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

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

SEPTEMBER 7, 2024

Eur Heart J 2018. No wall motion abnormality This shows that significant ACS can have ZERO WMA!! There are also subtly hyperacute T-wave in I, aVL, and V2-V6. There is also a very negative (reciprocally inverted) T-wave in lead III, and a down-up T-wave in aVF, both of which are highly suggestive of occlusion of the LAD or D1.

STEMI 116

STEMI ACS Critical Care OR 116

REBEL EM

FEBRUARY 12, 2024

” The Journal of Urology 199.4S (2018): e683-e684. PMID: 25229916 DOI: 10.1056/NEJMoa1404446 Westphalen AC, Hsia RY, Maselli JH, Wang R, Gonzales R. They conclude in young patients with no concern for alternative diagnosis, renal colic can be managed without CT imaging or just POCUS. Moore CL, Carpenter CR, Heilbrun ME, et al.

Emergency Department 83

Emergency Department ALS ACS EMS 83

Dr. Smith's ECG Blog

DECEMBER 27, 2023

As a result, even before looking at this patient's initial ECG — he falls into a high -prevalence likelihood group for ACS ( for an A cute C oronary S yndrome ). We therefore need to assume and rule "out" ACS — more than having to rule it "in". The "onus of proof" remains on us as medical providers to objectively rule out ACS.

E-9-1-1 120

E-9-1-1 OR Coronary ACS 120

EMS 12-Lead

APRIL 21, 2022

He reports to staff that for the past two months, approximately, he has experienced intermittent dyspnea on exertion when walking the dog, particularly when scaling an incline. He admits to a mostly sedentary lifestyle, however denies any smoking, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema. Here is the time-zero ECG (0939 hours).

Coronary 130

Coronary ALS OR ACS 130

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] 1] European guidelines add "regardless of biomarkers". But only 6.4%

STEMI 121

STEMI Coronary ALS CAD 121

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

NOVEMBER 14, 2023

For examples of this phenomenon — See My Comment in the February 14, 2018 — July 21, 2020 — and December 22, 2022 posts in Dr. Smith's ECG Blog ). The emergency physician was skeptical and believed the ECG to be a mimic, a false positive. So they looked into the patient's chart. Learning Point: 1. It is already approved in Europe.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. Nevertheless, the clinical situation made other etiologies unlikely. NTG drip started.

Coronary 52

Coronary ACS EMS ALS 52

Pediatric EM Morsels

APRIL 19, 2024

2018;Volume 00(00):DOI:10.1097/BPO.0000000000001169. This area of transition is ripe for fracture (Light, 1984) Fracture of only part of the cortex leads to plastic deformity and buckling , giving us the torus (buckle) fracture Fracture and plastic deformity of one side of the cortex give us the greenstick fracture. Clin Orthop Relat Res.

ALS 285

ALS ACS Emergency Department ED 285

Emergency Medicine Ireland

DECEMBER 17, 2020

2018 Mar;7(2):255-260. doi: 10.21037/acs.2018.03.01. . * pulling the ETT just above the cords and hyperinflating cuff and downward pressure forming a sort of poor man’s LMA * varying degrees of blunt dissection before the graduated dilator goes in. Some do entirely percutaneous, some do a lot of blunt dissection. 2018.03.01.

Critical Care 40

Critical Care ACS ICU OR 40

EMDocs

JUNE 7, 2023

7 Check out ToxCard: Nerve Agents by Dr. Sahi & Dr. Santos from July 2018 Organophosphates exert their toxic effects by inhibiting acetylcholinesterase within the synaptic cleft, which leads to accumulation of acetylcholine, with subsequent overstimulation of postsynaptic nicotinic and muscarinic receptors, and a predominant cholinergic effect.

E-9-1-1 83

E-9-1-1 ICU Emergency Department ED 83

Dr. Smith's ECG Blog

AUGUST 17, 2022

V5, 6) is 97% specific for OMI in a patient population at high risk of ACS. For review — GO TO: The June 4, 2018 post ( LA-LL reversal ). The July 29, 2018 post ( LA-RA reversal ). The November 4, 2018 post ( Leads V1,V2 misplacement ). The QRS complex in lead I looks "funny". The March 18, 2020 post ( LA-RA reversal ).

Coronary 52

Coronary ACS OR 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

My Comment , by K EN G RAUER, MD ( 10/24/2018 ): = Important teaching points are made in this post by Dr. JACC 2016;67:1531. My Comment , by K EN G RAUER, MD ( 10/24/2018 ): = Important teaching points are made in this post by Dr. Although still present in ECG #2 — note how much less prominent these J waves are after presumed reperfusion.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

JULY 31, 2018

Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. I saw this before any other information and knew immediately that it represented an LAD occlusion. There is 1 mm of STE in lead V2. This must be explained, and normally would be explained by "normal variant," or "early repol."

Coronary 52

Coronary ACS STEMI OR 52

ECG & Echo Learning

OCTOBER 2, 2022

JAMA 2018; 319:1889. 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). Minimal chronotropic effect. Increases coronary blood flow.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

Dr. Smith's ECG Blog

MAY 8, 2023

10 In 2018, the European Society of Cardiology guidelines 11 and the fourth universal definition of myocardial infarction 12 suggested utilizing the original Sgarbossa criteria (Figures 1A to 1C) for diagnosis of occlusion myocardial infarction in both left bundle branch block 13 , 14 and ventricular paced rhythm.15, No labs were performed.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. This case represents the same physiologic event as OMI in terms of the result on the myocardium, therefore with identical ECG features, however there may not be ACS! Clear lungs.

STEMI 52

STEMI ACS CAD OR 52

Dr. Smith's ECG Blog

NOVEMBER 24, 2018

There was no ACS here. There are well-formed R-waves -- Comment by K EN G RAUER, MD ( 11/24/2018 ): -- Excellent case — with the challenge being to interpret the initial ECG without any history ( TOP tracing in Figure-1 ). And it turns out that this was the baseline ECG. I always say that hyperacute T-waves are "Fat," not just tall.

ACS 52

ACS OR Coronary 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 142

Emergency Department E-9-1-1 ALS OR 142

Dr. Smith's ECG Blog

MAY 3, 2024

RBBB + LAFB in the setting of ACS is very bad. Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Patients with ACS and RBBB/LAFB usually have a left main vs. proximal LAD. There is STE in aVR.

ACS 118

ACS ED Coronary EMS 118

Dr. Smith's ECG Blog

OCTOBER 3, 2018

Here is our abstract from SAEM 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). Answer: There is a regular wide complex that looks like LBBB but there are no P-waves (i.e.,

Coronary 52

Coronary STEMI Paramedic ALS 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

Don't Forget the Bubbles

JULY 22, 2024

The 2018 PREVIEW trial reported a significant reduction in length of stay (LOS) in children given prednisolone in Australia (24-71 months, mean 41 months) compared to placebo. When is it no longer bronchiolitis , and when does it become asthma? It is hard to ignore the 170-minute difference in LOS.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

OCTOBER 26, 2020

Learning Points: The myocardium doesn't know the etiology of OMI (ACS, spasm, dissection, embolus, etc.), Learning Points: The myocardium doesn't know the etiology of OMI (ACS, spasm, dissection, embolus, etc.), That said, ACS is by far the most common and treatable cause. I suspect LAD or LM. standard lead format.

Coronary 52

Coronary Defibrillator ACS CAD 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

Abdominal pain can of course be a symptom of ACS, but it was brief and seemed to have resulted in a vasovagal event. For another case in which marked ST elevation in leads V1 and V2 could easily be mistaken for a hyperacute change — See the Figure I drew in My Comment at the bottom of the December 27, 2018 post on Dr. Smith’s ECG Blog.

ACS 52

ACS ED Coronary STEMI 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

EMDocs

JANUARY 6, 2024

10 Although this is not the same pathophysiology seen in ACS from an acute plaque rupture leading to coronary artery occlusion, patients can have relatively abrupt coronary ischemia causing ACS due to acute, concentric vessel narrowing. BNP should normalize after about 2 months. 13 Cefepime 2 g or Piperacillin-Tazobactam 4.5

EMS 63

EMS E-9-1-1 ACS Coronary 63

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 66

ACS Plasma OR ED 66

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

Dr. Smith's ECG Blog

MARCH 27, 2023

This is now further confirmation of ACS. The ACC/AHA guidelines mandate less than 2 hours cath for patients with ACS with refractory pain, pulmonary edema, or electrical or hemodynamic instability. Another ECG was recorded at 160 minutes: There is evolution, with worsening of ischemia. No wall motion abnormality.

ACS 52

ACS STEMI OR 52

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

NOVEMBER 3, 2017

Am J Cardiol 2018; 122(8):1303-1309. 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. 100% LAD occlusion.

STEMI 52

STEMI Coronary OR ALS 52

REBEL EM

FEBRUARY 2, 2023

Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). 2018, PMID: 30571262 Gritsenko, Diana, et al. However, digoxin is known for its rate-control properties and its direct vagal effect on the atrioventricular node. Paper: Mason JM, et al. Am J Emerg Med. PMID: 36115743 Panchal, Ashish R., Circulation , 5 Nov.

Emergency Department 52

Emergency Department ALS Critical Care ED 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

EMDocs

AUGUST 31, 2023

However, in 2015 crotalidae equine immune F(ab’) 2 (ANAVIP®) was approved by the FDA for rattlesnake envenomations, and distribution of this antivenom began in 2018. 1,2 Discussion: F(ab) vs. Table 1: Comparison of F(ab) and F(ab’) 2 antivenoms. Table 1: Comparison of F(ab) and F(ab’) 2 antivenoms. References: Ubani C, DeGelorm A, Sollee D.

Allergic Reaction 72

Allergic Reaction Plasma ALS EMS 72