2022 and ACS - Paramedicine Now

Clinical Conundrum: Should a Troponin Routinely be Ordered in Patients with SVT?

REBEL EM

SEPTEMBER 21, 2023

What Your Gut Says: The patient has a tachydysrhythmia which may be the presentation of acute coronary syndrome (ACS) even though the patient has no ischemic symptoms. Up to 80% of patients will have at least one troponin sent ( Gabrielli 2022 ). SVT is not a presenting dysrhythmia consistent w/ ACS. Cardiol Rev.

Coronary

Coronary ACS ED OR

emDOCs Podcast – Episode 100: Acute Chest Syndrome Part 1

EMDocs

MAY 15, 2024

Other causes of sickling: acidosis, dehydration, inflammation, infection, fever, and blood stasis Sickling leads to vascular occlusion, end-organ ischemia, and decreased RBC lifespan, which, in turn, leads to pain crisis, acute anemia, sequestration, infection, and acute chest syndrome (ACS.) Each episode of ACS has a 9% mortality rate.

E-9-1-1

E-9-1-1 ACS ALS OR

emDOCs Podcast – Episode 101: Acute Chest Syndrome Part 2

EMDocs

MAY 28, 2024

Sickling leads to vascular occlusion, end-organ ischemia, and decreased RBC lifespan, which, in turn, leads to pain crisis, acute anemia, sequestration, infection, and acute chest syndrome (ACS). ACS is lung injury due to vaso-occlusion in the pulmonary vasculature; many with ACS will have a concomitant vaso-occlusive pain crisis.

ACS

ACS E-9-1-1 ALS OR

SGEM#370: Listen to your Heart (Score)…MACE Incidence in Non-Low Risk Patients with known Coronary Artery Disease

The Skeptics' Guide to EM

JULY 2, 2022

Date: June 30th, 2022 Reference: McGinnis et al. AEM June 2022. Date: June 30th, 2022 Reference: McGinnis et al. AEM June 2022. If we thought about ACS, we brought them in. AEM June 2022. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter?

Coronary

Coronary Heart Attack ACS CAD

What happened after the Cath lab was activated for a chest pain patient with this ECG?

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

STEMI ACS ED

emDOCs Revamp – Acute Chest Syndrome

EMDocs

JUNE 27, 2024

2022 Jul 5;328(1):57-68. 2022 Aug;58:235244. Epub 2022 Jun 11. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. 2022 Aug;58:235-244. Epub 2022 Jun 11. 2022 Aug 29;13:796837. 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

E-9-1-1 ICU ACS EMS

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

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

Coronary CAD ACS ALS

Occlusion myocardial infarction is a clinical diagnosis

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

E-9-1-1 ACS Coronary STEMI

75 year old dialysis patient with nausea, vomiting and lightheadedness

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

STEMI ACS OR ALS

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

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

ACS Coronary ALS CAD

High sensitivity cardiac troponins for ED chest pain evaluation (2022 ACC pathway)

ALiEM

FEBRUARY 9, 2024

The 2022 American College of Cardiology (ACC) pathway provides timely guidance [1]. Applying the 2022 ACC guideline Before delving into the specifics of the hs-cTn pathways, start with the ECG. The ACC 2022 pathway has a section dedicated to ECGs in ischemia [1], and FOAMcast has a great visual summary.

E-9-1-1

E-9-1-1 ED Coronary ALS

"The dye don't lie".except when it does. Angiogram Negative, or is it?

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

OR Coronary ACS EMS

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

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

Coronary ACS STEMI ALS

Case Report: a High-Voltage Victim

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

Operating Room ACS Critical Care Coronary

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. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1.

Coronary

Coronary E-9-1-1 STEMI ACS

Fluoroquinolone Use In Children

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

E-9-1-1 OR ACS ALS

Watch what happens when you teach others how to find OMI

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

STEMI ACS CAD ED

Bubble Wrap PLUS – June 2023

Don't Forget the Bubbles

JUNE 14, 2023

2023 May 12:fetalneonatal-2022-324935. 2022 Dec 26;28(2):91-96. De Alwis AC, et al. Pediatr Nephrol. 2023 May 13. Haemodynamic assessment and management of hypotension in the preterm. Mullaly R, et al. Arch Dis Child Fetal Neonatal Ed. Drugs in focus: Domperidone. Puoti MG, et al. J Pediatr Gastroenterol Nutr. 2023 May 10.

ALS

ALS ACS ED OR

Is OMI an ECG Diagnosis?

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

STEMI Coronary ALS CAD

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

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

STEMI Coronary ACS OR

75 year old with 24 hours of chest pain, STEMI negative

Dr. Smith's ECG Blog

JUNE 8, 2023

As recurrent ischaemia is the principle event reduced by early intervention in NSTE-ACS, these are important endpoint events occurring with delayed angiography and there is a consistent signal for harm now from two data sources.”[5] J Am Coll Cardiol 2022 Nov 15;80(20):1925-1960 2. Kontos et al. Welsh et al.

STEMI

STEMI Coronary Paramedic ALS

Two ECGs texted to me in the same hour. What would you recommend?

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

STEMI Coronary ACS OR

Compare these two ECGs. Do either, neither, or both show anything important?

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

OR STEMI ACS Emergency Department

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

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

OR ACS STEMI Coronary

This ECG was handed over at triage. See how the Queen of Hearts AI does with these explainability images.

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

ACS ED STEMI OR

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

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

STEMI Coronary ACS ED

Popular Antiobesity Medications Bring New Challenges to Emergency Physicians

ACEP Now

FEBRUARY 11, 2024

ACS chemical neuroscience molecule spotlight on Contrave. ACS Chem Neurosci. Updated December 11, 2022. Accessed January 11, 2024. Contrave (naltrexone HCl/bupropion HCl) prescribing information. Deerfield, Illinois: Takeda Pharmaceuticals America Inc; 2014. 2011;2(9):484-486. Azer SA, Sankararaman S. Steatorrhea.

Overdose

Overdose ACS Plasma ALS

A man in his 60s with acute chest pain

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Corroborating this is the subtle ST depression in V2-V3 which is inappropriate for the normal QRS complex, and in the context of ACS, we have shown this is quite specific for posterior OMI. In the context of ACS, ST depression maximal in V1-V4 (rather than V5-V6) not due to a QRS abnormality is specific for posterior OMI.

ACS

ACS EMS STEMI Coronary

EM@3AM: Basilar Artery Occlusion

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

EMS ALS OR ACS

Does this ST Depression Maximal in V3 Represent Posterior OMI?

Dr. Smith's ECG Blog

AUGUST 17, 2022

V5, 6) is 97% specific for OMI in a patient population at high risk of ACS. This is in contrast to sinus rhythm with a heart rate below 100. == MY Comment, by K EN G RAUER, MD ( 8/17 /2022 ): == I was shown today's ECG without the benefit of any history. The April 17, 2022 post ( Leads V1,V2 misplacement ).

Coronary

Coronary ACS OR

Diagnostic Errors, Revisited: Where Do We Go Wrong, and How Can We Change?

ACEP Now

MAY 9, 2024

Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Dec. Available from: [link] Newman-Toker DE, Nassery N, Schaffer AC, et al. Diagnostic errors in the emergency department: a systematic review [internet]. Comparative Effectiveness Review, No. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf.

Emergency Department

Emergency Department ICU ALS ACS

Episode 79 – Kurious Keto

The Curious Clinicians

OCTOBER 19, 2023

Cooper, MD (@AvrahamCooperMD) August 14, 2022 CME/MOC Click here to obtain AMA PRA Category 1 Credits (0.5 Listen to the episode [link] Credits & Citatio n Episode written by Avi Cooper Show notes written by Tony Breu, Giancarlo Buonomo, and Avi Cooper Audio edited by Clair Morgan of nodderly.com Cooper AZ, Abrams HR, Breu AC.

ACS

ACS OR

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

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

E-9-1-1 Coronary EMS ED

A woman in her 70s with chest pain

Dr. Smith's ECG Blog

DECEMBER 18, 2022

In the context of ACS, ST depression maximal in V1-4 has been shown to be fairly specific for posterior OMI. STD maximal in V5-6 and lead II, with reciprocal STE in aVR, typically indicates global supply/demand mismatch subendocardial ischemia, which can be due to a huge variety of clinical causes, including life-threatening ACS.

Coronary

Coronary ACS OR EMS

Chest pain, and Cardiology didn't take the hint from the ICD

Dr. Smith's ECG Blog

JANUARY 23, 2023

Recall that, in the setting of ACS symptoms, ST depression that are maximal in leads V1-V4 (as opposed to V5 and V6) not attributable to an abnormal QRS complex is specific for OMI. Close up of V3 with baseline in red Close up of V4 with baseline in red This ECG alone is highly suspicious for posterior OMI!

ACS

ACS Coronary Defibrillator STEMI

Antibiotics in the paediatric emergency department

Don't Forget the Bubbles

SEPTEMBER 18, 2023

2022 Dec;41(12):947–52. Davidson L, Foley DA, Clifford P, Blyth CC, Bowen AC, Hazelton B, et al. 2022 Jun;58(6):1007–12. 2022 Dec;251:98-104.e5. NICE; [cited 2022 Dec 28]. 2017 Sep 7 [cited 2022 Dec 28];2022(8). 2020 Jun 4 [cited 2022 Dec 28];2020(6). Pediatr Infect Dis J. 2020 Nov 18;m4238.

Emergency Department

Emergency Department E-9-1-1 ALS OR

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

It is relieved with rest." == MY Comment, by K EN G RAUER, MD ( 11/1 /2022 ): == Like Dr. Smith — I interpreted the initial ECG in today’s case without the benefit of any history. Precordial Swirl in ECG #1: As discussed in the October 15, 2022 post in Dr. Smith's ECG Blog — Drs. Chest pain is squeezing or tight in nature.

Overdose

Overdose OR Coronary ACS

ABG Versus VBG in the Emergency Department

EMDocs

FEBRUARY 12, 2024

11) Webb RK, Ralston AC, Runciman WB. 2022 Nov;10(11):1086-1098. Epub 2022 Aug 29. Updated 2022 Sep 12]. PMID: 11685301. (10) 10) Jubran A. Pulse oximetry. Intensive Care Med. 2004 Nov;30(11):2017-20. doi: 10.1007/s00134-004-2399-x. Epub 2004 Jul 24. PMID: 15278272. (11) Potential errors in pulse oximetry. Anaesthesia.

Emergency Department

Emergency Department E-9-1-1 ED ICU

65 year old with syncope and a 'normal' ECG: discharge home?

Dr. Smith's ECG Blog

DECEMBER 6, 2022

S yncope is an uncommon presentation of ACS, but anginal equivalents are more likely in older patients with diabetes 2. On discharge the inferior deWinter waves resolved and the lateral T waves deflated and inverted. Take home 1. C ircumflex occlusions can have subtle to no ECG changes 3. Y ou can’t trust ECG's labeled "normal" 4.

STEMI

STEMI ACS Coronary OR

On the Scene: Prehospital Care for Electrical Burns for EMTs

EMT Training Station

FEBRUARY 11, 2024

Assessing the Severity The severity of an electrical burn depends on several factors: the type of current (AC or DC), voltage, the pathway of the current through the body, the duration of contact, and the victim’s overall health. As EMTs, we’re always prepared to address these life-threatening complications alongside the burns.

EMT

EMT EMT Emergency Medical Technician First Aid

A man in his 70s with acute chest pain and paced rhythm.

Dr. Smith's ECG Blog

MAY 8, 2023

This was several months after the 2022 ACC Guidelines adding modified Sgarbossa criteria as a STEMI equivalent in ventricular paced rhythm). Queen of Hearts interpretation: The cardiologist initially was not convinced, stating the ECG was not diagnostic or could not be diagnostic because it was paced. Modified Sgarbossa Criteria Refresher!

STEMI

STEMI Coronary ED ACS

Acute OMI or "Benign" Early Repolarization?

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

E-9-1-1 OR Coronary ACS

Choosing Wisely – Investigations for seizures that have returned to baseline

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

E-9-1-1 Emergency Department ALS OR

Fingertip Sensor Measures Lithium Levels in Sweat

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

Clinical Conundrum: Should a Troponin Routinely be Ordered in Patients with SVT?

emDOCs Podcast – Episode 100: Acute Chest Syndrome Part 1

Trending Sources

emDOCs Podcast – Episode 101: Acute Chest Syndrome Part 2

SGEM#370: Listen to your Heart (Score)…MACE Incidence in Non-Low Risk Patients with known Coronary Artery Disease

What happened after the Cath lab was activated for a chest pain patient with this ECG?

emDOCs Revamp – Acute Chest Syndrome

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Occlusion myocardial infarction is a clinical diagnosis

75 year old dialysis patient with nausea, vomiting and lightheadedness

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

High sensitivity cardiac troponins for ED chest pain evaluation (2022 ACC pathway)

"The dye don't lie".except when it does. Angiogram Negative, or is it?

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Case Report: a High-Voltage Victim

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

Fluoroquinolone Use In Children

Watch what happens when you teach others how to find OMI

Bubble Wrap PLUS – June 2023

Is OMI an ECG Diagnosis?

Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).

75 year old with 24 hours of chest pain, STEMI negative

Two ECGs texted to me in the same hour. What would you recommend?

Compare these two ECGs. Do either, neither, or both show anything important?

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

This ECG was handed over at triage. See how the Queen of Hearts AI does with these explainability images.

A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?

Popular Antiobesity Medications Bring New Challenges to Emergency Physicians

A man in his 60s with acute chest pain

EM@3AM: Basilar Artery Occlusion

Does this ST Depression Maximal in V3 Represent Posterior OMI?

Diagnostic Errors, Revisited: Where Do We Go Wrong, and How Can We Change?

Episode 79 – Kurious Keto

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

A woman in her 70s with chest pain

Chest pain, and Cardiology didn't take the hint from the ICD

Antibiotics in the paediatric emergency department

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

ABG Versus VBG in the Emergency Department

65 year old with syncope and a 'normal' ECG: discharge home?

On the Scene: Prehospital Care for Electrical Burns for EMTs

A man in his 70s with acute chest pain and paced rhythm.

Acute OMI or "Benign" Early Repolarization?

Choosing Wisely – Investigations for seizures that have returned to baseline

Fingertip Sensor Measures Lithium Levels in Sweat

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