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. Musculoskeletal Adverse Events include: Articular cartilage damage causing arthralgias or arthritis , Tendonitis , and Tendon rupture. Which is a risk of 1 event for 62.5

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 94

Coronary CAD ACS OR 94

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. It is not yet available, but this is your way to get on the list. link] Case continued She arrived in the ED and here is the first ED ECG.

Coronary 104

Coronary E-9-1-1 STEMI ACS 104

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

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] He reported to EMS a medical history of GERD only. He left AMA and is lost to follow-up. ST-elevation, Hyperacute T waves, etc.)

STEMI 130

STEMI ALS Coronary CAD 130

EMDocs

FEBRUARY 12, 2024

How would an ABG even change the initial stabilization of any of these patients? What alternative testing can be done in these circumstances? Recent studies suggest that clinicians can obtain similarly actionable results from VBGs as ABGs and using the “gold standard” ABG might not be as clinically relevant as it once was.

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. With me so far?

Critical Care 96

Critical Care ACS OR ALS 96

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. Learning Point: 1. It is already approved in Europe.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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

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

EMDocs

JUNE 14, 2023

He has a glove and stocking pattern of numbness to his extremities. Motor and sensory findings are symmetrical. Patellar reflexes are 1+. He has no saddle anesthesia or back pain and denies any difficulty urinating or issues with defecation. Paraquat Influenza vaccine Methanol Organophosphate Are his symptoms reversible?

E-9-1-1 70

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

EMDocs

JUNE 7, 2023

Questions: What is the most likely causative xenobiotic that led to these findings? Influenza vaccine Methanol Organophosphate Paraquat Are her symptoms reversible? Yes No What therapy or therapies are critical for this patient? The exposure can be either intentional or unintentional. 7, 9 Often have absence of excessive cholinergic stimulation.

E-9-1-1 83

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

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. ED consult for “non-STEMI” when the trop comes back elevated 3.

STEMI 63

STEMI Coronary Paramedic ALS 63

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. Here is his triage ECG: What do you think? Pericarditis?

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

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 118

ACS ED Coronary EMS 118

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 12, 2020

Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. In normal times, the most common use of cTni is in diagnosing, or ruling out, acute myocardial infarction (AMI, a subcategory of acute myocardial injury.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 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

Don't Forget the Bubbles

JULY 22, 2024

Since the PREVIEW trial, there have been more negative trials. One such trial was the WASP trial , which involved 477 children in New Zealand. This trial showed no difference in PRAM score or LOS in the prednisolone group compared to placebo. An IPD approach is a collaborative exercise including the authors of included studies and stakeholders.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

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

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

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. Written by Pendell Meyers A woman in her 70s with diabetes, hypertension, and hyperlipidemia suddenly developed nausea, diaphoresis, and brief syncope while eating at a restaurant. Let me know what happens."

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

Don't Forget the Bubbles

SEPTEMBER 18, 2023

However, symptoms may also be non-specific, including irritability, headache, poor feeding, vomiting, or diarrhoea. The diagnosis is clinical and can be made by directly visualising erythema or bulging of the tympanic membrane. Treatment is mainly symptomatic with analgesia. A throat culture is the gold standard for confirming a bacterial infection.

Emergency Department 142

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

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. Utilized Egger’s linear regression and Begg and Mazumdar’s rank correlation test to assess publication bias. 2.89, p = 0.01.

E-9-1-1 120

E-9-1-1 ALS ACS ICU 120

Dr. Smith's ECG Blog

MARCH 11, 2019

An angiogram confirmed ACS as the etiology. You do NOT see this in normal variant STE, nor in pericarditis. The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." The patient was managed in the ICU and had serial troponins. First was 2.9

OR 52

OR ACS ICU STEMI 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". STE occurs primarily in viable ischemic myocardium; persistent STE after completed infarction is ominous and portends development of an aneurysm. ng/mL (very elevated).

STEMI 52

STEMI ED ACS 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 66

ACS Plasma OR ED 66

Don't Forget the Bubbles

SEPTEMBER 13, 2023

Each article will take a deeper dive into each recommendation’s supporting evidence and practical implications. Do not order laboratory testing or a CT scan of the head for a patient with an unprovoked, generalized seizure or a simple febrile seizure who has returned to baseline mental status. What is the evidence for avoiding imaging?

E-9-1-1 131

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

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. 99% of inferior OMI are either obvious or have some amount of ST depression in aVL.

Coronary 52

Coronary ACS ED OR 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

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. QTc/QUc is in the range of 630 msec. What is the most likely cause of the patient’s ECG findings, and what would be your first step in management? We just finished training version 2 with some cases of hypokalemia, so that is in the future.

Overdose 116

Overdose OR ACS ICU 116

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

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. By the time the patient arrived at our facility, she had received aspirin and nitroglycerin, and her pain had apparently completely resolved.

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. This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. V1 has 0.5 mm of elevation. Learning Points: 1.

Emergency Department 52

Emergency Department E-9-1-1 Coronary 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. 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

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