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 107

Coronary CAD ACS ALS 107

ACEP Now

OCTOBER 11, 2024

References Webb AC, Wheeler A, Ricci A, et al. Pellegrino F, Raffaldi I, Rossi R, et al. 2023 Jun 14;49(1):74. Chotai PN, Manning L, Eithun B, et al. Kriz D, Piantino J, Fields D, et al. Bauman BD, Louiselle A, Nygaard RM, et al. Causey AL, Tilelli JA, Swanson ME. South Med J. Ital J Pediatr.

ALS 52

ALS Emergency Department Emergency Medical Services ED 52

ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. 2 Proposed hypothesis as described by Hsu et al., Accessed November 29, 2023.

STEMI 52

STEMI Coronary ACS Critical Care 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

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. Am J Emerg Med.

ACS 85

ACS Coronary ALS CAD 85

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. Lindahl et al. From Gue at al. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data.

Coronary 95

Coronary E-9-1-1 STEMI ACS 95

EMDocs

OCTOBER 21, 2023

The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. References: Gaillard F, Glick Y, Tatco V, et al. Reference article,   Radiopaedia.org (Accessed on 15 Apr 2023) [link] Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G: Basilar artery occlusion. Accessed April 13, 2023.

EMS 74

EMS ALS OR ACS 74

EMDocs

JUNE 27, 2024

Alkindi S, Al-Busaidi I, Al-Salami B, Raniga S, Pathare A, Ballas SK. Alghamdi FA, Al-Kasim F, Alshhada F, Ghareeb E, Azmet FR, Almudaibigh A, Baitalmal L, Alnawfal B, Alluqmani R. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. Epub 2023 Nov 27. 2023 Apr;98(4):620-627. Epub 2023 Feb 6.

E-9-1-1 76

E-9-1-1 ICU ACS EMS 76

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] Amsterdam et al. Alencar et al. Lupu et al. Herman, Meyers, Smith et al. But only 6.4% link] References 1.

STEMI 114

STEMI Coronary ALS CAD 114

ACEP Now

FEBRUARY 11, 2024

Sodhi M, Rezaeianzadeh R, Kezouh A, et al. Ahmann AJ, Capehorn M, Charpentier G, et al. Published December 18, 2023. ACS chemical neuroscience molecule spotlight on Contrave. ACS Chem Neurosci. Published January 2023.Updated Updated May 16, 2023. Bansal AB, Al Khalili Y. Published January 2023.

Overdose 52

Overdose ACS Plasma ALS 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation.

E-9-1-1 113

E-9-1-1 Coronary ACS BLS 113

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. Heitner et al. For this test it is VERY low (very good) at 4% at the 99th percentile -- 26 ng/L, but it will not be so good at a level of 9 ng/L. The troponin is trapped in the myocardium that is not being perfused.

ACS 101

ACS ALS OR STEMI 101

ACEP Now

MAY 9, 2024

Taking a different approach than the authors of the AHRQ report, Auerbach et al used a “look back” approach to perform both qualitative and quantitative evaluations of the types and frequencies of errors occurring in hospital settings. References Newman-Toker DE, Peterson SM, Badihian S, et al. Auerbach AD, Lee TM, Hubbard CC, et al.

Emergency Department 52

Emergency Department ICU ALS ACS 52

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 78

STEMI ACS OR ALS 78

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

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Studies such as those by Moise et al 14 and Ellis et al 39 have shown that the relative risk of developing an acute myocardial infarction in the territory supplied by an artery with a 70%. For more on MINOCA — See My Comment in the November 16, 2023 post in Dr. Smith's ECG Blog ).

Coronary 110

Coronary ACS OR EMR 110

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! There is profound "inferior" ST Depression.

Coronary 52

Coronary ACS Naloxone Plasma 52

The Curious Clinicians

OCTOBER 4, 2023

The idea that valves may be a site of immune privilege was first offered by Mohri et al who wrote in 1967 “the reason for the delayed or absent rejection of the homologous aortic valve, especially the fresh viable valve, remains obscure. Mitchell et al examined homograft hearts after death or retransplantation. October 4, 2023.

ALS 52

ALS OR ACS 52

Dr. Smith's ECG Blog

JANUARY 27, 2024

There were zero patients in this study with a "normal" ECG who had any kind of ACS! Deutch et al. This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value. So this study is actually worthless. West J Emerg Med 2024).

STEMI 96

STEMI Coronary ACS ED 96

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

link] Shvilkin et al. Thus, the very well informed physician could differentiate these ECGs from those of an LBBB patient with MI: 1) no concordance 2) no excessive discordance 3) LBBB with tachycardia, probably rate related 4) subsequent T wave inversion that, according to Shvilkin et al., is diagnostic of cardiac memory.

E-9-1-1 80

E-9-1-1 ACS ALS OR 80

Pediatric EM Morsels

AUGUST 18, 2023

References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. PMID: 27940800 Hersch AL, Gerber JS, Hicks LA, Pavia AT. However, Fluroquinolone resistance is increasing, so they should only be used if absolutely necessary! Nobody wants a pseudomonas superbug becoming prevalent! Pediatrics. 147(6):e202003316. Pediatr Infect Dis J.

E-9-1-1 130

E-9-1-1 ACS OR ALS 130

Dr. Smith's ECG Blog

MAY 31, 2023

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. de Winter et al in N Engl J Med 359:2071-2073, 2008. See this case: A man his 50s with chest pain.

STEMI 73

STEMI Coronary ACS OR 73

Don't Forget the Bubbles

JULY 22, 2024

Compare this with the Panickar et al. Fortunately, Lee et al. Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, et al. Future of Pre-School Wheeze Whilst Lee et al. Cronin JJ, McCoy S, Kennedy U, An Fhailí SN, Wakai A, Hayden J, et al. study from 200 9. The Lancet Respiratory Medicine [Internet].

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. Smith's book : Learning points: 1) OMI can be very subtle and RV infarction may manifest poorly on the standard ECG. 21, 2017 ).

STEMI 92

STEMI OR ACS ALS 92

Dr. Smith's ECG Blog

MAY 8, 2023

The ACC likely made this new recommendation for the MSC in ventricular paced rhythm in large part due to the "PERFECT" Study (Meyers is an author, and Smith was the senior author): Dodd et al. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STEMI 52

STEMI Coronary ED ACS 52

Don't Forget the Bubbles

SEPTEMBER 18, 2023

Antibiotics 2023, 12, 1092. Davidson L, Foley DA, Clifford P, Blyth CC, Bowen AC, Hazelton B, et al. Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. Tonsillitis Baker MG, Gurney J, Oliver J, Moreland NJ, Williamson DA, Pierse N, et al. cited 2023 Jan 3]. cited 2023 Jan 3].

Emergency Department 143

Emergency Department E-9-1-1 ALS OR 143

EMDocs

JANUARY 11, 2024

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association (AHA) and Neurocritical Care Society (NCS) released their 2023 Scientific Statement on the critical care management of post ROSC patients. 2023 Dec 1. Administer VTE prophylaxis in the first 48 hours, preferably LMWH.

Critical Care 75

Critical Care E-9-1-1 OR ICU 75

EMDocs

FEBRUARY 12, 2024

It has been found that using pulse oximetry to obtain the SpO 2 /FiO 2 ratio could help facilitate earlier ARDS recognition as pulse oximetry is more readily available and less time consuming to obtain compared with ABG, and this has been incorporated into the new proposed 2023 definition of ARDS (12). 2023 Mar 10;16(1):18.

Emergency Department 94

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

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Guideline-based and restricted fluid resuscitation strategy in sepsis patients with heart failure: A systematic review and meta-analysis [published online ahead of print, 2023 Aug 9]. References: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM.

E-9-1-1 119

E-9-1-1 ALS ACS ICU 119

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. Clin Exp Emerg Med 2023. References: Jaff MR et al. PMID: 21422387 Wan S et al. PMID: 15262836 Sharifi M et al. PMID: 27422214 Wang C et al. PMID: 19741062 Kucher N et al. PMID: 24226805 Piazza G et al. CHEST 2010.

ALS 136

ALS ACS OR CPR 136

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al. link] == MY Comment , by K EN G RAUER, MD ( 12/26/ 2023 ): == Interesting case by Dr. Frick — with superb illustration by him of cardiac cath findings! The link is quite modest, increasing the chance of VF from 3.4

E-9-1-1 111

E-9-1-1 OR Coronary ACS 111

Dr. Smith's ECG Blog

MARCH 4, 2023

MOREVER, the morphology of the TWI is just not right for ACS. S1Q3T3 This is a paper worth reading : Marchik et al. Kosuge et al. 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. inverted T-waves in V1 and V2, 1.8;

ACS 52

ACS ALS OR 52

ACEP Now

NOVEMBER 14, 2023

References Deshwal H, Sinha A, Mehta AC. Atchinson PRA, Hatton CJ, Roginski MA, et al. Ittrich H, Bockhorn M, Klose H, et al. Li H, Ding X, Zhai S, et al. Kathuria H, Hollingsworth HM, Vilvendhan R, et al. Accessed October 11, 2023. Fekri MS, Hashemi-Bajgani SM, Shafahi A, et al. 2021;42(1):145-159.

E-9-1-1 52

E-9-1-1 ALS Emergency Department OR 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. 2023 May 2;15(5):e38428. 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2023

I assumed it was from a patient with symptoms compatible with ACS/OMI. If you are convinced by all the data, including the troponin, that the patient's pain is due to ACS, and he has persistent pain, then he should go to the cath lab. Wereski R, Chapman AR, Lee KK, Smith SW, Lowe DJ, Gray A, et al. What do you think?

ACS 114

ACS ALS OR STEMI 114

Dr. Smith's ECG Blog

JANUARY 6, 2023

Lupu L, et al. 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. Unfortunately, they follow their own guidelines only 6% of the time!! mg/dL, K 3.5 OMI is not just an ECG diagnosis.

ACS 52

ACS Coronary ICU STEMI 52

EMDocs

SEPTEMBER 25, 2023

References: Heffner AC et al. PMID: 23911630 Kim WY et al. PMID: 23911630 Kim WY et al. PMID: 25402500 Forsythe SM et al. PMID: 10631227 Mosier JM et al. Riker RR, Shehabi Y, Bokesch PM, et al. Lowe J B, Yoo M J, Patrick J O, et al. Li, Timmy, et al. Resuscitation 2013; 84(11): 1500 – 4.

ED 66

ED Emergency Department ALS Paramedic 66