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. Type 2 MI is common in the ED and can result from vigorous exercise (common in athletes after marathons), sepsis, trauma and tachydysrhythmias including SVT.

Coronary 143

Coronary ACS ED OR 143

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 65

ED Emergency Department ALS Paramedic 65

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

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

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

SEPTEMBER 11, 2021

Date: September 8th, 2021 Reference: Desch et al. Date: September 8th, 2021 Reference: Desch et al. He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP).

EMR 130

EMR Coronary Defibrillator Life Support 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 OR 85

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. Reference: Wang et al. The utility of troponin testing to diagnose or exclude ACS. *

ACS 130

ACS Coronary Emergency Department OR 130

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

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

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

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 105

Coronary E-9-1-1 STEMI ACS 105

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 59

EMS ACS ALS ED 59

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

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

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 116

Coronary CAD ACS ALS 116

ACEP Now

OCTOBER 11, 2024

ED treatment should focus on airway, breathing, and circulation with consideration for cervical spine protection depending on the circumstances surrounding the event. References Webb AC, Wheeler A, Ricci A, et al. Pellegrino F, Raffaldi I, Rossi R, et al. Chotai PN, Manning L, Eithun B, et al. South Med J.

ALS 52

ALS Emergency Department Emergency Medical Services ED 52

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 95

E-9-1-1 Emergency Department ED ALS 95

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

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

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC. 2023 Jul 17.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

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

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

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 83

ACS Coronary ALS CAD 83

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.

ACS 52

ACS Coronary STEMI ALS 52

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 ACS ED 130

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 82

ED OR ACS ALS 82

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 107

STEMI Coronary ACS ED 107

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 75

E-9-1-1 ICU ACS EMS 75

ACEP Now

AUGUST 12, 2024

FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. Click to enlarge.) Click to enlarge.) Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52

ACEP Now

NOVEMBER 14, 2023

One of the most hair-raising presentations to the emergency department (ED) can be massive hemoptysis with respiratory failure. References Deshwal H, Sinha A, Mehta AC. Atchinson PRA, Hatton CJ, Roginski MA, et al. Ittrich H, Bockhorn M, Klose H, et al. Li H, Ding X, Zhai S, et al. Wand O, Guber E, Guber A, et al.

E-9-1-1 52

E-9-1-1 ALS Emergency Department OR 52

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

ACEP Now

MAY 9, 2024

It has been well over a year since the controversial publication of the Agency for Healthcare Research and Quality (AHRQ) report on diagnostic errors in the emergency department (ED). percent of ED visits resulted in preventable death as result of diagnostic error. References Newman-Toker DE, Peterson SM, Badihian S, et al.

Emergency Department 52

Emergency Department ICU ALS ACS 52

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). Paper: Mason JM, et al. The average time to control HR in the IV amiodarone was 1.7h, which is usually the average time for disposition from the ED. Am J Emerg Med.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

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 93

CAD STEMI ACS ALS 93

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 91

STEMI ACS OR ALS 91

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-9-1-1 122

E-9-1-1 OR Coronary ACS 122