Pediatric EM Morsels

AUGUST 18, 2023

Myth #1: Musculoskeletal Adverse Events (MAE) This concern is likely the most common reason fluoroquinolones are rarely used in children. Musculoskeletal Adverse Events include: Articular cartilage damage causing arthralgias or arthritis , Tendonitis , and Tendon rupture. Which is a risk of 1 event for 62.5 Binz 2015).

E-9-1-1 130

E-9-1-1 ACS OR ALS 130

Dr. Smith's ECG Blog

FEBRUARY 14, 2024

The faculty physician thought this is highly likely to be ACS. I do not think it is possible for a 2nd trop to remain undetectable in a patient then goes on to rule in for acute MI, unless there is a 2nd event. I know of no data on unstable angina/30-day adverse events/acute MI after 2 serial undetectable trops.

ACS 111

ACS Emergency Department OR 111

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Even in patients whose moderate stenosis undergoes thrombosis, most angiograms show greater than 50% stenosis after the event. From Gue at al.

Coronary 109

Coronary E-9-1-1 STEMI ACS 109

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). The ESC states that patients with suspected ACS should go to the cath lab in ＜2 hours "regardless of ECG or biomarker evidence of MI!!" See this case: A man his 50s with chest pain.

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

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. Even before looking at the initial ECG — this patient is in a high prevalence group for having an acute event. And — the Baseline ECG!

STEMI 121

STEMI EMS ACS ED 121

Medgadget

SEPTEMBER 7, 2023

The device could be very useful fo screening large numbers of people prior to access to an indoor event, for instance, or in community clinics to quickly determine if people are infected. Moreover, the technology could be adapted to detect other viruses, which may be useful for future outbreaks. “And,

ACS 93

ACS OR 93

Dr. Smith's ECG Blog

MAY 20, 2024

Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? Assuming that was indeed a culprit, then this was ACS. The T waves in leads II and aVF have deflated, and the T wave in lead III has become terminally negative. The ST depressions in I and aVL have resolved.

CAD 126

CAD STEMI Coronary ACS 126

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. Traditional teaching is that these patients are at risk for life-threatening bradydysrhythmias and should go to the ICU Literature here is non-existent.

ICU 104

ICU ALS ACS EMS 104

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

link] = My Comment by K EN G RAUER, MD ( 11/14 /2023 ): = One of the most helpful clinical clues in support that an acute cardiac event is ongoing — is the finding of " dynamic " ECG changes. that is, show a pattern of labile ST-T wave changes not due to an acute coronary event. 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

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation. This is not the case.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. As a result — the onset of any acute event that may have occurred is uncertain. 21, 2017 ).

STEMI 116

STEMI ACS OR ALS 116

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. For this test it is VERY low (very good) at 4% at the 99th percentile -- 26 ng/L, but it will not be so good at a level of 9 ng/L. Thus, one considers a test result that varies by 2 or less to be the same result. of the time.

ACS 121

ACS ALS OR STEMI 121

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 78

E-9-1-1 ACS STEMI Coronary 78

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. PMID: 23102885 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]. Clin Exp Emerg Med 2023. in the paper but 2.7%

ALS 136

ALS ACS OR CPR 136

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? For this reason we did not believe this was an acute coronary event and did not activate the cath lab. So we should activate the cath lab, right?

Defibrillator 133

Defibrillator Coronary Epinephrine CPR 133

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

No wall motion abnormality This shows that significant ACS can have ZERO WMA!! Impression: In a patient with new symptoms — early repolarization is a diagnosis of exclusion to be made only after you have ruled out the possibility of an acute event. The estimated pulmonary artery systolic pressure is 27 mmHg + RA pressure.

STEMI 116

STEMI ACS Critical Care Coronary 116

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. But I'd be less certain about an acute event without more information and prior and/or serial tracings. In aVF it is "coved" (upwardly convex). The T wave is inverted in III and aVF, and reciprocally upright in aVL, with reciprocal STD in aVL.

Defibrillator 135

Defibrillator Coronary STEMI CPR 135

Dr. Smith's ECG Blog

AUGUST 19, 2023

But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Dialysis patients have a high rate of ACS without chest pain and high rate of delayed diagnosis and delayed reperfusion 2.

STEMI 98

STEMI ACS OR ALS 98

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

In our opinion it should not be given in ACS unless you are committed to the cath lab. Learning Point: Any NSTEMI patient with active ongoing ACS symptoms refractory to medical management is supposed to go to the cath lab within 2 hours if available, per all guidelines in world, regardless of ECG findings. Unfortunately — 1.5

ACS 83

ACS Coronary ALS CAD 83

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

OCTOBER 15, 2023

In addition to the small size of the ECG complexes on this tracing — I did not think the ECG features of an acute event were at all obvious. Prior episodes had simply resolved after brief symptoms, but the current episode had lasted for 2 hours without improvement, so she presented to the ED.

ACS 117

ACS ED STEMI OR 117

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! This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value. So this study is actually worthless.

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

OCTOBER 24, 2019

SCAD isn’t rare, especially in women Historically SCAD had been identified in 22% of ACS cases in women. Pregnancy is not a common cause of SCAD When ACS occurs in the peripartum period, SCAD is responsible in 43% of cases. A recent study found that SCAD causes almost 20% of STEMI in young women.

Coronary 52

Coronary CAD ACS STEMI 52

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

DECEMBER 26, 2020

No obvious adverse events were attributed to the thrombolytics. Second, the increased demand created by extreme tachycardia may exceed the ability of the coronary arteries to supply sufficient blood (due to preexisting three vessel or left main disease, with or without ACS). There was again no intracranial hemorrhage.

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH) Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI. Translation from French: Acute Occlusion Myocardial Infarction with High Confidence.

STEMI 85

STEMI ACS OR 85

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

McLaren — the above demographic for today's patient is typical for a much higher-prevalence group for having SCAD as the cause of their acute event. Whereas SCAD is found in ~1-4% of all angiograms performed for ACS — this percentage increases to over 30% in middle-aged women.

OR 66

OR STEMI ACS Coronary 66

EMDocs

SEPTEMBER 25, 2023

The trade off to using FI for these challenging airways is the consideration of an aspiration event, the initial indication for RSI. First pass success (FPS) is key as increased attempts correlate to increased desaturation (>10%) events (~10% on first attempt, ~30% on second attempt, ~60% for 4+ attempts) (15).

ED 93

ED Emergency Department ALS Paramedic 93

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Moreover, the Queen is only supposed to be used with a high pretest probability of ACS/OMI. We just finished training version 2 with some cases of hypokalemia, so that is in the future. The patient’s VBG resulted as I was speaking with him and confirmed my suspicions, showing a potassium of 1.6 Magnesium later resulted at 0.8

Overdose 124

Overdose ACS OR ICU 124

Dr. Smith's ECG Blog

MAY 27, 2012

A 90 yo with a history of orthostatic hypotension had a near syncopal event followed by chest pain. Chest pain and possible ischemia were attributed not to ACS, but to transient hypoperfusion from orthostatic hypotension. Chest pain was resolved upon arrival in the ED. His previous ECG was normal. What is it? Answer below.

ACS 52

ACS STEMI OR ED 52

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. Takotsubo is a sudden event, not one with crescendo angina. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain.

Emergency Department 52

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

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Corroborating this is the subtle ST depression in V2-V3 which is inappropriate for the normal QRS complex, and in the context of ACS, we have shown this is quite specific for posterior OMI. In the context of ACS, ST depression maximal in V1-V4 (rather than V5-V6) not due to a QRS abnormality is specific for posterior OMI.

ACS 52

ACS EMS STEMI Coronary 52

FOAMfrat

OCTOBER 20, 2023

titled “Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients from 29 Countries,” at least one major critical event occurred after intubation in 45.2% The higher the shock index, the more likely adverse events are to occur; such as hypotension or cardiac arrest. Up to 44% per other sources [12].

E-9-1-1 52

E-9-1-1 ALS ACS OR 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Recall that, in the setting of ACS symptoms, ST depression that are maximal in leads V1-V4 (as opposed to V5 and V6) not attributable to an abnormal QRS complex is specific for OMI. The most recent event had occurred just before being triaged. This pattern is recognizable by the ST depressions maximal in lead V4.

ACS 52

ACS Coronary Defibrillator STEMI 52

ACEP Now

OCTOBER 11, 2024

ED treatment should focus on airway, breathing, and circulation with consideration for cervical spine protection depending on the circumstances surrounding the event. References Webb AC, Wheeler A, Ricci A, et al. Pediatric near-drowning events: do they warrant trauma team activation? 4 Another study cited only 2.3 South Med J.

ALS 52

ALS Emergency Department Emergency Medical Services ED 52

EMS 12-Lead

APRIL 2, 2022

Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. Whether this represents a potential acute cardiac event would depend on the history, comparison with prior tracings and serial tracings.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

OCTOBER 24, 2018

The patient would not have been diagnosed with acute coronary syndrome and would not have had an angiogram, would have been discharged (or perhaps had a stress test, which would be negative), and would be at great risk of another event, possibly resulting in death or heart failure. Mokhtari et al. JACC 2016;67:1531. sensitivity, 99.5%

E-9-1-1 40

E-9-1-1 STEMI ACS Coronary 40