The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Date: September 8th, 2021 Reference: Desch et al. Date: September 8th, 2021 Reference: Desch et al. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

APRIL 18, 2024

The ECG is just a test: a Bayesian approach to acute coronary occlusion If a patient with a recent femur fracture has sudden onset of pleuritic chest pain, shortness of breath, and hemoptysis, the D-dimer doesn’t matter: the patient’s pre-test likelihood for PE is so high that they need a CT. But does this matter?

STEMI 121

STEMI Coronary ALS CAD 121

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. Nikus et al. Kontos et al. Kontos et al. Bischof et al.

STEMI 122

STEMI Coronary ALS Emergency Department 122

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. Does the ECG normalize?

Coronary 130

Coronary ALS OR ACS 130

REBEL EM

JUNE 1, 2023

Article: Branch KHR et al. Indication for emergency invasive coronary angiography or had coronary angiography within 1 hour of arrival. Known obstructive coronary artery disease or known coronary stent. References: Branch KHR et al. Advanced imaging post-arrest is a possible modality to achieve this end.

Coronary 145

Coronary Defibrillator CPR ALS 145

REBEL EM

SEPTEMBER 14, 2023

Zeymer HT et al. The benefits of this strategy may be outweighed by the risk of the device-related complications (i.e. bleeding, stroke, limb ischemia, and hemolysis). The evidence for this practice has been sparse until now. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. Control: 53.4% D ECLS: 18.2% Control 8.7%

Life Support 133

Life Support Coronary CPR OR 133

Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI 70

STEMI Coronary ALS OR 70

EMS 12-Lead

JUNE 1, 2022

Such findings would normally suggest primary ischemia with concomitant surveillance of coronary occlusion, but these ST/T changes might very well be secondary to the Escape mechanism at hand. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated. Crew members note residual pallor and clammy skin.

Coronary 130

Coronary ALS Firefighter OR 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.) Click to enlarge.)

STEMI 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

JUNE 17, 2024

In fact, Kosuge et al. showed that among patients with either acute coronary syndrome or acute pulmonary embolism and negative T waves in the precordial leads (V1-V4), that inverted T waves in leads III and V1 were present in only 1% of patients with acute coronary syndrome and 88% of patients with pulmonary embolism. “The

E-9-1-1 139

E-9-1-1 ACS Emergency Department ALS 139

REBEL EM

SEPTEMBER 28, 2023

Paper: Van de Werf, F et al. STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. neoplasm, aneurysm, intracranial or spinal surgery) or recent trauma to head or cranium (i.e.

STEMI 135

STEMI Allergic Reaction Coronary Ambulance 135

The Skeptics' Guide to EM

OCTOBER 20, 2018

[display_podcast] Date: October 17th , 2018 Reference #1: Aycock, Westafer et al. Ann Emerg Med 2018 (CRD42017056195) Reference #2: Weisbord SD, Gallagher M, Jneid H, et al; PRESERVE Trial Group. display_podcast] Date: October 17th , 2018 Reference #1: Aycock, Westafer et al. Reference: Aycock, Westafer et al.

Coronary 171

Coronary Emergency Department ALS OR 171

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.

Coronary 130

Coronary STEMI Firefighter ED 130

EMS 12-Lead

JUNE 20, 2022

One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. Discussion When the QRS is normal, is the encountered ST/T changes that beget suspicion for LAD ACS (as in both of these cases) the result of occlusive coronary thrombus, or simply a normal variant?

ACS 130

ACS Coronary STEMI CAD 130

EMS 12-Lead

AUGUST 22, 2022

The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

REBEL EM

MARCH 2, 2023

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient ’ s oxygen saturation. More recent evidence, however, demonstrates that too much oxygen could be harmful ( AVOID Trial ) by causing coronary vasoconstriction and increasing oxidative stress. Low O2 protocol: 3.1%

ACS 52

ACS Coronary STEMI Ambulance 52

Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. We at Hennepin recently published this study Sharma et al. This study failed to do so. 5% vs. 58%!! 5% vs. 58%!!

Defibrillator 94

Defibrillator STEMI Coronary ALS 94

Dr. Smith's ECG Blog

DECEMBER 12, 2022

This " imbalance of precordial T waves" is not seen very often — and in the “right” clinical setting, has been associated with recent OMI from a LCx culprit artery ( See Manno et al: JACC 1:1213, 1983 — and the July 17, 2013 post by Salim Rezaie in ALiEM ). This is termed " pseudo-normalization."

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 122

E-9-1-1 Coronary ACS BLS 122

The Skeptics' Guide to EM

OCTOBER 22, 2017

[display_podcast] Date: October 19th, 2017 Reference: Hofmann et al. display_podcast] Date: October 19th, 2017 Reference: Hofmann et al. Studies have shown that oxygen can cause vasoconstriction, increase blood pressure and decrease coronary artery blood flow ( Kones et al AM J Med 2011). NEJM Sept 2017. NEJM Sept 2017.

Emergency Medical Services 130

Emergency Medical Services Coronary ALS STEMI 130

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? Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Reference: Wang et al.

ACS 130

ACS Coronary Emergency Department OR 130

Dr. Smith's ECG Blog

APRIL 22, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Lemkes JS, et al. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Pattern A evolves into Pattern B. Am Heart J.

Coronary 120

Coronary STEMI ED OR 120

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 116

Defibrillator Coronary ALS STEMI 116

EMS 12-Lead

APRIL 8, 2022

Cardiology admitted him for observation with plans for next-day coronary angiogram. A 56 y/o Male called 911 from his hotel room in the early morning hours after abruptly awakening from sleep with crushing chest discomfort and difficulty breathing. He reported to EMS a medical history of GERD only. He left AMA and is lost to follow-up.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

APRIL 17, 2023

Verouden, Wellens, and Wilde ) submitted a Letter to the Editor to the New England Journal of Medicine ( N Engl J Med 359:2071-2073, 2008 ) — in which they described a “new ECG pattern” without ST elevation that signifies acute occlusion of the proximal LAD ( L eft A nterior D escending ) coronary artery. QOH: "Not OMI, High confidence."

OR 52

OR STEMI ACS Emergency Department 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.

STEMI 96

STEMI Coronary Defibrillator EMS 96

Dr. Smith's ECG Blog

AUGUST 9, 2024

Serial ECGs enhance the diagnosis of acute coronary syndrome. Bigger et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the Crusade Quality Improvement Initiative. Sadowski ZP, Alexander JH, Skrabucha B, et al. Bigger JR Jr, Dresdale RJ, Heissenbuttel RH, et al.

STEMI 88

STEMI Coronary Heart Attack ACS 88

REBEL EM

SEPTEMBER 12, 2022

Background: Coronary artery disease can result in hibernating myocardium (chronic myocardial contractile dysfunction) due to ischemia. The theory is that there is reduced coronary blood flow and increased myocardial demand resulting in impaired contractility. Paper: Perera D et al. OMT: 38.0% HR 0.99; 95% CI 0.78 to 1.27; p = 0.96

Coronary 52

Coronary ALS OR EMS 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). link] [1] Zachary et al. Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. ECG's are difficult. 2] Costanzo, L. Physiology.

ACS 130

ACS Paramedic Coronary ALS 130

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.

STEMI 62

STEMI Coronary Paramedic ALS 62

Dr. Smith's ECG Blog

JANUARY 9, 2023

Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Finally, coronary angiography was performed (at least 5 days after presentation) which confirmed LAD aneurysm with large thrombus burden, TIMI 0 flow, thrombectomy performed. No similar symptoms in the past. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack OR 52

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

JULY 1, 2023

Upon further research in the 1970’s, retrospective data from autopsies of those patients showed coronary aneurysms 5 Pathophysiology: Kawasaki Disease is a vasculitis of medium sized arteries. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967.

EMS 66

EMS Coronary ED OR 66

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion. Deutch et al.

STEMI 104

STEMI Coronary ACS ED 104

Dr. Smith's ECG Blog

DECEMBER 29, 2023

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. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4. McLaren et al, including Meyers/Smith.

STEMI 74

STEMI Coronary OR ALS 74

EMDocs

FEBRUARY 7, 2024

GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. The effects of GLP-1 agonists are associated with the dose. Higher doses of GLP-1 agonists are associated with weight loss.

Allergic Reaction 75

Allergic Reaction ALS CAD OR 75

EMDocs

MARCH 25, 2024

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. Ross M, Brown M, McLaughlin K, et al. Dumbrava BD, Bass GA, Jumean A, et al. Ultrasound. 2014;22:223-228. Acad Emerg Med.

ALS 87

ALS Coronary Emergency Department ED 87