Don't Forget the Bubbles

JULY 22, 2024

The most recent meta-analysis , published in 2016 (comparing eleven studies from 1986 to 2009), struggled to reach a consensus because the trials were too heterogeneous to make robust conclusions. Since the PREVIEW trial, there have been more negative trials. One such trial was the WASP trial , which involved 477 children in New Zealand.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

DECEMBER 5, 2023

A final ECG was perfomed on hospital day 2: Persistent ST elevation in the inferior leads with slight reciprocal ST depression in aVL Teaching points - It is essential to consider ACS in all age groups. While ACS may be less common in the pediatric population, it is important to consider risk factors that may make OMI more likely (e.g.,

Coronary 112

Coronary CAD ACS ALS 112

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Studies without IRB approval Studies older than 2016 Intervention: Administration of <30 mL/kg IV crystalloid fluids within three hours of sepsis identification. References: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. 2.89, p = 0.01.

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E-9-1-1 ALS ACS ICU 122

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Click here to sign up for Queen of Hearts Access Given the lack of intracranial hemorrhage, the patient was administered aspirin for suspected ACS and cardiology was consulted. 2016 Nov;34(11):2182-2185. Epub 2016 Aug 27. or basilar ischemia. EKG on arrival to the ED is shown below: What do you think? Version 2 = 0.0272.

STEMI 98

STEMI Coronary Emergency Department OR 98

ACEP Now

MARCH 14, 2024

Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

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

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E-9-1-1 ICU ACS EMS 75

EMS 12-Lead

JUNE 1, 2022

In isolation, however, syncope does not hold significant weight for OMI – as opposed to something like crushing chest discomfort, for example – although stereotypical ACS might become blurry in both the elderly and diabetic populations. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated.

Coronary 130

Coronary ALS Firefighter ED 130

ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. The Case FIGURE 1: Initial EKG were notable for a leukocytosis of 23.19 Click to enlarge.)

STEMI 52

STEMI Coronary ACS Critical Care 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 137

ALS ACS OR CPR 137

AAAM

JANUARY 12, 2024

I have been using AIS since 2016, when I joined the trauma world. The most rewarding aspect of trauma data and analytics is knowing that my team and I are doing our part to support ACS verification here at our hospital. How long have you been using AIS? What inspired you to obtain CAISS credentials?

EMR 52

EMR ACS OR 52

EMS 12-Lead

APRIL 8, 2022

Smith and Meyers found that patients presenting with high-risk ACS and any ST-depression, even less than 1 mm, maximal in leads V1-V4 to be 97% specific for OMI and 96% specific for OMI requiring emergent PCI. [5] He reported to EMS a medical history of GERD only. He left AMA and is lost to follow-up. ST-elevation, Hyperacute T waves, etc.)

STEMI 130

STEMI ALS Coronary CAD 130

ACEP Now

OCTOBER 11, 2024

One question that is commonly raised is whether these patients should be trauma activations. One study demonstrated that the minority of the cases reviewed required surgical intervention or had identifiable traumatic injuries, making standard involvement of the trauma team unnecessary. 4 Another study cited only 2.3

ALS 52

ALS Emergency Department Emergency Medical Services ED 52

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-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

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 73

EMS ALS OR ACS 73

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS. showed that , when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS. What is an S1Q3T3?

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! There is profound "inferior" ST Depression.

Coronary 52

Coronary ACS Naloxone Plasma 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

REBEL EM

FEBRUARY 2, 2023

Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). However, digoxin is known for its rate-control properties and its direct vagal effect on the atrioventricular node. Paper: Mason JM, et al. Amiodarone versus digoxin for acute rate control of atrial fibrillation in the emergency department. Am J Emerg Med.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

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.

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

Dr. Smith's ECG Blog

OCTOBER 24, 2019

Angie Lobo ( @aloboMD ) (For open-access reviews of this literature, see Saw 2016 , Saw 2017 , or Hayes 2018.) SCAD isn’t rare, especially in women Historically SCAD had been identified in 22% of ACS cases in women. Pregnancy is not a common cause of SCAD When ACS occurs in the peripartum period, SCAD is responsible in 43% of cases.

Coronary 52

Coronary CAD ACS STEMI 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

REBEL EM

JULY 14, 2022

Assigning a patient a single PCAC score upfront may implicitly bias clinicians familiar with the score in how they care for patients. This becomes even more problematic if a patient was made a PCAC III as opposed to a PCAC II simply because of the vasopressor chosen or if they made significant improvements immediately after being scored.

ICU 52

ICU ALS OR CPR 52

ALiEM

SEPTEMBER 16, 2024

2016 Jun;21(3):264-73. 2016 Jun;21(3):264-73. Epub 2016 Feb 8. 2016 May; 5(3):256. doi: 10.21037/acs.2016.05.04. 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. g/dL, 41.5%

ACS 152

ACS Coronary OR 152

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 65

ED Emergency Department ALS OR 65

ECG & Echo Learning

OCTOBER 2, 2022

Gordon AC, Mason AJ, Thirunavukkarasu N, et al. JAMA 2016; 316:509. 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). Minimal chronotropic effect. Increases coronary blood flow. JAMA 2018; 319:1889.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

More comments by Smith Isolated precordial ST depression (without ST elevation) in ACS Isolated precordial ST depression (STD) may be due to either subendocardial ischemia (usually V4-V6) or be reciprocal to posterior ST Elevation (maximal STD in V1-V4). This can help in confirmation. O'Gara et al. Circulation.

STEMI 52

STEMI E-9-1-1 Coronary ALS 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Methods : The PERFECT study (#NCT02765477) is a retrospective, 16 center, international investigation of ED patients from 1/2008 - 12/2016 with VPR on the ECG and symptoms of acute coronary syndrome (ACS). Since you cannot see the pacing spikes, how would you know it is paced without the computer read? In normal conduction , (i.e.,

Coronary 52

Coronary STEMI Paramedic ALS 52

EMDocs

JANUARY 6, 2024

Answer : Cardiac Transplant Complications Epidemiology: There were over 3,000 heart transplants in North America in 2016. 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 63

EMS E-9-1-1 ACS Coronary 63

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

ACEP Now

NOVEMBER 7, 2023

8-12 A recent scoping review published in The American Journal of Emergency Medicine reviewed articles between 2016 and 2019, and found 18 observational studies, which failed to demonstrate sufficient evidence for widespread implementation of DSED. Emmerson AC, Whitbread M, Fothergill RT. 2011;13(8):1157–65. N Engl J Med. 20(S1):S67.

Defibrillator 52

Defibrillator E-9-1-1 ALS Epinephrine 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 94

Emergency Department E-9-1-1 ED ICU 94

Dr. Smith's ECG Blog

JUNE 8, 2023

As recurrent ischaemia is the principle event reduced by early intervention in NSTE-ACS, these are important endpoint events occurring with delayed angiography and there is a consistent signal for harm now from two data sources.”[5] Int J Cardiol 2016 3. ED consult for “non-STEMI” when the trop comes back elevated 3. Busk et al.

STEMI 63

STEMI Coronary Paramedic ALS 63

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 98

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

Dr. Smith's ECG Blog

APRIL 8, 2015

Summary of ED Approach to Syncope Please excuse the formatting problems, which I have not been able to fix! I have used this to educate our residents, and I think they find it useful. It is NOT a structured review or meta-analysis. First: Are you sure it was syncope, and not SEIZURE? Abnormal ECG – looks for cardiac syncope. Left BBB vi.

Emergency Department 52

Emergency Department E-9-1-1 ED OR 52