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 ALS 130

Don't Forget the Bubbles

MAY 19, 2025

Pain episodes, or vaso-occlusive crises (VOC), are a hallmark of sickle cell disease, often leading to prolonged hospital stays and serious complications like acute chest syndrome (ACS). While small studies suggest that early pain relief can shorten hospitalisation, the evidence remains limited.

Emergency Department 62

Emergency Department ACS EMS OR 62

Pediatric EM Morsels

APRIL 19, 2024

J Bone Joint Surg Br. 2001;83:1173-5. Oakley EA, Ooi KS, Barnett PLJ. A randomized controlled trial of 2 methods of immobilizing torus fractures of the distal forearm. Pediatr Emerg Care. 2008;24:65–70. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117:691–697.

ALS 293

ALS ACS Emergency Department ED 293

Emergency Medicine Cases

APRIL 14, 2020

In this ECG Cases blog we look at 6 patients who presented with cardiorespiratory symptoms, possibly from COVID and illustrate the dangers of anchoring, being hypervigilant for cardiovascular complications, and why testing for COVID in patients being admitted for ACS is important.

ACS 130

ACS STEMI 130

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?

ACS 52

ACS STEMI OR Critical Care 52

Dr. Smith's ECG Blog

JULY 2, 2023

This was texted to me from a former resident, while working at a small rural hospital, with the statement: "I can’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS." Chest pain or discomfort) What do you think? Here was my response: "Suspicious for inferior posterior OMI.

ACS 52

ACS Coronary OR 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

ACS would be highly unusual in a young athlete, and given the information on his race bib, one must first suspect that the abnormal ST elevation is due to demand ischemia, not ACS. A bedside echo performed by the emergency physician showed no wall motion abnormality and confirmed LVH.

ACS 52

ACS Defibrillator Epinephrine STEMI 52

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

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 125

Defibrillator Coronary Epinephrine ACS 125

EMS 12-Lead

AUGUST 18, 2024

I interpreted the ECG as VT with two primary etiological possibilities: 1. Abrupt plaque ulceration of Type 1 ACS leading to VT. Of interest, he specified that he awoke earlier that morning in his usual state of health, then developed chest discomfort, then developed palpitations.

CAD 147

CAD EMT EMT ACS 147

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

FOAMfrat

APRIL 25, 2024

References: Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J. The conversation concludes with a discussion on the transfer of pacing from one device to another and the importance of verifying capture during the process. Check out more from Josh, Judah, and Tom at EMS12LEAD.com. 2024 Mar 15:1-9.

Paramedic 128

Paramedic ACS EMS ED 128

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 120

STEMI ACS Coronary Emergency Department 120

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). ACS and hyperkalemia both have lethal downstream consequences, so it is imperative for the clinician to acclimate to the presentation, or developing, features of each. ECG's are difficult.

ACS 130

ACS Paramedic Coronary ALS 130

Medgadget

AUGUST 29, 2022

” The researchers presented their technology at the 2022 fall meeting of the American Chemical Society (ACS). Via: ACS. . “We already interact with a lot of touch-based electronics, such as smart phones and keyboards, so this sensor could integrate seamlessly into daily life.”

ACS 115

ACS 115

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. References Geddes G, Butterly MM, Patel SM, Marra S. Pediatric neck masses. Pediatr Rev. 2013 Mar;34(3):115-24; quiz 125. doi: 10.1542/pir.34-3-115.

ACS 161

ACS Emergency Department ED OR 161

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

MARCH 31, 2024

The person I was texting knows implicitly based on our experience together that I mean "Definite posterior OMI, assuming the patient's clinical presentation is consistent with ACS." The patient was a middle-aged female who had acute chest pain of approximately 6 hours duration. The pain was still active at the time of evaluation.

STEMI 111

STEMI ACS ED 111

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!!"

ACS 117

ACS STEMI OR 117

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 115

STEMI ACS Coronary OR 115

ALiEM

OCTOBER 30, 2024

DOI: Papudesi BN, Malayala SV, Regina AC. This month in JAAD Case Reports: August 2023: Xylazine and skin necrosis. Journal of the American Academy of Dermatology. 2023 Aug 1;89(2):231. Xylazine toxicity. 2023 [book]. PMID 37603662 Rose L, Kirven R, Tyler K, Chung C, Korman AM. JAAD Case Reports. 2023 Jun 1;36:113-5.

E-9-1-1 161

E-9-1-1 Naloxone Emergency Department ALS 161

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

Dr. Smith's ECG Blog

JUNE 5, 2024

As per my review of this subject ( Check out My Comment at the bottom of the page in the November 16, 2023 post in Dr. Smith's ECG Blog ) — the 3 most common Causes of ACS ( A cute C oronary S yndrome ) with a "negative" cath are: i ) Myocarditis; ii ) Takotsubo cardiomyopathy; and , iii ) MINOCA.

Coronary 123

Coronary ACS ALS OR 123

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. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1.

Coronary 110

Coronary E-9-1-1 STEMI ACS 110

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. Many of these OHCAs are due to ventricular fibrillation or pulseless VT. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006).

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Link to abstract Link to full text 2) Use of Morphine in Non-STE-ACS is independently associated with mortality, at odds ratio of 1.4

E-9-1-1 79

E-9-1-1 ACS STEMI Coronary 79

The Skeptics' Guide to EM

FEBRUARY 27, 2021

Exclusion criteria: Transferred patients, HR <40 or >140 bpm, SBP <90 or >180 mmHg, RR <6 or >36/min, GCS <15, possible ACS, headache, pregnancy, breastfeeding, known renal or hepatic failure, previous malignant hyperthermia, known sensitivity to fluorinated anesthetics, or agitated/aggressive per nursing staff.

Emergency Department 130

Emergency Department ACS ALS ED 130

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 81

ACS Critical Care OR 81

Dr. Smith's ECG Blog

MAY 20, 2024

Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? Assuming that was indeed a culprit, then this was ACS. The T waves in leads II and aVF have deflated, and the T wave in lead III has become terminally negative. The ST depressions in I and aVL have resolved.

CAD 127

CAD STEMI Coronary ACS 127

Broome Docs

DECEMBER 22, 2024

PECARN looks at probiotics for toddlers diarrhea… Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O’Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB.

E-9-1-1 52

E-9-1-1 ACS Paramedic Emergency Department 52

Dr. Smith's ECG Blog

DECEMBER 27, 2023

As a result, even before looking at this patient's initial ECG — he falls into a high -prevalence likelihood group for ACS ( for an A cute C oronary S yndrome ). We therefore need to assume and rule "out" ACS — more than having to rule it "in". The "onus of proof" remains on us as medical providers to objectively rule out ACS.

E-9-1-1 131

E-9-1-1 OR Coronary ACS 131

Broome Docs

JANUARY 27, 2025

Emerg Med J. 2019 Jan;36(1):2-3. doi: 10.1136/emermed-2018-208151. Epub 2018 Oct 25.

ED 100

ED OR ACS Critical Care 100

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

EMS 12-Lead

JULY 24, 2023

Category 1 : Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates. Smith : This is ACS even if the troponin returns normal, and the first troponin especially might return normal. This results in Type I MI.

Coronary 130

Coronary ACS CAD ED 130

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. Leads V7–V9 must be placed to reveal the ST-segment elevations.

STEMI 52

STEMI ACS OR 52

Emergency Medicine Ireland

JUNE 21, 2021

This week we’re looking at the other ACS, the surgical ACS, the old abdominal compartment syndrome. This week we’re looking at the other ACS, the surgical ACS, the old abdominal compartment syndrome. These are all very nice and should all be reflected upon and followed when appropriate in your ACS.

Critical Care 52

Critical Care ACS OR 52

Medgadget

OCTOBER 20, 2022

Study in ACS Applied Materials & Interfaces : Single-Step Direct Growth of Graphene on Cu Ink toward Flexible Hybrid Electronic Applications by Plasma-Enhanced Chemical Vapor Deposition. When the graphene coating was applied to gold components it also enhanced their ability to resist deterioration caused by human sweat. .

Plasma 92

Plasma ACS 92