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

REBEL EM

NOVEMBER 6, 2024

2023 Aug 4. PMID: 32644703 Robinson PM, Griffiths E, Watts AC. PMID: 27227986 Glover NM, Black AC, Murphy PB. 2023 Nov 5. Multiple Concomitant Injuries in One Upper Extremity: A Case Report. Am J Case Rep. 2016 Jan 6;17:6-11. doi: 10.12659/ajcr.894984. PMID: 26732673 Akhondi H, Varacallo M. In: StatPearls [Internet].

E-9-1-1 59

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

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-9-1-1 122

E-9-1-1 ALS ACS ICU 122

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 137

ALS ACS OR CPR 137

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

Don't Forget the Bubbles

OCTOBER 2, 2024

Pecenka C, et al. Winkler AE, et al. Bonifacio SL, et al. Brosnan B, et al. Panda PK, et al. Tangwijitsakul H, et al. Gunnarsdottir K, et al. Chong KH, et al. Blaabæk EH, et al. Rosati J, et al. Räty S, et al. Kemps N, et al. De la Cruz-Mena JE, et al.

ALS 52

ALS Emergency Department ED ACS 52

This Podcast Will Kill You

SEPTEMBER 24, 2024

Datz, Christian, et al. ACS omega , 7 (24), pp.20441-20456. Hodgskiss, Malcolm SW, et al. Moalem, Sharon, et al. Olejarz, Jason, et al. Tune in to catch us ironing out the details of this incredibly common genetic disorder. History Biology Adams, Paul C. “Hemochromatosis: ancient to the future.”

ALS 52

ALS ACS 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 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 102

Coronary E-9-1-1 STEMI ACS 102

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 83

ACS Coronary ALS CAD 83

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

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 73

EMS ALS OR ACS 73

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.

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E-9-1-1 ICU ACS EMS 75

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 118

STEMI Coronary ALS CAD 118

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-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

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 107

ACS ALS OR STEMI 107

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

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

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-9-1-1 117

E-9-1-1 OR Coronary ACS 117

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 86

STEMI ACS OR ALS 86

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

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

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

FOAMfrat

OCTOBER 20, 2023

And according to a paper from Russotto et al. Of note, in the paper by Russotto et al., Heffner et al, 2012, reports a study that "demonstrated pre-RSI systolic pressures less than 140 as independently associated with post-intubation hypotension, but SI was not included in this analysis" [14]. Sackles et al. Brown, C.A.

E-9-1-1 52

E-9-1-1 ALS ACS OR 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 102

STEMI Coronary ACS ED 102

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

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 OR ACS ALS 130

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 78

E-9-1-1 ACS ALS OR 78

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

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 81

STEMI Coronary ACS OR 81

ALiEM

OCTOBER 30, 2024

Multimodal medication options for fentanyl-xylazine withdrawal management in London et al. 2023 Jan 1;53(1):140-2. 2022; 06/26/2023. 2023 Jun 1;36:89-91. This month in JAAD Case Reports: August 2023: Xylazine and skin necrosis. 2023 Aug 1;89(2):231. DOI: Papudesi BN, Malayala SV, Regina AC.

E-9-1-1 161

E-9-1-1 Naloxone Emergency Department ALS 161

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 65

ED Emergency Department ALS OR 65

Don't Forget the Bubbles

JUNE 30, 2023

This post is part of the PEM Adventure at NEPTUNE 2023, hosted by Dani, Kat, Costas and Sarah. NEPTUNE 2023 was inaugural UK PEM trauma conference, hosted by Nottingham University Hospitals Trust, one of the largest major trauma centres in the UK. Laan DV, Vu TD, Thiels CA et al. 2023 Jun;35(3):412-419. Brie-liiant!

E-9-1-1 139

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

Dr. Smith's ECG Blog

JANUARY 17, 2023

My Comment by K EN G RAUER, MD ( 1/17 /2023 ): = As per Dr. Smith — pulse - tap artifact used to be a "new" phenomenon to us ( as well as to virtually all medical providers ). Additional review of ECG artifacts by Pérez-Riera et al ( Ann Noninvasic Electrocardiol 23:e12494, 2018 ) VT Artifact — by Knight et al: NEJM 341:1270-1274, 1999.

ALS 52

ALS ACS OR ED 52