Dr. Smith's ECG Blog

MARCH 31, 2024

The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration. The pain was still active at the time of evaluation.

STEMI 111

STEMI ACS ED 111

Medgadget

AUGUST 29, 2022

” The researchers presented their technology at the 2022 fall meeting of the American Chemical Society (ACS). Via: ACS. . “We already interact with a lot of touch-based electronics, such as smart phones and keyboards, so this sensor could integrate seamlessly into daily life.”

ACS 115

ACS 115

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

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-9-1-1 131

E-9-1-1 OR Coronary ACS 131

Don't Forget the Bubbles

SEPTEMBER 13, 2023

An expert committee appraised the evidence behind recommendations to avoid imaging to inform the 2022 NICE guidance. Published 2022 Jan 13. doi:10.1177/0883073818786086 Young AC, Costanzi JB, Mohr PD, Forbes WS. Paediatr Child Health. 2021;26(1):50-57 NICE. NICE guideline NG217. Accessed online at [link] NICE. Front Pediatr.

E-9-1-1 131

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

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!!" See this case: A man his 50s with chest pain.

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

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 98

STEMI ACS OR ALS 98

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.

Coronary 109

Coronary E-9-1-1 STEMI ACS 109

Pediatric EM Morsels

AUGUST 18, 2023

Morley 2022) This myth is: BUSTED. References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. Symptoms resolved within 24 hours of withdrawal of the medication. This is the 8 th case report which has identified fluoroquinolone-associated peripheral neuropathy in a child. Nobody wants a pseudomonas superbug becoming prevalent!

E-9-1-1 130

E-9-1-1 ACS OR ALS 130

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. Published 2022 Feb 20.

ACS 83

ACS Coronary ALS CAD 83

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 119

Coronary ACS ED OR 119

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] Clin Cardiol 2022 4. 1] European guidelines add "regardless of biomarkers". But only 6.4% Int J Cardiol 2024 3. Lupu et al.

STEMI 121

STEMI Coronary ALS CAD 121

Dr. Smith's ECG Blog

MAY 31, 2023

And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! 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. They are simply Hyperacute T-waves with depressed ST takeoff.

STEMI 96

STEMI Coronary ACS OR 96

Dr. Smith's ECG Blog

JUNE 15, 2023

Thus, this does NOT meet STEMI criteria (though, as of 2022, it is a formal "STEMI equivalent", assuming everyone agrees that this is de Winter morphology, for which there is currently no objective definition). Also, if you use the LAD OMI formula : QT = 420, RAV4 = 5 mm, QRSV2 = 6 mm, STE60V3 = 2.5 mm, the value is 22.2 (LAD

STEMI 98

STEMI Coronary ACS OR 98

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Anything more on history?

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

OCTOBER 15, 2023

NOTE: For more on “My Take” regarding a historical perspective, including current clinical relevance of recognizing Wellens' Syndrome — See My Comment at the bottom of the page of the August 12, 2022 post. How to Check Your Findings. To Emphasize — I would not be at all sure from the subtle findings in ECG #1 that there was ongoing LAD OMI.

ACS 117

ACS ED STEMI OR 117

EMDocs

SEPTEMBER 24, 2024

2022 Aug;58:223-228. Wilkerson RG, Ogunbodede AC. High risk and low prevalence diseases: Eclampsia. Am J Emerg Med. Fishel Bartal M, Sibai BM. Eclampsia in the 21st century. American journal of obstetrics and gynecology. 2022;226(2S):S1237-S1253. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222.

ED 105

ED OR ACS ALS 105

Don't Forget the Bubbles

MAY 17, 2023

2023 Apr 20:fetalneonatal-2022-324835. 2023 Apr 4:archdischild-2022-325281. De Alwis AC, et al. Effect of initial and subsequent mask applications on breathing and heart rate in preterm infants at birth. Kuypers KLAM, et al. Arch Dis Child Fetal Neonatal Ed. Hegeman EM, et al. Pediatr Infect Dis J. 2023 Apr 18. Arch Dis Child.

ALS 72

ALS ACS Emergency Department EMS 72

Dr. Smith's ECG Blog

MARCH 4, 2023

MOREVER, the morphology of the TWI is just not right 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. Figure-2: ECG findings associated of acute PE ( reproduced from My Comment in the March 28, 2022 post ).

ACS 52

ACS ALS OR 52

This Podcast Will Kill You

SEPTEMBER 24, 2024

ACS omega , 7 (24), pp.20441-20456. Algeo, Thomas J., and Jun Shen. “Theory and classification of mass extinction causation.” ” National Science Review 11.1 2024): nwad237. Olynyk, J.K. and Ramm, G.A., Hemochromatosis. New England Journal of Medicine , 387 (23), pp.2159-2170. Barton, James C. 2013): 403-412. . Girelli, D.,

ALS 52

ALS ACS 52

EMDocs

OCTOBER 21, 2023

The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. Updated 2022 Dec 22]. Updated 2022 Oct 15]. doi:10.1136/neurintsurg-2022-018715 Jorgensen H, Nakayama H, Raaschou H, Larsen K, Hubbe P, Olsen T. NIHSS does have limitations when applied to posterior circulation (PC) strokes.

EMS 97

EMS ALS OR ACS 97

EMDocs

OCTOBER 8, 2024

Lactate Troponin Could this be ACS or myocarditis? Treasure Island (FL): StatPearls Publishing; April 30, 2022. 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? Sinus Tachycardia.

E-9-1-1 105

E-9-1-1 Emergency Department ED ALS 105

Dr. Smith's ECG Blog

OCTOBER 10, 2022

If this is ACS with Aslanger's pattern , the ST depression vector of subendocardial ischemia (due to simultaneous 3 vessel or left main ACS) is directed toward lead II (inferior and lateral). Also, ACS does not cause hypoxemia out of proportion to hemodynamic compromise, as PE can.

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

MARCH 20, 2023

Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. Learning Points: To take optimal care of ACS patients, the initial providers who see the patient (hopefully assisted by AI soon) must be able to recognize subtle OMI findings.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

The patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. At that point, cardiology elected to treat for ACS. NOTE: For review of 20 cases of "Swirl" vs Swirl "Look-Alikes" — Check out the October 15, 2022 post in Dr. Smith's ECG Blog.

OR 66

OR Coronary ACS EMS 66

ACEP Now

AUGUST 12, 2024

Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. 2022 Nov, 80 (20) 1925–1960. 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking. J Am Coll Cardiol.

Emergency Department 52

Emergency Department STEMI ACS ED 52

ACEP Now

MARCH 14, 2024

Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

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 ). The emergency physician was skeptical and believed the ECG to be a mimic, a false positive. So they looked into the patient's chart.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 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

JANUARY 6, 2023

Clin Cardiol 2022; [link] Labs included: hsTnI 156 ng/L, Hb 12 g/dL, WBC 12x10^9/L, Cr. 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. Lupu L, et al. mg/dL, K 3.5

ACS 52

ACS Coronary ICU STEMI 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. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Don't Forget the Bubbles

JUNE 30, 2023

2022 Dec;57(12):986-993. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trials 23, 384 (2022). J Pediatr Surg. Trauma Surg Acute Care Open.

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

REBEL EM

FEBRUARY 2, 2023

Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). 2022 Sep 7. However, digoxin is known for its rate-control properties and its direct vagal effect on the atrioventricular node. Paper: Mason JM, et al. Amiodarone versus digoxin for acute rate control of atrial fibrillation in the emergency department. Am J Emerg Med.

Emergency Department 52

Emergency Department ALS Critical Care ED 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

APRIL 17, 2023

He had no symptoms of ACS. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." A troponin this high in a patient with no known chronic troponin elevation, and active acute ACS symptoms, has a very high likelihood of type 1 ACS regardless of the ECG.

OR 52

OR STEMI ACS Emergency Department 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. Comment by K EN G RAUER, MD ( 12/12 /2022 ): = I will summarize in 4 words the important message conveyed by Dr. Meyers in today's post = "Be Aware of Pseudo-Normalization!"

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JANUARY 17, 2023

In the December 5, 2022 post of Dr. Smith's ECG Blog — We show 4 additional cases of this pulse-tap artifact. Finally, as I discuss in My Comment in the August 26, 2022 post ( which applies the electrophysiologic principles of Rowlands & Moore: J. This is no longer the case! Why are the smallest artifactual deflections GREEN ?

ALS 52

ALS ACS OR ED 52