The Skeptics' Guide to EM

JANUARY 18, 2020

Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Andrew Huang: Andy is […] The post SGEM#280: This Old Heart of Mine and Troponin Testing first appeared on The Skeptics Guide to Emergency Medicine. Reference: Wang et al.

ACS 130

ACS Coronary Emergency Department OR 130

The Skeptics' Guide to EM

MAY 19, 2018

[display_podcast] Date: May 16, 2018 Reference: Freund et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. display_podcast] Date: May 16, 2018 Reference: Freund et al. Reference: Freund et al.

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Emergency Department ALS Coronary OR 130

EMS 12-Lead

MAY 20, 2022

Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. It is spread to V2 and V3. References Naidu, S.

Coronary 130

Coronary STEMI Firefighter ED 130

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram. link] [1] Mirand, D.

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Coronary ALS OR ACS 130

ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. 2 Proposed hypothesis as described by Hsu et al., Click to enlarge.)

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STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). Most OMI have a peak Troponin T over 1000 ng/L [reference: Baro R et al. Clinical Cardiology 2019.

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STEMI Coronary Defibrillator EMS 96

Dr. Smith's ECG Blog

OCTOBER 18, 2023

If you were working in a busy emergency department, would you like to be interrupted to interpret these ECGs or can these patients safely wait to be seen because of the normal computer interpretation? Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med.

STEMI 121

STEMI Emergency Department Coronary OR 121

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. Serial ECGs enhance the diagnosis of acute coronary syndrome. Bigger et al. Annals of Emergency Medicine , 31 (1), 3–11.

STEMI 88

STEMI Coronary Heart Attack ACS 88

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. STEMI criteria, and automated interpretations based on it, will miss acute coronary occlusion. Kontos et al.

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STEMI Coronary Paramedic ALS 62

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). link] [1] Zachary et al. Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. 2] Costanzo, L. Physiology. 3] Parham, W.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

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STEMI Coronary ACS ED 104

The Skeptics' Guide to EM

MARCH 10, 2018

[display_podcast] Date: March 6th, 2018 Reference: Zahed et al. Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. display_podcast] Date: March 6th, 2018 Reference: Zahed et al. Reference: Zahed et al. AEM March 2018.

Emergency Department 100

Emergency Department ALS Coronary OR 100

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Hgb 11g/dL (110g/L) and leukocytosis, and a mildly elevated troponin (36 ng/L, with normal 1mm STE in aVR due to ACS will require coronary artery bypass surgery for revascularization, the infarct artery is often not the LM, but rather the LAD or severe 3-vessel disease. Harhash AA, Huang JJ, Reddy S, et al. Knotts et al.

Coronary 52

Coronary ACS STEMI ALS 52

EMDocs

MARCH 25, 2024

2, 3 Biliary POCUS can help decrease patient length of stay in the Emergency Department. Video 3: Coronary approach to the gallbladder POCUS Findings Sonographically, the gallbladder is situated in the right upper quadrant as an elongated pear-shaped organ on the inferior surface of the liver. Acad Emerg Med. Ultrasound.

ALS 87

ALS Coronary Emergency Department ED 87

The Skeptics' Guide to EM

JUNE 14, 2017

It has been said that it can take 17 years for 14% of research to reach the patients’ bedside ( Morris et al 2011 ). Talk I: Knowledge Translation in the Digital Age The first talk was on knowledge translation (KT) in the digital age. A number of examples of the KT problem were provided.

Coronary 130

Coronary Emergency Department ALS 130

ACEP Now

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. Tintinalli JE, Stapczynski J, Ma O, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. A recent angiogram report indicated a totally occluded left anterior descending artery (LAD) and right coronary artery (RCA), with 30-40% narrowings in the left circumflex artery (LCx).

Coronary 99

Coronary EMR STEMI Emergency Department 99

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. References Hansen MS, et al. Rogers AM, et al. Cecconi M, et al. Circulation.

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ACS ALS ED OR 85

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Armstrong et al. What do you think? Just another NSTEMI.

STEMI 52

STEMI ACS Coronary Defibrillator 52

REBEL EM

FEBRUARY 22, 2023

difficult to see due to corneal edema) Emergency Department Management All patients should get emergency ophthalmologic consultation Start with eye drops (see table below) and add systemic medications if severe or refractory symptoms/IOP. et al, Emergency Medicine Clinical Essentials ed 2. Cup to disc ratio >0.6

Emergency Department 52

Emergency Department ALS ED Coronary 52

Core EM

JULY 23, 2024

Objective: Based on current evidence, this review article aims to guide the Emergency Department (ED) in providing care for patients with blast injuries. Cardiovascular: Injury: cardiac contusion, wall rupture, tamponade, papillary muscle rupture, valve injury, aortic arch injury, and coronary artery dissection. Nowadly C.D.,

EMS 100

EMS Emergency Medical Services OR Coronary 100

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. STEMI criteria is bad at differentiating between normal variant and acute coronary occlusion or reperfusion, and initial troponin levels don't differentiate between occlusive and non-occlusive MI 3. McLaren et al, including Meyers/Smith. Am J Emerg Med 2023 2.

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STEMI Coronary OR ALS 74

ALiEM

FEBRUARY 9, 2024

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. The patient has no previous stress testing or coronary angiogram, and he is not low risk by HEART or EDACS scoring.

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E-9-1-1 ED Coronary ALS 276

Dr. Smith's ECG Blog

MAY 23, 2023

Am J Emerg Med. I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. 2022 Jan;51:384-387.

STEMI 88

STEMI Coronary Paramedic OR 88

Core EM

MARCH 7, 2024

Objective: Based on current evidence, this review article aims to guide the Emergency Department (ED) in providing care for patients with blast injuries. Cardiovascular: Injury: cardiac contusion, wall rupture, tamponade, papillary muscle rupture, valve injury, aortic arch injury, and coronary artery dissection. Nowadly C.D.,

EMS 100

EMS Emergency Medical Services OR Coronary 100

EMDocs

OCTOBER 21, 2023

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. References: Gaillard F, Glick Y, Tatco V, et al. 61.4.496 Navi BB, Kamel H, Shah MP, et al. Arch Neurol.

EMS 74

EMS ALS OR ACS 74

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. Khan AR, Golwala H, Tripathi A, et al. What happened?" The medic recorded another 12-lead en route 13 minutes later: What do you think?

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The remainder of his Emergency Department stay was uneventful. Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours. de Winter et al in N Engl J Med 359:2071-2073, 2008. He had no symptoms of ACS. See text ).

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. 3–8 Shi et al. In acute MI, the T-wave is large, and the T/ST ratio is high. This is much more typical of myocarditis. Angiogram was negative.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. Karwowski et al showed that only 64% of 4581 STEMIs had TIMI 0 flow on angiogram. [25] 25] Stone et al found that 72% have TIMI 0 or 1 flow. [26]

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy.

Emergency Department 52

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

AAEM RSA

AUGUST 27, 2020

1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. Nielsen N, Wetterslev J, Cronberg T et al. By the time of the study by Nielsen et al. Kirkegaard et al.

E-9-1-1 52

E-9-1-1 CPR ICU ALS 52

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. References Tsao CW, et al. Benjamin EJ, et al. Kimblad H, et al. Adult cardiac arrest in the emergency department – A Swedish cohort study. Sakai T, et al. Kudenchuk PJ, et al.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e I B Patients transferred to PCI centres can bypass the emergency department to undergo primary PCI without delay. STEMI , ST-segment elevation acute myocardial infarction ).

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STEMI Coronary OR Defibrillator 40

Dr. Smith's ECG Blog

JULY 18, 2014

Raitt et al.), Armstrong et al.), 3) Oliva et al. (4) Armstrong PW et al. Baseline Q-wave surpasses time from symptom onset as a prognostic marker in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Very unlikely. J Am Coll Cardiol 1995;25(5):1084-8.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Reference: • Writing Committee, Kontos MC, de Lemos JA, et al. 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department: A report of the American college of cardiology solution set oversight committee. • Here it is: Obvious inferior posterior lateral OMI.

OR 52

OR STEMI ED Critical Care 52

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. Date: May 24th, 2022 Reference: Broder et al. Reference: Broder et al.

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Emergency Department ALS ACS Coronary 100