Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. The following ECG was obtained. ECG 1 What do you think? His angiogram is shown below.

ACS 121

ACS ALS OR STEMI 121

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

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. Because the lungs receive 100% of cardiac output, it has been hypothesized that a lower dose of thrombolytic therapy may still be effective with a better safety profile [3][4]. REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

ALS 136

ALS ACS OR CPR 136

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. References: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Guideline-based and restricted fluid resuscitation strategy in sepsis patients with heart failure: A systematic review and meta-analysis [published online ahead of print, 2023 Aug 9]. 2.89, p = 0.01.

E-9-1-1 121

E-9-1-1 ALS ACS ICU 121

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

The patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. At that point, cardiology elected to treat for ACS. The operator documented thoughtful consideration of risks and benefits of stent placement. Initial hscTnI was 10 ng/L (ref. <14).

OR 66

OR Coronary ACS EMS 66

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Click here to sign up for Queen of Hearts Access Given the lack of intracranial hemorrhage, the patient was administered aspirin for suspected ACS and cardiology was consulted. Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) or basilar ischemia. ng/mL and 0.10

STEMI 116

STEMI Coronary Emergency Department ACS 116

NCOAE

DECEMBER 11, 2023

The Eastern Association for the Surgery of Trauma (EAST) , the National Association of EMS Physicians (NAEMSP) , and the American College of Surgeons Committee on Trauma (ACS-COT) all support the recommendation against the use of spinal immobilization in patients with isolated penetrating injuries. to prevent movement of the spine.

OR 52

OR Emergency Medical Technician Emergency Department Emergency Medical Services 52

Pediatric EM Morsels

AUGUST 18, 2023

None of the patients were documented to have joint disease at follow up. 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.

E-9-1-1 130

E-9-1-1 ACS OR ALS 130

EMT Training Station

FEBRUARY 11, 2024

Assessing the Severity The severity of an electrical burn depends on several factors: the type of current (AC or DC), voltage, the pathway of the current through the body, the duration of contact, and the victim’s overall health. The entry and exit wounds are key indicators, but they can be small or hidden under clothing.

EMT 98

EMT EMT Emergency Medical Technician First Aid 98

FOAMfrat

APRIL 22, 2024

While one may argue that nitro really has no mortality benefit in ACS, I have seen patients with CHF present with hyper tension and inferior S-T elevation, in which the providers were scared to even look at the bottle of nitro. References Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J.

E-9-1-1 78

E-9-1-1 ACS Paramedic Critical Care 78

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

Dr. Smith's ECG Blog

MARCH 19, 2024

Cardiology documents their interpretation of ECG in their consult note - “atrial paced with old LBBB” The patient stayed at outside hospital (which does not have cardiac cath capabilities). The cath report showed: Significant stenosis with subtotal occlusion (99%) in the prox to mid Lcx, culprit of ACS, TIMI flow 1.

CAD 111

CAD STEMI ACS ALS 111

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Repeat trop 150 ng/L.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Because the most severe LAD OMIs can cause ischemic failure of the RBB and LAF, any patient with ACS symptoms and new RBBB and LAFB with any concordant STE has LAD OMI until proven otherwise. In EMS2 ECG, the T waves in V5 is possibly hyperacute. Post cath EF was estimated at 15% with severe global hypokinesis, and akinesis of the apex.

STEMI 121

STEMI EMS ACS ED 121

REBEL EM

SEPTEMBER 11, 2023

ACS surgeons appeared to select surgery as their initial choice substantially more frequently than other subspecialties. ACS surgeons would have sent 6/43 patients for ERCP or MRCP (14%), whereas surgical oncologists would have sent a higher percentage of patients for ERCP or MRCP (7/18 or 38.9%). and specificity of 88.0%

ED 68

ED ACS Emergency Department OR 68

Dr. Smith's ECG Blog

AUGUST 9, 2024

He had no previously documented medical problems except polysubstance use. 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. An ECG was obtained shortly after arrival: What do you think?

STEMI 107

STEMI Coronary Heart Attack ACS 107

Emergency Medicine Ireland

JULY 3, 2023

Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. This segues relatively nicely into a section of the document on palliative care. 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.

Critical Care 96

Critical Care ACS OR ALS 96

Dr. Smith's ECG Blog

OCTOBER 2, 2021

After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. We assume that at some point the patient's pain returned, but it is not documented, so exactly when this happened is uncertain. There is no age cut-off for ACS.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JANUARY 9, 2024

Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Cardioversion will address the rhythm problem immediately, also if the chest discomfort subsides when SR is restored, ischemia from ACS becomes much less likely. In either case, prompt cardioversion is indicated.

Coronary 119

Coronary ACS ED OR 119

EM Didactic

OCTOBER 15, 2018

It is worth doing and documenting serial abdomen exams in non-specific abdo pains. References Meltzer AC, Baumann BM, Chen EH, Shofer FS, Mills AM. Abdominal pain is a common ED presentation and one of the top differential for RLQ pain is Acute Appendicitis. The original Alvarado score was on a 10 point scale.

ACS 52

ACS ED OR 52

Dr. Smith's ECG Blog

JULY 3, 2018

The AHA/ACC guidelines recommend emergent cardiac catheterization for patients with concern for ACS and refractory chest pain despite maximum medical therapy defined as aspirin + clopidogrel/ticagrelor + heparin/enoxaparin. link] He was admitted to the cardiology unit for serial troponin measurements and concern for possible ACS.

ACS 52

ACS STEMI Coronary CAD 52

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. 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. What is an S1Q3T3?

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

ESO

OCTOBER 18, 2024

This new feature breaks down the data silos that are inherent in typical prehospital documentation and changes the paradigm of patient care documentation from encounter-based to patient-centric. You’ll now have a holistic view of frequent patients, along with the ability to view previous 12-leads, PCRs and HDE Outcomes.

Mobile Integrated Health 52

Mobile Integrated Health Community Paramedicine Critical Care MIH 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

EMDocs

JANUARY 11, 2024

Brain Oxygenation, Perfusion, Edema, and ICP Statements Takeaway: Avoid 100% oxygen saturation. Instead, target 92-98%. Keep hemoglobin > 7 g/dL. Consider lowering ICP if elevated (head of bed elevation, hyperosmolar therapy, etc.). Valproic acid and levetiracetam are reasonable first-line therapies for EEG or clinical seizure activity.

Critical Care 97

Critical Care E-9-1-1 OR ICU 97

Dr. Smith's ECG Blog

APRIL 14, 2023

It is easy to say this in retrospect, especially not being the one in charge of this overcrowded waiting room full of unseen patients, but an elderly patient with known CAD and ongoing ACS-sounding chest pain despite medical management with positive troponin is already an indication for emergent cath, regardless of the ECG!

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JUNE 27, 2021

If it is maximal in V1-V4, and the patient's presentation in consistent with ACS (as this certainly is), then it is DIAGNOSTIC of Occlusion with 90% specificity (We have an upcoming article that proves this). Angiogram: "ACS - Non ST Elevation Myocardial Infarction. This was not recognized. The patient was started on a nitro drip.

STEMI 40

STEMI ACS Coronary ED 40

Emergency Medicine Ireland

DECEMBER 17, 2020

There is a substantial ANZICS document on tracheostomy that forms the structure for this tasty morsel. doi: 10.21037/acs.2018.03.01. Intensivists have embraced the tracheostomy as an ICU procedure. It’s one of the most invasive and one of the riskier procedures we do. Surgical anatomy of the trachea. Ann Cardiothorac Surg.

Critical Care 40

Critical Care ACS ICU OR 40

Dr. Smith's ECG Blog

MARCH 8, 2021

Since ACS is so dynamic, with thrombi forming and lysing continuously, and because the ECG and angiogram are rarely simultaneous, it is probable that de Winter's T-waves are recorded in a window when the artery is barely open. This is the longest lasting I have ever documented a hyperacute T wave without going "up" or "down."

STEMI 52

STEMI ACS Critical Care OR 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. It is proven better than angiography alone in stable angina , and also has been shown to improve decisions on stenting non-culprit lesions in ACS. We need to do some more investigation.

ED 52

ED Coronary ACS CAD 52

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

ACEP Now

FEBRUARY 11, 2024

There have been documented cases of overdose, and of note, there is no known antidote. Given the fact that he has not had these headaches before and has diffuse symptoms including weakness, lab work and head imaging are obtained. There were no acute findings on head CT.

Overdose 52

Overdose ACS Plasma ALS 52

Dr. Smith's ECG Blog

APRIL 4, 2023

As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. As cardiology documented, “possible STEMI. Most importantly , while waiting for the paradigm to evolve, maintain focus on our true goal for our patients with ACS: to identify and reperfuse patients with acute occlusion MI.”

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

We can see that there is evolution of the elevations, worsening reciprocal change, as well as evolution of posterior involvement (right precordial R-waves with ST depression) There was very little documentation surrounding these ECGs. Beware of ACS presenting with atypical symptoms, including absence of chest pain.

STEMI 52

STEMI ACS Emergency Department OR 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

It is true that other documents occasionally describe "abnormal ST segment elevation" in the posterior leads (commonly accepted criteria is 0.5 mm in just one lead V7-9), but as far as I can tell all of these documents specifically avoid calling this condition STEMI and specifically avoid using any terminology similar to "STEMI equivalent."

STEMI 52

STEMI E-9-1-1 ACS OR 52

Dr. Smith's ECG Blog

JUNE 28, 2019

If a patient presents with symptoms of ACS, has an elevated troponin, and has persistent symptoms in spite of medical therapy [antiplatelet, antithrombotic, and anti-ischemic (nitro)], then cath lab activation is indicated regardless of ECG findings. 99% of inferior OMI are either obvious or have some amount of ST depression in aVL.

Coronary 52

Coronary ACS ED OR 52

Dr. Smith's ECG Blog

JULY 19, 2019

This prompted a repeat ECG (we do not have documentation from that time to tell us whether he had persistent, recurrent, or absent pain): Progression of anterior OMI to full Q-wave MI with large pathologic Q-waves in V2-V4 with persistent STE which now meets STEMI criteria (after full thickness infarction/stunning). ng/mL (very elevated).

STEMI 52

STEMI ED ACS OR 52