ACS and Document - 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. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Simple elbow dislocation. Shoulder Elbow. 2017 Jul;9(3):195-204. PMID: 28588660 Donohue KW, Mehlhoff TL. Chronic Elbow Dislocation: Evaluation and Management. J Am Acad Orthop Surg.

E-9-1-1

E-9-1-1 ACS OR Emergency Department

ED care of refugee populations from sub-Saharan Africa

EMDocs

JANUARY 6, 2025

4,5 Of particular concern is the Sudanese conflict, which began in April 2023, and which has caused the largest internal displacement of a population in documented history. link] Hummell AC, Cummings M. About three-quarters of the countries in sub-Saharan Africa serve as origin or destination points for refugees. 2022;37(1):41-49.

ED

ED E-9-1-1 ALS Frozen Plasma

Wave 2025 Recap: Top 5 Topics in Hospital and Trauma Care

ESO

MAY 9, 2025

.” Leveraging the ESO Patient Registry During an American College of Surg eons S ite Survey, presented by Matthew Derkrikorian, Trauma Program Manager at Rady Children’s Hospital, offered a look at how Rady Childrens Hospital prepared for and completed the first ACS Site Survey using ESOs updated registry. shared key takeaways.

EMS

EMS ACS First Responder Paramedic

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. A consensus document from the society for academic emergency medicine/heart failure society of America acute heart failure working group. What are the key tests? Tests: ECG , labs, chest imaging. Erratum in: Ann Emerg Med.

E-9-1-1

E-9-1-1 ALS Emergency Department OR

Interns are not (yet) poisoned by the STEMI/NSTEMI paradigm

Dr. Smith's ECG Blog

JUNE 10, 2025

When seeing a South Asian patient with chest pain, concern for ACS must be heightened, given their disproportionately higher risk of CAD, despite often lacking traditional risk factors.) At time of cardiology evaluation, patient was chest pain free, according to documentation.

STEMI

STEMI E-9-1-1 CAD ALS

EMCrit Guest Post – In Defense of Dignity by Chris Hicks, MD

EMCrit Project

JUNE 23, 2025

Most medical documentation is polluted with it, for want of using the persons actual name. The trauma team gathers, the patient is fully awake, listening, wondering what happened to them with a good amount of apprehension and fear. A few simple words by way of update can make all the difference.

Operating Room

Operating Room Critical Care Emergency Department OR

Episode 180 Food Dyes: It’s all marketing

This Podcast Will Kill You

JULY 1, 2025

Background document for the food advisory committee: certified color additives in food and possible association with attention deficit hyperactivity disorder in children. 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). 2017): 524-548.

E-9-1-1

E-9-1-1 ACS ALS OR

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

We documented that the majority of stenotic lesions had compensatory enlargement and thus exhibited remodeling. Strictly speaking — this case does not at this time qualify as MINOCA — because the negative cath and 2 normal hs-troponins done 6 hours apart failed to document infarction. (

Coronary

Coronary ACS OR EMR

Episode 97 – Cascading Prescriptions

The Curious Clinicians

OCTOBER 2, 2024

Sponsor Freed is an AI scribe that listens, transcribes, and writes medical documentation for you. It turns clinicians’ patient conversations into accurate documentation – instantly. Due to system constraints, VCU Health Continuing Education cannot offer subscription services at this time but hopes to do so in the future.

ACS

ACS ALS OR

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. The following ECG was obtained. ECG 1 What do you think? of the time.

ACS

ACS ALS OR STEMI

An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain

Dr. Smith's ECG Blog

MARCH 19, 2024

Cardiology documents their interpretation of ECG in their consult note - “atrial paced with old LBBB” The patient stayed at outside hospital (which does not have cardiac cath capabilities). The cath report showed: Significant stenosis with subtotal occlusion (99%) in the prox to mid Lcx, culprit of ACS, TIMI flow 1.

CAD

CAD STEMI ACS ALS

Acute OMI or "Benign" Early Repolarization?

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present." 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 ). Repeat cTnI drawn at around 8 AM was 3.910 ng/mL.

E-9-1-1

E-9-1-1 OR Coronary ACS

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." 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. Repeat trop 150 ng/L.

E-9-1-1

E-9-1-1 ACS STEMI Coronary

An elderly male with acute altered mental status and huge ST Elevation

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Click here to sign up for Queen of Hearts Access Given the lack of intracranial hemorrhage, the patient was administered aspirin for suspected ACS and cardiology was consulted. Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) Both highly negative. ng/mL and 0.10

STEMI

STEMI Coronary Emergency Department ACS

On the Scene: Prehospital Care for Electrical Burns for EMTs

EMT Training Station

FEBRUARY 11, 2024

Assessing the Severity The severity of an electrical burn depends on several factors: the type of current (AC or DC), voltage, the pathway of the current through the body, the duration of contact, and the victim’s overall health. As EMTs, we’re always prepared to address these life-threatening complications alongside the burns.

EMT

EMT EMT Emergency Medical Technician First Aid

Simulation Brain Wash

FOAMfrat

APRIL 22, 2024

While one may argue that nitro really has no mortality benefit in ACS, I have seen patients with CHF present with hyper tension and inferior S-T elevation, in which the providers were scared to even look at the bottle of nitro. References Kimbrell J, Kreinbrook J, Poke D, Kalosza B, Geldner J, Shekhar AC, Miele A, Bouthillet T, Vega J.

E-9-1-1

E-9-1-1 ACS Paramedic Critical Care

Fluoroquinolone Use In Children

Pediatric EM Morsels

AUGUST 18, 2023

None of the patients were documented to have joint disease at follow up. References: Ross RK, Kinlaw AC, Herzog MM, Funk MJ, Gerber JS. There were 2523 children included. Number of adverse effects was similar between the groups, however in the Levofloxacin group 85% of MSK complaints were arthralgias. Pediatrics. 147(6):e202003316.

E-9-1-1

E-9-1-1 ACS OR ALS

Can we rule out appendicitis with a low ALVARADO score?

EM Didactic

OCTOBER 15, 2018

It is worth doing and documenting serial abdomen exams in non-specific abdo pains. References Meltzer AC, Baumann BM, Chen EH, Shofer FS, Mills AM. d/w Surgical in-patient teams for possible admission for observation rather than directly jumping to imaging.

ACS

ACS ED OR

POCUS in the ED: Is Confirmatory RUQ US Still Necessary?

REBEL EM

SEPTEMBER 11, 2023

ACS surgeons appeared to select surgery as their initial choice substantially more frequently than other subspecialties. ACS surgeons would have sent 6/43 patients for ERCP or MRCP (14%), whereas surgical oncologists would have sent a higher percentage of patients for ERCP or MRCP (7/18 or 38.9%).

ED

ED ACS Emergency Department OR

Watch what happens when "pericarditis" and morphine cloud your judgment

Dr. Smith's ECG Blog

JULY 3, 2018

The AHA/ACC guidelines recommend emergent cardiac catheterization for patients with concern for ACS and refractory chest pain despite maximum medical therapy defined as aspirin + clopidogrel/ticagrelor + heparin/enoxaparin. link] He was admitted to the cardiology unit for serial troponin measurements and concern for possible ACS.

ACS

ACS STEMI Coronary CAD

Tasty Morsels of Critical Care 072 | Cardiorenal syndrome

Emergency Medicine Ireland

JULY 3, 2023

Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. This segues relatively nicely into a section of the document on palliative care. Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. To start with there are apparently 5 types of cardiorenal syndrome.

Critical Care

Critical Care ACS ALS OR

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Dr. Smith's ECG Blog

JANUARY 9, 2024

Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? Cardioversion will address the rhythm problem immediately, also if the chest discomfort subsides when SR is restored, ischemia from ACS becomes much less likely. In either case, prompt cardioversion is indicated.

Coronary

Coronary ACS ED OR

Are these Wellens' waves?

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS. showed that , when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS. Kosuge et al.

E-9-1-1

E-9-1-1 ACS ALS OR

(Q3/2024) ESO Updates: Quarterly Product Enhancements

ESO

OCTOBER 18, 2024

This new feature breaks down the data silos that are inherent in typical prehospital documentation and changes the paradigm of patient care documentation from encounter-based to patient-centric. You’ll now have a holistic view of frequent patients, along with the ability to view previous 12-leads, PCRs and HDE Outcomes.

Mobile Integrated Health

Mobile Integrated Health Critical Care MIH Community Paramedicine

"The dye don't lie".except when it does. Angiogram Negative, or is it?

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

The patient was thought to have low likelihood of ACS, and cardiology recommended repeat troponin, urine drug testing, and echocardiogram. At that point, cardiology elected to treat for ACS. The operator documented thoughtful consideration of risks and benefits of stent placement. Initial hscTnI was 10 ng/L (ref. <14).

OR

OR Coronary ACS EMS

A man in his 60s with acute chest pain and high voltage

Dr. Smith's ECG Blog

APRIL 14, 2023

It is easy to say this in retrospect, especially not being the one in charge of this overcrowded waiting room full of unseen patients, but an elderly patient with known CAD and ongoing ACS-sounding chest pain despite medical management with positive troponin is already an indication for emergent cath, regardless of the ECG!

CAD

CAD ACS STEMI Coronary

Compare these two ECGs. Do either, neither, or both show anything important?

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." A troponin this high in a patient with no known chronic troponin elevation, and active acute ACS symptoms, has a very high likelihood of type 1 ACS regardless of the ECG.

OR

OR STEMI ACS ALS

Will this case be flagged for Quality Improvement in the STEMI/NSTEMI Paradigm?

Dr. Smith's ECG Blog

MARCH 27, 2025

But there are also hyperacute T waves (HATW) in V4-5, which exclude early repolarization and pericarditis, leaving only LAD occlusion for this patient presenting with classic symptoms of ACS. But it was interpreted as no acute ischemia and the patient was referred to cardiology as Non-STEMI.

STEMI

STEMI Coronary ACS ED

Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)

Dr. Smith's ECG Blog

JUNE 27, 2021

If it is maximal in V1-V4, and the patient's presentation in consistent with ACS (as this certainly is), then it is DIAGNOSTIC of Occlusion with 90% specificity (We have an upcoming article that proves this). Angiogram: "ACS - Non ST Elevation Myocardial Infarction. This was not recognized. The patient was started on a nitro drip.

STEMI

STEMI ACS Coronary ED

Tasty Morsels of Critical Care 013 | Tracheostomy – Putting it in

Emergency Medicine Ireland

DECEMBER 17, 2020

There is a substantial ANZICS document on tracheostomy that forms the structure for this tasty morsel. doi: 10.21037/acs.2018.03.01. Intensivists have embraced the tracheostomy as an ICU procedure. It’s one of the most invasive and one of the riskier procedures we do. Surgical anatomy of the trachea. Ann Cardiothorac Surg.

Critical Care

Critical Care ICU ACS OR

H/o MI and stents with brief angina has this ED ECG. And what is Fractional Flow Reserve?

Dr. Smith's ECG Blog

JANUARY 31, 2020

But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. It is proven better than angiography alone in stable angina , and also has been shown to improve decisions on stenting non-culprit lesions in ACS. It could be acute, though probably is not.

ED

ED Coronary ACS CAD

Spinal Immobilization or Spinal Motion Restriction: Which is Safest?

NCOAE

DECEMBER 11, 2023

The Eastern Association for the Surgery of Trauma (EAST) , the National Association of EMS Physicians (NAEMSP) , and the American College of Surgeons Committee on Trauma (ACS-COT) all support the recommendation against the use of spinal immobilization in patients with isolated penetrating injuries.

OR

OR Emergency Medical Technician Emergency Department Emergency Medical Services

Profound ST depression in II, III, aVF

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! There is profound "inferior" ST Depression.

Coronary

Coronary ACS Naloxone Plasma

De Winter's T-waves are Not a Stable ECG condition. Upright T-waves in Posterior OMI are Distinct from de Winter's waves.

Dr. Smith's ECG Blog

MARCH 8, 2021

Since ACS is so dynamic, with thrombi forming and lysing continuously, and because the ECG and angiogram are rarely simultaneous, it is probable that de Winter's T-waves are recorded in a window when the artery is barely open. This is the longest lasting I have ever documented a hyperacute T wave without going "up" or "down."

STEMI

STEMI ACS Critical Care OR

Popular Antiobesity Medications Bring New Challenges to Emergency Physicians

ACEP Now

FEBRUARY 11, 2024

There have been documented cases of overdose, and of note, there is no known antidote. ACS chemical neuroscience molecule spotlight on Contrave. ACS Chem Neurosci. At times, patients may also be taking other diabetes medications such as sulfonylureas or insulin, which could precipitate worsening persistent hypoglycemia.

Overdose

Overdose ACS Plasma ALS

AHA/NCS Statement on Critical Care Management of Post ROSC Patients

EMDocs

JANUARY 11, 2024

Hematologic Management Takeaway : They recommend a transfusion threshold < 9 g/dL in those with ACS, but several studies (MINT trial) and guidelines suggest 8 g/dL can be used. Alternatively, a slightly lower PaCO2 within the normal range may be used to maintain a safe pH (>7.2)

Critical Care

Critical Care E-9-1-1 ICU OR

Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

We can see that there is evolution of the elevations, worsening reciprocal change, as well as evolution of posterior involvement (right precordial R-waves with ST depression) There was very little documentation surrounding these ECGs. Beware of ACS presenting with atypical symptoms, including absence of chest pain.

STEMI

STEMI ACS Emergency Department OR

How much time are you willing to wait for OMI to become STEMI (if it ever does)?

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

It is true that other documents occasionally describe "abnormal ST segment elevation" in the posterior leads (commonly accepted criteria is 0.5 mm in just one lead V7-9), but as far as I can tell all of these documents specifically avoid calling this condition STEMI and specifically avoid using any terminology similar to "STEMI equivalent."

STEMI

STEMI E-9-1-1 ACS OR

Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?

Dr. Smith's ECG Blog

JUNE 28, 2019

If a patient presents with symptoms of ACS, has an elevated troponin, and has persistent symptoms in spite of medical therapy [antiplatelet, antithrombotic, and anti-ischemic (nitro)], then cath lab activation is indicated regardless of ECG findings. In this case, one might say it is "obvious" MI because of a straight ST segment in aVF.

Coronary

Coronary ACS ED OR

70-year-old with acute chest pain, STEMI negative: just an old infarct?

Dr. Smith's ECG Blog

APRIL 4, 2023

As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. As cardiology documented, “possible STEMI. Most importantly , while waiting for the paradigm to evolve, maintain focus on our true goal for our patients with ACS: to identify and reperfuse patients with acute occlusion MI.”

STEMI

STEMI Coronary OR ACS

A man in his 40s with chest pain and syncope after cocaine use

Dr. Smith's ECG Blog

JULY 19, 2019

This prompted a repeat ECG (we do not have documentation from that time to tell us whether he had persistent, recurrent, or absent pain): Progression of anterior OMI to full Q-wave MI with large pathologic Q-waves in V2-V4 with persistent STE which now meets STEMI criteria (after full thickness infarction/stunning). ng/mL (very elevated).

STEMI

STEMI ED ACS OR

A "normal ECG" on a busy night

Dr. Smith's ECG Blog

OCTOBER 6, 2018

Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel: limitations of ST-segment elevation in standard and extended ECG leads. JACC 2010 Post hoc analysis of the TRITON-TIMI-38 randomized controlled trial comparing prasugrel with clopidogrel among ACS patients undergoing cardiac catheterization.

STEMI

STEMI Coronary ALS OR

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

REBEL EM

MARCH 2, 2023

REBEL Cast Ep114 – High Flow O2, Suspected ACS, and Mortality? PMID: 33653685 Clinical Question: Is there an association between high flow supplementary oxygen and 30-day mortality in patients presenting with a suspected acute coronary syndrome (ACS)? Click here for Direct Download of the Podcast Paper: Stewart, RAH et al.

ACS

ACS Coronary STEMI ALS

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Triage documented a complaint of left shoulder pain. Smith : As Willy states, 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!!"

E-9-1-1

E-9-1-1 Coronary ACS STEMI

Elbow Dislocations

ED care of refugee populations from sub-Saharan Africa

Trending Sources

Wave 2025 Recap: Top 5 Topics in Hospital and Trauma Care

emDOCs Podcast – Episode 123: Sympathetic Crashing Acute Pulmonary Edema

Interns are not (yet) poisoned by the STEMI/NSTEMI paradigm

EMCrit Guest Post – In Defense of Dignity by Chris Hicks, MD

Episode 180 Food Dyes: It’s all marketing

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Episode 97 – Cascading Prescriptions

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain

Acute OMI or "Benign" Early Repolarization?

Judge for yourself the management of this patient with "NSTEMI, multivessel disease"

An elderly male with acute altered mental status and huge ST Elevation

On the Scene: Prehospital Care for Electrical Burns for EMTs

Simulation Brain Wash

Fluoroquinolone Use In Children

Can we rule out appendicitis with a low ALVARADO score?

POCUS in the ED: Is Confirmatory RUQ US Still Necessary?

Watch what happens when "pericarditis" and morphine cloud your judgment

Tasty Morsels of Critical Care 072 | Cardiorenal syndrome

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Are these Wellens' waves?

(Q3/2024) ESO Updates: Quarterly Product Enhancements

"The dye don't lie".except when it does. Angiogram Negative, or is it?

A man in his 60s with acute chest pain and high voltage

Compare these two ECGs. Do either, neither, or both show anything important?

Will this case be flagged for Quality Improvement in the STEMI/NSTEMI Paradigm?

Ischemic ST depression maximal in V1-V4 (vs. V5-V6), even if less than 0.1 millivolt, is specific for Occlusion Myocardial Infarction (vs. subendocardial non-occlusive ischemia)

Tasty Morsels of Critical Care 013 | Tracheostomy – Putting it in

H/o MI and stents with brief angina has this ED ECG. And what is Fractional Flow Reserve?

Spinal Immobilization or Spinal Motion Restriction: Which is Safest?

Profound ST depression in II, III, aVF

De Winter's T-waves are Not a Stable ECG condition. Upright T-waves in Posterior OMI are Distinct from de Winter's waves.

Popular Antiobesity Medications Bring New Challenges to Emergency Physicians

AHA/NCS Statement on Critical Care Management of Post ROSC Patients

Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

How much time are you willing to wait for OMI to become STEMI (if it ever does)?

Inferior Subtle ST elevation: straight ST segment, but also no reciprocal ST depression in aVL: which is more important?

70-year-old with acute chest pain, STEMI negative: just an old infarct?

A man in his 40s with chest pain and syncope after cocaine use

A "normal ECG" on a busy night

REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality?

Occlusion myocardial infarction is a clinical diagnosis

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