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

Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. She arrives in the emergency department (ED) with decreased level of consciousness and shock. She has a history of hypertension and non-insulin dependent diabetes mellitus.

EMR 130

EMR Coronary Defibrillator Life Support 130

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 126

CAD STEMI Coronary ACS 126

Dr. Smith's ECG Blog

AUGUST 10, 2023

Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLaren A 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. The pain improved (6/10) but is persisting, which prompted him to visit the Emergency Department. Shroff, G.

STEMI 89

STEMI ACS Emergency Department ED 89

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. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 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.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

The Skeptics' Guide to EM

MAY 29, 2021

The patient is an adult male with a gunshot wound to the chest, and they’re combative with emergency medical services (EMS). 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).

Emergency Medical Services 130

Emergency Medical Services ACS ALS Emergency Department 130

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI 104

STEMI Coronary ACS ED 104

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. Ann Emerg Med. JAMA Intern Med.

Emergency Department 52

Emergency Department ICU ALS ACS 52

ALiEM

FEBRUARY 9, 2024

Encourage your ED to set up an algorithm that you can follow based on your laboratory’s assay. Low-risk patients do not routinely require stress testing in the ED. You (or someone in your department) needs to know which assay your ED has, and use the appropriate values for that assay.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

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. Am J Emerg Med. C or 100.4 mg/kg, max 0.4 Hosp Pract (1995).

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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 7, 2023

F, HR 48, RR 28, BP 104/62, SPO2 88% on non-rebreather mask The patient’s friend who brought her to the ED tells you the patient made suicidal statements earlier in the day and was found in her yard shed. These are send-out labs with turn-around times that make them unlikely to affect the ED course or guide treatment. BMC Res Notes.

E-9-1-1 83

E-9-1-1 ICU Emergency Department ED 83

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. paramedic transportation to the ED as “chest pain, STEMI negative” 2. Kontos et al. Welsh et al.

STEMI 62

STEMI Coronary Paramedic ALS 62

Dr. Smith's ECG Blog

MARCH 20, 2023

I finished my residency of Emergency Medicine and I’m working at a great Emergency Department here in Brazil. Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Since then, I started looking for OMI EKG findings and not just STEMI. Risk Factors: High Cholesterol.

STEMI 52

STEMI ACS CAD ED 52

EMDocs

JUNE 14, 2023

These are send-out labs with turn-around times that make them unlikely to affect the ED course. This prevents ongoing exposure to the patient and ED staff. In: Mattu A and Swadron S, ed. Parenteral organophosphorus poisoning in a rural emergency department: a case report. Pesticides and Cholinergics. CorePendium.

E-9-1-1 70

E-9-1-1 Emergency Department Plasma ED 70

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.

Defibrillator 133

Defibrillator Coronary STEMI CPR 133

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

Dr. Smith's ECG Blog

APRIL 17, 2023

One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. He had no symptoms of ACS. The remainder of his Emergency Department stay was uneventful. QOH: "OMI High confidence".

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. At the time of arrival to the ED, the patient reported 1/10 chest pain with normal vital signs. There is no age cut-off for ACS. 1] Wereski, R.,

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

An ECG was recorded quickly on return to the ED: (sorry for poor quality, cannot get originals) What do you think? On arrival to the PCI center's Emergency Department, the receiving team recorded an ECG on arrival: Persistent atrial flutter, however this time the QRS occurs on a slightly different portion of the flutter wave.

STEMI 52

STEMI ACS Coronary Emergency Department 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. We don’t want to go backwards!

ED 65

ED Emergency Department ALS OR 65

Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG: What do you think?

ACS 52

ACS Coronary Defibrillator STEMI 52

Pediatric EM Morsels

APRIL 19, 2024

Trauma season is at hand and like all other pediatric emergency departments in the country, we find our ED breaking ( pun intended ) at the seams with orthopedic injuries. Pediatr Emerg Care. We see all different flavors of upper extremity injuries. J Bone Joint Surg Br. 2001;83:1173-5. Oakley EA, Ooi KS, Barnett PLJ.

ALS 285

ALS ACS Emergency Department ED 285

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). Amiodarone versus digoxin for acute rate control of atrial fibrillation in the emergency department. Am J Emerg Med. Paper: Mason JM, et al.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

REBEL EM

SEPTEMBER 11, 2023

1 It is a quickly deployable and easily interpreted study that can be done in real time to guide decisions in the Emergency Department. However, many institutions’ surgical teams still require or request a formal study over a bedside exam, likely due to a lack of confidence in the accuracy of POCUS, resulting in longer ED stays.

ED 61

ED ACS Emergency Department OR 61

EMDocs

OCTOBER 21, 2023

The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. Median time from ED arrival to diagnosis was 8 hours 24 min in one study, with only 19% being diagnosed within the 4.5-hour Post TW, ed. NIHSS does have limitations when applied to posterior circulation (PC) strokes. Neurohospitalist.

EMS 74

EMS ALS OR ACS 74

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. Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." References: 1.

Emergency Department 52

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

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

ACEP Now

AUGUST 12, 2024

A 35-year-old male presented to the emergency department complaining of chest pain that started 1.5 FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. Dr. Young is an emergency physician at Saint Francis Hospital and Medical Center, Hartford, Conn. Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

AUGUST 26, 2019

She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? I wouldn't activate the lab for this EKG alone, but if the patient is clinically compatible with ACS you could call a heart alert.

STEMI 52

STEMI Coronary OR ED 52

The Skeptics' Guide to EM

MAY 28, 2022

Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department.

Emergency Department 100

Emergency Department ALS ACS Coronary 100

Dr. Smith's ECG Blog

OCTOBER 3, 2018

For some reason unknown to me, the interventionalist was in the ED. The Smith-Modified Sgarbossa Criteria Accurately Diagnose Acute Coronary Occlusion in Emergency Department Patients With Ventricular Paced Rhythm. , he recorded another: time 20 minutes It actually looks a bit better, but still diagnostic of LAD occlusion.

Coronary 52

Coronary STEMI Paramedic ALS 52

EMDocs

JANUARY 6, 2024

Louis, MO) // Reviewed by: Sophia Görgens, MD (EM Physician, Northwell, NY); Cassandra Mackey, MD (Assistant Professor of Emergency Medicine, UMass Chan Medical School); Brit Long, MD (@long_brit) Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics.

EMS 63

EMS E-9-1-1 ACS Coronary 63

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior.

E-9-1-1 119

E-9-1-1 OR Coronary ACS 119

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. of Cardiology AC, Others.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 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. He is the founder and host of Emergency Medicine Cases podcast and website. References Deshwal H, Sinha A, Mehta AC. Am J Emerg Med. A special thanks to Drs. 2021;42(1):145-159.

E-9-1-1 52

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