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

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

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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, vs 48.4% (OR 3.4, of the patients received vasopressors through a peripheral IV.

Overdose 67

Overdose ACS Critical Care OR 67

ACEP Now

OCTOBER 11, 2024

A pediatric submersion score was developed and validated in 2017 identifying five factors that, if present, suggest safe discharge from the ED after an eight-hour observation period. One question that is commonly raised is whether these patients should be trauma activations. 4 Another study cited only 2.3

ALS 52

ALS Emergency Department Emergency Medical Services ED 52

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

Emergency Medicine Ireland

JULY 3, 2023

Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. Eur Heart J 38, 1872–1882 (2017). To start with there are apparently 5 types of cardiorenal syndrome. I’ll let that sink in. You all thought there was one didn’t you? They get sneaky with type 3 calling it renocardiac syndrome.

Critical Care 96

Critical Care ACS OR ALS 96

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. Any cause of pulmonary hypertension. There is normal axis, normal R-wave progression in the precordial leads and no intraventricular conduction abnormalities.

STEMI 96

STEMI OR ACS ALS 96

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

REBEL EM

FEBRUARY 2, 2023

Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). Epub 2017 Jan 10. 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. 2, 2018, pp.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

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

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

ECG & Echo Learning

OCTOBER 2, 2022

Gordon AC, Mason AJ, Thirunavukkarasu N, et al. 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.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

ACEP Now

NOVEMBER 14, 2023

The definition of massive hemoptysis is variable across publications with expectorated blood volumes ranging from 100 to 1,000 mL per 24 hours, as these volumes are difficult to estimate for any given patient. 2 Death from hemoptysis is akin to drowning, so airway considerations usually take precedence over hemodynamic considerations.

E-9-1-1 52

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

Dr. Smith's ECG Blog

DECEMBER 6, 2022

S yncope is an uncommon presentation of ACS, but anginal equivalents are more likely in older patients with diabetes 2. The highest risk group are patients with a cardiac cause of their syncope, in whom 1-year mortality can reach 33% ( Koene et al: J Arrhythm 33(6):533-544, 2017 ). What do you think? Take home 1.

STEMI 52

STEMI ACS 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 73

EMS ALS OR ACS 73

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 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. The cardiologists felt that the ECG did not represent ACS, and thought it was more likely pericarditis, so they did not take him to the cath lab. Here is his triage ECG: What do you think? Pericarditis?

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

ECG & Echo Learning

JANUARY 18, 2023

I C Blood samples Management Recommendation Level of evidence Serum biomarkers of myocardial infarction ( troponin ) should be sampled as early as possible without delaying reperfusion therapy. I C Symptom relief Symptom Management Recommendation Level of evidence Hypoxia Oxygen is indicated if SaO2 < 90% or PaO2 < 60 mmHg.

STEMI 40

STEMI Coronary OR Defibrillator 40

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

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

The clinicians later stated they had had no suspicion of ACS, but that the faculty wanted a troponin anyway. An 80-something non-english speaking patient complained of vertigo. He was asked multiple times about chest pain or dyspnea, but repeatedly denied any such symptoms. His vital signs were all normal. His exam was normal.

STEMI 52

STEMI Emergency Department ED OR 52

ALiEM

OCTOBER 30, 2024

The biggest change has been the gradual replacement of diacetylmorphine (heroin) by fentanyl and other synthetic opioids. Along the same time, a veterinary sedative, xylazine , became popular in Puerto Rico in individuals who used injection drugs [3]. We treat with wound care and reserve surgical management only for limbs that are no longer viable.

E-9-1-1 161

E-9-1-1 Naloxone Emergency Department ALS 161

Dr. Smith's ECG Blog

OCTOBER 3, 2018

European Heart Journal 38(41):3082-3089; November 1, 2017. 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). underlying atrial fibrillation or atrial inactivity).

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

J Electrocardiology 50(5):561-569; September/October 2017. consistent with LAD occlusion) This prompted serial ECGs: These dynamic changes confirmed ACS There was a large obtuse marginal 100% occlusion (surprisingly not LAD! Thus, there must be ST Elevation of at least 1 mm in any of leads V2-V4. If there is LVH, it may not apply.

STEMI 52

STEMI Coronary OR ALS 52

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

Dr. Smith's ECG Blog

AUGUST 10, 2023

So now there was ACS + electrical instability, another indication for emergent angiogram. ACS with refractory ischemia and electrical instability are indications for emergent cath regardless of the ECG! This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram. Shroff, G. & Smith, S.

STEMI 90

STEMI ACS Emergency Department ED 90

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

EMDocs

NOVEMBER 4, 2024

million patient complaints in 2017, making it the second most common ED complaint. 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.

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