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

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-9-1-1 125

E-9-1-1 ACS Coronary STEMI 125

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

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 116

Coronary CAD ACS ALS 116

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

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 ). Thus, the lumen observed may actually still be the same size as the original, normal lumen.

Coronary 80

Coronary ACS OR EMR 80

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 OR ACS 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?

Coronary 52

Coronary ACS STEMI ALS 52

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-9-1-1 276

E-9-1-1 ED Coronary ALS 276

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 104

Coronary E-9-1-1 STEMI ACS 104

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

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". V2 has some changes, but at least to me it is not as clear what to make of them. Shmueli, H.,

E-9-1-1 120

E-9-1-1 OR Coronary ACS 120

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 121

STEMI Coronary ALS CAD 121

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 118

ALS ACS ED OR 118

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 80

STEMI Coronary ACS OR 80

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

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

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 63

STEMI Coronary Paramedic ALS 63

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

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. Learning Point: 1. It is already approved in Europe.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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

EMDocs

FEBRUARY 12, 2024

How would an ABG even change the initial stabilization of any of these patients? What alternative testing can be done in these circumstances? Recent studies suggest that clinicians can obtain similarly actionable results from VBGs as ABGs and using the “gold standard” ABG might not be as clinically relevant as it once was.

Emergency Department 94

Emergency Department E-9-1-1 ED ICU 94

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. 3 In their study, patients were identified retrospectively as having suffered deterioration following admission resulting in transfer to the intensive care unit, death, or both. BMJ Qual Saf.

Emergency Department 52

Emergency Department ICU ALS ACS 52

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 QRS complex in lead I looks "funny".

Coronary 52

Coronary ACS OR 52

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. The entry and exit wounds are key indicators, but they can be small or hidden under clothing.

EMT 98

EMT EMT Emergency Medical Technician First Aid 98

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

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 52

ACS OR 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. Her symptoms were described as "pressure" with left arm radiation. No diaphoresis or vomiting. How to Check Your Findings.

ACS 105

ACS ED STEMI OR 105

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, Smith A woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. She felt nauseous and lightheaded with no neurologic deficits. The probe was then moved to the aorta.

Coronary 52

Coronary ACS OR EMS 52

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. A 65 year old with diabetes presented with a syncopal episode while sitting, associated with weakness but no chest pain or shortness of breath. What do you think? Take home 1. Y ou can’t trust ECG's labeled "normal" 4.

STEMI 52

STEMI ACS Coronary OR 52

Don't Forget the Bubbles

SEPTEMBER 18, 2023

However, symptoms may also be non-specific, including irritability, headache, poor feeding, vomiting, or diarrhoea. The diagnosis is clinical and can be made by directly visualising erythema or bulging of the tympanic membrane. Treatment is mainly symptomatic with analgesia. A throat culture is the gold standard for confirming a bacterial infection.

Emergency Department 142

Emergency Department E-9-1-1 ALS OR 142

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 52

STEMI Coronary ED ACS 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. 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 52

ACS Coronary Defibrillator STEMI 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

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

Dr. Smith's ECG Blog

JANUARY 3, 2022

It encompasses the complete range of ACS, including OMI, NOMI, and coronary thromboses that have the potential to rapidly propagate and become OMI and therefore has no specificity. CJEM 2021 == MY Comment, by K EN G RAUER, MD ( 1/3/2022 ): == Excellent case presentation by Dr. Jesse McLaren!

STEMI 52

STEMI Coronary ALS ACS 52