EM Didactic

JANUARY 27, 2019

Myth 1 Absence of Classic Chest Pain obviates the need for ACS work up The absence of chest pain in no way excludes the diagnosis of ACS. Around 33-50% of the patients with ACS present to the hospital without chest pain. Close to 20% of patients diagnosed with acute MI present with symptoms other than chest pain.

ACS 52

ACS ALS Coronary Emergency Department 52

REBEL EM

NOVEMBER 6, 2024

PMID: 32644703 Robinson PM, Griffiths E, Watts AC. PMID: 27227986 Glover NM, Black AC, Murphy PB. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Simple elbow dislocation. Shoulder Elbow. 2017 Jul;9(3):195-204. PMID: 28588660 Donohue KW, Mehlhoff TL. Chronic Elbow Dislocation: Evaluation and Management. J Am Acad Orthop Surg.

E-9-1-1 107

E-9-1-1 ACS OR Emergency Department 107

REBEL EM

MARCH 2, 2023

REBEL Cast Ep114 – High Flow O2, Suspected ACS, and Mortality? PMID: 33653685 Clinical Question: Is there an association between high flow supplementary oxygen and 30-day mortality in patients presenting with a suspected acute coronary syndrome (ACS)? Click here for Direct Download of the Podcast Paper: Stewart, RAH et al.

ACS 52

ACS Coronary STEMI Ambulance 52

The Skeptics' Guide to EM

JANUARY 18, 2020

You turn to the attending and ask, “do you really think this could be acute coronary syndrome (ACS)?” ACS is usually amongst this differential, as cardiovascular disease is a leading cause of morbidity and mortality in this population. The proportion of patients with ACS at the index visit or within 30 days. *

ACS 130

ACS Coronary Emergency Department ALS 130

Pediatric EM Morsels

APRIL 19, 2024

J Bone Joint Surg Br. 2001;83:1173-5. Oakley EA, Ooi KS, Barnett PLJ. A randomized controlled trial of 2 methods of immobilizing torus fractures of the distal forearm. Pediatr Emerg Care. 2008;24:65–70. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117:691–697.

ALS 290

ALS ACS Emergency Department ED 290

The Skeptics' Guide to EM

SEPTEMBER 28, 2024

The patient has no specific risk factors for acute coronary syndrome (ACS) or dissection. Case: You are working a busy shift in a rural emergency department (ED) and your excellent Family Medicine trainee presents a case of a 63-year-old woman with chest pain and some intermittent radiation into the inter-scapular region.

Emergency Department 234

Emergency Department ACS Coronary ALS 234

EMDocs

MAY 15, 2024

Other causes of sickling: acidosis, dehydration, inflammation, infection, fever, and blood stasis Sickling leads to vascular occlusion, end-organ ischemia, and decreased RBC lifespan, which, in turn, leads to pain crisis, acute anemia, sequestration, infection, and acute chest syndrome (ACS.) Each episode of ACS has a 9% mortality rate.

E-9-1-1 103

E-9-1-1 ACS ALS OR 103

REBEL EM

SEPTEMBER 21, 2023

What Your Gut Says: The patient has a tachydysrhythmia which may be the presentation of acute coronary syndrome (ACS) even though the patient has no ischemic symptoms. If the patient continues to have symptoms concerning for ACS, troponin testing should be pursued. SVT is not a presenting dysrhythmia consistent w/ ACS.

Coronary 143

Coronary ACS ED OR 143

EMDocs

MAY 28, 2024

Sickling leads to vascular occlusion, end-organ ischemia, and decreased RBC lifespan, which, in turn, leads to pain crisis, acute anemia, sequestration, infection, and acute chest syndrome (ACS). ACS is lung injury due to vaso-occlusion in the pulmonary vasculature; many with ACS will have a concomitant vaso-occlusive pain crisis.

ACS 97

ACS E-9-1-1 ALS OR 97

Emergency Medicine Cases

APRIL 14, 2020

In this ECG Cases blog we look at 6 patients who presented with cardiorespiratory symptoms, possibly from COVID and illustrate the dangers of anchoring, being hypervigilant for cardiovascular complications, and why testing for COVID in patients being admitted for ACS is important.

ACS 130

ACS STEMI 130

Dr. Smith's ECG Blog

JULY 2, 2023

This was texted to me from a former resident, while working at a small rural hospital, with the statement: "I can’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS." Chest pain or discomfort) What do you think? Here was my response: "Suspicious for inferior posterior OMI.

ACS 52

ACS Coronary OR 52

The Skeptics' Guide to EM

MAY 25, 2019

The American College of Emergency Physicians (ACEP) and American College of Surgeons Committee on Trauma (ACS COT) in 2018 put out a joint statement for the use of REBOA [4]. ACEP and ACS COT also discuss the transfer, management, special circumstances (deployed military settings), training, credentialing and quality assurance of REBOA.

ACS 130

ACS Emergency Department ALS OR 130

Critical Care Scenarios

APRIL 26, 2023

Takeaway lessons * If considering ACS in any post-menopausal woman, you should also consider stress cardiomyopathy. Of course, atypical anatomical distributions can also occur in ACS due to distinct anatomy. ACE inhibition). * In general, TCM is a diagnosis of exclusion after ruling out ACS. Find us on Patreon here!

ACS 100

ACS OR 100

EMS 12-Lead

AUGUST 18, 2024

I interpreted the ECG as VT with two primary etiological possibilities: 1. Abrupt plaque ulceration of Type 1 ACS leading to VT. Of interest, he specified that he awoke earlier that morning in his usual state of health, then developed chest discomfort, then developed palpitations.

CAD 147

CAD EMT EMT ACS 147

Dr. Smith's ECG Blog

JULY 25, 2024

Then assume there is ACS. Therefore — recognition of DSI on ECG should prompt consideration of 2 Categories of diagnostic entities : Severe Coronary Disease ( due to LMain, proximal LAD, and/or severe 2- or 3-vessel disease ) — which in the right clinical context may indicate ACS ( A cute C oronary S yndrome ).

Defibrillator 125

Defibrillator Coronary Epinephrine ACS 125

FOAMfrat

APRIL 25, 2024

References: Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J. The conversation concludes with a discussion on the transfer of pacing from one device to another and the importance of verifying capture during the process. Check out more from Josh, Judah, and Tom at EMS12LEAD.com. 2024 Mar 15:1-9.

Paramedic 128

Paramedic ACS EMS ED 128

EMS 12-Lead

JUNE 20, 2022

Although the attending crews did not consider the ECG pathognomonic for occlusive thrombosis, they nonetheless considered the patient high-risk for ACS and implored him to reconsider. The attending crews were concerned for an ACS-equivalent of LAD occlusion and initiated a prehospital STEMI activation to the closest PCI center.

ACS 130

ACS Coronary STEMI CAD 130

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-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

Dr. Smith's ECG Blog

MARCH 31, 2024

The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration. The pain was still active at the time of evaluation.

STEMI 111

STEMI ACS ED 111

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. Learning Points: 1.

ACS 127

ACS ED Coronary EMS 127

Dr. Smith's ECG Blog

MARCH 14, 2024

These have all been small studies, studying very few patients with ACS, and often used final cardiology interpretation rather than patient outcome. Smith : This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG.

STEMI 120

STEMI ACS Coronary Emergency Department 120

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). ACS and hyperkalemia both have lethal downstream consequences, so it is imperative for the clinician to acclimate to the presentation, or developing, features of each. ECG's are difficult.

ACS 130

ACS Paramedic Coronary ALS 130

Medgadget

AUGUST 29, 2022

” The researchers presented their technology at the 2022 fall meeting of the American Chemical Society (ACS). Via: ACS. . “We already interact with a lot of touch-based electronics, such as smart phones and keyboards, so this sensor could integrate seamlessly into daily life.”

ACS 115

ACS 115

ALiEM

AUGUST 30, 2024

Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM; American Thyroid Association Task Force on Thyroid Hormone Replacement. References Geddes G, Butterly MM, Patel SM, Marra S. Pediatric neck masses. Pediatr Rev. 2013 Mar;34(3):115-24; quiz 125. doi: 10.1542/pir.34-3-115.

ACS 161

ACS Emergency Department ED OR 161

The Skeptics' Guide to EM

JULY 2, 2022

The bottom line from that episode was that the HEART Pathway appears to have the potential to safely decrease objective cardiac testing, increase early discharge rates and cut median length of stay in low-risk chest pain patients presenting to the ED with suspicion of ACS. If we thought about ACS, we brought them in. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

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.,

Coronary 129

Coronary ACS Emergency Department Defibrillator 129

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!!"

ACS 117

ACS STEMI OR 117

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Smith : As Willy states, 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!!" See this case: A man his 50s with chest pain.

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

EMS 12-Lead

JULY 30, 2023

This should prompt immediate investigation into supply-demand mismatching, or ACS. There is bradycardic Atrial Fibrillation with broad ST-depression in most leads and perceptible ST-elevation in aVR. But there’s some peculiar features about this ECG: The unusually short QT The “scooped out” appearance of the ST-segments.

EMT 130

EMT EMT ACS Coronary 130

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 123

Coronary ACS ALS OR 123

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. The patient is admitted for ACS to a cardiologist who says he will see the patient in the morning.

ACS 85

ACS ALS ED Coronary 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. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1.

Coronary 110

Coronary E-9-1-1 STEMI ACS 110

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. Many of these OHCAs are due to ventricular fibrillation or pulseless VT. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006).

EMR 130

EMR Coronary Defibrillator Life Support 130

The Skeptics' Guide to EM

FEBRUARY 27, 2021

Exclusion criteria: Transferred patients, HR <40 or >140 bpm, SBP <90 or >180 mmHg, RR <6 or >36/min, GCS <15, possible ACS, headache, pregnancy, breastfeeding, known renal or hepatic failure, previous malignant hyperthermia, known sensitivity to fluorinated anesthetics, or agitated/aggressive per nursing staff.

Emergency Department 130

Emergency Department ACS ALS ED 130

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 78

E-9-1-1 ACS STEMI Coronary 78

The Curious Clinicians

MARCH 4, 2024

Episode written by Jeff Kott and Tony Breu Kott J, Cooper AZ, Breu AC, Abrams HR. Nephmadness 2024. The Curious Clinicians Podcast. March 4th, 2024. Image source: [link]

ACS 81

ACS Critical Care OR 81

Dr. Smith's ECG Blog

MAY 20, 2024

Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? Assuming that was indeed a culprit, then this was ACS. The T waves in leads II and aVF have deflated, and the T wave in lead III has become terminally negative. The ST depressions in I and aVL have resolved.

CAD 126

CAD STEMI Coronary ACS 126