Dr. Smith's ECG Blog

JANUARY 9, 2024

Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Cardioversion will address the rhythm problem immediately, also if the chest discomfort subsides when SR is restored, ischemia from ACS becomes much less likely. In either case, prompt cardioversion is indicated.

Coronary 120

Coronary ACS ED OR 120

EMDocs

JANUARY 11, 2024

In ICUs where advanced cerebral monitoring is not in routine use, target an MAP >80 mm Hg unless there are clinical concerns or evidence of adverse consequences (82.6%, 19/23). In ICUs where noninvasive monitoring of cerebral autoregulation is in routine use, maintain MAP at or near the predicted MAPOPT (88.2%, 15/17).

Critical Care 94

Critical Care E-9-1-1 OR ICU 94

Don't Forget the Bubbles

JUNE 30, 2023

They found NO difference in drain failure rates ( 11% pigtail vs 13% chest tube P=0.74), total daily volume drained or length of ICU stay between groups. You ask your anaesthetist to get ready to sedate or intubate depending on their status – Significant risk to the department – you make sure security is aware And your patient arrives.

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

EMDocs

OCTOBER 21, 2023

More common in the setting of atherosclerotic lesions than emboli, which typically occur with sudden onset of symptoms. Symptoms may range from days to months prior to stroke onset. As many as two-thirds of patients with BAO experience prodromal symptoms, including TIAs, minor strokes, or other symptoms.

EMS 93

EMS ALS OR ACS 93

Dr. Smith's ECG Blog

JANUARY 6, 2023

Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Opioids in ACS may reduce the pain score, but do not provide reperfusion for ongoing ACS. Abstract 556.

ACS 52

ACS Coronary ICU STEMI 52

ACEP Now

MAY 9, 2024

After developing encephalopathy and hypoxemic respiratory failure, the patient was transferred to the ICU. Further diagnostic testing in the ICU identified salicylate toxicity. Further diagnostic testing in the ICU identified salicylate toxicity. Available from: [link] Newman-Toker DE, Nassery N, Schaffer AC, et al.

Emergency Department 52

Emergency Department ICU ALS ACS 52

Dr. Smith's ECG Blog

MARCH 12, 2018

It is also true that anterior and inferior T-wave inversion could be consistent with reperfusion of a type III wraparound LAD occlusion, despite the fact that Kosuge et al showed that T-wave inversion in lead III is much more likely to be PE than ACS if your differential contains nothing else. She was discharged and did well.

ACS 40

ACS Coronary ALS ICU 40

AAEM RSA

APRIL 1, 2021

1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 in the 1:1:1 group vs. 17.0% vs. 14.6%, p=0.03).

E-9-1-1 52

E-9-1-1 Plasma ACS ALS 52

Emergency Medicine Ireland

DECEMBER 17, 2020

Intensivists have embraced the tracheostomy as an ICU procedure. doi: 10.21037/acs.2018.03.01. In a breaking from what could only loosely be described as tradition at this point, this podcast is going to be in 2 parts. It’s one of the most invasive and one of the riskier procedures we do. Surgical anatomy of the trachea.

Critical Care 40

Critical Care ACS ICU OR 40

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). If for some reason the angiogram is delayed, they should receive maximal medical therapy in an ICU setting with continuous 12-lead ST segment monitoring under the close attention of a practitioner with advanced ECG interpretation training.

STEMI 52

STEMI ALS ACS ICU 52

REBEL EM

JULY 14, 2022

An example using a real case I had while on call in the ICU: A 61-year-old female had a post-induction arrest on the wards/hospital telemetry floor after being intubated for airway protection. Assigning a patient a single PCAC score upfront may implicitly bias clinicians familiar with the score in how they care for patients.

ICU 52

ICU ALS OR CPR 52

REBEL EM

FEBRUARY 2, 2023

2 Amiodarone is commonly known for its anti-arrhythmic properties and a commonly used agent in the Intensive Care Unit (ICU). Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). However, digoxin is known for its rate-control properties and its direct vagal effect on the atrioventricular node. Paper: Mason JM, et al.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

EMDocs

SEPTEMBER 25, 2023

Notable Physical Exam: General: Tripoding, severe respiratory distress. However, emergency physicians have recently faced a multitude of patients requiring ETI with anatomically and physiologically difficult airways; these patients increase the risk of a can’t intubate/can’t oxygenate scenario or significant hypoxemia, hypercarbia, or acidemia.

ED 84

ED Emergency Department ALS Paramedic 84

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. The cardiologists felt that the ECG did not represent ACS, and thought it was more likely pericarditis, so they did not take him to the cath lab. in the ICU but survived with excellent function.

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

ACEP Now

NOVEMBER 14, 2023

The definition of massive hemoptysis is variable across publications with expectorated blood volumes ranging from 100 to 1,000 mL per 24 hours, as these volumes are difficult to estimate for any given patient. 2 Death from hemoptysis is akin to drowning, so airway considerations usually take precedence over hemodynamic considerations.

E-9-1-1 52

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

ECG & Echo Learning

OCTOBER 2, 2022

Below follows a drug manual for use in the CCU (coronary care unit), ICU (intensive care unit) or ER (emergency room). Gordon AC, Mason AJ, Thirunavukkarasu N, et al. Several endogenous and synthetic agents exist and are frequently combined to achieve the desired hemodynamic outcome. Minimal chronotropic effect. JAMA 2018; 319:1889.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

Dr. Smith's ECG Blog

APRIL 20, 2018

I took part in her ICU care and she was extubated and stable to transfer to a stepdown unit after a few days. Patients like her are the reason we are advocating for a change in the ACS paradigm from STEMI to OMI. However, the prehospital ECG is more worrisome: the T-wave inversion in V5 and V6 is preceded by ST Elevation.

Coronary 40

Coronary STEMI EMS ACS 40

Dr. Smith's ECG Blog

MARCH 11, 2019

The patient was managed in the ICU and had serial troponins. An angiogram confirmed ACS as the etiology. You do NOT see this in normal variant STE, nor in pericarditis. The only time you see this without ischemia is when there is an abnormal QRS, such as LVH, LBBB, LV aneurysm (old MI with persistent STE) or WPW." First was 2.9

ACS 52

ACS OR ICU STEMI 52

ALiEM

OCTOBER 30, 2024

The biggest change has been the gradual replacement of diacetylmorphine (heroin) by fentanyl and other synthetic opioids. Along the same time, a veterinary sedative, xylazine , became popular in Puerto Rico in individuals who used injection drugs [3]. We treat with wound care and reserve surgical management only for limbs that are no longer viable.

E-9-1-1 161

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

EMDocs

JANUARY 6, 2024

10 Although this is not the same pathophysiology seen in ACS from an acute plaque rupture leading to coronary artery occlusion, patients can have relatively abrupt coronary ischemia causing ACS due to acute, concentric vessel narrowing. BNP should normalize after about 2 months. 13 Cefepime 2 g or Piperacillin-Tazobactam 4.5

EMS 80

EMS E-9-1-1 ACS Coronary 80

EMDocs

OCTOBER 7, 2023

Goodman AD, Got CJ, Weiss AC. Introduction Crush injury: result of physical trauma from prolonged compression that initially causes direct tissue damage and later results in downstream effects from hypoxic conditions suffered by those tissues. 6 Motor vehicle collisions that produce significant challenges to passenger extrication.

EMS 92

EMS E-9-1-1 Emergency Department ALS 92

EMDocs

FEBRUARY 12, 2024

In this situation, an ABG should be obtained periodically for correlation, though this is more relevant for the intensive care unit (ICU) setting than in routine ED care (5, 9). How would an ABG even change the initial stabilization of any of these patients? What alternative testing can be done in these circumstances?

Emergency Department 98

Emergency Department E-9-1-1 ED ICU 98

Don't Forget the Bubbles

MAY 3, 2023

Garabon JJW, Gunz AC, Ali A, Lim R. Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye. This time the PEM MSc team from QML , in association with DFTB, are taking over… Article 1: Insulin infusion in paediatric DKA – high or low?

CPR 52

CPR Emergency Department ALS ICU 52

EMDocs

JUNE 27, 2024

Left lower lung field end demonstrates expiratory wheezing on auscultation. Other lung fields unremarkable. smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02 mg/kg, max 0.4 C or 100.4

E-9-1-1 94

E-9-1-1 ICU ACS EMS 94

EMDocs

JUNE 7, 2023

Disposition is often admission to an intensive care unit (ICU) setting. Questions: What is the most likely causative xenobiotic that led to these findings? Influenza vaccine Methanol Organophosphate Paraquat Are her symptoms reversible? Yes No What therapy or therapies are critical for this patient? 7 May lead to respiratory failure.

E-9-1-1 97

E-9-1-1 ICU Emergency Department ED 97

Don't Forget the Bubbles

JULY 5, 2023

This process of sickling and unsickling goes on and off until the erythrocyte membrane is no longer flexible. Irreversible sickle cells undergo either intravascular haemolysis or extravascular removal by the reticulo-endothelial system resulting in anaemia and splenic sequestration. Blood culture is pending. How would you evaluate this child’s pain?

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

REBEL EM

DECEMBER 23, 2024

Paper: Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. To assess the clinical impact and relevance of these concerns, Alwang et al. performed the retrospective cohort study below ( Alwang 2024 ). Lactated Ringer vs Normal Saline Solution During Sickle Cell Vaso-Occlusive Episodes. JAMA Intern Med. 2024;184(11):1365-1372.

ALS 124

ALS ACS ED EMR 124

The Curious Clinicians

FEBRUARY 19, 2025

It’s easy to think of bacteria as always “wanting” to infect a host as quickly and aggressively as possible (and if you’ve ever taken care of someone with an acute PA bloodstream infection, you know how fast they can go from healthy to needing the ICU). Yes, that’s right. 2-AA helps PA do just that.

ACS 52

ACS ICU OR 52

EMDocs

JANUARY 6, 2025

History of Present Illness The collateral history indicates that her symptoms began one week into her journey, but medical care was inaccessible at the time. The family reports no history of food allergies, insect bites, or contact with sick individuals. The patient did not receive pre-travel prophylaxis for malaria, hepatitis A, or yellow fever.

ED 72

ED E-9-1-1 ALS Frozen Plasma 72