EMS 12-Lead

JUNE 20, 2022

Although the attending crews did not consider the ECG pathognomonic for occlusive thrombosis, they nonetheless considered the patient high-risk for ACS and implored him to reconsider. The attending crews were concerned for an ACS-equivalent of LAD occlusion and initiated a prehospital STEMI activation to the closest PCI center.

ACS 130

ACS Coronary STEMI CAD 130

Don't Forget the Bubbles

OCTOBER 7, 2024

This is supplied via alternating current (AC), increasing the risk of titanic contraction of skeletal muscle, leading to kids holding on to the electrical power source. Up to 5% of burns occur secondary to electrical injuries, and this rises to 27% in developing countries. Was the voltage high or low (as below)? Was there any syncope ?

ACS 80

ACS Life Support OR CPR 80

Pediatric EM Morsels

AUGUST 18, 2023

Wirth 2018) One study including 4.4 When you read the Morsel on Perichonditis of the ear last week ( or perhaps the Plantar Puncture Morsel from many many many weeks ago ) you may have objected because of the mention that, when indicated, fluroquinolones are safe in children. Which is a risk of 1 event for 62.5 Binz 2015).

E-9-1-1 130

E-9-1-1 OR ACS ALS 130

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). ACE inhibitors, or potassium-sparing diuretics), are particularly susceptible. In the case of ACS, the ECG can rapidly change from this. Past medical history included HTN, HLD, and MI 10 years prior.

ACS 130

ACS Paramedic Coronary ALS 130

The Skeptics' Guide to EM

MAY 25, 2019

The American College of Emergency Physicians (ACEP) and American College of Surgeons Committee on Trauma (ACS COT) in 2018 put out a joint statement for the use of REBOA [4]. Population: All adult (over 18 years of age) patients in the ACS-TQIP database from 2015-2016. This is Bob’s tenth visit to the SGEM.

ACS 130

ACS Emergency Department ALS OR 130

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 114

ACS ED Coronary EMS 114

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

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

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

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

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 85

Emergency Department ALS ACS EMS 85

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

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 113

STEMI ACS Critical Care OR 113

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

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 65

ACS Plasma OR ED 65

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

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

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

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 118

STEMI Coronary ALS CAD 118

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

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

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-9-1-1 107

E-9-1-1 Coronary EMS ED 107

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

JANUARY 17, 2023

The January 30, 2018 post — for arterial pulsation artifact. Additional review of ECG artifacts by Pérez-Riera et al ( Ann Noninvasic Electrocardiol 23:e12494, 2018 ) VT Artifact — by Knight et al: NEJM 341:1270-1274, 1999. I immediately recognized this as pulse tapping artifact. It is the left leg electrode that is abnormal.

ALS 52

ALS ACS OR 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

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

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 15, 2023

Learning Points : Serial ECG are very valuable when it comes to identifying a dynamic process such as ACS. For more on this mirror-image opposite ST-T wave relation in leads III vs aVL — See My Comment in the March 8, 2019 and August 9, 2018 posts in Dr. Smith's ECG Blog ). These changes confirm ongoing OMI with certainty.

ACS 60

ACS STEMI Coronary EMS 60

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