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. Here is the final ECG just prior to ED transfer. Attached below is the initial ED tracing upon hospital arrival, approximately 25 minutes after the prehospital ECG. No serial ECG’s were recorded.

ACS 130

ACS Coronary STEMI CAD 130

EMDocs

JULY 1, 2023

A 3-year-old male with no past medical history presents to the ED with one week of daily fevers >102°F associated with four days of rash on the trunk. We’ll keep it short, while you keep that EM brain sharp. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. C) for the past week.

EMS 65

EMS Coronary ED OR 65

Dr. Smith's ECG Blog

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. 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.

STEMI 77

STEMI Coronary ED 77

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]. Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present."

E-9-1-1 117

E-9-1-1 OR Coronary ACS 117

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. Chou's Electrocardiography in Clinical Practice, 6th ed. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

MAY 8, 2022

This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2] The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7 An ECG is recorded.

STEMI 130

STEMI ED EMS Firefighter 130

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. She was ultimately discharged home after ED workup. This case was published in Circulation on January 22, 2018 (thanks to Brooks Walsh for finding this!) 2018; 137: 402-404.

Coronary 52

Coronary Emergency Department ED OR 52

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. Initial ED ECG: What do you think? Coronary angiogram shows diffuse severe three-vessel disease. How Can We Prove that ECG #1 is VT?

Coronary 136

Coronary OR EMS ED 136

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. Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm.

OR 66

OR STEMI ACS Coronary 66

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. Chou’s Electrocardiography in Clinical Practice (6th ed). Friedman, M., Saini, A.,

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

EMDocs

OCTOBER 29, 2024

A 43-year-old male with a history of mitral valve regurgitation s/p valvular replacement, hypertension, hyperlipidemia was evaluated in the ED for septic shock secondary to a pyelonephritis with a renal abscess. doi:10.1136/BCR-2018-225879 Dawood S, Hill A, Al Rawi O. He has clinically deteriorated and required intubation. 2019;12(12).

E-9-1-1 86

E-9-1-1 ICU Epinephrine EMS 86

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). Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol 2013;46:240-8 2.

ACS 52

ACS Coronary STEMI ALS 52

Dr. Smith's ECG Blog

JUNE 2, 2023

Despite otherwise normal vital signs, she was appropriately triaged to the critical care area of the ED. They are rare and hard to find in normal practice in the ED. She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? J Electrocardiol, 42 (2009), pp.

ED 79

ED OR ALS CAD 79

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

EMS 12-Lead

APRIL 28, 2022

In most cases, rather, the culprit is gross ischemia due to myocardial infarction, cardiomyopathy, or advanced coronary artery disease. Josephson’s Clinical Cardiac Electrophysiology: Techniques and Interpretations (6th ed). Chou’s Electrocardiography in Clinical Practice (6th ed). Wolters-Kluwer: Philadelphia, PA. [2]

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

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. It is good to have terrible pain!

STEMI 108

STEMI Coronary Emergency Medical Services OR 108

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. 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.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. 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 is written by Brooks Walsh.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

MAY 3, 2024

But this time the Queen gets it wrong (thinks it is not OMI): There were runs of VT: Tha patient arrived in profound shock and had an ED ECG: Now there is some evolution to include the ST elevation (rather than ST depression) in V4-V6. Figure-1: I've labeled the initial EMS ECG and the 1st 12-lead tracing done on arrival in the ED.

ACS 114

ACS ED Coronary EMS 114

Don't Forget the Bubbles

OCTOBER 7, 2024

However, vertical flow can result in myocardial injury secondary to coronary artery spasm. In: Walls RM, ed. Household supply in the UK and Australia is typically capped at 230v, so children get low-voltage injuries. Chen P, Bukhman AK. Electrical and lightning injuries. Rosen’s Emergency Medicine: Concepts and Clinical Practice.

ACS 80

ACS Life Support OR CPR 80

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Both were awake and alert with normal vital signs.

OR 116

OR STEMI EMS ED 116

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. See these casese (and I have many others): First ED ECG is Wellens' (pain free). A 70-something y.o. Lemkes et al. Am Heart J.

STEMI 113

STEMI ACS Critical Care OR 113

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. Chou’s Electrocardiography in Clinical Practice, 6th ed. Goldberger’s Clinical Electrocardiography: A Simplified Approach, 9th ed. Attached is the first ECG. 5] Walsh, B.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

MAY 13, 2020

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." 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.

Coronary 52

Coronary ACS EMS STEMI 52

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. Then this was recorded in the ED 10 minutes after the first: Now there is massive STE Many inferior MI are associated with RV MI. BOTTOM — 2nd ECG obtained 10 minutes later in the ED ( See text ). She called 911.

Coronary 52

Coronary STEMI ED ALS 52

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. 2018 Nov;20(11):1-20. Acute myocardial infarction with normal and near normal coronary arteries. Electrical Injuries. 2023 Jul 17.

Operating Room 52

Operating Room ACS Critical Care Coronary 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

REBEL EM

FEBRUARY 22, 2023

et al, Emergency Medicine Clinical Essentials ed 2. 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

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

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. For some reason unknown to me, the interventionalist was in the ED. 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?" Dodd1 , Deborah L.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

If the patient only had these two ECGs recorded, it would have missed the transient time between them which were STEMI positive, and the patient would then have arrived at the ED as “serial ECGs STEMI negative." Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Meyers et al.

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. 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. For review — GO TO: The June 4, 2018 post ( LA-LL reversal ).

E-9-1-1 82

E-9-1-1 STEMI Coronary OR 82

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

Submitted and written by Alex Bracey, with edits by Pendell Meyers and Steve Smith: I was walking through the critical care section of the ED when I overheard a discussion about the following ECG. This ECG is diagnostic of an acute coronary occlusion of an artery supplying the inferior and posterior walls. What do you think?

Coronary 52

Coronary Critical Care STEMI ED 52

Dr. Smith's ECG Blog

DECEMBER 19, 2018

The pain had almost resolved by the time an ECG was obtained in the ED: Here is the computer diagnosis What do you think? Despite the computer interpretation, the ED physician was concerned about the ECG, and planned for serial troponins. A middle-aged woman had an acute onset of chest pain and dyspnea.

Coronary 52

Coronary ED OR Paramedic 52

Dr. Smith's ECG Blog

APRIL 15, 2019

Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. link] An angiogram was done: It showed no culprit and no coronary disease, but did show a myocardial bridge in the mid LAD.

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

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