The Skeptics' Guide to EM

FEBRUARY 27, 2021

Reference: Brichko et al. Reference: Brichko et al. Case: A 46-year-old female presents to the emergency department (ED) with sudden onset, severe right flank pain. Delays in providing adequate analgesia leads to poorer patient outcomes, prolonged ED length of stay and reduced patient satisfaction (17, 18). AEM Feb 2021.

Emergency Department 130

Emergency Department ACS ALS ED 130

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. Here is the final ECG just prior to ED transfer. It’s important to stress the presence of a normal QRS (i.e., The pathology is now painfully evident.

ACS 130

ACS Coronary STEMI CAD 130

The Skeptics' Guide to EM

JULY 2, 2022

Date: June 30th, 2022 Reference: McGinnis et al. Date: June 30th, 2022 Reference: McGinnis et al. Case: You are working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain. Background: Chest pain is one of the most common presentations to the ED. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

Dr. Smith's ECG Blog

JUNE 17, 2024

In fact, Kosuge et al. Stein et al. This is a paper worth reading : Marchik et al. 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. Witting et al. of patients with PE and 3.3%

E-9-1-1 138

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

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

Don't Forget the Bubbles

JULY 22, 2024

Pre-school wheezers remain a poorly understood cohort of children despite seeing them every day in paediatric EDs. However, there was no difference in LOS (83 minutes for placebo vs 79 minutes for prednisolone) in participants who were discharged straight from the ED ( 32% ). Compare this with the Panickar et al.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Don't Forget the Bubbles

JUNE 14, 2023

Lava SAG, et al. Hsiao W, et al. Mullaly R, et al. Arch Dis Child Fetal Neonatal Ed. Arch Dis Child Fetal Neonatal Ed. Puoti MG, et al. Stenson EK, et al. Bruinsma RA, et al. Rivetti G, et al. van Gameren-Oosterom HBM, et al. Lester TR, et al. Mansell H, et al.

ALS 119

ALS ACS ED OR 119

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 79

E-9-1-1 ACS ALS OR 79

The Skeptics' Guide to EM

MAY 29, 2021

Reference: Jhunjhunwala et al. Reference: Jhunjhunwala et al. Upon arrival in the emergency department (ED), the patient is incoherently speaking, has a pulse of 135 beats per minute, blood pressure of 85/50 mm Hg, and an obvious open wound in their left mid-axillary line at the level of the nipple.

Emergency Medical Services 130

Emergency Medical Services ACS ALS Emergency Department 130

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

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 76

ACS E-9-1-1 ALS OR 76

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. The writing group of GRACE-2 wanted to look at clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED. Reference: Broder et al.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

Dr. Smith's ECG Blog

DECEMBER 5, 2023

An ECG was perfomed on arrival to our ED: NSR with ST elevation II,III, aVF with reciprocal depression in aVL Would you refer this pediatric patient for emergent PCI? Pediatric cardiology performed a bedside echo in ED with EF estimation of 60%, no pericardial effusion, and no regional wall motion abnormalities. Epub 2021 May 20.

Coronary 112

Coronary CAD ACS ALS 112

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. 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.

Coronary 100

Coronary E-9-1-1 STEMI ACS 100

EMS 12-Lead

APRIL 8, 2022

1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. However, in this context (i.e. cessation of symptoms), and in this unique territory (V2-V4), the T-wave characteristics are consistent with posterior reperfusion! [1] 1] Driver, B. 3] Niu, T.,

STEMI 130

STEMI ALS Coronary CAD 130

REBEL EM

DECEMBER 23, 2024

To assess the clinical impact and relevance of these concerns, Alwang et al. Paper: Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. Applicability to Emergency Medicine: For emergency medicine providers, the greatest challenge with this study is that it did not include or account for ED care. Sickle Cell Disease in the ED.

ALS 82

ALS ED ACS EMR 82

EMDocs

SEPTEMBER 25, 2023

However, RSI has never been shown to reduce the risk of aspiration in the ED (13) or during emergent OR cases (14). While RSI should remain the gold standard in the vast majority of patients in the ED, FI presents an additional technique to mitigate anatomic or physiologic risk. To date, ketamine has been the agent of choice (12).

ED 66

ED Emergency Department ALS Paramedic 66

Don't Forget the Bubbles

JULY 5, 2023

Haematology specialist clinics are key to manage the chronic side of the disease, while ED doctors should be able to act rapidly on the common acute emergencies. with thanks A 15-month-old Kenyan boy presents to ED with right hand swelling. A 10-year-old boy with known SCA presents to ED due to severe pain in the legs.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

EMS 12-Lead

JUNE 1, 2022

He advises, however, recurrent syncopal episodes for the past six months, some of which have resulted in ED admission, yet no identifying mechanism could be determined. Chou’s Electrocardiography in Clinical Practice (6th ed). Josephson’s Clinical Cardiac Electrophysiology: Techniques and Interpretations (6th ed). 2] Meyers, H.

Coronary 130

Coronary ALS ED ACS 130

EMS 12-Lead

APRIL 21, 2022

The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. Such aggressive investigation was particularly warranted in this case because of symptoms compatible with ACS, as well as an equally frightening revelation of family history. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

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. Figure-1: I've labeled the initial ECG in the ED. KEY Point: All patients who present to the ED for new CP should promptly have a triage ECG recorded, that is then immediately interpreted by the ED physician.

STEMI 102

STEMI Coronary ACS ED 102

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

EMDocs

OCTOBER 8, 2024

Episode 108: Unexplained Sinus Tachycardia Mental Model Background: When a patient in the ED has sinus tachycardia our job as emergency physicians is to identify and treat of the underlying pathology. Lactate Troponin Could this be ACS or myocarditis? In the ED, our job is to identify and treat underlying causes. Ann Emerg Med.

E-9-1-1 96

E-9-1-1 Emergency Department ED ALS 96

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. In our opinion it should not be given in ACS unless you are committed to the cath lab. Hayakawa A, Tsukahara K, Miyagawa S, et al.

ACS 87

ACS Coronary ALS CAD 87

REBEL EM

OCTOBER 23, 2023

His parent noticed a dental problem and immediately brought the patient to the ED. The patient was walking his dog when it ran after a squirrel. The patient was pulled forward, causing him to hit his tooth on the asphalt. The physical exam is shown below. Which of the following is the best next recommendation? Dent Traumatol.

EMS 58

EMS ACS ALS ED 58

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. Chou’s Electrocardiography in Clinical Practice, 6th ed. 4] Baranchuk, A, et al. Goldberger’s Clinical Electrocardiography: A Simplified Approach, 9th ed. 2] Surawicz, B.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present." The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al. We therefore need to assume and rule "out" ACS — more than having to rule it "in".

E-9-1-1 117

E-9-1-1 OR Coronary ACS 117

Dr. Smith's ECG Blog

MARCH 19, 2024

The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." The cath report showed: Significant stenosis with subtotal occlusion (99%) in the prox to mid Lcx, culprit of ACS, TIMI flow 1. 2021;23:187.

CAD 90

CAD STEMI ACS ALS 90

Don't Forget the Bubbles

OCTOBER 2, 2024

Children often spend many hours in the emergency department (ED) before being sent home or admitted. The average waiting time for the first assessment was only a few minutes shorter when going through the ED. Still, treatment initiation was significantly faster (up to one hour) than admission through the ED. Pecenka C, et al.

ALS 52

ALS Emergency Department ED ACS 52

EMDocs

JUNE 27, 2024

An 8-year old male with a history of sickle cell anemia presents to the ED for evaluation of fever for 2 days and “feeling like I can’t get a full breath”. 768: Epidemiology of Hospital Based ED Visits due to Sickle Cell Crisis and Acute Chest Syndrome in Kids. Alkindi S, Al-Busaidi I, Al-Salami B, Raniga S, Pathare A, Ballas SK.

E-9-1-1 76

E-9-1-1 ICU ACS EMS 76

Dr. Smith's ECG Blog

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. Herzog et al. Khan et al.

STEMI 82

STEMI ACS OR ALS 82

EMDocs

SEPTEMBER 24, 2024

Key: Consider eclampsia in any pregnant and postpartum woman presenting to the ED, especially in patients with symptoms such as headache, confusion/altered mental status, vision changes, and hypertension. ED Evaluation: Assessment focuses on looking for complications and mimics. Wilkerson RG, Ogunbodede AC. 2019;37(2):301-316.

ED 83

ED OR ACS ALS 83

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

ECG 1 at time zero EARLY REPOLARIZATION ABNORMAL ECG ED final official overread: "early repol vs hyperacute T, minimal changes from previous (previous shown below)" What do YOU think? Lemkes et al. No wall motion abnormality This shows that significant ACS can have ZERO WMA!! A 70-something y.o. Eur Heart J 2018. Full text link.

STEMI 114

STEMI ACS Critical Care Coronary 114

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. After all, there is no S wave in lead V3.

E-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

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

AUGUST 9, 2019

Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded. She had a proven 100% Left Main occlusion No ST shift in aVR This pattern of RBBB/LAFB was also the most common pattern in Fiol et al. Widimsky P et al. Knotts et al. TIMI 0/1 flow).(61,62)

Coronary 52

Coronary STEMI ACS ALS 52

EMDocs

JUNE 7, 2023

F, HR 48, RR 28, BP 104/62, SPO2 88% on non-rebreather mask The patient’s friend who brought her to the ED tells you the patient made suicidal statements earlier in the day and was found in her yard shed. These are send-out labs with turn-around times that make them unlikely to affect the ED course or guide treatment. BMC Res Notes.

E-9-1-1 84

E-9-1-1 ICU Emergency Department ED 84