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Defining Appropriate Responses in a Tiered System

High Performance EMS

Some computer-aided dispatch (CAD) software did better than others by considering the average travel time of an actual route instead of allowing nearness to be determined by a straight-line distance. If available, the supervisor is added to effectively create an ALS transport ambulance.

BLS 264
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See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Dr. Smith's ECG Blog

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. Hayakawa A, Tsukahara K, Miyagawa S, et al. Written by Nathanael Franks MD, reviewed by Meyers, Smith, Grauer, etc. Am J Emerg Med.

ACS 87
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A 40 year old man with chest pain since last night

Dr. Smith's ECG Blog

He also had non-acute CAD of the RCA (50%) and LCX (50%). B OTTOM L ine : While ECG #1 does not satisfy the definition of a STEMI — as per Dr. Meyers, it really looks like a cute L AD O MI. CLICK HERE — for a brief article by Rowlands et al that explains these concepts in more detail. Cath images: Before intervention.

STEMI 52
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Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting."

Dr. Smith's ECG Blog

Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. J Electrocardiol [Internet] 2022;Available from: [link] Cardiology opinion: Takotsubo Cardiomyopathy (EF 30-35%) V Fib Cardiac arrest Prolonged QTC NSTEMI (Smith comment: is it NSTEMI or is it Takotsubo? -- these are entirely different) Moderate single-vessel CAD.

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A man in his 70s with weakness and syncope

Dr. Smith's ECG Blog

The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. In the largest study looking at this topic by Mizusawa et al., Recently the rate of true arrhythmic events related to fevers in the classic Brugada Type 1 syndrome was explored by Michowitz et al.

E-9-1-1 70
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What will you do for this patient transferred to you who is now asymptomatic?

Dr. Smith's ECG Blog

Lead I has a definitively hyperacute T-wave without STE. She also had non-acute CAD of the left main (50%) and LCX (75%). Patel et al., Krucoff et al.) Patel et al. Krucoff et al. Schomig et al. This ECG shows persistent Occlusion MI but does not meet STEMI criteria. II, III, aVF, and V6 have STD.

STEMI 52
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Hyperthermia and ST Elevation

Dr. Smith's ECG Blog

A formal echocardiogram was completed the next day and again showed a normal ejection fraction without any focal wall motion abnormalities to suggest CAD. In the largest study looking at this topic by Mizusawa et al., She has not had a heart catheterization or after this event so the presence or absence of CAD is still unknown.

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