Don't Forget the Bubbles

JULY 22, 2024

Pre-school wheezers remain a poorly understood cohort of children despite seeing them every day in paediatric EDs. However, there was no difference in LOS (83 minutes for placebo vs 79 minutes for prednisolone) in participants who were discharged straight from the ED ( 32% ). Reattendance to GP/ED was more important.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

EMDocs

OCTOBER 8, 2024

Episode 108: Unexplained Sinus Tachycardia Mental Model Background: When a patient in the ED has sinus tachycardia our job as emergency physicians is to identify and treat of the underlying pathology. Lactate Troponin Could this be ACS or myocarditis? In the ED, our job is to identify and treat underlying causes. Ann Emerg Med.

E-9-1-1 94

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

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Submitted by Dr. George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. Whereas SCAD is found in ~1-4% of all angiograms performed for ACS — this percentage increases to over 30% in middle-aged women.

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. I don't know if her pain was getting better or not.

Coronary 102

Coronary E-9-1-1 STEMI ACS 102

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

Don't Forget the Bubbles

JULY 5, 2023

Haematology specialist clinics are key to manage the chronic side of the disease, while ED doctors should be able to act rapidly on the common acute emergencies. with thanks A 15-month-old Kenyan boy presents to ED with right hand swelling. A 10-year-old boy with known SCA presents to ED due to severe pain in the legs.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

Dr. Smith's ECG Blog

MARCH 8, 2019

Jerry Jones commented: "Any ST depression on the ECG of a patient with chest pain credible for ACS represents a reciprocal change until proved otherwise." For clarity — I show in Figure-1 the i nitial E CG obtained in the ED ( = E CG # 1 ) — together with the p rehospital E CG that I have pieced together ( = E CG # 2 ).

ED 52

ED STEMI ACS OR 52

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

EMDocs

JULY 19, 2023

This would be a send-out test and would be unlikely to help us acutely in the ED. 7 We are commonly taught that metals are not amenable to treatment with activated charcoal (AC).However, 2019 Jan 16;2019:4275918. doi: 10.1155/2019/4275918. 6 Urine heavy metals screens are not recommended for asymptomatic patients.

ACS 66

ACS Plasma OR ED 66

EMDocs

JUNE 27, 2024

An 8-year old male with a history of sickle cell anemia presents to the ED for evaluation of fever for 2 days and “feeling like I can’t get a full breath”. 768: Epidemiology of Hospital Based ED Visits due to Sickle Cell Crisis and Acute Chest Syndrome in Kids. 2019 Jan 24;14:263-292. C or 100.4 mg/kg, max 0.4 Hosp Pract (1995).

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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. This patient presented to the ED “after a couple of days of chest discomfort”.

Coronary 99

Coronary ACS ED OR 99

EMS 12-Lead

APRIL 8, 2022

1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. However, in this context (i.e. cessation of symptoms), and in this unique territory (V2-V4), the T-wave characteristics are consistent with posterior reperfusion! [1] 3] Niu, T., 4] Yang, T.,

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL. 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 ). So they looked into the patient's chart.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. 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

Dr. Smith's ECG Blog

OCTOBER 12, 2024

EKG on arrival to the ED is shown below: What do you think? 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. or basilar ischemia. However, T waves do not appear to be hyperacute or hyperkalemic.

STEMI 98

STEMI Coronary Emergency Department OR 98

EMDocs

JUNE 7, 2023

F, HR 48, RR 28, BP 104/62, SPO2 88% on non-rebreather mask The patient’s friend who brought her to the ED tells you the patient made suicidal statements earlier in the day and was found in her yard shed. These are send-out labs with turn-around times that make them unlikely to affect the ED course or guide treatment. doi:10.1111/bcp.12784

E-9-1-1 83

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

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). The average time to control HR in the IV amiodarone was 1.7h, which is usually the average time for disposition from the ED. Paper: Mason JM, et al.

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. Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main."

Coronary 52

Coronary ACS EMS ALS 52

EMDocs

JUNE 14, 2023

These are send-out labs with turn-around times that make them unlikely to affect the ED course. This prevents ongoing exposure to the patient and ED staff. In: Mattu A and Swadron S, ed. 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 70

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

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. The patient is a man in his 60s with established severe alcohol use disorder — and epidural abscess being treated with longterm Ciprofloxacin — who presented to the ED following a syncopal episode. Magnesium later resulted at 0.8 As per Drs.

Overdose 112

Overdose OR ACS ICU 112

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

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

MARCH 6, 2019

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

STEMI 52

STEMI ALS ACS OR 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] 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

JULY 11, 2019

Cardiology was called and the patient was taken for urgent catheterization with the time from ED arrival to cath about 1 hour and 45 minutes. 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.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

JANUARY 17, 2023

A 60 year old with chest pain presented to the ED. The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. Here is his first ECG: What do you think? It looks bizarre, doesn't it? There are lots of ST-T abnormalities, but they just don't look recognizable.

ALS 52

ALS ACS OR ED 52

Don't Forget the Bubbles

JUNE 30, 2023

All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. The ODP is caught up leaving theatres and has not yet made it down to ED. Back in ED with Ranulf, and pack two has gone through. 2019 Aug;31(4):683-687. The trauma call goes out. His heart rate is creeping up, now 140.

E-9-1-1 139

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

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

He was found in ventricular fibrillation and defibrillated, then brought to a local ED which does not have a cath lab. Here is the initial ED ECG: This is pretty obviously and inferior posterior OMI, right? He was treated medically for ACS and did not get an angiogram within 72 hours. And we wouldn't do it tomorrow either."

STEMI 52

STEMI Defibrillator ED ACS 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. 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. of Cardiology AC, Others.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time." 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 ).

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

JULY 19, 2019

He still had active pain on arrival to the ED. This is the most important exception to the classic teaching of "diffuse STE without reciprocal depression is less likely ACS, more likely pericarditis". His initial ECG in the ED ( = E CG # 1 ) is shown in Figure-1. Here is his triage ECG: What do you think?

STEMI 52

STEMI ED ACS OR 52

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. BUT — this patient did present to the ED with new non-chest pain symptoms ( including syncope ) that could reflect an acute cardiac event. Let me know what happens." The clue is T-wave inversion in aVL.

STEMI 52

STEMI Coronary OR 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

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. For clarity — I have combined in Figure-1 the first 2 ECGs done in the ED, as well as the prior tracing done on this patient. It is interesting to compare this prior ECG with the initial ECG done in the ED.

STEMI 52

STEMI Emergency Department ED OR 52

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. The patient had a p rior h istory of MI + stents.

Coronary 52

Coronary ACS ED OR 52

EMDocs

FEBRUARY 12, 2024

As the only respiratory therapist in the ED has been paged and is starting BiPAP for this patient, an overhead call for two incoming trauma alerts from a multivehicle collision sounds. Because the RT responsible for drawing arterial blood gases is busy caring for these patients, ABGs will be delayed.

Emergency Department 94

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

Dr. Smith's ECG Blog

MARCH 11, 2019

An angiogram confirmed ACS as the etiology. Figure-1: The first 2 ECGs shown in this case ( See text ). == C OMMENT : As per Dr. Smith — E CG # 1 was the initial tracing on this patient who presented to the ED already intubated for respiratory failure. He was discharged and returned again. Learning Points 1.

OR 52

OR ACS ICU STEMI 52