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 139

Coronary OR EMS ED 139

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.

Coronary 52

Coronary ACS STEMI ALS 52

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

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 116

STEMI ACS Critical Care OR 116

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

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 112

STEMI Coronary Emergency Medical Services OR 112

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-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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 120

OR STEMI EMS ED 120

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 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

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

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.

ED 52

ED Coronary 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

Dr. Smith's ECG Blog

JUNE 28, 2018

Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. de Zwaan C et al. Am Ht J 117(3): 657-665; March 1989. Wehrens XH, Doevendans PA, Ophuis TJ, Wellens HJ.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

DECEMBER 11, 2018

Prehospital EKG and strips (not shown) had "heart rate 156" (according to the computer interpretation) and "Bigeminal PVCs" The prehospital 12-lead looked just like the first ED ECG: What do you think? C OMMENT — An ECG can often be obtained in the ED before lab values come back. This suggest this is a coronary sinus rhythm.

Coronary 52

Coronary OR ED 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

Whenever the only presenting symptom is syncope, without any other symptom, I am very skeptical that coronary occlusion (OMI) is the etiology. 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. I’ll explain below the 3rd image in this Figure.

ACS 52

ACS ED Coronary STEMI 52

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Heart disease and stroke statistics—2018 update: A report from the American Heart Association. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest.

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

E-9-1-1 120

E-9-1-1 OR Coronary ACS 120

Dr. Smith's ECG Blog

JUNE 20, 2018

Upwardly Concave ST Segment Morphology Is Common in Acute Left Anterior Descending Coronary Artery Occlusion. Journal of Electrocardiology 2018. Myocarditis is virtually indistinguishable in the ED from MI. 2 comments : 1. 40-50% of acute LAD occlusion have upwardly concave ST segments in all of V2-V5. That may be the case.

Overdose 52

Overdose OR STEMI Coronary 52

Dr. Smith's ECG Blog

JULY 24, 2018

Acute coronary syndrome is unlikely to be one of those entities. Bottom Line: Hyperkalemia is an increasingly common ED diagnosis that must not be missed. Given the absence of chest pain — cardiac contusion is also unlikely. Awareness of WHAT you are looking for on a test — is the 1st step in finding what there is to be found.

Epinephrine 52

Epinephrine ICU Coronary EMS 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. Am J Cardiol 2018; 122(8):1303-1309. He went for Coronary bypass (CABG). Instructions for using free subtleSTEMI iPhone app for the 3-variable formula.

STEMI 52

STEMI Coronary OR 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 78

ED OR ALS CAD 78

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

His ED cardiac ultrasound (which is not at all ideal for detecting wall motion abnormalities, and is also very operator dependent for this finding) was significant for depressed global EF. The baseline is on the left, and now it looks as if the ST segment is rising, with less downsloping. The patient's initial troponin I was 2.0

CAD 52

CAD OR ED ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

A 30-something was in the ED for some minor trauma when he was noted to have a fast heart rate. Meyers, Smith; Weingart wrote an extensive review on Idiopathic VT in the September 14, 2018 post of Dr. Smith’s ECG Blog. 14, 2018 post adds a series of PEARLS on “My Take” regarding this subject. but only when asked.

E-9-1-1 52

E-9-1-1 ALS OR Coronary 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. 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

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

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 118

ACS ED Coronary EMS 118

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

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

Don't Forget the Bubbles

AUGUST 21, 2023

“Hi, phoning from ED with a referral. The ED team helpfully did a gas while you headed down to review, and as you scan the numbers, you see that the baby has a severe mixed respiratory/lactic acidosis. Over a 10-year period from 2008 to 2018, 334 heart transplants were performed on children in the UK. 266; 162-166.

ALS 98

ALS Critical Care ED OR 98