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 99

ICU ALS ACS EMS 99

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

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 109

Coronary ACS ALS OR 109

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

SEPTEMBER 11, 2021

Date: September 8th, 2021 Reference: Desch et al. Date: September 8th, 2021 Reference: Desch et al. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients.

EMR 130

EMR Coronary Defibrillator Life Support 130

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 Emergency Department 52

The Skeptics' Guide to EM

MAY 25, 2019

Date: May 23rd, 2019 Reference: Joseph et al. Date: May 23rd, 2019 Reference: Joseph et al. 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]. Reference: Joseph et al. JAMA Surgery March 2019.

ACS 130

ACS Emergency Department ALS OR 130

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). ACE inhibitors, or potassium-sparing diuretics), are particularly susceptible. In the case of ACS, the ECG can rapidly change from this. link] [1] Zachary et al. ECG's are difficult. 2] Costanzo, L.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

DECEMBER 12, 2022

You must understand this and the dynamic nature of ACS to provide excellent care for such patients. Here is the OMI progression of ECG findings for review: You can see that OMI ECG findings must "deflate" and pass through normal or near-normal in order to get to reperfusion findings. This is termed " pseudo-normalization."

OR 52

OR ACS STEMI Coronary 52

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., Click to enlarge.)

STEMI 52

STEMI Coronary ACS Critical Care 52

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. It is not yet available, but this is your way to get on the list. I don't know if her pain was getting better or not.

Coronary 103

Coronary E-9-1-1 STEMI ACS 103

Dr. Smith's ECG Blog

DECEMBER 5, 2023

A final ECG was perfomed on hospital day 2: Persistent ST elevation in the inferior leads with slight reciprocal ST depression in aVL Teaching points - It is essential to consider ACS in all age groups. While ACS may be less common in the pediatric population, it is important to consider risk factors that may make OMI more likely (e.g.,

Coronary 115

Coronary CAD ACS ALS 115

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 ALS ACS ED 130

Don't Forget the Bubbles

JUNE 14, 2023

Lava SAG, et al. Hsiao W, et al. Mullaly R, et al. 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. Fernandes AER, et al. Wolstencroft J, et al. Roodbol J, et al.

ALS 118

ALS ACS ED OR 118

FOAMcast

OCTOBER 17, 2023

” As a result, Jansen et al. ” As a result, Jansen et al. ” However, “REBOA is less invasive than resuscitative thoracotomy and in skilled hands may be more rapidly applied as compared with resuscitative thoracotomy.” undertook a pragmatic RCT to investigate the use of REBOA in trauma. . 2023 JAMA.

ACS 52

ACS ALS OR 52

ACEP Now

MARCH 14, 2024

Current can be alternating current (AC) or direct current (DC) with AC typically more dangerous as it is more likely to cause tetanic contractions and increase contact time with the electrical source. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

The Skeptics' Guide to EM

MAY 29, 2021

Reference: Jhunjhunwala et al. Reference: Jhunjhunwala et al. According to a recent study in the Journal of Surgical Research [3] , 44% of all penetrating thoracic trauma patients presented to a non-trauma center (not a level 1 or level 2 ACS defined trauma center). Journal of Trauma and Acute Care Surgery.

Emergency Medical Services 130

Emergency Medical Services ACS ALS Emergency Department 130

EMS 12-Lead

APRIL 8, 2022

Smith and Meyers found that patients presenting with high-risk ACS and any ST-depression, even less than 1 mm, maximal in leads V1-V4 to be 97% specific for OMI and 96% specific for OMI requiring emergent PCI. [5] He reported to EMS a medical history of GERD only. He left AMA and is lost to follow-up. ST-elevation, Hyperacute T waves, etc.)

STEMI 130

STEMI ALS Coronary CAD 130

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. Anything more on history?

Coronary 52

Coronary ACS STEMI ALS 52

EMDocs

JUNE 27, 2024

Left lower lung field end demonstrates expiratory wheezing on auscultation. Other lung fields unremarkable. smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02 mg/kg, max 0.4 C or 100.4

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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 69

Emergency Department ALS ACS EMS 69

Dr. Smith's ECG Blog

AUGUST 9, 2024

Similarly, the OMI paradigm respects ACS as a dynamic process in which ECG changes reflect the phase of myocardial injury and risk stratify which patients may benefit from emergent PCI. Bigger et al. Sadowski ZP, Alexander JH, Skrabucha B, et al. Bigger JR Jr, Dresdale RJ, Heissenbuttel RH, et al. Leave it alone.

STEMI 88

STEMI Coronary Heart Attack ACS 88

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. He was diagnosed as NSTEMI.

ACS 87

ACS Coronary ALS CAD 87

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

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. Smith comment: No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matter how normal the ECG. His angiogram is shown below.

ACS 109

ACS ALS OR STEMI 109

EMS 12-Lead

APRIL 21, 2022

He reports to staff that for the past two months, approximately, he has experienced intermittent dyspnea on exertion when walking the dog, particularly when scaling an incline. He admits to a mostly sedentary lifestyle, however denies any smoking, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema. Here is the time-zero ECG (0939 hours).

Coronary 130

Coronary ALS OR ACS 130

EMS 12-Lead

JUNE 1, 2022

In isolation, however, syncope does not hold significant weight for OMI – as opposed to something like crushing chest discomfort, for example – although stereotypical ACS might become blurry in both the elderly and diabetic populations. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated.

Coronary 130

Coronary ALS Firefighter 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!! There are also subtly hyperacute T-wave in I, aVL, and V2-V6. There is also a very negative (reciprocally inverted) T-wave in lead III, and a down-up T-wave in aVF, both of which are highly suggestive of occlusion of the LAD or D1. Am Heart J.

STEMI 115

STEMI ACS Critical Care OR 115

EMDocs

SEPTEMBER 6, 2023

2016 study published in American Journal of Emergency Medicine , “ Urinary obstruction is an important complicating factor in patients with septic shock due to urinary infection ” by Reyner et al. Reference: Reyner K, Heffner AC, Karvetski CH. IV fluids administrated, IV vancomycin and piperacillin-tazobactam. Am J Emerg Med.

ACS 71

ACS ICU EMS ALS 71

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. 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. Herzog et al. Khan et al.

STEMI 85

STEMI ACS OR ALS 85

Pediatric EM Morsels

AUGUST 18, 2023

References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. When you read the Morsel on Perichonditis of the ear last week ( or perhaps the Plantar Puncture Morsel from many many many weeks ago ) you may have objected because of the mention that, when indicated, fluroquinolones are safe in children. Which is a risk of 1 event for 62.5

E-9-1-1 130

E-9-1-1 OR ACS ALS 130

Dr. Smith's ECG Blog

JUNE 19, 2023

Armstrong et al. ST depression maximal in V1-V4, without a QRS abnormality clearly causing it, in the setting of ACS symptoms, is very concerning for posterior MI until proven otherwise. Here is his triage ECG which was obtained at 20:34 during active pain. What do you think? mm STE in III, and possibly 0.5 Just another NSTEMI.

STEMI 52

STEMI ACS Coronary Defibrillator 52

EMDocs

OCTOBER 21, 2023

More common in the setting of atherosclerotic lesions than emboli, which typically occur with sudden onset of symptoms. Symptoms may range from days to months prior to stroke onset. As many as two-thirds of patients with BAO experience prodromal symptoms, including TIAs, minor strokes, or other symptoms.

EMS 74

EMS ALS OR ACS 74

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. Fortunately, that is exactly what happened.

E-9-1-1 122

E-9-1-1 Coronary ACS BLS 122

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

Emergency Medicine Ireland

JULY 3, 2023

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? Type 2 is the slow and chronic deterioration of kidney function in the chronically failing heart. Nijst, P. &

Critical Care 96

Critical Care ACS OR ALS 96

ACEP Now

MAY 9, 2024

Taking a different approach than the authors of the AHRQ report, Auerbach et al used a “look back” approach to perform both qualitative and quantitative evaluations of the types and frequencies of errors occurring in hospital settings. References Newman-Toker DE, Peterson SM, Badihian S, et al. Auerbach AD, Lee TM, Hubbard CC, et al.

Emergency Department 52

Emergency Department ICU ALS ACS 52