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

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!" This is termed " pseudo-normalization."

OR 52

OR ACS STEMI Coronary 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

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

JUNE 27, 2024

Left lower lung field end demonstrates expiratory wheezing on auscultation. Other lung fields unremarkable. smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02 mg/kg, max 0.4 C or 100.4

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

REBEL EM

NOVEMBER 6, 2024

Elbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow ( Cohen 1998 ) Posterolateral is the most common type of dislocation (..)

E-9-1-1 59

E-9-1-1 ACS OR Emergency Department 59

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). Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). So I would be worried about inferior OMI. At midnight.

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

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. He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival. He awoke with naloxone. He denied any CP or SOB. It does not radiate.

Overdose 52

Overdose OR Coronary ACS 52

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. Each article will take a deeper dive into each recommendation’s supporting evidence and practical implications. The parents of 18-month-old Susie brought her to the Emergency Department after she had a seizure at home.

E-9-1-1 131

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

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

AUGUST 19, 2023

But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. 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. Potassium was normal.

STEMI 86

STEMI ACS OR ALS 86

Pediatric EM Morsels

AUGUST 18, 2023

Morley 2022) This myth is: BUSTED. When you read the Morsel on Perichonditis of the ear last week ( or perhaps the Plantar Puncture Morsel from many many many weeks ago ) you may have objected because of the mention that, when indicated, fluroquinolones are safe in children. Which is a risk of 1 event for 62.5

E-9-1-1 130

E-9-1-1 ACS OR ALS 130

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 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?

ACS 52

ACS Coronary STEMI ALS 52

EMDocs

OCTOBER 8, 2024

At this point there are two large questions. #1. Am I missing anything? #2. What is this patient’s disposition? Pathophysiology and Etiology: In adults, sinus tachycardia is a heart rate greater than 100 beats per minute (bpm) originating from the sinoatrial (SA) node. This cardiac output increase is often due to need for increased oxygen delivery.

E-9-1-1 95

E-9-1-1 Emergency Department ED ALS 95

EMDocs

SEPTEMBER 24, 2024

Episode 107: Eclampsia Definition: Severe hypertensive disease of pregnancy (HDP) with new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a patient who is pregnant or postpartum and there’s no other causative etiologies. This is not borne out in the literature. The incidence is 1.5

ED 82

ED OR ACS ALS 82

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. It is not yet available, but this is your way to get on the list. link] Case continued She arrived in the ED and here is the first ED ECG.

Coronary 101

Coronary E-9-1-1 STEMI ACS 101

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 82

ACS Coronary ALS CAD 82

Don't Forget the Bubbles

JULY 22, 2024

Since the PREVIEW trial, there have been more negative trials. One such trial was the WASP trial , which involved 477 children in New Zealand. This trial showed no difference in PRAM score or LOS in the prednisolone group compared to placebo. An IPD approach is a collaborative exercise including the authors of included studies and stakeholders.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

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.

ACS 66

ACS Plasma OR ED 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. Discussion The initial EKG performed demonstrated pseudonormalization of the T-wave in the presence of myocardial ischemia. J Am Coll Cardiol.

Emergency Department 52

Emergency Department STEMI ACS ED 52

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 117

STEMI Coronary ALS CAD 117

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. De Alwis AC, et al. We suggest this list can help you discover relevant or interesting articles for your local journal club or allow you to keep a finger on the pulse of paediatric research. Kuypers KLAM, et al. 2023 Apr 18.

ALS 72

ALS ACS Emergency Department EMS 72

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 98

Coronary ACS ED OR 98

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). Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

ACS 52

ACS CPR CAD Heart Attack 52

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. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. This month’s list features answers to intriguing questions such as: ‘ Do children with enuresis sleep differently ? Pediatr Nephrol.

ALS 119

ALS ACS ED OR 119

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

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. Do NOT give it unless you are committed to the cath lab!!

STEMI 81

STEMI Coronary ACS OR 81

ACEP Now

OCTOBER 11, 2024

One question that is commonly raised is whether these patients should be trauma activations. One study demonstrated that the minority of the cases reviewed required surgical intervention or had identifiable traumatic injuries, making standard involvement of the trauma team unnecessary. 4 Another study cited only 2.3

ALS 52

ALS Emergency Department Emergency Medical Services ED 52

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. No wall motion abnormality.

ACS 52

ACS STEMI OR 52

REBEL EM

FEBRUARY 2, 2023

Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). 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

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 What a farce.

STEMI 93

STEMI Coronary ACS OR 93

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. No history of GIB, dysuria, or GU symptoms.

ACS 52

ACS Coronary ICU STEMI 52

EMDocs

OCTOBER 21, 2023

More common in the setting of atherosclerotic lesions than emboli, which typically occur with sudden onset of symptoms. Symptoms may range from days to months prior to stroke onset. As many as two-thirds of patients with BAO experience prodromal symptoms, including TIAs, minor strokes, or other symptoms.

EMS 74

EMS ALS OR ACS 74

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. This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. V1 has 0.5 mm of elevation. Learning Points: 1.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 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. I immediately recognized this as pulse tapping artifact. Since lead I looks relatively normal , that means that the right arm and left arm electrodes must be OK. It is the left leg electrode that is abnormal. . =

ALS 52

ALS ACS OR ED 52

ACEP Now

FEBRUARY 11, 2024

Given the fact that he has not had these headaches before and has diffuse symptoms including weakness, lab work and head imaging are obtained. There were no acute findings on head CT. His lab values demonstrate no anemia, leukocytosis, or electrolyte abnormalities except for an elevated creatinine.

Overdose 52

Overdose ACS Plasma ALS 52