2022 and ACS - Paramedicine Now

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

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Review of the 2 ECGs in today's case is insightful ( Figure-1 ): The initial ECG shows sinus rhythm, LAHB and meets Peguero Criteria for LVH ( See My Comment in the August 15, 2022 post of Dr. Smith's ECG Blog for more on LVH criteria ). Nor was there a challenge to look for coronary spasm.

Coronary

Coronary ACS OR EMR

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

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

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

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

SGEM#367: GRACE2 – Low-Risk, Recurrent Abdominal Pain

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

Emergency Department ALS ACS Coronary

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

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

Episode 152 Hemochromatosis: Ironing out the details

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

ALS ACS

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

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

Elbow Dislocations

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

E-9-1-1 ACS OR Emergency Department

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

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

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

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

Case Report: The Not So Normal, Normal EKG

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

Emergency Department STEMI ACS ED

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

A 30-something with Chest pain and SOB

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

ACS ALS OR

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

"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

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

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

ACS CPR CAD Heart Attack

ToxCard: Organic Mercury Poisoning

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

ACS Plasma OR 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

Bubble Wrap PLUS – May 2023

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

ALS ACS Emergency Department EMS

Steroids in preschool wheeze

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

E-9-1-1 ALS ACS ED

A 40-something with 100 minutes of chest pain

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

ACS STEMI OR

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

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

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

Coronary 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

A woman in her 50s with acute chest pain

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

ACS Coronary ICU STEMI

emDOCs Podcast – Episode 107: Eclampsia

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

ED OR ACS 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

emDOCs Podcast: Episode 108 – Unexplained Sinus Tachycardia Mental Model

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

E-9-1-1 Emergency Department ED OR

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

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

Emergency Department E-9-1-1 Coronary STEMI

Amiodarone Versus Digoxin for Acute Rate Control of Atrial Fibrillation in the Emergency Department

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

Emergency Department ALS Critical Care ED

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

A 60 year old with chest pain

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

ALS ACS OR ED

Pediatric Submersion Injury Tips

ACEP Now

OCTOBER 11, 2024

References Webb AC, Wheeler A, Ricci A, et al. Buckets associated home drowning in Indian infants and toddlers: an analysis of 18 fatalities from 2016-2022. Making affordable, culturally appropriate, and accessible interventions available to this population is key. South Med J. 2021;114(5):266-270. 2022;17(11):e0276374.

ALS

ALS Emergency Department Emergency Medical Services ED

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

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Trending Sources

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

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

emDOCs Podcast – Episode 100: Acute Chest Syndrome Part 1

emDOCs Podcast – Episode 101: Acute Chest Syndrome Part 2

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

SGEM#367: GRACE2 – Low-Risk, Recurrent Abdominal Pain

Fingertip Sensor Measures Lithium Levels in Sweat

emDOCs Revamp – Acute Chest Syndrome

Episode 152 Hemochromatosis: Ironing out the details

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

Acute OMI or "Benign" Early Repolarization?

Elbow Dislocations

Occlusion myocardial infarction is a clinical diagnosis

75 year old dialysis patient with nausea, vomiting and lightheadedness

Choosing Wisely – Investigations for seizures that have returned to baseline

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

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

Case Report: The Not So Normal, Normal EKG

Case Report: a High-Voltage Victim

A 30-something with Chest pain and SOB

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

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

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

ToxCard: Organic Mercury Poisoning

Bubble Wrap PLUS – June 2023

Bubble Wrap PLUS – May 2023

Steroids in preschool wheeze

A 40-something with 100 minutes of chest pain

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

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Is OMI an ECG Diagnosis?

A woman in her 50s with acute chest pain

emDOCs Podcast – Episode 107: Eclampsia

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

emDOCs Podcast: Episode 108 – Unexplained Sinus Tachycardia Mental Model

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Amiodarone Versus Digoxin for Acute Rate Control of Atrial Fibrillation in the Emergency Department

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

A 60 year old with chest pain

Pediatric Submersion Injury Tips

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