REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Kuttab et al’s findings, constituting 45% of the review’s weight, suggest that administering <30cc/kg IVF is associated with increased odds of mortality, delayed hypotension, and increased ICU utilization. times more intubations and 2.15

E-9-1-1 122

E-9-1-1 ALS ACS ICU 122

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

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 101

Coronary E-9-1-1 STEMI ACS 101

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. Reaffirmed October 17, 2020 Jaffe M, Bar-Joseph G, Tirosh E. doi:10.1177/0883073818786086 Young AC, Costanzi JB, Mohr PD, Forbes WS. J Trop Pediatr. 2020;66(3):299-314. J Am Coll Radiol.

E-9-1-1 131

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

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. Am J Emerg Med.

ACS 82

ACS Coronary ALS CAD 82

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. 2020 Nov 21;41(44):4258]. doi:10.1093/eurheartj/ehz467 Fleming S, Thompson M, Stevens R, et al. Is there additional imaging indicated? Ann Emerg Med. Eur Heart J.

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

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

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

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] Amsterdam et al. Alencar et al. Lupu et al. Herman, Meyers, Smith et al. But only 6.4% link] References 1.

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. Readers interested in a more robust discussion of STD vectors, and their implications in OMI, are encouraged to read this phenomenal post at the Smith ECG Blog.

Coronary 130

Coronary ALS OR ACS 130

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

NOVEMBER 9, 2023

link] Shvilkin et al. Thus, the very well informed physician could differentiate these ECGs from those of an LBBB patient with MI: 1) no concordance 2) no excessive discordance 3) LBBB with tachycardia, probably rate related 4) subsequent T wave inversion that, according to Shvilkin et al., is diagnostic of cardiac memory.

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

EMDocs

JUNE 27, 2024

Alkindi S, Al-Busaidi I, Al-Salami B, Raniga S, Pathare A, Ballas SK. 2020 Feb 12;10(1):2470. 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 Annu Rev Pathol.

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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

ACEP Now

NOVEMBER 14, 2023

References Deshwal H, Sinha A, Mehta AC. Atchinson PRA, Hatton CJ, Roginski MA, et al. Ittrich H, Bockhorn M, Klose H, et al. Li H, Ding X, Zhai S, et al. Kathuria H, Hollingsworth HM, Vilvendhan R, et al. Fekri MS, Hashemi-Bajgani SM, Shafahi A, et al. Wand O, Guber E, Guber A, et al. Am J Emerg Med.

E-9-1-1 52

E-9-1-1 ALS Emergency Department OR 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. link] Updated September 14, 2020.

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. 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

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. Epub 2020 Dec 9. Riker RR, Shehabi Y, Bokesch PM, et al. Lowe J B, Yoo M J, Patrick J O, et al. Resuscitation 2013; 84(11): 1500 – 4.

ED 65

ED Emergency Department ALS Paramedic 65

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. Verbrugge, F.

Critical Care 96

Critical Care ACS OR ALS 96

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al. 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 ). per 100,000 to 11 per 100,000 [Rosso].

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

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

EMDocs

JUNE 14, 2023

Boostani R, Mellat A, Afshari R, et al: Delayed polyneuropathy in farm sprayers due to chronic low dose pesticide exposure. link] Updated September 14, 2020. Accessed December 14, 2020. PMID: 23163581] Muñoz-Quezada MT, Lucero BA, Iglesias VP, et al. Iran Red Crescent Med J 16: e5072, 2014. Pesticides and Cholinergics.

E-9-1-1 69

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

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

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

Dr. Smith's ECG Blog

JANUARY 6, 2023

Lupu L, et al. 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. Unfortunately, they follow their own guidelines only 6% of the time!! mg/dL, K 3.5 Abstract 556.

ACS 52

ACS Coronary ICU STEMI 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. 3–8 Shi et al. Sandoval Y, Smith SW, Sexter A, et al. Shi S, Qin M, Shen B, et al. JAMA Cardiol [Internet] 2020;Available from: [link] 4.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 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. de Winter et al in N Engl J Med 359:2071-2073, 2008. See this case: A man his 50s with chest pain.

STEMI 81

STEMI Coronary ACS OR 81

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

Dr. Smith's ECG Blog

JANUARY 17, 2023

Repositioning the LL electrode must have resolved this problem. == REFERENCE: For those interested in More on Recognition of ECG Artifact: The October 17, 2020 post — for a 70-year old woman with " Artifactual VT ". The January 30, 2018 post — for arterial pulsation artifact. Brief review by Tom Bouthillet on some common causes of artifact.

ALS 52

ALS ACS OR ED 52

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

Dr. Smith's ECG Blog

DECEMBER 12, 2022

You must understand this and the dynamic nature of ACS to provide excellent care for such patients. One year later: EKG#5 (one year later) Inferior Q waves persist, as do inferior T wave inversions. Learning Points: The ECG can pass through normal or near-normal on its way from occlusion to reperfusion, or vice versa.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Canto et al. And a complication. == MY Comment by K EN G RAUER, MD ( 10/11/2020 ): == It cannot be stated any clearer than what Dr. Meyers states above. PEARL #3: I’ve described the Mirror Test on a number of occasions in Dr. Smith’s ECG Blog ( Please see My Comment in the September 21, 2020 post). Is that normal?

STEMI 52

STEMI ACS OR Coronary 52

Pediatric EM Morsels

SEPTEMBER 20, 2024

Schnadower, D., Finkelstein, Y.,Desai, Bergmann, K., Hariharan, S., HUS and RRT in STEC-infected Children.

Emergency Department 161

Emergency Department ACS ALS EMS 161

ALiEM

OCTOBER 30, 2024

Multimodal medication options for fentanyl-xylazine withdrawal management in London et al. DOI: Papudesi BN, Malayala SV, Regina AC. PMID 35774687 D’Onofrio G, Chawarski MC, O’Connor PG, et al. PMID 28194688 D’Onofrio G, O’Connor PG, Pantalon MV, et al. Microdosing Methods Help, 2020. 2024 study [16]. 2023 [book].

E-9-1-1 161

E-9-1-1 Naloxone Emergency Department ALS 161

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. 2020 May;10(5):e035343. 2020 Nov 18;m4238. Tonsillitis Baker MG, Gurney J, Oliver J, Moreland NJ, Williamson DA, Pierse N, et al. 2020 Jun 4 [cited 2022 Dec 28];2020(6).

Emergency Department 143

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

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. CREDIT to Drs.

STEMI 52

STEMI ACS OR ED 52

EMDocs

JANUARY 20, 2024

Rosh Review Website Link Further Reading Further FOAMed: [link] [link] References: Ahmad SA, Brito D, Khalid N, et al. 2020 Apr;7(2):400-406. Additional fluids will not improve her condition and may worsen it. Takotsubo Cardiomyopathy. Updated 2023 Jan 9]. In: StatPearls [Internet]. ESC Heart Fail. J Med Life. 2020;13(1):3-7.

E-9-1-1 74

E-9-1-1 EMS Coronary ACS 74