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. Here is the OMI progression of ECG findings for review: You can see that OMI ECG findings must "deflate" and pass through normal or near-normal in order to get to reperfusion findings. This is termed " pseudo-normalization."

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JUNE 5, 2024

As per my review of this subject ( Check out My Comment at the bottom of the page in the November 16, 2023 post in Dr. Smith's ECG Blog ) — the 3 most common Causes of ACS ( A cute C oronary S yndrome ) with a "negative" cath are: i ) Myocarditis; ii ) Takotsubo cardiomyopathy; and , iii ) MINOCA.

Coronary 111

Coronary ACS ALS OR 111

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. Listen to the episode !

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). Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). So I would be worried about inferior OMI. At midnight.

E-9-1-1 122

E-9-1-1 ACS Coronary STEMI 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 116

Coronary CAD ACS ALS 116

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival. He awoke with naloxone. This EKG was recorded as part of a standing order for critical care. He denied any CP or SOB. An EKG was repeated at 5 minutes The T-wave is less hyperacute. Maybe there is some spontaneous reperfusion? It does not radiate.

Overdose 52

Overdose OR Coronary ACS 52

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

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

EMDocs

OCTOBER 8, 2024

At this point there are two large questions. #1. Am I missing anything? #2. What is this patient’s disposition? Pathophysiology and Etiology: In adults, sinus tachycardia is a heart rate greater than 100 beats per minute (bpm) originating from the sinoatrial (SA) node. This cardiac output increase is often due to need for increased oxygen delivery.

E-9-1-1 94

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

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. Utilized Egger’s linear regression and Begg and Mazumdar’s rank correlation test to assess publication bias. 2.89, p = 0.01. 2020;4(5):537-541. Hamdon, M.

E-9-1-1 122

E-9-1-1 ALS ACS ICU 122

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. After reviewing the case, cardiology requested that the patient be admitted to observation for stress testing the next morning.

OR 52

OR ACS STEMI Coronary 52

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 105

Coronary E-9-1-1 STEMI ACS 105

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 96

Coronary CAD ACS OR 96

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

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 65

ACS Plasma OR ED 65

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-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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

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. He was diagnosed as NSTEMI.

ACS 83

ACS Coronary ALS CAD 83

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. 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. Potassium was normal.

STEMI 91

STEMI ACS OR ALS 91

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

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

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 ). But the patient has active chest pain.

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

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. No wall motion abnormality.

ACS 52

ACS STEMI OR 52

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

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. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated.

Coronary 130

Coronary ALS Firefighter ACS 130

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. Fortunately, that is exactly what happened.

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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). To start with there are apparently 5 types of cardiorenal syndrome. I’ll let that sink in. You all thought there was one didn’t you? They get sneaky with type 3 calling it renocardiac syndrome.

Critical Care 96

Critical Care ACS OR ALS 96

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 78

STEMI Paramedic Coronary EMS 78

EMS 12-Lead

APRIL 21, 2022

He reports to staff that for the past two months, approximately, he has experienced intermittent dyspnea on exertion when walking the dog, particularly when scaling an incline. He admits to a mostly sedentary lifestyle, however denies any smoking, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema. Here is the time-zero ECG (0939 hours).

Coronary 130

Coronary ALS OR ACS 130

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. 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. Abstract 556.

ACS 52

ACS Coronary ICU STEMI 52

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 106

ACS ED STEMI OR 106

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 120

STEMI Coronary ALS CAD 120

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 69

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

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

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

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. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. Abstract 556.

STEMI 86

STEMI Coronary ACS OR 86

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 103

Coronary ACS ED OR 103