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 122

Coronary ACS ALS OR 122

The Skeptics' Guide to EM

JULY 2, 2022

Date: June 30th, 2022 Reference: McGinnis et al. Date: June 30th, 2022 Reference: McGinnis et al. If we thought about ACS, we brought them in. Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? AEM June 2022. AEM June 2022. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

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. link] [1] Zachary et al. 2] Costanzo, L.

ACS 130

ACS Paramedic Coronary ALS 130

The Skeptics' Guide to EM

FEBRUARY 27, 2021

Reference: Brichko et al. Reference: Brichko et al. Reference: Brichko et al. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. AEM Feb 2021. AEM Feb 2021.

Emergency Department 130

Emergency Department ACS ALS ED 130

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 109

Coronary E-9-1-1 STEMI ACS 109

REBEL EM

MAY 29, 2024

VS abnormalities can drive this as well Strongly consider reversal of AC (this will typically come after control) Stopping the Bleeding PPE: these things bleed like stink. EMRAP HD: Epistaxis Posterior Pack References Cassisi NJ et al. PMID: 5569677 Zeyyan E et al. PMID: 20938948 Loftus BC et al.

ICU 102

ICU ALS ACS EMS 102

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

Broome Docs

JANUARY 27, 2025

100% seems too good to be true Morello et al., Clin Exp Allergy. 2024 Oct 9. doi: 10.1111/cea.14565. Epub ahead of print. PMID: 39383344 Profundus Trial – Can we actually exclude acute aortic syndromes with this protocol? Diagnosis of acute aortic syndromes with ultrasound and D-dimer: the PROFUNDUS study. Emerg Med J. Epub 2018 Oct 25.

ED 101

ED OR ACS Critical Care 101

Broome Docs

DECEMBER 22, 2024

PECARN looks at probiotics for toddlers diarrhea… Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O’Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB.

E-9-1-1 52

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

Don't Forget the Bubbles

SEPTEMBER 13, 2023

doi:10.1093/tropej/fmz071 Expert Panel on Pediatric Imaging, Trofimova A, Milla SS, et al. 2019-0134 Hirtz D, Ashwal S, Berg A, et al. Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. J Trop Pediatr. 2020;66(3):299-314. J Am Coll Radiol.

E-9-1-1 131

E-9-1-1 Emergency Department ALS OR 131

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 120

ACS ALS OR STEMI 120

Don't Forget the Bubbles

MAY 17, 2023

Antonaci L, et al. Tritos NA, et al. Levi M, et al. Fishbein MH, et al. Cetinkaya PG, et al. Niu T, et al. Verkuijl SJ, et al. Varni JW, et al. Dias FC, et al. Peter C, et al. Ahlberg R, et al. Shir A, et al. Kuypers KLAM, et al. Hegeman EM, et al.

ALS 72

ALS ACS Emergency Department EMS 72

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 82

ACS Coronary ALS CAD 82

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 121

STEMI Coronary ALS CAD 121

EMOttawa

DECEMBER 18, 2023

Methodology: 3/5 Usefulness: 1/5 Georgiopoulos G, et al. 2023 Oct 1;8(10):946-956 Question: Does the modified GRACE score incorporating continuous troponin improve ACS risk prediction? JAMA Cardiol. Methods: Retrospective.

Coronary 52

Coronary ACS ALS 52

The Curious Clinicians

OCTOBER 2, 2024

Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Credits & Suggested Citation Episode written by Tony Breu Show notes written by Giancarlo Buonomo and Tony Breu Audio edited by Clair Morgan of nodderly.com Breu AC, Abrams HR, Cooper AZ, Buonomo G. J Am Geriatr Soc. October 2nd, 2024.

ACS 105

ACS ALS OR 105

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. 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 ). per 100,000 to 11 per 100,000 [Rosso].

E-9-1-1 130

E-9-1-1 OR Coronary ACS 130

REBEL EM

FEBRUARY 12, 2024

Read More First10EM: Imaging for Renal Colic SGEM : SGEM XTRA: COME TOGETHER, RIGHT NOW – OVER RENAL COLIC References Chang, Helena, et al. Moore CL, Carpenter CR, Heilbrun ME, et al. Smith-Bindman R, Aubin C, Bailitz J, et al. PMID: 25229916 DOI: 10.1056/NEJMoa1404446 Westphalen AC, Hsia RY, Maselli JH, Wang R, Gonzales R.

Emergency Department 73

Emergency Department ALS ACS EMS 73

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 98

STEMI ACS OR ALS 98

REBEL EM

OCTOBER 23, 2023

Follow up with the dentist in the morning Reinsert the tooth and avoid solid food Reinsert the tooth and stabilize it with a bridge Remove the tooth and repair the gingival laceration Remove the tooth and wrap it in saline-soaked gauze FOR THE RIGHT ANSWER CLICK ON THE ROSH REVIEW LOGO BELOW References Day PF, Flores MT, O’Connell AC, et al.

EMS 58

EMS ACS ALS ED 58

Dr. Smith's ECG Blog

MARCH 19, 2024

The cath report showed: Significant stenosis with subtotal occlusion (99%) in the prox to mid Lcx, culprit of ACS, TIMI flow 1. Available from: [link] If you are wondering about the Barcelona rule, then you should read the above paper by Khawaja et al. Cardiac catheterization occurred around 1pm (18 hours after arrival). 2021;23:187.

CAD 111

CAD STEMI ACS ALS 111

EMS 12-Lead

APRIL 2, 2022

Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. 4] Baranchuk, A, et al. Given such findings, serial ECG’s are prudent to consider, and carry significant impact moving forward, which has been demonstrated in previous posts. 2] Surawicz, B.

ALS 130

ALS STEMI Coronary OR 130

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., Yu ES, Lange JJ, Broor A, et al.

STEMI 52

STEMI Coronary ACS Critical Care 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. 61.4.496 Navi BB, Kamel H, Shah MP, et al. Goldmakher GV, Camargo EC, Furie KL, Singhal AB, Roccatagliata L, Halpern EF, et al. link] Burns JD, Rindler RS, Carr C, et al.

EMS 97

EMS ALS OR ACS 97

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-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS. 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.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Knotts et al.

Coronary 52

Coronary ACS STEMI ALS 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 117

STEMI Coronary ACS ED 117

FOAMcast

OCTOBER 17, 2023

” As a result, Jansen et al. ” As a result, Jansen et al. Despite initial enthusiasm for widespread use, there are minimal data suggesting significant mortality benefit. undertook a pragmatic RCT to investigate the use of REBOA in trauma. . undertook a pragmatic RCT to investigate the use of REBOA in trauma. 2023 JAMA.

ACS 52

ACS ALS OR 52

Emergency Medicine Ireland

JULY 3, 2023

Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. To start with there are apparently 5 types of cardiorenal syndrome. I’ll let that sink in. You all thought there was one didn’t you? Nijst, P. &

Critical Care 96

Critical Care ACS OR ALS 96

EMDocs

AUGUST 31, 2023

link] Li Z, Krippendorff BF, Sharma S, Walz AC, Lavé T, Shah DK. Bush SP, Ruha AM, Seifert SA, et al. link] Kanaan NC, Ray J, Stewart M, et al. [link] Full prescribing information. Crotalidae polyvalent immune fab (ovine). Published online January 2018. Accessed August 17, 2023. 2016;8(1):113-119. Published online November 2020.

Allergic Reaction 96

Allergic Reaction Plasma ALS EMS 96

Dr. Smith's ECG Blog

OCTOBER 24, 2019

SCAD isn’t rare, especially in women Historically SCAD had been identified in 22% of ACS cases in women. Pregnancy is not a common cause of SCAD When ACS occurs in the peripartum period, SCAD is responsible in 43% of cases. A study by Hassan et al. A study by Hassan et al. Lobo et al. The SCAD cases in Lobo et al.

Coronary 52

Coronary CAD ACS STEMI 52

FOAMcast

MARCH 27, 2023

References: Metlay JP, Waterer GW, Long AC, et al. ESCAPe found no benefit in their trial of a continuous infusion of methylprednisolone in severely ill patients with CAP). In this podcast episode, we review a new multicenter randomized trial of hydrocortisone in severe CAP.

Critical Care 52

Critical Care ACS ALS 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 ACS OR ALS 130

Dr. Smith's ECG Blog

OCTOBER 28, 2013

Here is an article I wrote: Updates on the ECG in ACS. In left main occlusion, by blocking flow to both the anterior wall (LAD) and posterior wall (circ), the ST depression of posterior ischemia could theoretically diminish the ST elevation of anterior ischemia and leave only V1 with significant ST elevation (Nikus, et al. see below).

Defibrillator 52

Defibrillator ACS CPR 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 96

STEMI Coronary ACS OR 96

ACEP Now

NOVEMBER 7, 2023

References Go AS, Mozaffarian D, Roger VL, et al. Larribau R, Deham H, Niquille M, et al. Margey R, Browne L, Murphy E, et al. Kudenchuk PJ, Brown SP, Daya M, et al. Spies DM, Kiekenap J, Rupp D, et al. Holmén J, Hollenberg J, Claesson A, et al. Yannopoulos D, Bartos J, Raveendran G, et al.

Defibrillator 52

Defibrillator E-9-1-1 ALS Epinephrine 52