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 OR ACS ALS 130

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 93

Coronary CAD ACS OR 93

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 103

Coronary E-9-1-1 STEMI ACS 103

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

FEBRUARY 12, 2024

11) Webb RK, Ralston AC, Runciman WB. Journal of Trauma and Injury 2019; 32(4): 238-242. Epub 2019 Dec 30. Epub 2019 Jul 18. Epub 2019 Jul 18. Epub 2019 Dec 19. 2019 Jun;23(6):258-262. PMID: 11685301. (10) 10) Jubran A. Pulse oximetry. Intensive Care Med. 2004 Nov;30(11):2017-20. Epub 2004 Jul 24.

Emergency Department 94

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

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

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

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 ALS 52

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

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] Eur Heart J 2019 5. Eur Heart J 2009 4 Lemkes et al. Bergmark BA, Faxxon DP.

STEMI 62

STEMI Coronary Paramedic ALS 62

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. Learning Points: 1.

ACS 117

ACS ED Coronary EMS 117

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-9-1-1 110

E-9-1-1 Coronary EMS ED 110

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 70

E-9-1-1 Emergency Department Plasma ED 70

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

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

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

Dr. Smith's ECG Blog

AUGUST 15, 2019

He had multiple cardiovascular risk factors and the EM physician strongly suspected ACS. Ongoing ischemia (by symptoms, ECG, or troponin) despite maximal medical management is an indication for emergent cath lab activation. == MY Comment by K EN G RAUER, MD ( 8/15/2019 ): == Once again, the w rong q uestion was a sked in this case.

STEMI 52

STEMI ACS OR EMS 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). Association of Coronavirus Disease 2019 (COVID-19) With Myocardial Injury and Mortality. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis. of Cardiology AC, Others.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JULY 11, 2019

When in doubt, record serial ECGs and watch out for signs of ischemia despite medical management. == Comment by K EN G RAUER, MD ( 7/11/2019 ): == Our thanks to Drs. Meyers : This ECG was texted to me with no clinical information, and my response was: "That looks like a very subtle LAD OMI. Mogul, Meyers and Smith for this illustrative case.

STEMI 52

STEMI ACS CAD ED 52

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

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-9-1-1 113

E-9-1-1 ALS ACS ICU 113

Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pediatric team felt it might be ACS, but on review of his prior ECGs, it was thought to be really unchanged from the 2 prior and more consistent with myocarditis. This ECG was recorded at 16 hours: Computer reads Acute MI It's not clear to me why the computer read this as such. What I find interesting here is the new Q-wave in lead III.

E-9-1-1 52

E-9-1-1 Coronary OR ACS 52

Dr. Smith's ECG Blog

FEBRUARY 14, 2020

This pattern in isolation would signify diffuse supply/demand mismatch without focal complete occlusion, which would be a very large differential of anything causing severe global supply demand mismatch, including ACS and various other processes. However, there is STE in V1 with a large area T-wave which is hyperacute.

STEMI 52

STEMI ACS OR ED 52

Don't Forget the Bubbles

SEPTEMBER 18, 2023

Davidson L, Foley DA, Clifford P, Blyth CC, Bowen AC, Hazelton B, et al. 2019 Nov 15;16(22):4515. 2019 May;19(5):477–86. McMullan BJ, Andresen D, Blyth CC, Avent ML, Bowen AC, Britton PN, et al. 2019 Feb 28 [cited 2022 Dec 28];Publish Ahead of Print. Pediatr Infect Dis J. 2022 Dec;41(12):947–52. Banerjee S, Ford C.

Emergency Department 142

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

Dr. Smith's ECG Blog

AUGUST 26, 2019

I wouldn't activate the lab for this EKG alone, but if the patient is clinically compatible with ACS you could call a heart alert. There is definite STE inferior and lateral but it just doesn't look like true positive STE to me. I would do echo for WMA, q15 min EKGs - if it's real it will be dynamic and become clear soon.

STEMI 52

STEMI Coronary OR ED 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. 2019 Jan 16;2019:4275918.

ACS 66

ACS Plasma OR ED 66

Dr. Smith's ECG Blog

JUNE 28, 2019

If a patient presents with symptoms of ACS, has an elevated troponin, and has persistent symptoms in spite of medical therapy [antiplatelet, antithrombotic, and anti-ischemic (nitro)], then cath lab activation is indicated regardless of ECG findings. Compare with an old ECG.

Coronary 52

Coronary ACS ED OR 52

Dr. Smith's ECG Blog

JULY 19, 2019

This is the most important exception to the classic teaching of "diffuse STE without reciprocal depression is less likely ACS, more likely pericarditis".

STEMI 52

STEMI ED ACS OR 52

Dr. Smith's ECG Blog

MARCH 11, 2019

An angiogram confirmed ACS as the etiology. Management on this 2nd presentation: The troponin was 0.224 ng/mL and falling, and thought to be due to demand ischemia again [though they were merely coming down after previous (type 1 MI)]. He was discharged and returned again. Learning Points 1. Again, a computer "Normal ECG" is often abnormal.

OR 52

OR ACS ICU STEMI 52

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 102

Coronary ACS ED OR 102

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

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

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

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

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 110

ACS OR 110

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 115

Overdose OR ACS ICU 115