REBEL EM

MARCH 2, 2023

REBEL Cast Ep114 – High Flow O2, Suspected ACS, and Mortality? PMID: 33653685 Clinical Question: Is there an association between high flow supplementary oxygen and 30-day mortality in patients presenting with a suspected acute coronary syndrome (ACS)? Click here for Direct Download of the Podcast Paper: Stewart, RAH et al.

ACS 52

ACS Coronary STEMI Ambulance 52

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

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. If the patient continues to have symptoms concerning for ACS, troponin testing should be pursued. SVT is not a presenting dysrhythmia consistent w/ ACS.

Coronary 143

Coronary ACS ED OR 143

EMDocs

OCTOBER 21, 2023

We’ll keep it short, while you keep that EM brain sharp. The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. The post EM@3AM: Basilar Artery Occlusion appeared first on emDOCs.net - Emergency Medicine Education. Lancet Neurol 2009; 8:724-730.

EMS 98

EMS ALS OR ACS 98

ALiEM

OCTOBER 30, 2024

Case A patient arrives via EMS from the bus station complaining of fever, vomiting, and back pain. Our experience: It was not long ago that we instructed our staff that: ‘COWS >8, give ’em 8 (mg of buprenorphine).’ DOI: Papudesi BN, Malayala SV, Regina AC. They report insufflating ‘a bundle’ of tranq dope per day.

E-9-1-1 161

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

EMS 12-Lead

JUNE 20, 2022

According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician. According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

JULY 25, 2024

EMS arrived and found him in Ventricular Fibrillation (VF). Then assume there is ACS. This patient was witnessed by bystanders to collapse. They started CPR. He was defibrillated into VT. He then underwent dual sequential defibrillation into asystole. After 1 mg of epinephrine they achieved ROSC. sodium bicarbonate.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. The TOMAHAWK Investigators.

EMR 130

EMR Coronary Defibrillator Life Support 130

EMS 12-Lead

APRIL 14, 2022

He presented to EMS with extreme pallor, Levine sign, diaphoresis, bilateral arm pain, and an apprehensive sense of doom. It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). In the case of ACS, the ECG can rapidly change from this. ECG's are difficult.

ACS 130

ACS Paramedic Coronary ALS 130

REBEL EM

OCTOBER 23, 2023

Follow up with the dentist in the morning Reinsert the tooth and avoid solid food Reinsert the tooth and stabilize it with a bridge Remove the tooth and repair the gingival laceration Remove the tooth and wrap it in saline-soaked gauze FOR THE RIGHT ANSWER CLICK ON THE ROSH REVIEW LOGO BELOW References Day PF, Flores MT, O’Connell AC, et al.

EMS 58

EMS ACS ALS ED 58

Pediatric EM Morsels

SEPTEMBER 20, 2024

The post Hemolytic Uremic Syndrome (HUS): Rebaked Morsel appeared first on Pediatric EM Morsels. 2021 May;232:200-206.e4. doi: 10.1016/j.jpeds.2020.12.077. 2020.12.077. Epub 2021 Jan 5. PMID: 33417918; PMCID: PMC8084908.

Emergency Department 164

Emergency Department ACS ALS EMS 164

Dr. Smith's ECG Blog

MAY 3, 2024

RBBB + LAFB in the setting of ACS is very bad. Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Patients with ACS and RBBB/LAFB usually have a left main vs. proximal LAD. Learning Points: 1.

ACS 127

ACS ED Coronary EMS 127

EMS 12-Lead

AUGUST 18, 2024

I interpreted the ECG as VT with two primary etiological possibilities: 1. Abrupt plaque ulceration of Type 1 ACS leading to VT. Of interest, he specified that he awoke earlier that morning in his usual state of health, then developed chest discomfort, then developed palpitations.

CAD 147

CAD EMT EMT ACS 147

Dr. Smith's ECG Blog

JUNE 17, 2024

Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. 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. looked at consecutive patients with PE, ACS, or neither.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Written by Pendell Meyers A man in his 40s called EMS for acute chest pain that awoke him from sleep, along with nausea and shortness of breath. 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.

STEMI 121

STEMI EMS ACS ED 121

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. REBEL EM: Do Patients with Posterior Epistaxis Managed by Posterior Packs Require ICU Admission? This will be pretty location specific.

ICU 104

ICU ALS ACS EMS 104

EMDocs

SEPTEMBER 6, 2023

Reference: EM@3AM – Heat Stroke Case 2: 40-year-0ld female feels unwell but no other specific complaints. Reference: Reyner K, Heffner AC, Karvetski CH. Complete primary and secondary survey. Start cooling as quickly as you can, and stop at 102. Resuscitate and administer antibiotics. ROS unremarkable. Am J Emerg Med.

ACS 97

ACS ICU EMS ALS 97

EMS 12-Lead

APRIL 8, 2022

He reported to EMS a medical history of GERD only. V2 – in the final EMS ECG the ST segment was baseline. V3 – in the final EMS ECG the ST segment was still slightly depressed. The EMS crews were correct moving forward with STEMI activation. However, in this context (i.e.

STEMI 130

STEMI ALS Coronary CAD 130

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

The Skeptics' Guide to EM

MAY 28, 2022

The SGEM bottom line was there is moderate level of evidence that ACS can be excluded in adult patients with recurrent, low-risk chest pain using a single hs-troponin below a validated threshold without further diagnostic testing in patients who have a CCTA within the past two years showing no coronary stenosis.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

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

EMS 12-Lead

JULY 30, 2023

This should prompt immediate investigation into supply-demand mismatching, or ACS. There is bradycardic Atrial Fibrillation with broad ST-depression in most leads and perceptible ST-elevation in aVR. But there’s some peculiar features about this ECG: The unusually short QT The “scooped out” appearance of the ST-segments.

EMT 130

EMT EMT ACS Coronary 130

Broome Docs

DECEMBER 22, 2024

PARAMEDIC 3 randomized 6,000 (but they were supposed to get to 15,000) patients with out of hospital arrest from multiple EMS agencies in the UK to either an IO or IV to start. PMID: 39480221 We have 2 studies looking at the same question published in the same edition of the NEJM, so I will tackle them together. ( of the IO group and 5.1%

E-9-1-1 52

E-9-1-1 ACS Paramedic Emergency Department 52

Dr. Smith's ECG Blog

MAY 20, 2024

He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? Assuming that was indeed a culprit, then this was ACS. The ST depressions in I and aVL have resolved.

CAD 126

CAD STEMI Coronary ACS 126

Dr. Smith's ECG Blog

AUGUST 11, 2024

As Smith and Meyers explained in a 2020 article in EM News : “What should we do in the meantime while we are still stuck in the STEMI paradigm in daily practice? 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 100

STEMI Paramedic Coronary EMS 100

FOAMfrat

APRIL 22, 2024

Simulation allows EMS clinicians to train for scenarios they may encounter in the field. Depending on the EMS providers, these scenarios may be ones that they have already encountered or those that they have yet to see in real life. False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series.

E-9-1-1 78

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

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. Rezaie, MD (Twitter/X: @srrezaie ) The post Congestive Heart Failure and Sepsis: A Closer Look at Fluid Management appeared first on REBEL EM - Emergency Medicine Blog.

E-9-1-1 121

E-9-1-1 ALS ACS ICU 121

Dr. Smith's ECG Blog

DECEMBER 19, 2023

EMS obtained the following vital signs: pulse 50, respiratory rate 16, blood pressure 96/49. It appears EMS obtained two EKGs, but unfortunately these were not saved in the medical record. The EMS crew was only BLS certified, so EKG interpretation is not within their scope of practice.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

AUGUST 9, 2024

About 2 hours later the patient arrived at a PCI-capable center and repeat ECG was obtained: The transferring EMS crew noted “runs of VT” during transport. 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.

STEMI 107

STEMI Coronary Heart Attack ACS 107

EMS 12-Lead

JULY 24, 2023

Category 1 : Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates. Smith : This is ACS even if the troponin returns normal, and the first troponin especially might return normal. This results in Type I MI.

Coronary 130

Coronary ACS CAD ED 130

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. PMID: 23102885 Aykan AC et al. appeared first on REBEL EM - Emergency Medicine Blog. 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].

ALS 136

ALS ACS OR CPR 136

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%).

ED 68

ED ACS Emergency Department OR 68

EMS 12-Lead

JUNE 1, 2022

EMS finds him supine, alert and oriented, and without any gross distress. 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.

Coronary 130

Coronary ALS ED ACS 130

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

EMS arrived — and recorded 2 ECGs. I added dotted RED lines at the transition between leads V2 and V3 in both of the prehospital ECGs to highlight this common featur e in EMS tracings — in which large QRS complexes will often be truncated. 14 minutes later — ECG #2 was recorded by EMS. So they looked into the patient's chart.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Dr. Smith's ECG Blog

APRIL 2, 2024

I was there and said, "No, I think this is all due to severe chronic cardiomyopathy and cardiac arrest due to primary ventricular fibrillation, not due to ACS." _ Why did I say that? Patient received 11 shocks by ICD and was in V-fib when EMS arrived. So we should activate the cath lab, right? The QRS is extremely wide.

Defibrillator 133

Defibrillator Coronary Epinephrine CPR 133

EMDocs

AUGUST 17, 2023

Welcome back to the “52 in 52” series. This collection of posts features recently published must-know articles. Today we look at the CENSER trial. vs 48.4% (OR 3.4, 5.53) Takeaways: Positive trial => there was a statistically significant rate of shock control attained with the treatment arm.

Overdose 95

Overdose ACS Critical Care OR 95

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

Queen of Hearts now thinks that this one looks like posterior OMI, since the STD does appear worst in V3-4: None of this seems to have been understood by the EM doctor or the cardiologist who was consulted. In our opinion it should not be given in ACS unless you are committed to the cath lab. He was diagnosed as NSTEMI.

ACS 83

ACS Coronary ALS CAD 83