EM Didactic

JANUARY 27, 2019

Myth 1 Absence of Classic Chest Pain obviates the need for ACS work up The absence of chest pain in no way excludes the diagnosis of ACS. Around 33-50% of the patients with ACS present to the hospital without chest pain. Close to 20% of patients diagnosed with acute MI present with symptoms other than chest pain.

ACS 52

ACS ALS Coronary Emergency Department 52

EMS 12-Lead

APRIL 9, 2024

Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates). Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates). The CXR demonstrated no pulmonary edema.

Coronary 290

Coronary ACS CAD ED 290

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

This is very specific for PE vs. ACS. Also, and much less teachable: the T-waves just don't look right for ACS. Meyers and Smith ) : When there is T wave inversion in the chest leads — IF there is T wave inversion in both lead V1 and lead III ==> Think acute PE ( and not ACS! ). PEARL ( as per Drs.

ACS 93

ACS OR 93

EMDocs

MAY 15, 2024

Other causes of sickling: acidosis, dehydration, inflammation, infection, fever, and blood stasis Sickling leads to vascular occlusion, end-organ ischemia, and decreased RBC lifespan, which, in turn, leads to pain crisis, acute anemia, sequestration, infection, and acute chest syndrome (ACS.) Each episode of ACS has a 9% mortality rate.

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

EMDocs

MAY 28, 2024

Sickling leads to vascular occlusion, end-organ ischemia, and decreased RBC lifespan, which, in turn, leads to pain crisis, acute anemia, sequestration, infection, and acute chest syndrome (ACS). ACS is lung injury due to vaso-occlusion in the pulmonary vasculature; many with ACS will have a concomitant vaso-occlusive pain crisis.

ACS 76

ACS E-9-1-1 ALS OR 76

The Skeptics' Guide to EM

SEPTEMBER 28, 2024

The patient has no specific risk factors for acute coronary syndrome (ACS) or dissection. Case: You are working a busy shift in a rural emergency department (ED) and your excellent Family Medicine trainee presents a case of a 63-year-old woman with chest pain and some intermittent radiation into the inter-scapular region.

Emergency Department 195

Emergency Department ACS Coronary ALS 195

Critical Care Scenarios

APRIL 26, 2023

Takeaway lessons * If considering ACS in any post-menopausal woman, you should also consider stress cardiomyopathy. Of course, atypical anatomical distributions can also occur in ACS due to distinct anatomy. ACE inhibition). * In general, TCM is a diagnosis of exclusion after ruling out ACS. Find us on Patreon here!

ACS 100

ACS OR 100

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

JULY 25, 2024

Then assume there is ACS. Therefore — recognition of DSI on ECG should prompt consideration of 2 Categories of diagnostic entities : Severe Coronary Disease ( due to LMain, proximal LAD, and/or severe 2- or 3-vessel disease ) — which in the right clinical context may indicate ACS ( A cute C oronary S yndrome ).

Defibrillator 113

Defibrillator Coronary Epinephrine ACS 113

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

NCOAE

DECEMBER 11, 2023

The Eastern Association for the Surgery of Trauma (EAST) , the National Association of EMS Physicians (NAEMSP) , and the American College of Surgeons Committee on Trauma (ACS-COT) all support the recommendation against the use of spinal immobilization in patients with isolated penetrating injuries. to prevent movement of the spine.

OR 52

OR Emergency Medical Technician Emergency Department Emergency Medical Services 52

Emergency Medicine Cases

JULY 30, 2019

What are the most useful historical factors to increase and decrease your pretest probability for ACS? Which cardiac risk factors have predictive value for ACS? Why should the words "troponitis" and "troponemia" be banned? How should high sensitivity troponin be interpreted differently than conventional troponin? and many more.

ACS 130

ACS ED OR EMS 130

Pediatric EM Morsels

APRIL 19, 2024

Pediatric Buckle and Greenstick Forearm Fractures: Basics The junction of the metaphysis and diaphysis in pediatric long bones is an area of biomechanical transition (Light, 1984) Thin metaphyseal cortex meets the thick cortex of the diaphysis Or in Emergency Medicine terms, “ Thick bone meet thin bone.” J Bone Joint Surg Br. 2001;83:1173-5.

ALS 286

ALS ACS Emergency Department ED 286

EMDocs

NOVEMBER 9, 2024

Source Antithrombotic Strategies in Atrial Fibrillation After ACS and/or PCI: A 4-Way Comparison From AUGUSTUS. We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. Originally published at JournalFeed , a site that provides daily or weekly literature updates. 2024 Sep 16:e2415815.

ACS 79

ACS Coronary OR 79

ALiEM

AUGUST 30, 2024

Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM; American Thyroid Association Task Force on Thyroid Hormone Replacement. The patient had no significant past medical history. She also endorsed three weeks of cough and congestion, and one day of muffled voice. Pediatr Rev.

ACS 161

ACS Emergency Department ED OR 161

The Skeptics' Guide to EM

JANUARY 18, 2020

You turn to the attending and ask, “do you really think this could be acute coronary syndrome (ACS)?” ACS is usually amongst this differential, as cardiovascular disease is a leading cause of morbidity and mortality in this population. The proportion of patients with ACS at the index visit or within 30 days. *

ACS 130

ACS Coronary Emergency Department OR 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

EMS 12-Lead

JUNE 20, 2022

Although the attending crews did not consider the ECG pathognomonic for occlusive thrombosis, they nonetheless considered the patient high-risk for ACS and implored him to reconsider. The attending crews were concerned for an ACS-equivalent of LAD occlusion and initiated a prehospital STEMI activation to the closest PCI center.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

MARCH 14, 2024

These have all been small studies, studying very few patients with ACS, and often used final cardiology interpretation rather than patient outcome. Smith : This study had such low risk patients that not a single patient was ultimately diagnosed with ACS. It is well known that NOMI usually has a normal ECG or nonspecific ECG.

STEMI 110

STEMI ACS Coronary Emergency Department 110

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). sepsis, anemia, hypoxemia, severe hypotension etc., Unless some LMCA flow is restored he will not survive.

Coronary 126

Coronary ACS Emergency Department Defibrillator 126

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

ACEP Now

MAY 3, 2023

Acute chest syndrome (ACS) is a potentially life-threatening complication of sickle cell disease characterized by lung infiltrates, fever, and respiratory symptoms, including cough, tachypnea, wheeze, increased work of breathing or shortness of breath, and reduced oxygen saturation. Sickle cell disease is the primary risk factor for ACS.

ACS 52

ACS OR 52

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

If there were diffuse ischemic STD, with precordial STDmaxV5-6 and reciprocal STE-aVR, this would be non-specific subendocardial ischemia from ACS or supply-demand mismatch. The new ESC guidelines has for the first time merged both STEMI and non-STEMI in the same guideline because they are both on the spectrum of ACS.

STEMI 113

STEMI ACS Coronary OR 113

Dr. Smith's ECG Blog

JUNE 17, 2024

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. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with Acute PE (p less than 0.001).

E-9-1-1 137

E-9-1-1 ACS Emergency Department Coronary 137

Don't Forget the Bubbles

OCTOBER 7, 2024

This is supplied via alternating current (AC), increasing the risk of titanic contraction of skeletal muscle, leading to kids holding on to the electrical power source. Up to 5% of burns occur secondary to electrical injuries, and this rises to 27% in developing countries. Was the voltage high or low (as below)? Was there any syncope ?

ACS 78

ACS Life Support OR CPR 78

The Skeptics' Guide to EM

JULY 2, 2022

The bottom line from that episode was that the HEART Pathway appears to have the potential to safely decrease objective cardiac testing, increase early discharge rates and cut median length of stay in low-risk chest pain patients presenting to the ED with suspicion of ACS. If we thought about ACS, we brought them in. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

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-9-1-1 122

E-9-1-1 ACS Coronary STEMI 122

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

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. An EKG was repeated at 5 minutes The T-wave is less hyperacute. Maybe there is some spontaneous reperfusion? It does not radiate.

Overdose 52

Overdose OR Coronary ACS 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

DECEMBER 22, 2023

Comment : 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!!" There are no hyperacute T waves. There is no inappropriate ST depression.

ACS 106

ACS STEMI OR 106

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 117

ACS ED Coronary EMS 117

The Curious Clinicians

MARCH 4, 2024

Episode written by Jeff Kott and Tony Breu Kott J, Cooper AZ, Breu AC, Abrams HR. Nephmadness 2024. The Curious Clinicians Podcast. March 4th, 2024. Image source: [link]

ACS 82

ACS Critical Care OR 82

Dr. Smith's ECG Blog

OCTOBER 26, 2010

ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. Then ACS (STEMI) might be primary; this might be cardiogenic shock. One must clearly rule out these processes before jumping on the ACS diagnosis. Are the lungs clear? Is the patient cool and pale? Large volume fluid resuscitation was undertaken.

ACS 52

ACS STEMI OR Critical Care 52

ECG & Echo Learning

JUNE 28, 2023

North American (AHA, ACC) and European (ESC) guidelines recommend that patients presenting with ST segment depressions in V1–V3 should be managed as patients with STE-ACS (STEMI) if there are symptoms suggestive of myocardial ischemia. This positions the basal portion of the left lateral wall posteriorly in thorax (Figure 1).

STEMI 52

STEMI ACS OR 52

EMS 12-Lead

APRIL 14, 2022

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. In the case of ACS, the ECG can rapidly change from this. Past medical history included HTN, HLD, and MI 10 years prior.

ACS 130

ACS Paramedic Coronary ALS 130

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

ALiEM

FEBRUARY 9, 2024

Low-risk patients do not routinely require stress testing in the ED. Intermediate-risk patients may be further stratified based on recent stress testing or coronary angiogram findings plus a modified HEART or Emergency Department Assessment of Chest Pain (EDACS) score. That’s because these values are assay specific. She does not smoke.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276