2019, Coronary and E-9-1-1 - Paramedicine Now

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2019

Coronary

E-9-1-1

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What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

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. CORONARY ARTERIES: Exam was not directly tailored for coronary artery evaluation, noting recent diagnostic coronary angiogram.

Coronary E-9-1-1 STEMI ACS

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Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. Challenge QUESTION: The relative change in T-QRS-D is not the only thing that changes during period of time that passed between recording of the 2 ECGs shown in Figure-1.

E-9-1-1

E-9-1-1 Coronary ACS BLS

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What Lies Beneath

EMS 12-Lead

AUGUST 22, 2022

Question 1: What is the rhythm? Beat 1 : Sinus, narrow QRS complex. The assumption is that a premature complex discharged prior to Beat 1, which prolonged its respective refractory period in the same manner as Beat 5. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration.

E-9-1-1

E-9-1-1 Coronary ALS ICU

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How important are old ECGs in Non-obvious cases of potential OMI?

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

We who know ischemic ECGs know that really when T-wave inversion is specific for coronary thrombosis that it indicates reperfusion of the artery, not active occlusion. Learning Point: 1. 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 ).

E-9-1-1

E-9-1-1 Coronary EMS ED

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Teenager with chest pain and slightly elevated troponin. What happens then?

Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pain is described as located in the midsternal area, radiating to the right arm, described as 8-9/10 and worse with deep inspirations. In the evening, he became diaphoretic and complained of 9/10 continuous chest pain. If there is NO WMA, then it is not coronary occlusion, but if there IS one, then you still don't have a diagnosis.

E-9-1-1

E-9-1-1 Coronary OR ACS

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A man in his 50s with chest pain

Dr. Smith's ECG Blog

MARCH 9, 2023

He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. Proven STEMI has an open artery in 19% to 36% of cases, depending on whether it is TIMI −1, −2, or −3 flow. 25] Stone et al found that 72% have TIMI 0 or 1 flow.

E-9-1-1

E-9-1-1 STEMI Coronary ALS

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Extreme shock and cardiac arrest in COVID patient

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. Here they are: Learning Points: 1. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. In acute MI, the T-wave is large, and the T/ST ratio is high. This is much more typical of myocarditis.

E-9-1-1

E-9-1-1 STEMI Coronary ALS

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"Pericarditis" strikes again

Dr. Smith's ECG Blog

DECEMBER 13, 2019

On review of systems the patient reported back pain for approximately 1 week which he was treating with NSAIDs with minimal relief. 15-9/6/2017 ). Figure-1: Excerpt from ESC review on acute pericarditis ( See text ). P EARL # 1 — The appearance of the ST-T wave in lead II tends to resemble that in lead I with acute pericarditis.

E-9-1-1

E-9-1-1 ACS Coronary CAD

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Young Man with a Heart Rate of 257. What is it and how to manage?

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

The Differential Diagnosis is: SVT with aberrancy(#) [AVNRT vs. WPW (also called AVRT*)] Atrial flutter with 1:1 conduction, with aberrancy VT coming from the anterior fascicle ( fascicular VT )@ *AVRT = AV Reciprocating Tachycardia (Tachycardic loop that uses both the AV node and an accessory pathway. See Learning point 1 below.

E-9-1-1

E-9-1-1 ALS OR Coronary

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Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

mm of ST segment elevation, V2 and V3 have 1 mm of elevation, v4 has 2 mm of elevation and v5 around 1.5 Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. What do you think?

Emergency Department

Emergency Department E-9-1-1 Coronary STEMI

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Chest pain, shortness of breath, T wave inversion, and rising troponin in a young healthy runner.

Dr. Smith's ECG Blog

MAY 19, 2022

Ct coronary angiogram showed normal coronary arteries. Smith note: I think CT coronary angiogram is reasonable with the elevated troponins and symptoms. International Journal of Cardiology 2019. He was given aspirin and heparin and transferred to the local cardiac center for further evaluation. ng/L; 3 hours, 38.3

E-9-1-1

E-9-1-1 Coronary OR ED

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Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Dr. Smith's ECG Blog

APRIL 22, 2022

But these cases show the potential dangers of delayed recognition and treatment of inferior reperfusion Take away 1. ECG’s can be labeled as ‘normal’ by the computer (and confirmed by cardiology) even with diagnostic signs of occlusion or reperfusion References 1. JAMA Intern Med 2019 9. C ASE # 1: Great point by Drs.

E-9-1-1

E-9-1-1 STEMI ALS ED

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Contrast Media Shortage of 2022 – Lessons Learned

EMDocs

OCTOBER 30, 2023

1 The shortage in supply posed difficulties for hospitals that significantly depend on GE Healthcare as their supplier, which encompassed approximately 50% of hospitals in the United States (US). 11 Table 1. Preparation 9 Hospitals had to prepare for the impending contrast shortage as soon as potential shortage news occurred.

E-9-1-1

E-9-1-1 Emergency Department ALS ED

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What is the infarct artery????? And have you ever seen a troponin this high?

Dr. Smith's ECG Blog

JANUARY 16, 2020

Angiogram showed a 99% left main thrombotic occlusion with TIMI-1 flow (this is considered "occlusion" even though there is some flow. not left main occlusion == MY Comment by K EN G RAUER, MD ( 1/16/2020 ): == I did not correctly identify the “culprit artery” in this case. mEq/L Her BP with pressors came up to 80, then 100.

E-9-1-1

E-9-1-1 STEMI Coronary

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Are these Wellens' waves?

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

4 important features that indicate acute right hear strain: 1. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with APE (p less than 0.001). They found that only 11% of PE had 1 mm T-wave inversions in both lead III and lead V1, vs. 4.6%

E-9-1-1

E-9-1-1 ACS ALS OR

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TEG-Guided Resuscitation of Patients with Cirrhosis and Non-Variceal Bleeding

REBEL EM

SEPTEMBER 26, 2022

2020;71(1):235-246. Plt 37×10^9/L and 40×10^9/L, SOC and TEG, respectively) All patients enrolled had an upper endoscopy and verified the source of bleeding. Article: Kumar M et al. Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial.

FFP

FFP E-9-1-1 ICU ALS

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What happens when a patient with LAD OMI does not go immediately to the cath lab?

Dr. Smith's ECG Blog

APRIL 3, 2019

Learning Points: 1. When I heard she had not undergone immediate angiogram, my first question was, "Did she die?" == Comment by K EN G RAUER, MD ( 4/3/2019 ): == Insightful case presented by Dr. Smith — of an elderly woman with acute LAD OMI. Thus, the patient may be pain free from infarct alone, even without spontaneous reperfusion.

E-9-1-1

E-9-1-1 STEMI OR Coronary

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CT Angiography Head and Neck: Indications and Limitations

EMDocs

NOVEMBER 13, 2023

1 One study found that CTA head and neck was ordered for 2.5% 2019) argue against a minimum NIHSS score to trigger the use of CTA, instead purporting that clinical suspicion of acute ischemic stroke presenting within 24 hours of the last known well was sufficient evidence to order the study. vs. 38.1%) with a good functional outcome.

E-9-1-1

E-9-1-1 ALS Emergency Department ED

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EM@3AM: Takotsubo Cardiomyopathy

EMDocs

JANUARY 20, 2024

She describes the pain as left-sided, non-radiating, and 9/10 in severity. The catheterization lab is activated, but catheterization shows no coronary artery occlusion. A 67-year-old female with past medical history of hypertension presents with acute onset of chest pain without associated symptoms. What is the diagnosis?

E-9-1-1

E-9-1-1 EMS Coronary ACS