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. The proportion of patients with ACS at the index visit or within 30 days. *

ACS 130

ACS Coronary Emergency Department ALS 130

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

EMS 12-Lead

AUGUST 18, 2024

David Didlake EMT-P, RN, ACNP @DidlakeDW An adult male self-presented to the ED with palpitations and the following ECG. I interpreted the ECG as VT with two primary etiological possibilities: 1. Abrupt plaque ulceration of Type 1 ACS leading to VT. The patient was very uncomfortable, dyspneic, and displayed an SpO2 90% on RA.

CAD 147

CAD EMT EMT ACS 147

FOAMfrat

APRIL 25, 2024

They also discuss the challenges of pulse palpation and the need for more rigorous research in EMS and ED settings. References: Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J. They emphasize the importance of confirming electrical capture before assuming mechanical capture.

Paramedic 128

Paramedic ACS EMS ED 128

ALiEM

AUGUST 30, 2024

A 5-year-old female presented to the emergency department (ED) with a one-year history of gradually increasing anterior neck swelling. She was discharged from the ED on levothyroxine 25 mcg daily with endocrinology outpatient follow-up. The patient had no significant past medical history. Pediatric neck masses. Pediatr Rev.

ACS 161

ACS Emergency Department ED OR 161

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

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. In prior decades nearly all patients presenting to EDs with chest pain were admitted to hospital. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

Dr. Smith's ECG Blog

JULY 25, 2024

The patient was brought to the ED and had this ECG recorded: What do you think? Then assume there is ACS. After 1 mg of epinephrine they achieved ROSC. Total prehospital meds were epinephrine 1 mg x 3, amiodarone 300 mg and 100 mL of 8.4% sodium bicarbonate. And what do you want to do?

Defibrillator 116

Defibrillator Coronary Epinephrine ACS 116

The Skeptics' Guide to EM

FEBRUARY 27, 2021

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. Reference: Brichko et al.

Emergency Department 130

Emergency Department ACS ALS ED 130

Dr. Smith's ECG Blog

JUNE 17, 2024

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. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with Acute PE (p less than 0.001).

E-9-1-1 140

E-9-1-1 ACS Emergency Department Coronary 140

Dr. Smith's ECG Blog

MAY 3, 2024

But this time the Queen gets it wrong (thinks it is not OMI): There were runs of VT: Tha patient arrived in profound shock and had an ED ECG: Now there is some evolution to include the ST elevation (rather than ST depression) in V4-V6. RBBB + LAFB in the setting of ACS is very bad. Posterior and high lateral OMI. Learning Points: 1.

ACS 120

ACS ED Coronary EMS 120

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

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). She arrives in the emergency department (ED) with decreased level of consciousness and shock.

EMR 130

EMR Coronary Defibrillator Life Support 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). 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. ECG's are difficult. Hyperkalemia revisited.

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

JULY 30, 2023

David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath. This should prompt immediate investigation into supply-demand mismatching, or ACS. She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease.

EMT 130

EMT EMT ACS Coronary 130

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

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? The ST depressions in I and aVL have resolved.

CAD 128

CAD STEMI Coronary ACS 128

Dr. Smith's ECG Blog

MARCH 31, 2024

The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI").

STEMI 97

STEMI ACS ED 97

EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. A 12 Lead ECG was captured on her arrival.

Coronary 130

Coronary ACS CAD ED 130

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

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 118

Coronary CAD ACS ALS 118

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

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

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). Those who make it to the ED usually have transient occlusions with reperfusion.

Coronary 130

Coronary ACS Emergency Department Defibrillator 130

Dr. Smith's ECG Blog

MARCH 13, 2023

This is acute ACS, but it almost always seen in a pain free state. An ED ECG, if recorded with pain, should show LAD OMI. That said — severe chest pain was present at the time the patient arrived in the ED ( corresponding to the time ECG #2 was recorded ).

ED 52

ED ACS Coronary Paramedic 52

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

Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). She contacted her neighbor, a nurse, for help.

E-9-1-1 126

E-9-1-1 ACS Coronary STEMI 126

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. I don't know if her pain was getting better or not.

Coronary 105

Coronary E-9-1-1 STEMI ACS 105

The Skeptics' Guide to EM

MAY 29, 2021

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. Case: You receive a call on the Biocom for an incoming Type A trauma, three minutes out.

Emergency Medical Services 130

Emergency Medical Services ACS ALS Emergency Department 130

The Skeptics' Guide to EM

MAY 28, 2022

AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

Dr. Smith's ECG Blog

APRIL 2, 2024

He was unidentified and there were no records available After 7 shocks, he was successfully defibrillated and brought to the ED. Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. Here is the initial ED ECG. What do you think? Rhythm : Residents asked me why it is not VT. The QRS is extremely wide.

Defibrillator 133

Defibrillator Coronary Epinephrine CPR 133

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% ). Reattendance to GP/ED was more important.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

REBEL EM

DECEMBER 23, 2024

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. Characteristics of sickle cell patients with frequent ED visits and hospitalizations. JAMA Intern Med.

ALS 82

ALS ED ACS EMR 82

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

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. Link to abstract Link to full text 2) Use of Morphine in Non-STE-ACS is independently associated with mortality, at odds ratio of 1.4

E-9-1-1 82

E-9-1-1 ACS STEMI Coronary 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! 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

Dr. Smith's ECG Blog

MARCH 8, 2019

Jerry Jones commented: "Any ST depression on the ECG of a patient with chest pain credible for ACS represents a reciprocal change until proved otherwise." For clarity — I show in Figure-1 the i nitial E CG obtained in the ED ( = E CG # 1 ) — together with the p rehospital E CG that I have pieced together ( = E CG # 2 ).

ED 52

ED STEMI ACS OR 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

A middle-aged man complained of 15 minutes of classic angina that resolved upon arrival to the ED. 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. Figure-1: The initial ECG that was done in the ED ( See text ).

ED 52

ED Coronary ACS CAD 52

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." As a result, even before looking at this patient's initial ECG — he falls into a high -prevalence likelihood group for ACS ( for an A cute C oronary S yndrome ). Repeat cTnI drawn at around 8 AM was 3.910 ng/mL.

E-9-1-1 122

E-9-1-1 OR Coronary ACS 122