FOAMcast

MARCH 27, 2023

In 2019, the Infectious Disease Society of America recommended against the routine use of steroids in hospitalized patients with community-acquired pneumonia (CAP) while the Society for Critical Care Medicine recommends steroids in these patients. References: Metlay JP, Waterer GW, Long AC, et al.

Critical Care 52

Critical Care ACS ALS 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. Am J Med 2019, 132(5):622-630.

ACS 52

ACS Coronary STEMI ALS 52

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. References: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. May 1, 2019 , A5999-A5999. As the debate continues, one thing remains clear: flexibility and clinical judgment are key to optimizing patient outcomes. Mayo Clin Proc Innov Qual Outcomes.

E-9-1-1 122

E-9-1-1 ALS ACS ICU 122

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. After all, there is no S wave in lead V3.

E-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Whereas SCAD is found in ~1-4% of all angiograms performed for ACS — this percentage increases to over 30% in middle-aged women. The risk of SCAD is even higher in pregnancy — accounting for over 40% of angiograms performed for ACS during the peripartum period.

OR 66

OR STEMI ACS Coronary 66

Don't Forget the Bubbles

JULY 22, 2024

References BTS_SIGN Guideline for the management of asthma 2019.pdf. Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, et al. Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, et al. 2019 Aug;9(8):e028511. Yao TC, Wang JY, Chang SM, Chang YC, Tsai YF, Wu AC, et al.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Pediatric EM Morsels

AUGUST 18, 2023

Etminan 2019) In Belgium between 2010 – 2013, of the 262 children treated with fluroquinolones while hospitalized, only 17% were used for labelled indications. References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. Nearly 400,000 prescriptions were written and 22% were found to be inappropriate based on clinical guidelines.

E-9-1-1 130

E-9-1-1 ACS OR ALS 130

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1.

Coronary 102

Coronary E-9-1-1 STEMI ACS 102

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. Smith's ECG Blog — it may sometimes not be possible to distinguish between acute myocarditis vs acute OMI on the basis of ECG findings and clinical history ( See My Comments in the April 25, 2023 — July 21, 2019 — December 10, 2019 — and January 10, 2020 posts). HR about 90-100/min.

Coronary 91

Coronary CAD ACS OR 91

Don't Forget the Bubbles

JULY 5, 2023

Opioids do not cause ACS but they can exacerbate hypoxia in patients with ACS. Older children and adults usually present with ACS 2-3 days after hospitalisation due to pulmonary infarction (in situ sickling), hypoventilation due to rib infarction (which may be exacerbated by recent narcotic administration) or fat embolism.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

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. 2019 Jan 16;2019:4275918.

ACS 65

ACS Plasma OR ED 65

This Podcast Will Kill You

SEPTEMBER 24, 2024

ACS omega , 7 (24), pp.20441-20456. ” Proceedings of the National Academy of Sciences 116.35 (2019): 17207-17212. Cianciosi, D., and Capanoglu, E., Iron absorption: factors, limitations, and improvement methods. 20441-20456. Hodgskiss, Malcolm SW, et al. “A productivity collapse to end Earth’s Great Oxidation.”

ALS 52

ALS ACS 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

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. JACC 2019 Sep 10;74(10):1290-1300.

Coronary 52

Coronary CAD ACS STEMI 52

EMDocs

JUNE 27, 2024

2019 Jan 24;14:263-292. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. -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 2 mcg/kg, max 100 mcg) while obtaining IV access 20 IV/IM ketorolac (1 mg/kg, max 15 mg) Morphine (05-0.1

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

EMDocs

OCTOBER 8, 2024

Lactate Troponin Could this be ACS or myocarditis? 2019 ESC Guidelines for the management of patients with supraventricular tachycardia: The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC) [published correction appears in Eur Heart J. A Nonconcurrent Cohort Study.

E-9-1-1 94

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

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. Kosuge et al.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

The Curious Clinicians

JANUARY 31, 2024

One 2019 study showed that thalidomide reduced expression of angiogenin (a major angiogenic factor) by almost 3-fold in mice. Listen to the episode [link] Credits & Citatio n Episode written by Avi Cooper Show notes written by Giancarlo Buonomo and Avi Cooper Audio edited by Clair Morgan of nodderly.com Cooper AZ, Breu AC, Abrams HR.

ACS 111

ACS OR 111

Dr. Smith's ECG Blog

JANUARY 9, 2024

Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Cardioversion will address the rhythm problem immediately, also if the chest discomfort subsides when SR is restored, ischemia from ACS becomes much less likely. In either case, prompt cardioversion is indicated.

Coronary 99

Coronary ACS ED OR 99

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] Netherlands Heart Journal, 15 (1), 16-21. [3] 3] Niu, T., The delayed action wave in non-ST-elevation myocardial infarction.

STEMI 130

STEMI ALS Coronary CAD 130

Emergency Medicine Ireland

JULY 3, 2023

Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. Circulation 139, e840–e878 (2019). Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. To start with there are apparently 5 types of cardiorenal syndrome. I’ll let that sink in. – Mullens, W.,

Critical Care 96

Critical Care ACS OR ALS 96

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. Version 2 = 0.0272. Both highly negative. Nicholson — there is no T-QRS-D ( T erminal QRS D istortion ).

STEMI 98

STEMI Coronary Emergency Department OR 98

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.

Coronary 52

Coronary ACS EMS STEMI 52

Don't Forget the Bubbles

SEPTEMBER 13, 2023

2019-0134 Hirtz D, Ashwal S, Berg A, et al. doi:10.1177/0883073818786086 Young AC, Costanzi JB, Mohr PD, Forbes WS. ACR Appropriateness Criteria® Seizures-Child. J Am Coll Radiol. 2021;18(5S):S199-S211. doi:10.1016/j.jacr.2021.02.020 2021.02.020 Fine A, Wirrell EC. Seizures in Children. Pediatr Rev. 2020;41(7):321-347. doi:10.1542/pir.2019-0134

E-9-1-1 131

E-9-1-1 Emergency Department ALS OR 131

The Curious Clinicians

DECEMBER 5, 2023

Cooper, MD (@AvrahamCooperMD) December 10, 2019 CME/MOC Click here to obtain AMA PRA Category 1 Credits (0.5 Listen to the episode [link] Credits & Citation Episode written by Avi Cooper Show notes written by Giancarlo Buonomo and Avi Cooper Audio edited by Clair Morgan of nodderly.com Breu AC, Cooper AZ, Abrams HR.

ACS 52

ACS OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1. Lindahl B, Baron T, Erlinge D, et al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Moreover, the Queen is only supposed to be used with a high pretest probability of ACS/OMI. We just finished training version 2 with some cases of hypokalemia, so that is in the future. The patient’s VBG resulted as I was speaking with him and confirmed my suspicions, showing a potassium of 1.6 Magnesium later resulted at 0.8

Overdose 112

Overdose OR ACS ICU 112

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

For examples of such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 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.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

EMDocs

JUNE 14, 2023

doi:10.1080/10773525.2015.1123848 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L. Treatment mainstay is avoidance of further exposure. Otherwise, provide supportive care. Possible incorporation and development of new therapies incoming. References: Tintinalli, J. McGraw-Hill Education. Section 15: Toxicology: 1301-1303.

E-9-1-1 69

E-9-1-1 Emergency Department Plasma ACS 69

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). I believe this is by far the most common outcome for this patient around the world in 2019. European Heart Journal 2019. She was asymptomatic at the time of this ECG recorded on arrival to our ED: What do you think? Lemkes et al.

STEMI 52

STEMI ALS ACS OR 52

REBEL EM

FEBRUARY 2, 2023

Based on 2019 American Heart Association (AHA) guidelines, amiodarone and digoxin have been suggested as alternative options in controlling ventricular rate refractory to first-line BBs and non-DHP CCBs. Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc).

Emergency Department 52

Emergency Department ALS Critical Care ED 52

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. His first troponin T then resulted elevated at 0.19

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

EMDocs

JUNE 7, 2023

12784 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L. Br J Clin Pharmacol. 2016;81(3):462-470. doi:10.1111/bcp.12784 Acute ill-health in sheep farmers following use of pesticides. Occup Med (Lond). 2012;62(7):541-548. doi:10.1093/occmed/kqs099 Tintinalli, J.

E-9-1-1 83

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

FOAMfrat

OCTOBER 20, 2023

Heffner AC, Swords DS, Neale MN, Jones AE. 2019 Jan;7(1):21-27. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study. Crit Care Med. 2018 Apr;46(4):532-539. doi: 10.1097/CCM.0000000000002925. 2013.07.022.

E-9-1-1 52

E-9-1-1 ALS ACS OR 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. Int J Cardiol 2019 2. -- Meyers HP, Bracey, Smith et al. J Electrocardiol 2019 6. -- Amsterdam EA, Wenger NK, Brindis RG, et al.

STEMI 52

STEMI Coronary ALS ACS 52

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 ).

ACS 60

ACS STEMI Coronary EMS 60

Dr. Smith's ECG Blog

JANUARY 17, 2023

The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. Physiologic Artifact Sources — include patient movement and/or voluntary or involuntary muscular activity (ie, tremor, shivering, scratching, coughing, hiccups, distressed breathing, etc.).

ALS 52

ALS ACS OR ED 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

For more on T-QRS-D — Please see My Comment at the bottom of the page in the November 14, 2019 post in Dr. Smith's ECG Blog ). In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5,

Overdose 52

Overdose OR Coronary ACS 52