Dr. Smith's ECG Blog

APRIL 18, 2024

Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1] 2014 AHA/ACC guideline for the management of patients with non-ST elevation acute coronary syndromes. Circulation 2014 2.

STEMI 121

STEMI Coronary ALS CAD 121

Don't Forget the Bubbles

JUNE 30, 2023

You ask your anaesthetist to get ready to sedate or intubate depending on their status – Significant risk to the department – you make sure security is aware And your patient arrives. Ranulf is quite a sweet, round-faced boy, accompanied by his traumatised-looking mother as he is wheeled to your trauma bay.

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

Dr. Smith's ECG Blog

DECEMBER 14, 2016

This is from the 2014 ACC/AHA guidelines. Here are the European Guidelines : Timing of invasive strategy: Immediate invasive strategy (less than 2 h) in Very-high-risk NSTE-ACS patients (i.e. It was not relieved by anything. The pain was not positional, pleuritic, or reproducible. He had no previous medical history. mm STE in one lead.

ACS 52

ACS STEMI Coronary OR 52

EMDocs

OCTOBER 21, 2023

More common in the setting of atherosclerotic lesions than emboli, which typically occur with sudden onset of symptoms. Symptoms may range from days to months prior to stroke onset. As many as two-thirds of patients with BAO experience prodromal symptoms, including TIAs, minor strokes, or other symptoms.

EMS 97

EMS ALS OR ACS 97

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 52

ACS Coronary STEMI ALS 52

Dr. Smith's ECG Blog

JULY 3, 2018

The AHA/ACC guidelines recommend emergent cardiac catheterization for patients with concern for ACS and refractory chest pain despite maximum medical therapy defined as aspirin + clopidogrel/ticagrelor + heparin/enoxaparin. link] He was admitted to the cardiology unit for serial troponin measurements and concern for possible ACS.

ACS 52

ACS STEMI Coronary CAD 52

EM Didactic

OCTOBER 7, 2018

ACS and Aortic Dissection - For ACS and Dissection, the higher CRP levels, the worse prognosis. It is not used to diagnose ACS/Dissection. 2014 Jan 1;3(1):1-5. Utility of CRP 1. Increased CRP levels were independently associated with mortality. CRP is an independent biomarker of severity in community-acquired pneumonia.

Emergency Department 40

Emergency Department ACS Critical Care Coronary 40

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

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

JANUARY 2, 2016

Journal of Electrocardiology 47 (2014) 655–660. In this paper, Dr. Birnbaum writes: "In patients with ACS without LVH, ST depression with negative T waves in the lateral leads is a sign of sub-endocardial ischemia and is an independent predictor of adverse outcome [11 – 13]. Echo showed massive concentric LVH. Birnbaum Y and Mahboob A.

STEMI 52

STEMI ACS ALS OR 52

AAEM RSA

APRIL 1, 2021

1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 in the 1:1:1 group vs. 17.0% vs. 14.6%, p=0.03).

E-9-1-1 52

E-9-1-1 Plasma ACS ALS 52

Dr. Smith's ECG Blog

MARCH 8, 2021

Echo immediate: 35% EF with anterior, septal, and apical wall motion abnormalities Echo convalescent, 2 months later: Better, with EF up to 45-50% I posted this in 2014: Is the LAD really completely occluded when there are de Winter's waves? Peak troponin I (contemporary) was 101.0 Of course, the ECG after the cath was very much changed.

STEMI 52

STEMI ACS Critical Care OR 52

ACEP Now

NOVEMBER 7, 2023

Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Emmerson AC, Whitbread M, Fothergill RT. Out-of-hospital cardiac arrest unfortunately occurs relatively commonly and emergency physicians must be equipped to diagnose and treat this rapidly. References Go AS, Mozaffarian D, Roger VL, et al.

Defibrillator 52

Defibrillator E-9-1-1 ALS Epinephrine 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

The patient was given sublingual nitroglycerine and his symptoms greatly improved, and another ECG was recorded: Now there is much less ST Elevation If you had not seen the prior ECG, you might have called this normal variant STE, or early repolarization --there are well-formed J-waves. Suppose you had used the formula? Thelin et al. Mokhtari et al.

E-9-1-1 40

E-9-1-1 STEMI ACS Coronary 40

Dr. Smith's ECG Blog

OCTOBER 13, 2022

The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS. In this case there are tall R waves in precordial leads (from a left sided accessory pathway), which are followed by discordant ST depression and T wave inversion. WPW can mimic old MI with persisting Q wave.

STEMI 52

STEMI Coronary OR ACS 52

ACEP Now

FEBRUARY 11, 2024

Given the fact that he has not had these headaches before and has diffuse symptoms including weakness, lab work and head imaging are obtained. There were no acute findings on head CT. His lab values demonstrate no anemia, leukocytosis, or electrolyte abnormalities except for an elevated creatinine.

Overdose 52

Overdose ACS Plasma ALS 52

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). By the time the patient arrived at our facility, she had received aspirin and nitroglycerin, and her pain had apparently completely resolved. She was asymptomatic at the time of this ECG recorded on arrival to our ED: What do you think?

STEMI 52

STEMI ALS ACS ICU 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

It encompasses the complete range of ACS, including OMI, NOMI, and coronary thromboses that have the potential to rapidly propagate and become OMI and therefore has no specificity. Circulation 2014 7. -- McLaren JTT, Meyers HP, Smith SW, Chartier LB. This shows that "NSTEMI" is a worthless term.

STEMI 52

STEMI Coronary ALS ACS 52

The Curious Clinicians

OCTOBER 4, 2023

The 1960s saw the emerging use of these homografts. But the success of these human valves and their advantages over plastic or mechanical led to the realization that limited availability would preclude their wide use; as with any human organ or tissue transplant, demand outstrips supply. There were also issues raised about size mismatch.

ALS 52

ALS OR ACS 52

ECG & Echo Learning

OCTOBER 2, 2022

J Cardiovasc Pharmacol Therap (2014). Several endogenous and synthetic agents exist and are frequently combined to achieve the desired hemodynamic outcome. Most agents exhibit both vasopressor and inotropic effects (Figure 1). μg/kg/min Safe for peripheral use ++ ++ 0 Potent vasoconstrictor with mild inotropic effect. Circulation 2011.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

Don't Forget the Bubbles

MAY 3, 2023

Garabon JJW, Gunz AC, Ali A, Lim R. Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye. This time the PEM MSc team from QML , in association with DFTB, are taking over… Article 1: Insulin infusion in paediatric DKA – high or low?

CPR 52

CPR Emergency Department ALS ICU 52

Dr. Smith's ECG Blog

MARCH 11, 2019

Here is data from a study we published in 2014 for type II NonSTEMI: Sandoval Y. An angiogram confirmed ACS as the etiology. You do NOT see this in normal variant STE, nor in pericarditis. The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW."

OR 52

OR ACS ICU STEMI 52

ALiEM

SEPTEMBER 16, 2024

doi: 10.21037/acs.2016.05.04. 2014 Jul; 3(4):351-67. Neuro : Awake, alert, oriented x 3. 0/5 strength in bilateral lower extremities. 5/5 strength in bilateral upper extremities. They are cool to the touch with poor capillary refill. Palpable left dorsalis pedis pulse, absent right dorsalis pedis pulse. g/dL, 41.5% Aortic Dissection.

ACS 152

ACS Coronary OR 152

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

EMDocs

JANUARY 6, 2024

You review his chart and note that he had a heart transplant in 2014 but has not followed up with a cardiologist for at least 3 years. 15 Patients with a heart transplant can have ACS though they are unlikely to present with classic, crushing chest pain due to transplant-induced changes in cardiac innervation.

EMS 89

EMS E-9-1-1 ACS Coronary 89

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 97

E-9-1-1 ICU ACS EMS 97

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

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 95

E-9-1-1 Emergency Department Plasma ED 95

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 ACS 143

EMDocs

NOVEMBER 4, 2024

The pain is worse with deep breaths, coughing, or certain movements, and improves with rest and nonsteroidal anti-inflammatory drugs (NSAIDs). A 45-year-old male presents to the ED after a motor vehicle collision where he was the restrained driver. He reports severe, localized chest pain, worsened by breathing, coughing, and movement.

ED 105

ED E-9-1-1 Emergency Department ALS 105

EMDocs

JULY 19, 2023

7 We are commonly taught that metals are not amenable to treatment with activated charcoal (AC).However, In short, there is not a whole lot of evidence to support this, but if patient has had a recent ingestion and is not altered, you can consider gastrointestinal decontamination with AC.

ACS 92

ACS Plasma OR ED 92

Don't Forget the Bubbles

JULY 5, 2023

This process of sickling and unsickling goes on and off until the erythrocyte membrane is no longer flexible. Irreversible sickle cells undergo either intravascular haemolysis or extravascular removal by the reticulo-endothelial system resulting in anaemia and splenic sequestration. Blood culture is pending. How would you evaluate this child’s pain?

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

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

JANUARY 6, 2025

History of Present Illness The collateral history indicates that her symptoms began one week into her journey, but medical care was inaccessible at the time. The family reports no history of food allergies, insect bites, or contact with sick individuals. The patient did not receive pre-travel prophylaxis for malaria, hepatitis A, or yellow fever.

ED 75

ED E-9-1-1 ALS Emergency Department 75