EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

The Skeptics' Guide to EM

MAY 19, 2018

[display_podcast] Date: May 16, 2018 Reference: Freund et al. JAMA February 2018. display_podcast] Date: May 16, 2018 Reference: Freund et al. JAMA February 2018. JAMA February 2018. PROPER stands for PERC Rule to Exclude Pulmonary Embolism in the Emergency Department.

Emergency Department 130

Emergency Department ALS Coronary OR 130

Dr. Smith's ECG Blog

OCTOBER 6, 2024

Click here to sign up for Queen of Hearts Access == == MY Comment , by K EN G RAUER, MD ( 10/6 /2024 ): == Today's case provides an excellent example of how prompt recognition of acute OMI worked as it should to expedite cardiac cath and coronary reperfusion. I focus my comment on the initial ECG — that I've reproduced in Figure-1.

STEMI 77

STEMI Coronary ED 77

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!

MICU 130

MICU STEMI 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

ACEP Now

JULY 7, 2023

Extracorporeal membrane oxygenation Of patients with out-of-hospital cardiac arrest presenting to the ED in refractory VF, a majority have significant coronary artery disease, much of which is amenable to percutaneous coronary intervention. Heart disease and stroke statistics—2018 update: A report from the American Heart Association.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. Chest pain reproducible on palpation does not rule out acute coronary syndrome. Guagliumi, G., Iwaoka, R.

E-9-1-1 117

E-9-1-1 OR Coronary ACS 117

EMDocs

SEPTEMBER 26, 2024

Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. J Am Coll Rad 15:4;639-647, April 1, 2018. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. Baccei SJ et al. Tyler W et al.

Emergency Department 74

Emergency Department ED Coronary ALS 74

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

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 65

EMS Coronary ED OR 65

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 136

Coronary OR EMS ED 136

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?

ACS 52

ACS Coronary 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

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 77

Defibrillator ALS Coronary OR 77

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 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS 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 108

STEMI Coronary Emergency Medical Services OR 108

Dr. Smith's ECG Blog

JANUARY 6, 2024

Therefore the impulse must have originated somewhere lower in the atria, perhaps near the coronary sinus. In the 500+ Comments I have written on Dr. Smith's ECG Blog since becoming an Associate Editor in 2018 — I do not believe we have had a case of RA-LL lead reversal. For review — GO TO: The June 4, 2018 post ( LA-LL reversal ).

ALS 91

ALS STEMI Coronary OR 91

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 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 STEMI 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

EMDocs

OCTOBER 29, 2024

doi:10.1136/BCR-2018-225879 Dawood S, Hill A, Al Rawi O. 2024;166(4):A3026-A3027. doi:10.1016/J.CHEST.2024.06.1821 2024.06.1821 Mampuya WM, Dumont J, Lamontagne F. Norepinephrine-associated left ventricular outflow tract obstruction and systolic anterior movement. BMJ Case Rep. 2019;12(12). Anaesth Reports. 2021;9(1):e12099.

E-9-1-1 86

E-9-1-1 ICU Epinephrine EMS 86

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

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

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. BP 110/67 HR 68 RR 14 (non-labored) SpO2 95 RA Physical exam revealed slight pallor and diaphoresis. Attached is the first ECG. Annals of Noninvasive Electrocardiology, 20 (1), 7-17.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. The condition of the coronary artery at the time of angiogram may be different than it was 30 minutes prior during recording of the ECG. A 40-something woman had sudden chest pain. She called 911.

Coronary 52

Coronary STEMI ED ALS 52

Dr. Smith's ECG Blog

OCTOBER 10, 2024

KEY Point: The best way to confirm acute RV MI — is with use of right -sided leads ( See My Comment in the July 19, 2020 and July 11, 2018 posts). Angiogram showed no significant disease of the left main, LAD, or LCX, but acute culprit lesion of the proximal RCA with "99% stenosis" and TIMI 2 flow.

STEMI 98

STEMI EMS Coronary OR 98

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 101

Coronary OR ALS 101

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

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

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

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 82

E-9-1-1 STEMI Coronary OR 82