Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Submitted by Dr. George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. Whereas SCAD is found in ~1-4% of all angiograms performed for ACS — this percentage increases to over 30% in middle-aged women.

OR 66

OR STEMI ACS Coronary 66

Don't Forget the Bubbles

JULY 5, 2023

Haematology specialist clinics are key to manage the chronic side of the disease, while ED doctors should be able to act rapidly on the common acute emergencies. with thanks A 15-month-old Kenyan boy presents to ED with right hand swelling. A 10-year-old boy with known SCA presents to ED due to severe pain in the legs.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

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. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC. 2023 Jul 17.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

EMDocs

JUNE 27, 2024

An 8-year old male with a history of sickle cell anemia presents to the ED for evaluation of fever for 2 days and “feeling like I can’t get a full breath”. 2018 Aug;46(3):144-151. 768: Epidemiology of Hospital Based ED Visits due to Sickle Cell Crisis and Acute Chest Syndrome in Kids. Epub 2018 Oct 17. C or 100.4

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E-9-1-1 ICU ACS EMS 75

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. Anything more on history?

Coronary 52

Coronary ACS STEMI ALS 52

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.

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E-9-1-1 OR Coronary ACS 117

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). The average time to control HR in the IV amiodarone was 1.7h, which is usually the average time for disposition from the ED. 2018, PMID: 30571262 Gritsenko, Diana, et al.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

ECG 1 at time zero EARLY REPOLARIZATION ABNORMAL ECG ED final official overread: "early repol vs hyperacute T, minimal changes from previous (previous shown below)" What do YOU think? Eur Heart J 2018. No wall motion abnormality This shows that significant ACS can have ZERO WMA!! A 70-something y.o. Lemkes et al. Full text link.

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STEMI ACS Critical Care OR 113

EMDocs

JULY 19, 2023

This would be a send-out test and would be unlikely to help us acutely in the ED. 7 We are commonly taught that metals are not amenable to treatment with activated charcoal (AC).However, 2018, February 1). 6 Urine heavy metals screens are not recommended for asymptomatic patients. Resources: S. Food and Drug Administration.

ACS 66

ACS Plasma OR ED 66

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL. For examples of this phenomenon — See My Comment in the February 14, 2018 — July 21, 2020 — and December 22, 2022 posts in Dr. Smith's ECG Blog ). So they looked into the patient's chart.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

EMS 12-Lead

APRIL 21, 2022

The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. Such aggressive investigation was particularly warranted in this case because of symptoms compatible with ACS, as well as an equally frightening revelation of family history. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

EMDocs

JUNE 7, 2023

F, HR 48, RR 28, BP 104/62, SPO2 88% on non-rebreather mask The patient’s friend who brought her to the ED tells you the patient made suicidal statements earlier in the day and was found in her yard shed. These are send-out labs with turn-around times that make them unlikely to affect the ED course or guide treatment. Toxicology.

E-9-1-1 83

E-9-1-1 ICU Emergency Department ED 83

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. Chou’s Electrocardiography in Clinical Practice, 6th ed. Goldberger’s Clinical Electrocardiography: A Simplified Approach, 9th ed. Annals of Noninvasive Electrocardiology, 18 (1), 21-28.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main."

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. Angie Lobo ( @aloboMD ) (For open-access reviews of this literature, see Saw 2016 , Saw 2017 , or Hayes 2018.) SCAD isn’t rare, especially in women Historically SCAD had been identified in 22% of ACS cases in women. This is written by Brooks Walsh.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. I cannot be anything else.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

JANUARY 17, 2023

A 60 year old with chest pain presented to the ED. The January 30, 2018 post — for arterial pulsation artifact. Additional review of ECG artifacts by Pérez-Riera et al ( Ann Noninvasic Electrocardiol 23:e12494, 2018 ) VT Artifact — by Knight et al: NEJM 341:1270-1274, 1999. Here is his first ECG: What do you think?

ALS 52

ALS ACS OR ED 52

Dr. Smith's ECG Blog

JULY 31, 2018

Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. In middle age women, it accounts for 22-35% of all ACS presentations 1,3 , and the reported incidence of ST-elevation myocardial infarction in this subset of patients is variable, but estimated to be between 24-50% 4.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

Abdominal pain can of course be a symptom of ACS, but it was brief and seemed to have resulted in a vasovagal event. We recorded an ED ECG: The STD, STE, and T-wave inversion are all there, but in this one the voltage is indeed high and diagnostic of LVH. It is certainly possible, but the pretest probability is very low.

ACS 52

ACS ED Coronary STEMI 52

Don't Forget the Bubbles

JUNE 30, 2023

All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. The ODP is caught up leaving theatres and has not yet made it down to ED. Back in ED with Ranulf, and pack two has gone through. The trauma call goes out. Would you like a pigtail catheter or a surgical chest tube?

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

Dr. Smith's ECG Blog

OCTOBER 3, 2018

For some reason unknown to me, the interventionalist was in the ED. Here is our abstract from SAEM 2018. Methods : The PERFECT study (#NCT02765477) is a retrospective, 16 center, international investigation of ED patients from 1/2008 - 12/2016 with VPR on the ECG and symptoms of acute coronary syndrome (ACS).

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). She was asymptomatic at the time of this ECG recorded on arrival to our ED: What do you think? American Journal of Cardiology 2018. What will you do for this asymptomatic patient??? Blondheim et al.

STEMI 52

STEMI ALS ACS OR 52

REBEL EM

JULY 14, 2022

Epub 2018 Jul 4. PMID: 30060961 Koller AC, et al. Resuscitation. Epub 2016 Jun 28. PMID: 27368428 Elmer J, et al. Long-Term Outcomes of Out-of-Hospital Cardiac Arrest Care at Regionalized Centers. Ann Emerg Med. Comparison of three cognitive exams in cardiac arrest survivors. Resuscitation.

ICU 52

ICU ALS OR CPR 52

EMDocs

JANUARY 6, 2024

A 64-year-old male presents by EMS to the ED with shortness of breath. 1 There are over 50,000 visits related to heart transplant in the United States each year and over half of these patients are admitted to the hospital from the ED. We’ll keep it short, while you keep that EM brain sharp.

EMS 63

EMS E-9-1-1 ACS Coronary 63

Dr. Smith's ECG Blog

OCTOBER 6, 2018

We performed a beside US (shown below) which showed lateral wall hypokinesis as read by an US-boarded ED attending in real time. JACC 2010 Post hoc analysis of the TRITON-TIMI-38 randomized controlled trial comparing prasugrel with clopidogrel among ACS patients undergoing cardiac catheterization.

STEMI 52

STEMI Coronary ALS OR 52

EMDocs

FEBRUARY 12, 2024

As the only respiratory therapist in the ED has been paged and is starting BiPAP for this patient, an overhead call for two incoming trauma alerts from a multivehicle collision sounds. Because the RT responsible for drawing arterial blood gases is busy caring for these patients, ABGs will be delayed.

Emergency Department 94

Emergency Department E-9-1-1 ED ICU 94

EMDocs

JANUARY 20, 2024

Prior to this intervention, management in the ED is mainly supportive of the patient’s hemodynamic and cardiac status. doi:10.25122/jml-2018-0067 Takotsubo syndrome. ESC Heart Fail. 2020 Apr;7(2):400-406. doi: 10.1002/ehf2.12603 Amin HZ, Amin LZ, Pradipta A. Takotsubo Cardiomyopathy: A Brief Review. J Med Life. 2020;13(1):3-7.

E-9-1-1 74

E-9-1-1 EMS Coronary ACS 74

EMDocs

NOVEMBER 4, 2024

Jafar Mahmood, MD (Pain Medicine Attending, Paincare Medical Practice) // Reviewed by: Jessica Pelletier, DO, MHPE (EM Attending, APD, University of Missouri-Columbia), Marina Boushra, MD (EM-CCM Attending, Cleveland Clinic); Brit Long, MD (@long_brit) Introduction: Pain management in the ED can be a unique challenge.

ED 98

ED E-9-1-1 Emergency Department ALS 98

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Am J Cardiol 2018; 122(8):1303-1309. This is the initial ED ECG of a 46 year old male with chest pain: The QTc was 420 ST Elevation at 60 ms after the J-point in lead V3 = 2.5 Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? consistent with LAD occlusion) 4-variable formula = 21.09 (above 18.2,

STEMI 52

STEMI Coronary OR ALS 52