was completely comatose (GCS = 3) and pupils were midposition and fixed. Later in the case there was some respiratory effort but no improvement in pupils or any other aspect of the neurologic exam. Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI. Kurkciyan et al.

STEMI 52

STEMI Coronary ACS Emergency Department 52

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. The ED physician attempted to explain the modified Sgarbossa criteria, but without success.

STEMI 52

STEMI Coronary ED ACS 52

EMDocs

FEBRUARY 12, 2024

How would an ABG even change the initial stabilization of any of these patients? What alternative testing can be done in these circumstances? Recent studies suggest that clinicians can obtain similarly actionable results from VBGs as ABGs and using the “gold standard” ABG might not be as clinically relevant as it once was.

Emergency Department 98

Emergency Department E-9-1-1 ED ICU 98

Don't Forget the Bubbles

SEPTEMBER 18, 2023

However, symptoms may also be non-specific, including irritability, headache, poor feeding, vomiting, or diarrhoea. The diagnosis is clinical and can be made by directly visualising erythema or bulging of the tympanic membrane. Treatment is mainly symptomatic with analgesia. A throat culture is the gold standard for confirming a bacterial infection.

Emergency Department 143

Emergency Department E-9-1-1 ALS OR 143

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. Lactated Ringer (LR) and 0.9% To assess the clinical impact and relevance of these concerns, Alwang et al.

ALS 128

ALS ED ACS EMR 128

Dr. Smith's ECG Blog

APRIL 13, 2025

Myocardial Infarction with Non-Obstructive Coronary Arteries. Etiologies (list not comprehensive): Coronary Spasm. Provocative testing is very helpful for this Coronary Thrombus with lysis (one must do optical coherence tomography or at least intravascular ultrasound to find thes non-obstructive plaques that ruptured. Embolism with lysis.

Coronary 84

Coronary STEMI EMS ALS 84

EMDocs

JUNE 14, 2023

He has a glove and stocking pattern of numbness to his extremities. Motor and sensory findings are symmetrical. Patellar reflexes are 1+. He has no saddle anesthesia or back pain and denies any difficulty urinating or issues with defecation. Paraquat Influenza vaccine Methanol Organophosphate Are his symptoms reversible?

E-9-1-1 96

E-9-1-1 Emergency Department Plasma ED 96

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. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. N Engl J Med. 2023 May 11;388(19):1755-1766. Mondardini MC, et al. Eur J Pediatr. Buonsenso D, et al.

ALS 119

ALS ACS ED OR 119

EMDocs

JUNE 27, 2024

Left lower lung field end demonstrates expiratory wheezing on auscultation. Other lung fields unremarkable. 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 4 mg per dose q20-30min) or hydromorphone (0.01-0.02 mg/kg, max 0.4 C or 100.4

E-9-1-1 98

E-9-1-1 ICU ACS EMS 98

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

Patients with suspected ACS should be evaluated with echocardiography. It will probably show an occlusion of the LAD, and it might be difficult to know how long the occlusion has been there and how viable the myocardium is, but it needs to be opened. Let us have a look at the limb lead ST-T changes. Is this ST elevation ischemic in nature?

STEMI 89

STEMI ALS OR Coronary 89

EMDocs

JUNE 7, 2023

Questions: What is the most likely causative xenobiotic that led to these findings? Influenza vaccine Methanol Organophosphate Paraquat Are her symptoms reversible? Yes No What therapy or therapies are critical for this patient? The exposure can be either intentional or unintentional. 7, 9 Often have absence of excessive cholinergic stimulation.

E-9-1-1 98

E-9-1-1 ICU Emergency Department ED 98

Dr. Smith's ECG Blog

MARCH 8, 2025

After completing the ACS algorithm with amiodarone and lidocaine, there are diminishing returns on further treatments. In lab, patients are monitored on continuous abbreviated ECG with 5 electrodes. During ballooning, we often see immediate hyperacute T waves. The patient's ECG at the beginning of the case is shown below. SanzRuiz, R.,

E-9-1-1 75

E-9-1-1 OR Defibrillator Coronary 75

EMDocs

MARCH 24, 2025

The patient denies any current symptoms but states that he just wants to get checked out. He has no chronic medical conditions, does not take any medications, and does not use any drugs or alcohol. Vital signs are within normal limits, with BP 110/70 mmHg, HR 60 bpm, RR 18 breaths/min, O2 saturation 98% on RA, T 37 C.

E-9-1-1 92

E-9-1-1 ALS ED OR 92