2013, ACS and ALS - Paramedicine Now

Elbow Dislocations

REBEL EM

NOVEMBER 6, 2024

PMID: 32644703 Robinson PM, Griffiths E, Watts AC. PMID: 27227986 Glover NM, Black AC, Murphy PB. Commentary on an article by Marc Schnetzke, MD, et al.: “Determination of Elbow Laxity in a Sequential Soft-Tissue Injury Model. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Simple elbow dislocation. 2023 Nov 5.

E-9-1-1

E-9-1-1 ACS OR Emergency Department

Rethinking Fluid Resuscitation in Vaso-Occlusive Crisis: Is Lactated Ringer’s the Superior Choice?

REBEL EM

DECEMBER 23, 2024

saline (NS) solutions are both isotonic crystalloids widely used for intravenous fluid resuscitation across many contexts and disease states ( Myburgh 2013 ). To assess the clinical impact and relevance of these concerns, Alwang et al. Paper: Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. Lactated Ringer (LR) and 0.9%

ALS

ALS ED ACS EMR

emDOCs Podcast – Episode 123: Sympathetic Crashing Acute Pulmonary Edema

EMDocs

JULY 21, 2025

Causes: ACS, arrhythmia, valvular dysfunction, infection, nonadherence to meds, myocarditis, volume overload. Heidenreich PA, Bozkurt B, Aguilar D, et al. Collins S, Storrow AB, Albert NM, et al. Yancy CW, Jessup M, Bozkurt B, et al. Yancy CW, Jessup M, Bozkurt B, et al. J Am Coll Cardiol 2013; 62(16):e147–239.

E-9-1-1

E-9-1-1 ALS Emergency Department OR

A Practical Approach to HIV/AIDS: Part 1

EMDocs

MARCH 24, 2025

doi:10.3390/v3050586 Myburgh D, Rabie H, Slogrove AL, Edson C, Cotton MF, Dramowski A. 2020.06.081 Balkhair AA, Al-Muharrmi ZK, Ganguly S, Al-Jabri AA. doi:10.12816/0003169 Stanley K, Lora M, Merjavy S, et al. 13077 Bozzette SA, Berry SH, Duan N, et al. link] Jung AC, Paauw DS. 2011;3(5):586-612.

E-9-1-1

E-9-1-1 ALS ED OR

Episode 180 Food Dyes: It’s all marketing

This Podcast Will Kill You

JULY 1, 2025

Scientific Opinion on the re‐evaluation of Allura Red AC (E 129) as a food additive. Refined exposure assessment for Allura Red AC (E 129). .” Heliyon (2024). From FDA News release “HHS, FDA to phase out petroleum-based synthetic dyes in nation’s food supply” released April 22,2025 [link]. Ardila-Leal, Leidy D., Stuckler, D.,

E-9-1-1

E-9-1-1 ACS ALS OR

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Lindahl et al. From Gue at al. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data.

Coronary

Coronary E-9-1-1 STEMI ACS

REBEL Core Cast 123.0 – Posterior Epistaxis

REBEL EM

MAY 29, 2024

VS abnormalities can drive this as well Strongly consider reversal of AC (this will typically come after control) Stopping the Bleeding PPE: these things bleed like stink. EMRAP HD: Epistaxis Posterior Pack References Cassisi NJ et al. PMID: 5569677 Zeyyan E et al. PMID: 20938948 Loftus BC et al.

ICU

ICU ALS ACS EMS

Target Acquired

EMS 12-Lead

APRIL 2, 2022

Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. 4] Baranchuk, A, et al. Given such findings, serial ECG’s are prudent to consider, and carry significant impact moving forward, which has been demonstrated in previous posts. 2] Surawicz, B.

ALS

ALS STEMI Coronary OR

Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation.

E-9-1-1

E-9-1-1 Coronary ACS BLS

Fluoroquinolone Use In Children

Pediatric EM Morsels

AUGUST 18, 2023

Etminan 2019) In Belgium between 2010 – 2013, of the 262 children treated with fluroquinolones while hospitalized, only 17% were used for labelled indications. References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. PMID: 27940800 Hersch AL, Gerber JS, Hicks LA, Pavia AT. Pediatrics. 147(6):e202003316. 38 (3):268-270.

E-9-1-1

E-9-1-1 ACS OR ALS

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Knotts et al.

Coronary

Coronary ACS STEMI ALS

Cardiac arrest: even after the angiogram, the diagnosis is not always clear

Dr. Smith's ECG Blog

OCTOBER 28, 2013

Here is an article I wrote: Updates on the ECG in ACS. In left main occlusion, by blocking flow to both the anterior wall (LAD) and posterior wall (circ), the ST depression of posterior ischemia could theoretically diminish the ST elevation of anterior ischemia and leave only V1 with significant ST elevation (Nikus, et al. see below).

Defibrillator

Defibrillator ACS CPR STEMI

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Although this is considered a "STEMI equivalent" and the ACC/AHA guidelines even approve of thrombolytics for ACS with this ECG, the usual criteria used to alert the cath lab team of an inbound Code STEMI are not met by this ECG. For instance: sepsis, bleeding, dehydration, hypoxia, and mild ACS. Taglieri N, Marzocchi A, Saia F, et al.

Coronary

Coronary ACS ALS STEMI

Right precordial ST depression in a patient with chest pain

Dr. Smith's ECG Blog

AUGUST 3, 2017

Matetzky S, Friemark D, Feinberg MS, et al. O'Gara et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. O'Gara et al. Wang T, Zhang M, Fu Y, et al. Circulation.

STEMI

STEMI E-9-1-1 Coronary ALS

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

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. One year later: EKG#5 (one year later) Inferior Q waves persist, as do inferior T wave inversions. Learning Points: The ECG can pass through normal or near-normal on its way from occlusion to reperfusion, or vice versa.

OR

OR ACS STEMI Coronary

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

Dr. Smith's ECG Blog

DECEMBER 16, 2019

This was formerly an indication for cath lab activation, but was abandoned in the 2013 guidelines because of poor specificity. Chang et al. Here is an algorithm that is very useful in such cases, published by Cai and Sgarbossa in 2013. Excessively discordant STE, as defined by at least 1 mm and with an ST/S ratio of 25% or more.

ED

ED ACS OR ALS

REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. References: Jaff MR et al. PMID: 21422387 Wan S et al. PMID: 15262836 Sharifi M et al. PMID: 27422214 Wang C et al. PMID: 19741062 Kucher N et al. PMID: 24226805 Piazza G et al. PMID: 26315743 Tapson VF et al.

ALS

ALS ACS OR CPR

Steroids in preschool wheeze

Don't Forget the Bubbles

JULY 22, 2024

Compare this with the Panickar et al. Fortunately, Lee et al. Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, et al. Future of Pre-School Wheeze Whilst Lee et al. Cronin JJ, McCoy S, Kennedy U, An Fhailí SN, Wakai A, Hayden J, et al. study from 200 9. The Lancet Respiratory Medicine [Internet].

E-9-1-1

E-9-1-1 ALS ACS ED

Beyond Ketamine: When to use Facilitated Intubation in the ED

EMDocs

SEPTEMBER 25, 2023

References: Heffner AC et al. Resuscitation 2013; 84(11): 1500 – 4. PMID: 23911630 Kim WY et al. PMID: 23911630 Kim WY et al. PMID: 25402500 Forsythe SM et al. PMID: 10631227 Mosier JM et al. 2013): 71-78. Riker RR, Shehabi Y, Bokesch PM, et al. Lowe J B, Yoo M J, Patrick J O, et al.

ED

ED Emergency Department ALS OR

How does Acute Total Left Main Coronary occlusion present on the ECG?

Dr. Smith's ECG Blog

AUGUST 9, 2019

But if they do present: The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion , though it might be due to sub total LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. Widimsky P et al. Knotts et al. TIMI 0/1 flow).(61,62)

Coronary

Coronary STEMI ACS ALS

Optimizing Hemodynamics Prior to RSI

FOAMfrat

OCTOBER 20, 2023

And according to a paper from Russotto et al. Of note, in the paper by Russotto et al., Heffner et al, 2012, reports a study that "demonstrated pre-RSI systolic pressures less than 140 as independently associated with post-intubation hypotension, but SI was not included in this analysis" [14]. Sackles et al. Brown, C.A.

E-9-1-1

E-9-1-1 ALS ACS OR

Middle Aged Woman with Asystolic Cardiac Arrest, Resuscitated: Cath Lab?

Dr. Smith's ECG Blog

OCTOBER 20, 2013

Kurkciyan et al. Kurkciyan et al., Two prehospital 12-lead ECGs looked similar to this ED ECG: This shows diffuse ST depression (I, II, III, aVL, aVF, V3-V6) with reciprocal ST elevation in lead aVR. This ECG is diagnostic of diffuse subendocardial ischemia. In 25 (93%), the initial rhythm was asystole or PEA.

STEMI

STEMI Coronary ACS Emergency Department

A man in his 70s with acute chest pain and paced rhythm.

Dr. Smith's ECG Blog

MAY 8, 2023

The ACC likely made this new recommendation for the MSC in ventricular paced rhythm in large part due to the "PERFECT" Study (Meyers is an author, and Smith was the senior author): Dodd et al. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STEMI

STEMI Coronary ED ALS

Antibiotics in the paediatric emergency department

Don't Forget the Bubbles

SEPTEMBER 18, 2023

Davidson L, Foley DA, Clifford P, Blyth CC, Bowen AC, Hazelton B, et al. Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. Tonsillitis Baker MG, Gurney J, Oliver J, Moreland NJ, Williamson DA, Pierse N, et al. 2013 Sep 1;88(5):338–40. Addo-Yobo E, Chisaka N, Hassan M, Hibberd P, Lozano JM, Jeena P, et al.

Emergency Department

Emergency Department E-9-1-1 ALS ACS

ABG Versus VBG in the Emergency Department

EMDocs

FEBRUARY 12, 2024

References/Further Reading (1) Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. 11) Webb RK, Ralston AC, Runciman WB. 2013 May;14(3):212-7. doi: 10.1136/emermed-2013-202879. Epub 2013 Oct 17. Peripheral venous and arterial blood gas analysis in adults: are they comparable? PMID: 11685301. (10)

Emergency Department

Emergency Department E-9-1-1 ED ICU

Episode 152 Hemochromatosis: Ironing out the details

This Podcast Will Kill You

SEPTEMBER 24, 2024

2013): 403-412. 2013): 788. Datz, Christian, et al. ACS omega , 7 (24), pp.20441-20456. Hodgskiss, Malcolm SW, et al. Moalem, Sharon, et al. Olejarz, Jason, et al. New England Journal of Medicine , 387 (23), pp.2159-2170. Barton, James C. “Hemochromatosis and iron overload: from bench to clinic.”

ALS

ALS ACS

Bubble Wrap PLUS – June 2023

Don't Forget the Bubbles

JUNE 14, 2023

Lava SAG, et al. Hsiao W, et al. Mullaly R, et al. Puoti MG, et al. Stenson EK, et al. Bruinsma RA, et al. Rivetti G, et al. van Gameren-Oosterom HBM, et al. Lester TR, et al. Mansell H, et al. Fernandes AER, et al. Wolstencroft J, et al. Roodbol J, et al.

ALS

ALS ACS ED OR

ToxCard: Chronic Organophosphate Toxicity

EMDocs

JUNE 14, 2023

Boostani R, Mellat A, Afshari R, et al: Delayed polyneuropathy in farm sprayers due to chronic low dose pesticide exposure. Published 2013 Dec 9. PMID: 23163581] Muñoz-Quezada MT, Lucero BA, Iglesias VP, et al. doi:10.1080/10773525.2015.1123848 Povey AC, Rees HG, Thompson JP, Watkins G, Stocks SJ, Karalliedde L.

E-9-1-1

E-9-1-1 Plasma Emergency Department ED

emDOCs Revamp – Acute Chest Syndrome

EMDocs

JUNE 27, 2024

Critical Care Medicine 41(12):p A191, December 2013. Alkindi S, Al-Busaidi I, Al-Salami B, Raniga S, Pathare A, Ballas SK. Alghamdi FA, Al-Kasim F, Alshhada F, Ghareeb E, Azmet FR, Almudaibigh A, Baitalmal L, Alnawfal B, Alluqmani R. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. 2013 Jan-Mar;16(1):91-5.

E-9-1-1

E-9-1-1 ICU ACS EMS

ToxCard: Acute Organophosphate Toxicity

EMDocs

JUNE 7, 2023

References: Boostani R, Mellat A, Afshari R, et al: Delayed polyneuropathy in farm sprayers due to chronic low dose pesticide exposure. 2013; 6:524. Published 2013 Dec 9. doi:10.1186/1756-0500-6-524 Muñoz-Quezada MT, Lucero BA, Iglesias VP, et al. Published 2013 Dec 9. Clin Toxicol (Phila) 51: 838, 2013.

E-9-1-1

E-9-1-1 ICU ED Plasma

Chest pain and this ECG. Angiogram totally normal. Is this myocarditis?

Dr. Smith's ECG Blog

APRIL 13, 2025

Additional Points about MINOCA: I found it surprising to learn that the initial description of acute MI despite normal coronary vessels is not a new concept having been first described ~80 years ago ( with eventual adoption of the term, "MINOCA" in 2013 ). As I wrote in that Nov.

Coronary

Coronary STEMI EMS ALS

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

See Raitt et al.: Oliva et al. [ Patients with suspected ACS should be evaluated with echocardiography. Incidence and Prognosis of Pericarditis After ST-Elevation Myocardial Infarction (from the Acute Coronary Syndrome Israeli Survey 2000 to 2013 Registry Database). This correlates with potentially salvageable myocardium.

STEMI

STEMI ALS OR Coronary

Paramedicine Now

Elbow Dislocations

Rethinking Fluid Resuscitation in Vaso-Occlusive Crisis: Is Lactated Ringer’s the Superior Choice?

Trending Sources

emDOCs Podcast – Episode 123: Sympathetic Crashing Acute Pulmonary Edema

A Practical Approach to HIV/AIDS: Part 1

Episode 180 Food Dyes: It’s all marketing

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

REBEL Core Cast 123.0 – Posterior Epistaxis

Target Acquired

Concerning EKG with a Non-obstructive angiogram. What happened?

Fluoroquinolone Use In Children

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Cardiac arrest: even after the angiogram, the diagnosis is not always clear

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Right precordial ST depression in a patient with chest pain

On its way from occlusion to reperfusion (or vice versa), the ECG can be normal or near normal

A 50-something with 5 hours of typical chest pain and Left Bundle Branch Block

REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?

Steroids in preschool wheeze

Beyond Ketamine: When to use Facilitated Intubation in the ED

How does Acute Total Left Main Coronary occlusion present on the ECG?

Optimizing Hemodynamics Prior to RSI

Middle Aged Woman with Asystolic Cardiac Arrest, Resuscitated: Cath Lab?

A man in his 70s with acute chest pain and paced rhythm.

Antibiotics in the paediatric emergency department

ABG Versus VBG in the Emergency Department

Episode 152 Hemochromatosis: Ironing out the details

Bubble Wrap PLUS – June 2023

ToxCard: Chronic Organophosphate Toxicity

emDOCs Revamp – Acute Chest Syndrome

ToxCard: Acute Organophosphate Toxicity

Chest pain and this ECG. Angiogram totally normal. Is this myocarditis?

Chest pain followed by 6 days of increasing dyspnea -- what happened?

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