EMDocs

NOVEMBER 6, 2023

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association 2023 Guideline for managing cardiac arrest or life-threatening toxicity due to poisoning was recently released. Editorial Comment : Use standard BLS/ALS measures, especially if in cardiac arrest. Top 10 Take Home Pearls 1.

Naloxone 93

Naloxone OR Overdose BLS 93

Dr. Smith's ECG Blog

APRIL 18, 2024

The ECG is just a test: a Bayesian approach to acute coronary occlusion If a patient with a recent femur fracture has sudden onset of pleuritic chest pain, shortness of breath, and hemoptysis, the D-dimer doesn’t matter: the patient’s pre-test likelihood for PE is so high that they need a CT. Amsterdam et al. Alencar et al.

STEMI 120

STEMI Coronary ALS CAD 120

REBEL EM

JUNE 1, 2023

Article: Branch KHR et al. Resus 2023. Indication for emergency invasive coronary angiography or had coronary angiography within 1 hour of arrival. Known obstructive coronary artery disease or known coronary stent. References: Branch KHR et al. Resus 2023. Known cardiac defibrillator.

Coronary 145

Coronary Defibrillator CPR ALS 145

REBEL EM

SEPTEMBER 14, 2023

Zeymer HT et al. References: Zeymer HT et al. The benefits of this strategy may be outweighed by the risk of the device-related complications (i.e. bleeding, stroke, limb ischemia, and hemolysis). The evidence for this practice has been sparse until now. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. Control: 53.4%

Life Support 137

Life Support Coronary CPR ICU 137

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Not OMI with High Confidence Click here to sign up for Queen of Hearts Access We showed that the Queen of Hearts decreases false positive cath lab activations: 1) Published recently in Prehospital Emergency Care Baker PO et al. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al.

E-9-1-1 115

E-9-1-1 Coronary ALS ED 115

Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI 66

STEMI Coronary ALS OR 66

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1 115

E-9-1-1 Coronary STEMI ALS 115

REBEL EM

SEPTEMBER 28, 2023

Paper: Van de Werf, F et al. STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. References: Van de Werf, F et al. PMID: 37439219 Armstrong P et al.

STEMI 138

STEMI Allergic Reaction Coronary Ambulance 138

ACEP Now

JULY 7, 2023

Extracorporeal membrane oxygenation Of patients with out-of-hospital cardiac arrest presenting to the ED in refractory VF, a majority have significant coronary artery disease, much of which is amenable to percutaneous coronary intervention. References Tsao CW, et al. Benjamin EJ, et al. Kimblad H, et al.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

JUNE 17, 2024

In fact, Kosuge et al. showed that among patients with either acute coronary syndrome or acute pulmonary embolism and negative T waves in the precordial leads (V1-V4), that inverted T waves in leads III and V1 were present in only 1% of patients with acute coronary syndrome and 88% of patients with pulmonary embolism. “The

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

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

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

Dr. Smith's ECG Blog

JUNE 14, 2024

He underwent coronary angiography which showed severe multivessel disease, and he agreed to proceed with workup for CABG. The September 15, 2023 post — for PTA ( Pulse-Tap Artifact ). The April 6, 2023 post — excessive baseline artifact misdiagnosed as AFib ( instead of sinus rhythm with AV Wenckebach — as in Figure-4 in this post ).

Defibrillator 79

Defibrillator ALS Coronary OR 79

EMDocs

FEBRUARY 7, 2024

GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. 2023 observational study found increased risk of pancreatitis (adjusted HR of 9.09, 95% CI 1.25-66). 2023 Oct 5:e2319574.

Allergic Reaction 74

Allergic Reaction ALS CAD OR 74

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

EMDocs

OCTOBER 30, 2023

Production levels increased steadily back to baseline, achieving normal supply levels in February 2023. 16 In a study conducted by Millet et al. A retrospective study done in May 2023, by Shaish et al 24 showed a 30 % reduction in accuracy of NCCT compared to CECT in a study done among 201 adult ED patients with abdominal pain.

E-9-1-1 73

E-9-1-1 Emergency Department ALS ED 73

EMDocs

OCTOBER 21, 2023

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. References: Gaillard F, Glick Y, Tatco V, et al. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

EMS 73

EMS ALS OR ACS 73

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Acute MI per se usually does not depress cardiac function and blood pressure enough to cause syncope ( Mostafa et al — J Com Hosp Intern Med Perspect 13(4):9-12, 2023 - ).

EMS 110

EMS CPR ED Coronary 110

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Hayakawa A, Tsukahara K, Miyagawa S, et al. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients. 2009;95:1701–1706. As per Drs.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Finally, coronary angiography was performed (at least 5 days after presentation) which confirmed LAD aneurysm with large thrombus burden, TIMI 0 flow, thrombectomy performed. A missed OMI like this can be devastating. =

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

STEMI criteria is bad at differentiating between normal variant and acute coronary occlusion or reperfusion, and initial troponin levels don't differentiate between occlusive and non-occlusive MI 3. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4. McLaren et al, including Meyers/Smith.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion. Deutch et al.

STEMI 107

STEMI Coronary ACS ED 107

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al.

E-9-1-1 122

E-9-1-1 OR Coronary ACS 122

ACEP Now

MARCH 14, 2024

2023 Jul 17. Treasure Island (FL): StatPearls Publishing; 2023 Jan– PMID: 28846317. Tintinalli JE, Stapczynski J, Ma O, et al. Accessed October 21, 2023. Acute myocardial infarction with normal and near normal coronary arteries. Arnoldo BD, Purdue GF, Kowalske K, et al. In: StatPearls [Internet].

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JANUARY 23, 2024

Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. A DDENDUM: There are many potential causes of AV block.

Coronary 88

Coronary OR Defibrillator ALS 88

Dr. Smith's ECG Blog

FEBRUARY 10, 2023

Inferior ST Depression does NOT mean there is inferior subendocardial ischemia; it is generally reciprocal to high lateral (aVL) subepicardial ischemia (OMI/STEMI) == MY Comment by K EN G RAUER, MD ( 2/10/2023 ): == There are certain patterns in ECG interpretation that experienced providers are able to immediately recognize. See text ).

STEMI 52

STEMI ALS Coronary OR 52

Dr. Smith's ECG Blog

JULY 27, 2023

I was not worried for a coronary etiology. PEARL #3: The pathophysiologic mechanism for producing amphetamine-induced acute MI is unclear ( Bazmi et al — SQUMJ 17(10); e31-37, 2017 — and — Sinha et al — Case Rep Cardiol, 2016 ). The precordial findings are typical for a young AA male See 20 similar cases here.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

His medical history includes hypertension, a decade-long battle with diabetes, ischemic heart disease, a coronary bypass graft surgery ten years ago, a diagnosis of congestive heart failure for the last five years, and a prior ICD implantation five years ago.

Coronary 102

Coronary EMR STEMI Emergency Department 102

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al.

STEMI 119

STEMI Emergency Department Coronary OR 119

Dr. Smith's ECG Blog

APRIL 25, 2023

But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

Coronary 52

Coronary STEMI ALS OR 52

Dr. Smith's ECG Blog

MAY 23, 2023

I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. So this study is worthless and must be ignored.

STEMI 93

STEMI Coronary Paramedic OR 93

Dr. Smith's ECG Blog

JANUARY 6, 2024

Therefore the impulse must have originated somewhere lower in the atria, perhaps near the coronary sinus. The January 15, 2023 post ( LA-LL reversal; Lead V1,V2 ). The May 13, 2023 post ( LA-RA reversal ). The September 15, 2023 post — for PTA ( Pulse-Tap Artifact ). The March 17, 2023 post — for PTA.

ALS 95

ALS STEMI Coronary OR 95

Dr. Smith's ECG Blog

MAY 26, 2023

If the situation is not right for acute coronary occlusion, then the ECG findings probably do not represent acute coronary occlusion. Severely ill patients from any etiology can have very abnormal ECGs = My Comment by K EN G RAUER, MD ( 5/26 /2023 ): = There are more questions than answers in today's case.

Overdose 92

Overdose E-9-1-1 Coronary OR 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

ACEP Now

AUGUST 12, 2024

Sequence of events in angina at rest: Primary reduction in coronary flow. 2023 May 2;15(5):e38428. Normalization of abnormal T waves in ischemia. Arch Intern Med. 1976 Apr;136(4):391-5. Chierchia S, Brunelli C, Simonetti I, Lazzari M, Maseri A. Circulation. 1980 Apr;61(4):759-68. Pseudonormalisation of the T wave: old wine?:

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Meyers et al. Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Aslanger et al. DIagnostic accuracy oF electrocardiogram for acute coronary OCClusion resulTing in myocardial infarction (DIFOCCULT study). Lemkes et al. Bergmark et al.

STEMI 52

STEMI Paramedic Coronary ALS 52