Dr. Smith's ECG Blog

DECEMBER 5, 2023

A final ECG was perfomed on hospital day 2: Persistent ST elevation in the inferior leads with slight reciprocal ST depression in aVL Teaching points - It is essential to consider ACS in all age groups. While ACS may be less common in the pediatric population, it is important to consider risk factors that may make OMI more likely (e.g.,

Coronary 112

Coronary CAD ACS ALS 112

The Curious Clinicians

NOVEMBER 13, 2024

On June 3rd, 2020, when the world was still in lockdown, we released our very first episode on the pathophysiology of fingernail clubbing. What have we learned after 100 episodes? How time flies! More than four years and dozens of shows later, we thought we’d celebrate the podcast with a special 100th episode. Episode 100.

ACS 52

ACS OR 52

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). The ESC states that patients with suspected ACS should go to the cath lab in ＜2 hours "regardless of ECG or biomarker evidence of MI!!" Academic Emergency Medicine 27(S1): S220; May 2020.

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Link to abstract Link to full text 2) Use of Morphine in Non-STE-ACS is independently associated with mortality, at odds ratio of 1.4

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

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. This is not the case.

Coronary 101

Coronary E-9-1-1 STEMI ACS 101

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). On arrival patient was slightly tachycardic.

Coronary 91

Coronary CAD ACS OR 91

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. Published 2020 Aug 19. 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-9-1-1 122

E-9-1-1 ALS ACS ICU 122

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

In our opinion it should not be given in ACS unless you are committed to the cath lab. Learning Point: Any NSTEMI patient with active ongoing ACS symptoms refractory to medical management is supposed to go to the cath lab within 2 hours if available, per all guidelines in world, regardless of ECG findings.

ACS 82

ACS Coronary ALS CAD 82

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. 2020 Aug 15;417:213343. Epub 2020 May 7.

ACS 66

ACS Plasma OR ED 66

This Podcast Will Kill You

SEPTEMBER 24, 2024

” Clinical Liver Disease 16 (2020): 83-90. ACS omega , 7 (24), pp.20441-20456. Tune in to catch us ironing out the details of this incredibly common genetic disorder. History Biology Adams, Paul C. “Hemochromatosis: ancient to the future.” Adams, P.C., Jeffrey, G. and Ryan, J., Haemochromatosis. Algeo, Thomas J.,

ALS 52

ALS ACS 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 case I presented in My Comment to that March 9, 2020 post showed a patient with this pattern — who on cath had no more than minimal coronary disease.

Coronary 52

Coronary ACS EMS STEMI 52

Don't Forget the Bubbles

SEPTEMBER 13, 2023

Reaffirmed October 17, 2020 Jaffe M, Bar-Joseph G, Tirosh E. doi:10.1177/0883073818786086 Young AC, Costanzi JB, Mohr PD, Forbes WS. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. 2000; 55(5):616-623. Pediatrics. Afebrile Seizures.

E-9-1-1 131

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

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Taking a Closer LOOK: We have periodically reviewed cases with low voltage in Dr. Smith’s ECG Blog ( Please see My Comment at the bottom of the page in the November 12, 2020 post, among others ). 12, 2020 post — are 2 causes potentially relevant to my initial considerations in today’s patient, who was found to have acute LAD OMI.

ACS 101

ACS ED STEMI OR 101

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

For examples of this phenomenon — See My Comment in the February 14, 2018 — July 21, 2020 — and December 22, 2022 posts in Dr. Smith's ECG Blog ). 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

Don't Forget the Bubbles

JULY 22, 2024

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. Yao TC, Wang JY, Chang SM, Chang YC, Tsai YF, Wu AC, et al. Seven provided individual participant data (1728 children between 12-71 months) for the IPD meta-analysis.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

DECEMBER 27, 2023

As a result, even before looking at this patient's initial ECG — he falls into a high -prevalence likelihood group for ACS ( for an A cute C oronary S yndrome ). We therefore need to assume and rule "out" ACS — more than having to rule it "in". The "onus of proof" remains on us as medical providers to objectively rule out ACS.

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

Dr. Smith's ECG Blog

MARCH 27, 2023

This is now further confirmation of ACS. The ACC/AHA guidelines mandate less than 2 hours cath for patients with ACS with refractory pain, pulmonary edema, or electrical or hemodynamic instability. Another ECG was recorded at 160 minutes: There is evolution, with worsening of ischemia.

ACS 52

ACS STEMI OR 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Dialysis patients have a high rate of ACS without chest pain and high rate of delayed diagnosis and delayed reperfusion 2.

STEMI 86

STEMI ACS OR ALS 86

FOAMfrat

OCTOBER 20, 2023

In a 2020 research article titled, Risk Factors for and Prediction of Post-Intubation Hypotension in Critically Ill Adults: A Multicenter Prospective Cohort Study, they report an increased risk of post-intubation hypotension once SBP fell below 130 mmHg. Heffner AC, Swords DS, Neale MN, Jones AE. 2020 Fall;20(3):97-102.

E-9-1-1 52

E-9-1-1 ALS ACS OR 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Opioids in ACS may reduce the pain score, but do not provide reperfusion for ongoing ACS. Association between opioid analgesia and delays to cardiac catheterization of patients with occlusion Myocardial Infarctions.

ACS 52

ACS Coronary ICU STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

This usually occurs in association with an increase in rate — in which the QRS widens when the rate accelerates to a certain amount — and then narrows again after the rate slows down ( For more on the phenomenon of rate-related BBB — See My Comment in the April 22, 2020 post in Dr. Smith's ECG Blog ).

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

EMDocs

JUNE 27, 2024

2020 Feb 12;10(1):2470. 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

OCTOBER 8, 2024

Lactate Troponin Could this be ACS or myocarditis? 2020 Nov 21;41(44):4258]. Tox Ethanol ASA/APAP Serum Osm On repeat exam is there any more concern for toxic ingestion we may consider adding on APAP/ASA or looking for toxic alcohols. Is there additional imaging indicated? Ann Emerg Med. 2017;70(3):268-276.e2. Eur Heart J.

E-9-1-1 95

E-9-1-1 Emergency Department ED ALS 95

EMDocs

JUNE 7, 2023

12784 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L. link] Updated September 14, 2020. Accessed December 14, 2020. Retrieved December 15, 2020, from [link] The post ToxCard: Acute Organophosphate Toxicity appeared first on emDOCs.net - Emergency Medicine Education. Toxicology. 2001;160(1-3):27-33.

E-9-1-1 83

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

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

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI 52

STEMI Coronary ACS ED 52

Emergency Medicine Ireland

JULY 3, 2023

Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. Eur J Heart Fail 22, 584–603 (2020). 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.

Critical Care 96

Critical Care ACS OR ALS 96

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! There is profound "inferior" ST Depression.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

MAY 31, 2023

See this study showing an association between morphine and mortality in ACS: Use of Morphine in ACS is independently associated with mortality, at odds ratio of 1.4. Academic Emergency Medicine 27(S1): S220; May 2020. See this case: A man his 50s with chest pain. Abstract 556.

STEMI 81

STEMI Coronary ACS OR 81

Dr. Smith's ECG Blog

AUGUST 11, 2024

As Smith and Meyers explained in a 2020 article in EM News : “What should we do in the meantime while we are still stuck in the STEMI paradigm in daily practice? Most importantly, while waiting for the paradigm to evolve, maintain focus on our true goal for our patients with ACS: to identify and reperfuse patients with acute occlusion MI.”

STEMI 74

STEMI Paramedic Coronary EMS 74

EMDocs

JUNE 14, 2023

link] Updated September 14, 2020. Accessed December 14, 2020. doi:10.1080/10773525.2015.1123848 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L. [PMID: 25031861] Cook Matt, Frey Aaron. Pesticides and Cholinergics. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. BMC Res Notes.

E-9-1-1 70

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

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. This is not the case.

E-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

EMS 12-Lead

JUNE 1, 2022

In isolation, however, syncope does not hold significant weight for OMI – as opposed to something like crushing chest discomfort, for example – although stereotypical ACS might become blurry in both the elderly and diabetic populations. This is important because we must rely on the ECG to further elucidate the story when the patient cannot.

Coronary 130

Coronary ALS ACS ED 130

Dr. Smith's ECG Blog

OCTOBER 2, 2021

After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. There is no age cut-off for ACS. Approximately 4 hours after arrival, the patient was re-examined by the emergency physician. 1] Wereski, R., Chapman, A.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

AUGUST 17, 2022

V5, 6) is 97% specific for OMI in a patient population at high risk of ACS. The February 11, 2020 post ( LA-RA reversal ). The March 18, 2020 post ( LA-RA reversal ). The August 28, 2020 post ( LA-LL reversal ). The November 19, 2020 post ( LA-LL reversal ). The July 29, 2018 post ( LA-RA reversal ).

Coronary 52

Coronary ACS OR 52

Dr. Smith's ECG Blog

APRIL 18, 2024

Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1] 1] European guidelines add "regardless of biomarkers". But only 6.4%

STEMI 117

STEMI Coronary ALS CAD 117

EMS 12-Lead

APRIL 21, 2022

Such aggressive investigation was particularly warranted in this case because of symptoms compatible with ACS, as well as an equally frightening revelation of family history. Conjecture aside, I believe the lesson here, ultimately, is serial ECG’s. Canadian Journal of Cardiology, 34 ; 132-145. [2] 2] Aslanger, E., 3] deWinter, R.

Coronary 130

Coronary ALS OR ACS 130