ACEP Now

MAY 3, 2023

Acute chest syndrome (ACS) is a potentially life-threatening complication of sickle cell disease characterized by lung infiltrates, fever, and respiratory symptoms, including cough, tachypnea, wheeze, increased work of breathing or shortness of breath, and reduced oxygen saturation. Sickle cell disease is the primary risk factor for ACS.

ACS 52

ACS OR 52

Dr. Smith's ECG Blog

JUNE 17, 2024

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. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with Acute PE (p less than 0.001).

E-9-1-1 134

E-9-1-1 ACS Emergency Department ALS 134

FOAMcast

OCTOBER 17, 2023

Published online October 12, 2023. Published online October 12, 2023. Published online October 12, 2023. ” However, “REBOA is less invasive than resuscitative thoracotomy and in skilled hands may be more rapidly applied as compared with resuscitative thoracotomy.” ” As a result, Jansen et al.

ACS 52

ACS ALS OR 52

Dr. Smith's ECG Blog

JUNE 5, 2024

As per my review of this subject ( Check out My Comment at the bottom of the page in the November 16, 2023 post in Dr. Smith's ECG Blog ) — the 3 most common Causes of ACS ( A cute C oronary S yndrome ) with a "negative" cath are: i ) Myocarditis; ii ) Takotsubo cardiomyopathy; and , iii ) MINOCA.

Coronary 101

Coronary ACS ALS OR 101

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

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

Dr. Smith's ECG Blog

DECEMBER 22, 2023

Comment : ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). The ESC states that patients with suspected ACS should go to the cath lab in ＜2 hours "regardless of ECG or biomarker evidence of MI!!" There are no hyperacute T waves. There is no inappropriate ST depression.

ACS 97

ACS STEMI OR 97

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

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Link to abstract Link to full text 2) Use of Morphine in Non-STE-ACS is independently associated with mortality, at odds ratio of 1.4

E-9-1-1 80

E-9-1-1 ACS STEMI Coronary 80

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 76

E-9-1-1 ICU ACS EMS 76

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

For more on MINOCA — See My Comment in the November 16, 2023 post in Dr. Smith's ECG Blog ). Thus, the lumen observed may actually still be the same size as the original, normal lumen. years, with the interval as long as 12 or 18 years in some studies.

Coronary 110

Coronary ACS OR EMR 110

Don't Forget the Bubbles

OCTOBER 2, 2024

2024 Sep 19:archdischild-2023-326507. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. 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. Kemps N, et al.

ALS 52

ALS Emergency Department ED 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. The Case FIGURE 1: Initial EKG were notable for a leukocytosis of 23.19 Click to enlarge.)

STEMI 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

MARCH 1, 2023

This pattern occurs regardless of whether the cause is ACS (decreased supply) or any other cause of decreased supply or increased demand. You must understand that this pattern does not differentiate ACS from other causes of supply/demand mismatch. A "STEMI alert" was called and soon cancelled.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine 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. 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 95

Coronary E-9-1-1 STEMI ACS 95

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. He was diagnosed as NSTEMI.

ACS 85

ACS Coronary ALS CAD 85

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. Fortunately, that is exactly what happened.

E-9-1-1 113

E-9-1-1 Coronary ACS BLS 113

Dr. Smith's ECG Blog

AUGUST 10, 2023

So now there was ACS + electrical instability, another indication for emergent angiogram. Emergency Medicine Journal , 34 (2), 119-123. == MY Comment, by K EN G RAUER, MD ( 8/10 /2023 ): == Today's case by Drs. This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram. Shroff, G.

STEMI 82

STEMI ACS Emergency Department ED 82

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

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

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

Pediatric EM Morsels

AUGUST 18, 2023

References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. 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

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] 1] European guidelines add "regardless of biomarkers". But only 6.4% Eur Heart J Digital Health 2024 5. McLaren and Smith.

STEMI 114

STEMI Coronary ALS CAD 114

Dr. Smith's ECG Blog

DECEMBER 27, 2023

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! 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 ).

E-9-1-1 111

E-9-1-1 OR Coronary ACS 111

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 78

STEMI ACS OR ALS 78

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. Smith comment: No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matter how normal the ECG. His angiogram is shown below. Heitner et al.

ACS 101

ACS ALS OR STEMI 101

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. That is what Emergency Medicine is all about. == MY Comment , by K EN G RAUER, MD ( 9/3 /2023 ): == I’ve seen a “common theme” with many of the ECGs that Drs. He reports feeling nauseated with emesis. There is ischemic ST depression in V4-V6.

Defibrillator 126

Defibrillator Coronary STEMI CPR 126

Dr. Smith's ECG Blog

MARCH 13, 2023

This is acute ACS, but it almost always seen in a pain free state. My Comment by K EN G RAUER, MD ( 3/13 /2023 ): = Today's case illustrates optimal clinical use of a pre-hospital Wellens' pattern for understanding the evolution of acute OMI. An ED ECG, if recorded with pain, should show LAD OMI.

ED 52

ED ACS Coronary Paramedic 52

Dr. Smith's ECG Blog

APRIL 14, 2023

It is easy to say this in retrospect, especially not being the one in charge of this overcrowded waiting room full of unseen patients, but an elderly patient with known CAD and ongoing ACS-sounding chest pain despite medical management with positive troponin is already an indication for emergent cath, regardless of the ECG!

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. Smith's ECG Blog — it may sometimes not be possible to distinguish between acute myocarditis vs acute OMI on the basis of ECG findings and clinical history ( See My Comments in the April 25, 2023 — July 21, 2019 — December 10, 2019 — and January 10, 2020 posts). On arrival patient was slightly tachycardic.

Coronary 85

Coronary CAD ACS OR 85

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! 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. Deutch et al. West J Emerg Med 2024).

STEMI 96

STEMI Coronary ACS ED 96

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

link] = My Comment by K EN G RAUER, MD ( 11/14 /2023 ): = One of the most helpful clinical clues in support that an acute cardiac event is ongoing — is the finding of " dynamic " ECG changes. For examples of such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 posts in Dr. Smith's ECG Blog ).

E-9-1-1 101

E-9-1-1 Coronary EMS ED 101

The Curious Clinicians

JANUARY 16, 2024

There is one value, however, which we not only leave alone until it is well below normal, but only replenish to barely half the normal value: Hemoglobin (Hgb). We’d never let a patient leave the office with a potassium of 10, or discontinue antibiotics with a white count of “only” 18,000. Let’s focus on that last point.

Plasma 52

Plasma ACS Critical Care OR 52

The Curious Clinicians

NOVEMBER 7, 2023

It should be noted that ACE inhibitors are not a panacea: in the same study, 44% of those treated still either died early or required permanent dialysis. However, the positive effect of ACE inhibitors on scleroderma renal crisis morbidity and mortality is incontrovertible. November 8, 2023. Let's have a look.

ACS 52

ACS OR 52

The Curious Clinicians

OCTOBER 4, 2023

The 1960s saw the emerging use of these homografts. But the success of these human valves and their advantages over plastic or mechanical led to the realization that limited availability would preclude their wide use; as with any human organ or tissue transplant, demand outstrips supply. There were also issues raised about size mismatch.

ALS 52

ALS OR ACS 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. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. I think it is OMI; am I right? See this case: A man his 50s with chest pain.

STEMI 73

STEMI Coronary ACS OR 73

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

This case fits this definition of cardiac memory. == MY Comment , by K EN G RAUER, MD ( 11/9 /2023 ): == I found Dr. Smith's presentation of today's case highly insightful for the changes in ST-T wave appearance that may sometimes be seen, depending on whether or not LBBB ( L eft B undle B ranch B lock ) is present. Is it Wellens' syndrome?

E-9-1-1 80

E-9-1-1 ACS ALS OR 80