Pediatric EM Morsels

AUGUST 18, 2023

Myth #1: Musculoskeletal Adverse Events (MAE) This concern is likely the most common reason fluoroquinolones are rarely used in children. Musculoskeletal Adverse Events include: Articular cartilage damage causing arthralgias or arthritis , Tendonitis , and Tendon rupture. Which is a risk of 1 event for 62.5 Binz 2015).

E-9-1-1 130

E-9-1-1 ACS OR ALS 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. Even in patients whose moderate stenosis undergoes thrombosis, most angiograms show greater than 50% stenosis after the event. Lindahl et al.

Coronary 102

Coronary E-9-1-1 STEMI ACS 102

Don't Forget the Bubbles

JULY 5, 2023

Opioids do not cause ACS but they can exacerbate hypoxia in patients with ACS. Older children and adults usually present with ACS 2-3 days after hospitalisation due to pulmonary infarction (in situ sickling), hypoventilation due to rib infarction (which may be exacerbated by recent narcotic administration) or fat embolism.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

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 109

ACS ALS OR STEMI 109

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. This is not the case.

E-9-1-1 121

E-9-1-1 Coronary ACS BLS 121

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 86

ACS Coronary ALS CAD 86

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. Whether this represents a potential acute cardiac event would depend on the history, comparison with prior tracings and serial tracings. 4] Baranchuk, A, et al. 2] Surawicz, B.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Lemkes et al. No wall motion abnormality This shows that significant ACS can have ZERO WMA!! Impression: In a patient with new symptoms — early repolarization is a diagnosis of exclusion to be made only after you have ruled out the possibility of an acute event. The Proximal LAD thrombus lysed or partially lysed, restoring flow.

STEMI 115

STEMI ACS Critical Care Coronary 115

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. As a result — the onset of any acute event that may have occurred is uncertain. 21, 2017 ).

STEMI 98

STEMI OR ACS ALS 98

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

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 104

STEMI Coronary ACS ED 104

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

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 85

STEMI ACS OR ALS 85

This Podcast Will Kill You

SEPTEMBER 24, 2024

Datz, Christian, et al. ACS omega , 7 (24), pp.20441-20456. Hodgskiss, Malcolm SW, et al. Moalem, Sharon, et al. Olejarz, Jason, et al. “The Great Oxygenation Event as a consequence of ecological dynamics modulated by planetary change.” Wade, Jon, et al. 1991): 28-31. Pietrangelo, A.,

ALS 52

ALS ACS 52

FOAMfrat

OCTOBER 20, 2023

And according to a paper from Russotto et al. titled “Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients from 29 Countries,” at least one major critical event occurred after intubation in 45.2% Of note, in the paper by Russotto et al., are at high risk.

E-9-1-1 52

E-9-1-1 ALS ACS OR 52

EMDocs

JUNE 27, 2024

Alkindi S, Al-Busaidi I, Al-Salami B, Raniga S, Pathare A, Ballas SK. Alghamdi FA, Al-Kasim F, Alshhada F, Ghareeb E, Azmet FR, Almudaibigh A, Baitalmal L, Alnawfal B, Alluqmani R. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. C or 100.4 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02

E-9-1-1 76

E-9-1-1 ICU ACS EMS 76

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. Takotsubo is a sudden event, not one with crescendo angina. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Lindahl et al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

EMDocs

SEPTEMBER 25, 2023

The trade off to using FI for these challenging airways is the consideration of an aspiration event, the initial indication for RSI. First pass success (FPS) is key as increased attempts correlate to increased desaturation (>10%) events (~10% on first attempt, ~30% on second attempt, ~60% for 4+ attempts) (15).

ED 66

ED Emergency Department ALS Paramedic 66

AAEM RSA

APRIL 1, 2021

1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 Holcomb JB, Tilley BC, Baraniuk S, et al.

E-9-1-1 52

E-9-1-1 Plasma ACS ALS 52

Dr. Smith's ECG Blog

MARCH 12, 2018

It is also true that anterior and inferior T-wave inversion could be consistent with reperfusion of a type III wraparound LAD occlusion, despite the fact that Kosuge et al showed that T-wave inversion in lead III is much more likely to be PE than ACS if your differential contains nothing else. Stein et al. Kosuge et al.

ACS 40

ACS Coronary ALS ICU 40

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! There is profound "inferior" ST Depression.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

The patient would not have been diagnosed with acute coronary syndrome and would not have had an angiogram, would have been discharged (or perhaps had a stress test, which would be negative), and would be at great risk of another event, possibly resulting in death or heart failure. Thelin et al. Mokhtari et al.

E-9-1-1 40

E-9-1-1 STEMI ACS Coronary 40

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Although this is considered a "STEMI equivalent" and the ACC/AHA guidelines even approve of thrombolytics for ACS with this ECG, the usual criteria used to alert the cath lab team of an inbound Code STEMI are not met by this ECG. For instance: sepsis, bleeding, dehydration, hypoxia, and mild ACS. NEJM 362(9):779; March 4, 2009.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). Patel et al., Krucoff et al.) Patel et al. Krucoff et al. Schomig et al. Krucoff et al.) ) to disastrous consequences that may deteriorate before the patient can be rushed to the cath lab. Heart 1996.

STEMI 52

STEMI ALS ACS OR 52

ACEP Now

FEBRUARY 11, 2024

Sodhi M, Rezaeianzadeh R, Kezouh A, et al. Risk of gastrointestinal adverse events associated with glucagon-like peptide-1 receptor agonists for weight loss. Ahmann AJ, Capehorn M, Charpentier G, et al. ACS chemical neuroscience molecule spotlight on Contrave. ACS Chem Neurosci. Bansal AB, Al Khalili Y.

Overdose 52

Overdose ACS Plasma ALS 52

ACEP Now

AUGUST 12, 2024

Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. Sequence of events in angina at rest: Primary reduction in coronary flow. References Noble RJ, Rothbaum DA, Knoebel SB, McHenry PL, Anderson GJ. Arch Intern Med.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." A troponin this high in a patient with no known chronic troponin elevation, and active acute ACS symptoms, has a very high likelihood of type 1 ACS regardless of the ECG.

OR 52

OR STEMI ACS ALS 52

Dr. Smith's ECG Blog

JANUARY 17, 2023

MY Impression of ECG #2: Keeping in mind that the patient in today's case presented with chest pain — the nonspecific ST-T wave flattening in multiple leads, with T wave inversion in lead V2 could be ischemic — albeit clearly not suggestive of an acute event! The January 30, 2018 post — for arterial pulsation artifact.

ALS 52

ALS ACS OR ED 52

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

3–8 Shi et al. Sandoval Y, Smith SW, Sexter A, et al. Shi S, Qin M, Shen B, et al. Guo T, Fan Y, Chen M, et al. Lala A, Johnson KW, Russak AJ, et al. He XW, Lai JS, Cheng J, et al. of Cardiology AC, Others. Sandoval Y, Thordsen SE, Smith SW, et al. Bangalore S, Sharma A, Slotwiner A, et al.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JULY 11, 2019

The more additional leads that we can identify in ECG #1 that show ST-T wave abnormalities — the greater the likelihood that our suspicion for an acute cardiac event ( based on this history + the ST-T wave appearance in leads V2 and V3 ) is correct: The ST-T wave in neighboring lead V 1 of ECG #1 is abnormal. It is not normal to see ≥1.5

STEMI 52

STEMI ACS CAD ED 52

ALiEM

OCTOBER 30, 2024

That discussion can be deferred until the patient is stable, the risk of such an event is mitigated, and other medications can be given for their withdrawal symptoms and pain. Multimodal medication options for fentanyl-xylazine withdrawal management in London et al. DOI: Papudesi BN, Malayala SV, Regina AC. 2024 study [16].

E-9-1-1 161

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

ECG & Echo Learning

JANUARY 18, 2023

I C Glucose-lowering therapy should be considered in ACS patients with glucose levels >10 mmol/L (>180 mg/dL), while episodes of hypoglycaemia (defined as glucose levels <_3.9 I C In patients on metformin and/or SGLT2 inhibitors, renal function should be monitored for at least 3 days after angiography.

STEMI 40

STEMI Coronary OR Defibrillator 40

EMDocs

JANUARY 20, 2024

Answer: Takotsubo Cardiomyopathy 1-18 Background: Also known as transient apical ballooning syndrome, apical ballooning cardiomyopathy, stress-induced cardiomyopathy, stress cardiomyopathy, Gebrochenes-Herz syndrome, and broken-heart syndrome.

E-9-1-1 74

E-9-1-1 EMS Coronary ACS 74

Don't Forget the Bubbles

MAY 3, 2023

Forestell B, Battaglia F, Sharif S, et al. Results of this study showed that the use of low-dose insulin infusion led to similar clinical outcomes and fewer adverse events compared to the standard-dose insulin infusion. units/kg/hr ) is as efficacious as standard-dose, with fewer adverse events. O’Connell et al.

CPR 52

CPR Emergency Department ALS ICU 52

EMDocs

OCTOBER 7, 2023

6 Prolonged down time from falls, usually in the elderly Incidence is difficult to ascertain due to broad definition and that events that cause crush injuries are rather rare. Oda J, Tanaka H, Yoshioka T, et al. Tanaka H, Oda J, Iwai A, et al. Goodman AD, Got CJ, Weiss AC. Chen CY, Lin YR, Zhao LL, et al.

EMS 74

EMS E-9-1-1 Emergency Department ALS 74

Dr. Smith's ECG Blog

JUNE 8, 2023

There were trends toward larger infarct size with delayed angiography, both by cMR and integral high-sensitivity troponin concentration, as well as toward higher rate of major adverse cardiovascular events (MACE) (8.5 Kontos et al. Welsh et al. Busk et al. Eur Heart J 2009 4 Lemkes et al. Int J Cardiol 2016 3.

STEMI 62

STEMI Coronary Paramedic ALS 62