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

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 76

ACS E-9-1-1 ALS OR 76

REBEL EM

NOVEMBER 6, 2024

2022 Aug 2. PMID: 32644703 Robinson PM, Griffiths E, Watts AC. PMID: 27227986 Glover NM, Black AC, Murphy PB. J Am Acad Orthop Surg. 1998 Jan-Feb;6(1):15-23. doi: 10.5435/00124635-199801000-00002. PMID: 9692937 Decker N, Norse A. Anterior Elbow Dislocation. In: StatPearls [Internet]. Simple elbow dislocation. Shoulder Elbow.

E-9-1-1 118

E-9-1-1 ACS OR Emergency Department 118

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 92

STEMI ACS ED 92

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 Coronary ACS STEMI 123

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

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-9-1-1 117

E-9-1-1 OR Coronary ACS 117

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 87

ACS Coronary ALS CAD 87

REBEL EM

DECEMBER 23, 2024

Paper: Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. Target trial emulation is a methodologic framework to improve observational studies that begins by creating a hypothetical protocol for the ideal RCT, and then designing your observational protocol to emulate it as closely as possible ( Hernn 2022 ). JAMA Intern Med.

ALS 82

ALS ED ACS EMR 82

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 76

E-9-1-1 ICU ACS EMS 76

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 82

STEMI ACS OR ALS 82

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 119

ALS ACS ED OR 119

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 100

Coronary E-9-1-1 STEMI ACS 100

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 119

STEMI Coronary ALS CAD 119

Dr. Smith's ECG Blog

DECEMBER 3, 2024

This dynamic change is diagnostic of ACS. Cardiology was consulted and agreed that his history was high risk for ACS and a next-day angiogram was merited. This was also non-diagnostic for OMI, although the dynamic changes are diagnostic of ACS. ECG at time 82 minutes: What do you think?

ED 96

ED Coronary ACS STEMI 96

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 99

Coronary ACS ED OR 99

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. 2022 Sep 4 [cited 2024 Jan 30];60(suppl 66). Yao TC, Wang JY, Chang SM, Chang YC, Tsai YF, Wu AC, et al. Annals of Emergency Medicine. 2016 May;67(5):593-601.e3.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

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

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 90

STEMI Coronary ACS OR 90

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

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. 2022, February 25). Resources: S.

ACS 67

ACS Plasma OR ED 67

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 77

STEMI Coronary ACS OR 77

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

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

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

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 101

ACS ED STEMI OR 101

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 70

OR Coronary ACS EMS 70

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

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

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 96

E-9-1-1 Emergency Department ED ALS 96

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 83

ED OR ACS ALS 83

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 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-9-1-1 107

E-9-1-1 Coronary EMS ED 107