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.

Coronary 52

Coronary ACS STEMI ALS 52

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. Lindahl et al. From Gue at al. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data.

Coronary 105

Coronary E-9-1-1 STEMI ACS 105

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-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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] 1] Driver, B. Posterior wall reperfusion T-waves: Wellens’ syndrome of the posterior wall. Emergency Medicine Journal, 1-5. [2]

STEMI 130

STEMI ALS Coronary CAD 130

EMDocs

OCTOBER 8, 2024

Lactate Troponin Could this be ACS or myocarditis? 2006.11.018 Gabayan GZ, Sun BC, Asch SM, et al. 2016.12.010 Brugada J, Katritsis DG, Arbelo E, et al. 2016.12.010 Brugada J, Katritsis DG, Arbelo E, et al. doi:10.1093/eurheartj/ehz467 Fleming S, Thompson M, Stevens R, et al. Is there additional imaging indicated?

E-9-1-1 94

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

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. PMID: 27940800 Hersch AL, Gerber JS, Hicks LA, Pavia AT. Pediatrics. 147(6):e202003316. 38 (3):268-270.

E-9-1-1 130

E-9-1-1 ACS OR ALS 130

Don't Forget the Bubbles

SEPTEMBER 13, 2023

doi:10.1093/tropej/fmz071 Expert Panel on Pediatric Imaging, Trofimova A, Milla SS, et al. 2019-0134 Hirtz D, Ashwal S, Berg A, et al. Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. J Trop Pediatr. 2020;66(3):299-314. Pediatr Rev.

E-9-1-1 131

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

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

JUNE 27, 2024

Alkindi S, Al-Busaidi I, Al-Salami B, Raniga S, Pathare A, Ballas SK. 2019 Jan 24;14:263-292. Alghamdi FA, Al-Kasim F, Alshhada F, Ghareeb E, Azmet FR, Almudaibigh A, Baitalmal L, Alnawfal B, Alluqmani R. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. C or 100.4 mg/kg, max 0.4 2020 Feb 12;10(1):2470.

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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. A study by Hassan et al. A study by Hassan et al. Lobo et al. The SCAD cases in Lobo et al.

Coronary 52

Coronary CAD ACS STEMI 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. Kosuge et al. 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.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

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

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. Paper: Mason JM, et al. These results were corroborated with other another study by Gritensko et al. Am J Emerg Med.

Emergency Department 52

Emergency Department ALS Critical Care ED 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. Today’s Post by Dr.

Coronary 52

Coronary ACS EMS STEMI 52

FOAMfrat

OCTOBER 20, 2023

And according to a paper from Russotto et al. Of note, in the paper by Russotto et al., Heffner et al, 2012, reports a study that "demonstrated pre-RSI systolic pressures less than 140 as independently associated with post-intubation hypotension, but SI was not included in this analysis" [14]. Sackles et al. Brown, C.A.

E-9-1-1 52

E-9-1-1 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. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Lindahl et al. From Gue at al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 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. Patel et al., Krucoff et al.) Patel et al. Krucoff et al. What will you do for this asymptomatic patient??? Heart 1996.

STEMI 52

STEMI ALS ACS OR 52

EMDocs

JUNE 14, 2023

Boostani R, Mellat A, Afshari R, et al: Delayed polyneuropathy in farm sprayers due to chronic low dose pesticide exposure. PMID: 23163581] Muñoz-Quezada MT, Lucero BA, Iglesias VP, et al. doi:10.1080/10773525.2015.1123848 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L. References: Tintinalli, J.

E-9-1-1 69

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

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. References 1. -- Hillinger P, Strebel I, Abacherli R, et al. Int J Cardiol 2019 2. -- Meyers HP, Bracey, Smith et al. J of Emerg Med 2021.

STEMI 52

STEMI Coronary ALS ACS 52

EMDocs

JUNE 7, 2023

References: Boostani R, Mellat A, Afshari R, et al: Delayed polyneuropathy in farm sprayers due to chronic low dose pesticide exposure. doi:10.1186/1756-0500-6-524 Muñoz-Quezada MT, Lucero BA, Iglesias VP, et al. 12784 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L. Otherwise, provide supportive care.

E-9-1-1 83

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

EMDocs

SEPTEMBER 25, 2023

References: Heffner AC et al. PMID: 23911630 Kim WY et al. PMID: 23911630 Kim WY et al. PMID: 25402500 Forsythe SM et al. PMID: 10631227 Mosier JM et al. Riker RR, Shehabi Y, Bokesch PM, et al. Lowe J B, Yoo M J, Patrick J O, et al. 2019, 64:617-28. Li, Timmy, et al. 2007): 748.

ED 65

ED Emergency Department ALS Paramedic 65

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

3–8 Shi et al. Sandoval Y, Smith SW, Sexter A, et al. Shi S, Qin M, Shen B, et al. Guo T, Fan Y, Chen M, et al. 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.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

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. 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. CLICK HERE.

ALS 52

ALS ACS OR ED 52

Don't Forget the Bubbles

JUNE 30, 2023

Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Laan DV, Vu TD, Thiels CA et al. 2019 Aug;31(4):683-687. Trauma Surg Acute Care Open.

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

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. CLICK HERE — for a brief article by Rowlands et al that explains these concepts in more detail. Mogul, Meyers and Smith for this illustrative case.

STEMI 52

STEMI ACS CAD ED 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. Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. Tonsillitis Baker MG, Gurney J, Oliver J, Moreland NJ, Williamson DA, Pierse N, et al. 2019 Nov 15;16(22):4515. Addo-Yobo E, Chisaka N, Hassan M, Hibberd P, Lozano JM, Jeena P, et al.

Emergency Department 143

Emergency Department E-9-1-1 ALS OR 143

EMDocs

JANUARY 20, 2024

Rosh Review Website Link Further Reading Further FOAMed: [link] [link] References: Ahmad SA, Brito D, Khalid N, et al. Takotsubo syndrome in Heart Failure and World Congress on Acute Heart Failure 2019: highlights from the experts. Additional fluids will not improve her condition and may worsen it. Takotsubo Cardiomyopathy.

E-9-1-1 74

E-9-1-1 EMS Coronary ACS 74

ACEP Now

NOVEMBER 7, 2023

8-12 A recent scoping review published in The American Journal of Emergency Medicine reviewed articles between 2016 and 2019, and found 18 observational studies, which failed to demonstrate sufficient evidence for widespread implementation of DSED. References Go AS, Mozaffarian D, Roger VL, et al. Margey R, Browne L, Murphy E, et al.

Defibrillator 52

Defibrillator E-9-1-1 ALS Epinephrine 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. Sandoval Y et al. There actually was an old ECG from about 4 years prior (ECG-2), which I'm not sure anyone saw: Here the limb leads have much higher QRS voltage, without a correspondingly larger ST-T voltage.

STEMI 52

STEMI Emergency Department ED 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] Kontos et al. Welsh et al. Busk et al. Eur Heart J 2009 4 Lemkes et al.

STEMI 66

STEMI Coronary Paramedic ALS 66

EMDocs

FEBRUARY 12, 2024

References/Further Reading (1) Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. 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. A systematic review and meta-analysis.

Emergency Department 93

Emergency Department E-9-1-1 ED ICU 93