EMS 12-Lead

AUGUST 14, 2022

A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis. Here the ST segments are not so deep, nor are the T waves so wide and bulky, because of improved coronary flow at the level of the occlusion. But the lesion is still active!

STEMI 130

STEMI MICU CAD Coronary 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

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. Eur Heart J 2018.

ACS 52

ACS Coronary STEMI Ambulance 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. 2018; 3: e41-e45. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. In: Post TW, ed.

EMS 66

EMS Coronary ED OR 66

Dr. Smith's ECG Blog

JUNE 14, 2024

He underwent coronary angiography which showed severe multivessel disease, and he agreed to proceed with workup for CABG. The January 30, 2018 post — for PTA. 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.

Defibrillator 78

Defibrillator ALS Coronary OR 78

The Skeptics' Guide to EM

MARCH 10, 2018

[display_podcast] Date: March 6th, 2018 Reference: Zahed et al. AEM March 2018. display_podcast] Date: March 6th, 2018 Reference: Zahed et al. AEM March 2018. AEM March 2018. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario.

Emergency Department 100

Emergency Department ALS Coronary OR 100

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. A b rief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality. Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease.

Coronary 138

Coronary OR EMS ED 138

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. Incidence of an acute coronary occlusion. Left main?

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

MARCH 17, 2023

She had a prior history of "NSTEMI" one month ago, during which she had a coronary angiogram reportedly showing no stenosis in any coronary artery. This case was published in Circulation on January 22, 2018 (thanks to Brooks Walsh for finding this!) 2018; 137: 402-404. Her vitals were within normal limits. 2010.12.162.

Coronary 52

Coronary Emergency Department ED OR 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). Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. Past medical history included HTN, HLD, and MI 10 years prior. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 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. Furthermore, pertinent electrolyte values (e.g. potassium) were within normal parameter.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

Shark Fin has also been called: " Giant R-wave " " Triangular QRS-ST-T waveform " Usually shark fin is in one coronary distribution and represents massive ST elevation that is as high as the peak of the R-wave and therefore fuses the R-wave and ST segment. She was taken to the cath lab and her coronaries were clean!!

Coronary 52

Coronary STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

There was a weak correlation between history of ischemic heart disease (r = 0.16, p = 0.001), percutaneous coronary intervention (r = 0.16, p = 0.001), left anterior descending artery (r = 0.12, p = 0.012) as the culprit vessel and a weak negative correlation between age (r = -0.14, p = 0.039) and chest pain.

STEMI 111

STEMI Coronary Emergency Medical Services OR 111

Dr. Smith's ECG Blog

OCTOBER 28, 2022

Electrocardiographic diagnosis of acute coronary Occlusion Myocardial Infarction in ventricular paced rhythm using the modified Sgarbossa criteria. There is no doubt about these 2 EKGs: they are due to acute coronary occlusion. Annals of Emergency Medicine 2021. Diagnosis: Obvious Inferior and lateral Occlusion MI.

Coronary 52

Coronary Paramedic EMS ICU 52

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The finding of dynamic ST-T wave changes on serial tracings in association with a change in chest pain symptoms ( SEE My Comment in the July 21, 2020 post ).

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

MAY 19, 2020

Angiography showed normal coronaries. MINOCA: Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease). Here is my comment on MINOCA: "Non-obstructive coronary disease" does not necessarily imply "no plaque rupture with thrombus." 2) overlooked obstructive coronary disease (e.g., The K was normal.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

MAY 13, 2020

The case I presented in My Comment to that March 9, 2020 post showed a patient with this pattern — who on cath had no more than minimal coronary disease. Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; shock/profound hypotension; GI bleeding; anemia; etc. ). Smith adds to our knowledge of this syndrome.

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

JULY 31, 2018

Next day, t he patient was taken for an angiogram and found to have a reperfused LAD lesion with good flow that appeared to the angiographer as if it was a spontaneous coronary artery dissection. What is Spontaneous Coronary Artery Dissection (SCAD)? Case continued Fortunately, the patient remained stable. The lesion was stented.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Eur Heart J 2018. A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Here it is not at all clear that they recognized that this was a transient OMI. Lemkes et al. Full text link. Am Heart J. 2000 Mar;139(3):430-6.

STEMI 115

STEMI ACS Critical Care OR 115

Dr. Smith's ECG Blog

MAY 8, 2023

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria. Immediate ECG diagnosis of an acute coronary lesion resulting in occlusion myocardial infarction is critical in the modern reperfusion era. Annals of Emergency Medicine 2021.

STEMI 52

STEMI Coronary ED ACS 52

FOAMfrat

JUNE 30, 2023

This includes cardiomyopathy, aortic stenosis, and coronary artery disease." (2) Relation between pulsus alternans and transient occlusion of the left anterior descending coronary artery. Steven McGee, 2018.Evidence-Based Left ventricular alternans occur in the setting of severe left ventricular dysfunction. Fujimura, S., &

Coronary 52

Coronary OR EMS 52

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. As I illustrated in detail in My Comment of the October 3, 2018 post of Dr. Smith's ECG Blog — I favor a qualitative approach based on shape.

Coronary 103

Coronary OR ALS 103

ECG & Echo Learning

OCTOBER 2, 2022

Below follows a drug manual for use in the CCU (coronary care unit), ICU (intensive care unit) or ER (emergency room). μg/kg/min + + + ++ Low dose dopamine stimulates D1 receptors and induces vasodilation in coronary, renal, cerebral and mesenteric vessels. Increases coronary blood flow. Coronary flow enhanced.

E-9-1-1 52

E-9-1-1 ALS Coronary Epinephrine 52

FOAMfrat

JUNE 25, 2024

Other risk factors include heavy physical exertion, alcohol consumption, dehydration, and existing co-morbidities that may affect acclimatization such as coronary artery disease, COPD, hypertension, obesity, and sickle cell trait/anemia. 2018 Jul 25;19(1):59. 2018 Jul 25;19(1):59. J Headache Pain. doi: 10.1186/s10194-018-0878-7.

OR 87

OR Coronary ALS 87

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. Here is our abstract from SAEM 2018. What happened?" The medic recorded another 12-lead en route 13 minutes later: What do you think?

Coronary 52

Coronary STEMI Paramedic ALS 52

ACEP Now

MARCH 14, 2024

2018 Nov;20(11):1-20. Acute myocardial infarction with normal and near normal coronary arteries. Documentation with coronary arteriography within 12 1/2 hours of the onset of symptoms in two cases (three episodes). Gentges J, Schieche C. Electrical injuries in the emergency department: an evidence-based review. Emerg Med Pract.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

We who know ischemic ECGs know that really when T-wave inversion is specific for coronary thrombosis that it indicates reperfusion of the artery, not active occlusion. 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 ). Some patients do this.

E-9-1-1 110

E-9-1-1 Coronary EMS ED 110

Dr. Smith's ECG Blog

MAY 30, 2023

Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. METHODS: We studied 267 patients with recanalized IMI due to the right coronary artery (RCA) occlusion within 6h after symptom onset.

E-9-1-1 81

E-9-1-1 STEMI Coronary OR 81

EMS 12-Lead

MAY 8, 2022

Cardiology was consulted, who advised to surveil a metabolic process as this did not strike them as acute coronary syndrome. No calcium was administered during pre-hospital transport. The following ECG was captured upon arrival at the receiving ED. The serum K returned 8.7, along with a pH 6.94, and an HCO3 of 5. 3] Costanzo, L. Physiology.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

AUGUST 17, 2022

The modest HS troponin elevation with lack of wall motion abnormality and excellent ejection fraction on Echo were consistent with Type-2 MI — confirming that the initial ECG did indeed give the false impression of acute coronary occlusion. For review — GO TO: The June 4, 2018 post ( LA-LL reversal ).

Coronary 52

Coronary ACS OR 52

Dr. Smith's ECG Blog

APRIL 15, 2019

[link] An angiogram was done: It showed no culprit and no coronary disease, but did show a myocardial bridge in the mid LAD. An excellent review of myocardial bridging, with full text: [link] Myocardial bridging is when the coronary artery, usually the LAD, dives into the myocardium.

Coronary 52

Coronary STEMI OR ED 52

Dr. Smith's ECG Blog

MARCH 31, 2023

The 2 clinical areas of most potential benefit to emergency care from computerized interpretations are: i ) Cardiac arrhythmias; and , ii ) Rapid detection of acute coronary O cclusion ( ie, detection of acute O MI ) in cases for which easily recognizable STEMI-criteria are not present. Meyers, Weingart and Smith in their 2018 OMI Manifesto.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

This new ECG was still interpreted as STEMI and the patient was taken to the cath lab where the angiogram showed completely normal coronary arteries throughout. But still, low confidence should not be dismissed , and still requires emergent evaluation.

OR 119

OR STEMI EMS ED 119

REBEL EM

FEBRUARY 22, 2023

Philadelphia: Elsevier, 2018 (Ch) 61: p. Eye Emergencies, in Tintinalli J et al (eds): Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition New York City: McGraw-Hill 2016 (Ch) 241 Guluma K, Lee JE. Ophthalmology, in Marx J et al (eds): Rosens Emergency Medicine: Concepts and Practice, ed 9.

Emergency Department 52

Emergency Department ALS ED Coronary 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

The coronaries were clean (this is not the gold standard, however, as some patients with ischemic ST elevation may have clean coronaries). ACTUAL CORONARY ANATOMY: Dominance: Right LM: A 5 mm vessel which bifurcates into the LAD and LCx coronary artery. QRSV2 = 16 RAV4 = 14 Value = 20.24 (The cutoff of 18.2

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

Dr. Smith's ECG Blog

OCTOBER 8, 2018

However, I was a little unsure on scene whether it was a problem of his coronaries." "But His case provides a perfect example of how sometimes acute coronary occlusion may only be recognized by PVC morphology! Surprisingly enough he had undertaken a tour on the bike just two days ago without any complaints." "He

STEMI 52

STEMI Coronary OR 52

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e III A Primary percutaneous coronary intervention strategy Management Recommendation Level of evidence Primary PCI of the infarct related artery (IRA) is indicated.

STEMI 40

STEMI Coronary OR Defibrillator 40