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

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. He called 911, and EMS crews subsequently found him diaphoretic and vomiting. A 12 Lead ECG was recorded. It’s important to stress the presence of a normal QRS (i.e.,

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

EMDocs

OCTOBER 21, 2023

We’ll keep it short, while you keep that EM brain sharp. A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. Symptoms may range from days to months prior to stroke onset.

EMS 97

EMS ALS OR ACS 97

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). ACE inhibitors, or potassium-sparing diuretics), are particularly susceptible.

ACS 130

ACS Paramedic Coronary ALS 130

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. There is STE in aVR.

ACS 127

ACS ED Coronary EMS 127

Pediatric EM Morsels

SEPTEMBER 20, 2024

The post Hemolytic Uremic Syndrome (HUS): Rebaked Morsel appeared first on Pediatric EM Morsels. HUS is often associated with bloody diarrhea … but… There is a variant of HUS (D-) that is not associated with diarrhea; HUS (D-) does not have seasonal variation and is relatively uncommon. 2021 May;232:200-206.e4. 2020.12.077.

Emergency Department 164

Emergency Department ACS ALS EMS 164

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

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 physical exam was unremarkable for diaphoresis or pallor, and he denied any episodes of vomiting. However, in this context (i.e. ST-elevation, etc.)

STEMI 130

STEMI ALS Coronary CAD 130

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

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

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

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? Smith comment 2: I frequently see failure to control BP in patients with acute chest pain or acute heart failure. Smith: What???!!!

CAD 126

CAD STEMI Coronary ACS 126

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. This month we cover a few out-of-hospital arrest trials. More PECARN goodness and we answer the question: are ants better doctors than human doctors? N Engl J Med.

E-9-1-1 52

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

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

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 96

ACS ICU EMS ALS 96

NCOAE

DECEMBER 11, 2023

A study published by Cambridge University Press examined patient outcomes over a decade during which Emergency Medical Service (EMS) systems decreased backboard use as they transitioned from SI to SMR protocols. However, recent research has called this practice into question. to prevent movement of the spine.

OR 52

OR Emergency Medical Technician Emergency Department Emergency Medical Services 52

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

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

She took an oxycodone and called EMS. 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. Written by Willy Frick A 40 year old woman was at home cooking when she developed chest pain.

OR 66

OR Coronary ACS EMS 66

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. This results in Type II MI. Severe HTN d.

Coronary 130

Coronary ACS CAD ED 130

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

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

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. Before and after of the LAD shown below.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

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. This was a real issue because all our friends lived down and across the street.

E-9-1-1 78

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

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. His vital signs are normal.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

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. 2.89, p = 0.01.

E-9-1-1 121

E-9-1-1 ALS ACS ICU 121

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

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

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

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

EMS arrived — and recorded 2 ECGs. The emergency physician was skeptical and believed the ECG to be a mimic, a false positive. So they looked into the patient's chart. Learning Point: 1. If you have old ECGs available, seek them out and compare today's ECGs to those old one. That is coming in the future with further training.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

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 ACS OR ALS 130

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. Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines.

Defibrillator 133

Defibrillator Coronary Epinephrine CPR 133

Dr. Smith's ECG Blog

OCTOBER 12, 2024

With EMS, patient had a GCS of 3 and was saturating 60% on room air. He improved to 100% with the addition of non-rebreather, however remained altered and was intubated by EMS with ketamine and succinylcholine. Vital signs were within normal limits on arrival to the Emergency Department. or basilar ischemia. Version 2 = 0.0272.

STEMI 116

STEMI Coronary Emergency Department ACS 116

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

OCTOBER 2, 2021

Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Pain largely resolved prior to EMS arrival but completely subsided after prehospital NTG and aspirin. There is no age cut-off for ACS. At the time of arrival to the ED, the patient reported 1/10 chest pain with normal vital signs.

OR 52

OR ACS STEMI Coronary 52

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. vs 48.4% (OR 3.4,

Overdose 93

Overdose ACS Critical Care OR 93