Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). sepsis, anemia, hypoxemia, severe hypotension etc., Unless some LMCA flow is restored he will not survive.

Coronary 126

Coronary ACS Emergency Department Epinephrine 126

Broome Docs

DECEMBER 22, 2024

2024 Oct 9. 2024 Oct 31:10.1056/NEJMoa2407780. 2024 Oct 31. This month we cover a few out-of-hospital arrest trials. More PECARN goodness and we answer the question: are ants better doctors than human doctors? There is a bunch more – so have a listen or watch us on Youtube feed below. doi: 10.1001/jama.2024.20424.

E-9-1-1 52

E-9-1-1 ACS Paramedic Emergency Department 52

Don't Forget the Bubbles

OCTOBER 2, 2024

2024 Sep 1;154(3):e2024066681. 2024 Sep 30. 2024 Sep 27:archdischild-2024-327433. 2024 Sep 17:fetalneonatal-2024-327678. 2024 Sep 21;404(10458):1157-1170. This comprehensive list is developed from 34 journals, including major and subspecialty paediatric journals. Soll RF, Edwards EM. Pediatrics.

ALS 52

ALS Emergency Department ED ACS 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A healthy 45-year-old female presented with chest pain, with normal vitals. The computer interpretation was “ST elevation, consider early repolarization, pericarditis or injury.” What do you think? There’s normal sinus rhythm, normal conduction, borderline right axis, and normal voltages. There’s TWI in aVL but this is concordant to its QRS.

OR 70

OR STEMI ACS Coronary 70

The Curious Clinicians

OCTOBER 2, 2024

2024 Jun;72(6):1728-1740. As of January 1, 2024, VCU Health Continuing Education will charge a CME credit claim fee of $10.00 Episodes prior to January 1, 2024, will remain free. October 2nd, 2024. Some of these cascades, even if cumbersome to the patient, make a certain amount of physiological sense. J Am Geriatr Soc.

ACS 105

ACS ALS OR 105

Don't Forget the Bubbles

JULY 22, 2024

2024 Mar 22 [cited 2024 Mar 25];0(0) Methods – What is an IPD meta-analysis? 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.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

MAY 3, 2024

RBBB + LAFB in the setting of ACS is very bad. Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Patients with ACS and RBBB/LAFB usually have a left main vs. proximal LAD. There is STE in aVR.

ACS 112

ACS ED Coronary EMS 112

REBEL EM

DECEMBER 23, 2024

Both these physiologic principles and recent preclinical evidence have called into question whether NS is the best resuscitation fluid for patients experiencing VOE due to concerns its tonicity and tendency to induce acidosis may promote sickling ( Carden 2017a , Carden 2017b , Alwang 2024 ).

ALS 105

ALS ED ACS EMR 105

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

The patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. At that point, cardiology elected to treat for ACS. Initial hscTnI was 10 ng/L (ref. <14). There was no recommendation for repeat ECG. Angiography is shown below.

OR 70

OR Coronary ACS EMS 70

Dr. Smith's ECG Blog

DECEMBER 3, 2024

This dynamic change is diagnostic of ACS. Cardiology was consulted and agreed that his history was high risk for ACS and a next-day angiogram was merited. This was also non-diagnostic for OMI, although the dynamic changes are diagnostic of ACS. Another EKG was also obtained. ECG at time 82 minutes: What do you think?

ED 94

ED Coronary ACS STEMI 94

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] Int J Cardiol 2024 3. Eur Heart J Digital Health 2024 5. 1] European guidelines add "regardless of biomarkers". Lupu et al.

STEMI 118

STEMI Coronary ALS CAD 118

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

OCTOBER 12, 2024

Click here to sign up for Queen of Hearts Access Given the lack of intracranial hemorrhage, the patient was administered aspirin for suspected ACS and cardiology was consulted. or basilar ischemia. EKG on arrival to the ED is shown below: What do you think? However, T waves do not appear to be hyperacute or hyperkalemic. Version 2 = 0.0272.

STEMI 96

STEMI Coronary Emergency Department ACS 96

FOAMfrat

APRIL 22, 2024

While one may argue that nitro really has no mortality benefit in ACS, I have seen patients with CHF present with hyper tension and inferior S-T elevation, in which the providers were scared to even look at the bottle of nitro. References Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J.

E-9-1-1 78

E-9-1-1 ACS Paramedic Critical Care 78

The Curious Clinicians

JANUARY 31, 2024

Listen to the episode [link] Credits & Citatio n Episode written by Avi Cooper Show notes written by Giancarlo Buonomo and Avi Cooper Audio edited by Clair Morgan of nodderly.com Cooper AZ, Breu AC, Abrams HR. January 31st, 2024. Rabbits treated with PNB in-utero had almost no instances of phocomelia or other defects.

ACS 110

ACS OR 110

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! West J Emerg Med 2024). 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.

STEMI 100

STEMI Coronary ACS ED 100

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. Sometimes it can take 12 or 24 hours to see ECG evidence of reperfusion. == MY Comment , by K EN G RAUER, MD ( 1/4/ 2024 ): == Superb and thorough discussion by Dr. Frick of today's case! His angiogram is shown below.

ACS 105

ACS ALS OR STEMI 105

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Because the most severe LAD OMIs can cause ischemic failure of the RBB and LAF, any patient with ACS symptoms and new RBBB and LAFB with any concordant STE has LAD OMI until proven otherwise. In EMS2 ECG, the T waves in V5 is possibly hyperacute. Post cath EF was estimated at 15% with severe global hypokinesis, and akinesis of the apex.

STEMI 116

STEMI EMS ACS ED 116

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 87

ACS Coronary ALS CAD 87

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

No wall motion abnormality This shows that significant ACS can have ZERO WMA!! There are also subtly hyperacute T-wave in I, aVL, and V2-V6. There is also a very negative (reciprocally inverted) T-wave in lead III, and a down-up T-wave in aVF, both of which are highly suggestive of occlusion of the LAD or D1. The S-wave is reconstituted.

STEMI 112

STEMI ACS Critical Care Coronary 112

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. link] == MY Comment , by K EN G RAUER, MD ( 4/9 /2024 ): == One can never get too much practice in recognizing acute tracings that must be distinguished from OMI mimics. On arrival patient was slightly tachycardic. HR about 90-100/min. Other vital signs normal. Final diagnosis was myocarditis.

Coronary 89

Coronary CAD ACS OR 89

The Curious Clinicians

FEBRUARY 21, 2024

There are likely additional ways that HFE modulates the immune system that we’re still learning about Listen to the episode [link] Credits & Citatio n Episode written by Hannah Abrams Audio edited by Clair Morgan of nodderly.com Cooper AZ, Breu AC, Abrams HR. February 21st, 2024. The Curious Clinicians Podcast.

ACS 40

ACS OR 40

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

The Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. The emergency physician was skeptical and believed the ECG to be a mimic, a false positive. So they looked into the patient's chart. If you have old ECGs available, seek them out and compare today's ECGs to those old one. It is already approved in Europe.

E-9-1-1 106

E-9-1-1 Coronary EMS ED 106

Dr. Smith's ECG Blog

JULY 11, 2024

A 2-day history of a "crushing and discomforting feeling" that is worse with exertion and not relieved by any home measures that are tried — even if primarily "epigastric" in location — is a potential presentation for ACS ( A cute C oronary S yndrome ) that needs to be recognized. There are many reasons that this ECG is diagnostic of LAD OMI.

Coronary 93

Coronary ED ACS OR 93

Dr. Smith's ECG Blog

JANUARY 9, 2024

Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Cardioversion will address the rhythm problem immediately, also if the chest discomfort subsides when SR is restored, ischemia from ACS becomes much less likely. In either case, prompt cardioversion is indicated.

Coronary 98

Coronary ACS ED OR 98

Dr. Smith's ECG Blog

AUGUST 9, 2024

Similarly, the OMI paradigm respects ACS as a dynamic process in which ECG changes reflect the phase of myocardial injury and risk stratify which patients may benefit from emergent PCI. This can occur due to scar ( e.g. post infarct VT) or anatomical variants ( e.g. AVNRT or AVRT). In fact, use of antidyrhythimcs (e.g., Leave it alone.

STEMI 85

STEMI Coronary Heart Attack ACS 85

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH) Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI. Translation from French: Acute Occlusion Myocardial Infarction with High Confidence.

STEMI 77

STEMI ACS OR 77

Dr. Smith's ECG Blog

AUGUST 11, 2024

Most importantly, while waiting for the paradigm to evolve, maintain focus on our true goal for our patients with ACS: to identify and reperfuse patients with acute occlusion MI.” In isolation this ECG does not show OMI, but following the paramedic ECGs this indicates spontaneous LAD reperfusion. McLaren ) that no "set" rhythm is present.

STEMI 77

STEMI Coronary Paramedic EMS 77

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

ACEP Now

MAY 9, 2024

Available from: [link] Newman-Toker DE, Nassery N, Schaffer AC, et al. Published 2024 Jan 19. 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.

Emergency Department 52

Emergency Department ICU ALS ACS 52

ALiEM

OCTOBER 30, 2024

The biggest change has been the gradual replacement of diacetylmorphine (heroin) by fentanyl and other synthetic opioids. Along the same time, a veterinary sedative, xylazine , became popular in Puerto Rico in individuals who used injection drugs [3]. We treat with wound care and reserve surgical management only for limbs that are no longer viable.

E-9-1-1 161

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

Pediatric EM Morsels

SEPTEMBER 20, 2024

HUS is often associated with bloody diarrhea … but… There is a variant of HUS (D-) that is not associated with diarrhea; HUS (D-) does not have seasonal variation and is relatively uncommon. Hemolytic Uremic Syndrome: Presentation The diarrhea associated with typical HUS may be bloody or watery.

Emergency Department 161

Emergency Department ACS ALS EMS 161

ESO

OCTOBER 18, 2024

Injury Prevention Summary ACS PRQ- Hospice ACS PRQ – Solid organ injuries PtReg: 2.5 Injury Prevention Summary ACS PRQ- Hospice ACS PRQ – Solid organ injuries PtReg: 2.5 Thanks to your feedback, we’ve also enhanced our process for introducing new dashboards, making it more efficient and responsive.

Mobile Integrated Health 52

Mobile Integrated Health Community Paramedicine Critical Care MIH 52

EMDocs

NOVEMBER 4, 2024

The pain is worse with deep breaths, coughing, or certain movements, and improves with rest and nonsteroidal anti-inflammatory drugs (NSAIDs). A 45-year-old male presents to the ED after a motor vehicle collision where he was the restrained driver. He reports severe, localized chest pain, worsened by breathing, coughing, and movement.

ED 99

ED E-9-1-1 Emergency Department ALS 99

EMDocs

NOVEMBER 25, 2024

Treasure Island (FL): StatPearls Publishing; 2024 Jan-. 5 Epidemiology Onchocerciasis is endemic in 31 African countries but is also problematic in Brazil, Venezuela, and Yemen. 6 By 2030, it is estimated that Nigeria followed by the Democratic Republic of the Congo and South Sudan will have the greatest disease burden. 7 Approximately 14.6

E-9-1-1 54

E-9-1-1 ALS Emergency Department OR 54

Dr. Smith's ECG Blog

DECEMBER 31, 2024

But thankfully, when the clinical context is clearly and highly concerning for ongoing ischemia from ACS, this distinction doesn't matter much. One could argue or wonder if there is both subendocardial ischemia AND posterior OMI pattern, since the STD in V4 may be equal or possibly slightly worse proportionally than V6.

Coronary 113

Coronary ACS STEMI CAD 113

EMDocs

JANUARY 6, 2025

History of Present Illness The collateral history indicates that her symptoms began one week into her journey, but medical care was inaccessible at the time. The family reports no history of food allergies, insect bites, or contact with sick individuals. The patient did not receive pre-travel prophylaxis for malaria, hepatitis A, or yellow fever.

ED 57

ED E-9-1-1 ALS Emergency Department 57