Dr. Smith's ECG Blog

NOVEMBER 14, 2024

History of diabetes type II and stent placement in 2018. The patient is a 54yo man with diabetes and a known history of coronary diseae ( prior stent placement ) — who presented with new CP ( C hest P ain ) — therefore very high likelihood for having an acute coronary event. What do you think? And Right Ventricular.

ED 116

ED Coronary Paramedic OR 116

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. Smith : this ECG is definitely not OMI, but could be mistaken for Swirl pattern, which is a septal OMI with STE in V1 and STD in V6. Unfortunately no echo was available.

OR 116

OR STEMI EMS ED 116

Dr. Smith's ECG Blog

APRIL 18, 2024

The ECG is just a test: a Bayesian approach to acute coronary occlusion If a patient with a recent femur fracture has sudden onset of pleuritic chest pain, shortness of breath, and hemoptysis, the D-dimer doesn’t matter: the patient’s pre-test likelihood for PE is so high that they need a CT. But does this matter?

STEMI 118

STEMI Coronary ALS CAD 118

EMS 12-Lead

MAY 20, 2022

Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. It is spread to V2 and V3.

Coronary 130

Coronary STEMI Firefighter ED 130

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. Does the ECG normalize?

Coronary 130

Coronary ALS OR ACS 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

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

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

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. Low O2 protocol: 3.1%

ACS 52

ACS Coronary STEMI Ambulance 52

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. Always consider aortic dissection when the pain is also abdominal.

Emergency Department 74

Emergency Department ED ALS Coronary 74

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. Why did I say that?

Coronary 136

Coronary OR EMS ED 136

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. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967.

EMS 65

EMS Coronary ED OR 65

Dr. Smith's ECG Blog

DECEMBER 29, 2018

Repeat ECGs make difficult decisions easier. -- Comment by K EN G RAUER, MD ( 12/29/2018 ): -- Superb case by Dr. Pendell Meyers, which highlights recognition of subtle acute findings. There is a small amount of STE in V2 and V3, with a very small amount of STD in V4-V6. The T-waves are not definitively hyperacute. The patient did well.

OR 52

OR STEMI Coronary ED 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. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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. ECG's are difficult.

ACS 130

ACS Paramedic Coronary ALS 130

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

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

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

OCTOBER 29, 2024

m/s)—problematic and elevated > 50 mm Hg (2.5 m/s)—problematic and elevated > 50 mm Hg (2.5 m/s)—problematic and elevated > 50 mm Hg (2.5 Reversible systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction in association with Takotsubo syndrome. Echocardiography. 2011;28(8):921-924. doi:10.1111/J.1540-8175.2011.01446.X

E-9-1-1 86

E-9-1-1 ICU Epinephrine EMS 86

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

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

Don't Forget the Bubbles

OCTOBER 7, 2024

However, vertical flow can result in myocardial injury secondary to coronary artery spasm. Electrical injuries can range from something minor that needs no medical input to tetany of respiratory muscles through to cardiac arrest secondary to dysrhythmia (VF, VT or asystole). Was the voltage high or low (as below)?

ACS 80

ACS Life Support OR CPR 80

FOAMfrat

JUNE 25, 2024

Since then, I’ve developed a habit for outdoor recreation and light versions of mountaineering, which led me to realize that altitude illness can occur in much less extreme conditions than I’d previously thought and that these pathophysiologies might actually be relevant to those of us not living in Nepal.

OR 86

OR Coronary ALS 86

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. He denied difficulty breathing, epigastric pain, or chest discomfort. BP 110/67 HR 68 RR 14 (non-labored) SpO2 95 RA Physical exam revealed slight pallor and diaphoresis. Figure 1-2.

ALS 130

ALS STEMI Coronary OR 130

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. She's had multiple PCI procedures. On the day of presentation she complained of typical chest pain, and stated it feels like prior MI. It is shown below.

Coronary 101

Coronary OR ALS 101

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. Moreover, front office staff advise that she is a new tenant, and thus have nothing more to offer than a name and assigned apartment number. In general, monomorphic VT has a single, stable QRS morphology.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

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

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 more leads in a given lead area that show hyperacute changes — the greater the concern for acute OMI.

STEMI 52

STEMI Coronary EMR ALS 52

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. Great job!!

Coronary 52

Coronary Paramedic EMS ICU 52

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

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. There are also subtly hyperacute T-wave in I, aVL, and V2-V6. The S-wave is reconstituted. The inferior findings are much less pronounced. Lemkes et al.

STEMI 113

STEMI ACS Critical Care OR 113

FOAMfrat

JUNE 30, 2023

This includes cardiomyopathy, aortic stenosis, and coronary artery disease." (2) What would your impression of your patient be if you noticed alternating large and small beats on your arterial line tracing or pleth wave on the SPO2? 1) Here's a monitor that shows both. As we continue, we hit the plateau phase in yellow.

Coronary 52

Coronary OR EMS 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

ACEP Now

MARCH 14, 2024

Thick, dry, and calloused skin of a construction worker can have as much as 100 times more resistance than the previous example. 4 This may lead to more heat dissipated at the skin with impressive burns to skin, but less transmission of electricity to deeper tissues. High voltage” is defined by texts as 600 V and 1,000 V. Click to enlarge.)

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 ). Learning Point: 1.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

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. EMS gave 324 mg aspirin and 3 sublingual NTG, which the patient stated reduced the substernal chest pain from an 8/10 to 4/10. Cath lab activated Dual antiplatelet therapy and heparin given.

Coronary 52

Coronary ACS EMS 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. What is the atrial activity? Is it sinus arrest with junctional escape? There is an obvious inferior posterior STEMI(+) OMI.

E-9-1-1 82

E-9-1-1 STEMI Coronary OR 82