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

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 110

ACS Emergency Department OR 110

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A healthy 45-year-old female presented with chest pain, with normal vitals. The computer interpretation was “ST elevation, consider early repolarization, pericarditis or injury.” What do you think? There’s normal sinus rhythm, normal conduction, borderline right axis, and normal voltages. There’s TWI in aVL but this is concordant to its QRS.

OR 66

OR STEMI ACS Coronary 66

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). Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). So I would be worried about inferior OMI. At midnight.

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

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.

Coronary 109

Coronary E-9-1-1 STEMI ACS 109

Dr. Smith's ECG Blog

MAY 20, 2024

Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? If you are worried about aortic dissection, you also want the BP to be lowered, though you would do it first with esmolol to decrease the dP/dT (change in pressure over change in time). The ST depressions in I and aVL have resolved. Probably the latter.

CAD 125

CAD STEMI Coronary ACS 125

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. Take Home Points: Posterior epistaxis is a rare, life-threatning presentation. Literature doesn’t defend this approach but, the lit is pretty sparse.

ICU 104

ICU ALS ACS EMS 104

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. However, if we are to learn the lessons of the pandemic, we need to develop strategies that will assist us with the next one.

ACS 93

ACS OR 93

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. Long term outcome is unavailable.

STEMI 121

STEMI EMS ACS ED 121

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. Fortunately, that is exactly what happened.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

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. 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.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

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

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. Any cause of pulmonary hypertension.

STEMI 116

STEMI OR ACS ALS 116

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

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. Initial hscTnI was 10 ng/L (ref. <14). There was no recommendation for repeat ECG. Angiography is shown below.

OR 66

OR Coronary ACS EMS 66

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. Smith comment: No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matter how normal the ECG. His angiogram is shown below. Heitner et al.

ACS 120

ACS ALS OR STEMI 120

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. He reports feeling nauseated with emesis. He denies taking aspirin or antihypertensive medications for the last year and a half.

Defibrillator 135

Defibrillator Coronary STEMI CPR 135

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

No wall motion abnormality This shows that significant ACS can have ZERO WMA!! There are also subtly hyperacute T-wave in I, aVL, and V2-V6. There is also a very negative (reciprocally inverted) T-wave in lead III, and a down-up T-wave in aVF, both of which are highly suggestive of occlusion of the LAD or D1. The S-wave is reconstituted.

STEMI 115

STEMI ACS Critical Care Coronary 115

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. Here is the initial ED ECG. What do you think?

Defibrillator 132

Defibrillator Coronary Epinephrine CPR 132

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

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. 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. Potassium was normal.

STEMI 98

STEMI ACS OR ALS 98

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." A troponin this high in a patient with no known chronic troponin elevation, and active acute ACS symptoms, has a very high likelihood of type 1 ACS regardless of the ECG.

OR 52

OR STEMI ACS Emergency Department 52

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. Deutch et al. West J Emerg Med 2024).

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival. He awoke with naloxone. This EKG was recorded as part of a standing order for critical care. He denied any CP or SOB. It does not radiate.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

But it still doesn’t meet STEMI criteria, so the patient was referred to cardiology as ACS. Are there any signs of occlusion or reperfusion? There’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression and normal voltages.

OR 52

OR STEMI Coronary ACS 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. He denied any chest discomfort, or difficulty breathing.

ALS 130

ALS STEMI Coronary OR 130

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. QTc/QUc is in the range of 630 msec. What is the most likely cause of the patient’s ECG findings, and what would be your first step in management? We just finished training version 2 with some cases of hypokalemia, so that is in the future.

Overdose 123

Overdose ACS OR ICU 123

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 92

ED Emergency Department ALS Paramedic 92

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. He was diagnosed as NSTEMI.

ACS 82

ACS Coronary ALS CAD 82

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 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. This rate and height of troponin rise strongly suggested a type 1 MI. This case occurred 10+ years ago.

Coronary 52

Coronary CAD ACS STEMI 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. No diaphoresis or vomiting.

ACS 116

ACS ED STEMI OR 116

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). Christmas Eve Special Gift!! Serial troponins were negative.

STEMI 52

STEMI ACS Coronary Emergency Department 52

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

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

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% Up to 44% per other sources [12]. And according to a paper from Russotto et al. Of note, in the paper by Russotto et al.,

E-9-1-1 52

E-9-1-1 ALS ACS OR 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

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. One question that is commonly raised is whether these patients should be trauma activations. 4 Another study cited only 2.3

ALS 52

ALS Emergency Department Emergency Medical Services ED 52