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 98

ACS E-9-1-1 ALS OR 98

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

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 interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI").

STEMI 111

STEMI ACS ED 111

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present." 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 ). Repeat cTnI drawn at around 8 AM was 3.910 ng/mL.

E-9-1-1 131

E-9-1-1 OR Coronary ACS 131

Dr. Smith's ECG Blog

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. Below is the 15 lead ECG.

STEMI 98

STEMI ACS OR ALS 98

Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). She contacted her neighbor, a nurse, for help. Clin Cardiol [Internet].

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. I don't know if her pain was getting better or not.

Coronary 109

Coronary E-9-1-1 STEMI ACS 109

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. This patient presented to the ED “after a couple of days of chest discomfort”.

Coronary 119

Coronary ACS ED OR 119

EMDocs

SEPTEMBER 24, 2024

Key: Consider eclampsia in any pregnant and postpartum woman presenting to the ED, especially in patients with symptoms such as headache, confusion/altered mental status, vision changes, and hypertension. ED Evaluation: Assessment focuses on looking for complications and mimics. 2022 Aug;58:223-228. Wilkerson RG, Ogunbodede AC.

ED 105

ED OR ACS ALS 105

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Prior episodes had simply resolved after brief symptoms, but the current episode had lasted for 2 hours without improvement, so she presented to the ED. At triage she stated her pain is still persistent, but it is mildly improved compared to when she decided to come to the ED. No diaphoresis or vomiting. How to Check Your Findings.

ACS 117

ACS ED STEMI OR 117

EMDocs

OCTOBER 8, 2024

Episode 108: Unexplained Sinus Tachycardia Mental Model Background: When a patient in the ED has sinus tachycardia our job as emergency physicians is to identify and treat of the underlying pathology. Lactate Troponin Could this be ACS or myocarditis? In the ED, our job is to identify and treat underlying causes. Clin Cardiol.

E-9-1-1 105

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

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. In our opinion it should not be given in ACS unless you are committed to the cath lab. Published 2022 Feb 20. 2022.01.006 6.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL. 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 ). So they looked into the patient's chart.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Don't Forget the Bubbles

MAY 17, 2023

Arch Dis Child Fetal Neonatal Ed. 2023 Apr 20:fetalneonatal-2022-324835. Arch Dis Child Fetal Neonatal Ed. 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. Hegeman EM, et al.

ALS 72

ALS ACS Emergency Department EMS 72

EMDocs

OCTOBER 21, 2023

The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. Median time from ED arrival to diagnosis was 8 hours 24 min in one study, with only 19% being diagnosed within the 4.5-hour Updated 2022 Dec 22]. Updated 2022 Oct 15]. Post TW, ed. hour IV thrombolytic window.

EMS 98

EMS ALS OR ACS 98

ACEP Now

AUGUST 12, 2024

FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. 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. Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52

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

MARCH 20, 2023

Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. Since then, I started looking for OMI EKG findings and not just STEMI. Risk Factors: High Cholesterol.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

He reportedly told his family "I think I'm having a heart attack", then they immediately drove him to the ED, and he was able to ambulate into the triage area before he collapsed and became unresponsive. CPR was initiated immediately. It was reportedly a PEA arrest; there was no recorded V Fib and no defibrillation.

ACS 52

ACS CPR CAD Heart Attack 52

Don't Forget the Bubbles

JUNE 30, 2023

All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. The ODP is caught up leaving theatres and has not yet made it down to ED. Back in ED with Ranulf, and pack two has gone through. 2022 Dec;57(12):986-993. Trials 23, 384 (2022). The trauma call goes out.

E-9-1-1 139

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

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). The average time to control HR in the IV amiodarone was 1.7h, which is usually the average time for disposition from the ED. Paper: Mason JM, et al. Am J Emerg Med.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

ACEP Now

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC. 2023 Jul 17.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JANUARY 6, 2023

The patient vomited once and given the more intense pain decided to come to the ED. 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. No history of GIB, dysuria, or GU symptoms. mg/dL, K 3.5

ACS 52

ACS Coronary ICU STEMI 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

ACEP Now

OCTOBER 11, 2024

ED treatment should focus on airway, breathing, and circulation with consideration for cervical spine protection depending on the circumstances surrounding the event. References Webb AC, Wheeler A, Ricci A, et al. Johnson MB, Boriack ED, McConnell CM, et al. 4 Another study cited only 2.3 South Med J. 2021;114(5):266-270.

ALS 52

ALS Emergency Department Emergency Medical Services ED 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

About an hour later, he was then found on the floor in cardiac arrest in the ED. ST depression maximal in V1-V4, in the context of ACS symptoms and unexplained by QRS abnormality or tachydysrhythmia, should be considered posterior OMI until proven otherwise. His initial troponin T was 15 ng/L (only two hours since pain onset).

Coronary 52

Coronary Heart Attack ED CPR 52

Dr. Smith's ECG Blog

APRIL 17, 2023

One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. He had no symptoms of ACS. Full case details and outcomes are below. Case 1: Case 2: Case 1: What do you think? Physician: "No STEMI."

OR 52

OR STEMI ACS Emergency Department 52

ACEP Now

MAY 9, 2024

It has been well over a year since the controversial publication of the Agency for Healthcare Research and Quality (AHRQ) report on diagnostic errors in the emergency department (ED). percent of ED visits resulted in preventable death as result of diagnostic error. Available from: [link] Newman-Toker DE, Nassery N, Schaffer AC, et al.

Emergency Department 52

Emergency Department ICU ALS ACS 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

Dr. Smith's ECG Blog

JANUARY 17, 2023

A 60 year old with chest pain presented to the ED. 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!

ALS 52

ALS ACS OR ED 52

Dr. Smith's ECG Blog

FEBRUARY 18, 2022

It was shown to me with worry for ischemic ST elevation, which is certainly possible from severe CO toxicity, or concomitant ACS. Figure-1: Comparison of the initial ECG in the ED ( = ECG #1 ) with the follow-up ECG done the next day ( = ECG #2 ). Routine ECG recorded before hyperbaric therapy.Are they related?

ACS 52

ACS Plasma OR STEMI 52

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. I cannot be anything else.

STEMI 52

STEMI Coronary ED ACS 52

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 52

ACS EMS STEMI Coronary 52

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. That this might happen should not be surprising — since the patient's chest pain was already ongoing for 3 hours prior to arrival in the ED.

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Here is her ECG on arrival to the ED: What is your differential? Cardiothoracic and vascular surgery were consulted and the patient was taken to the OR within an hour and a half of her arrival to the ED. Her initial ED high sensitivity troponin was less than 6ng/L (below limit of detection), and none further were ordered.

Coronary 40

Coronary ACS EMS ED 40

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time." Precordial Swirl in ECG #1: As discussed in the October 15, 2022 post in Dr. Smith's ECG Blog — Drs. It does not radiate.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

MAY 10, 2023

CT Coronary angiogram is usually used to make ACS much less likely in the context of a patient who is ruled out for acute MI by troponins. Thus, Wellens' syndrome should be thought of as a transient OMI or transient STEMI. Transient STEMI is at high risk of re-occlusion.

Coronary 52

Coronary STEMI CAD OR 52