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 September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. The September 22, 2019 post — intermittent ST-T wave artifact.

Defibrillator 79

Defibrillator ALS Coronary OR 79

Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. We at Hennepin recently published this study Sharma et al. This study failed to do so. 5% vs. 58%!! 5% vs. 58%!!

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). Most OMI have a peak Troponin T over 1000 ng/L [reference: Baro R et al. Clinical Cardiology 2019.

STEMI 97

STEMI Coronary Defibrillator EMS 97

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

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. STEMI criteria, and automated interpretations based on it, will miss acute coronary occlusion. Kontos et al.

STEMI 63

STEMI Coronary Paramedic ALS 63

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. Harhash AA, Huang JJ, Reddy S, et al. Knotts et al.

Coronary 52

Coronary ACS STEMI ALS 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). link] [1] Zachary et al. Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. Western Journal of Emergency Medicine, 18 (4), 752-760. [2]

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

APRIL 8, 2022

Cardiology admitted him for observation with plans for next-day coronary angiogram. Unfortunately, due to the patient’s abrupt exodus from the PCI center – without benefit of coronary angiogram, or echo, for example – the disposition will forever remain unknown. [1] 1] Driver, B. Emergency Medicine Journal, 1-5. [2] 3] Niu, T.,

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

APRIL 25, 2023

But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

Coronary 52

Coronary STEMI ALS OR 52

Emergency Medicine Ireland

OCTOBER 30, 2023

This vasoconstriction affects pretty much all the vasculature including things like the coronaries (not so good) but does seem to spare the pulmonary arteries meaning it may be good in those with pulmonary hypertension. First up is the VASST trial, (Russel et al 2008 NEJM). Nagendran 2019 in CCM. Gordon, A. Nagendran, M.

Critical Care 52

Critical Care ALS Coronary ICU 52

Dr. Smith's ECG Blog

FEBRUARY 10, 2023

Because of the importance of this entity — we continue to periodically review it in cases we present ( See the May 2, 2019 post — among many others ). NOTE: For illustrative purposes — I’ve adapted Figure-1 from the original manuscript by de Winter et al, published in this 2008 NEJM citation. D e W inter T Waves : In 2008 — Robert J.

ALS 52

ALS STEMI Coronary OR 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 article by Aslanger, Smith et al that is featured above in today’s post has just been published. P.S.: Our September 3, 2020 post features Dr.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

His medical history includes hypertension, a decade-long battle with diabetes, ischemic heart disease, a coronary bypass graft surgery ten years ago, a diagnosis of congestive heart failure for the last five years, and a prior ICD implantation five years ago.

Coronary 100

Coronary EMR STEMI Emergency Department 100

Dr. Smith's ECG Blog

JANUARY 3, 2022

It was a 60yo with a history of stents to the circumflex and right coronary arteries, who presented with 9 hours of fluctuating central chest pain. This is step 4 : relying on the first troponin level to rule out acute coronary occlusion. 4] CT revealed no dissection but extensive coronary atherosclerosis. J of Emerg Med 2021.

STEMI 52

STEMI Coronary ALS ACS 52

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. 2] Birnbaum, Y., Physiology.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

MAY 13, 2020

Smith presented results from a 2019 article by Harhash et al, that confirm how the ECG pattern shown in Figure-1 does not represent acute LMain occlusion — but rather the differential diagnosis that I show above. Today’s Post by Dr. Smith adds to our knowledge of this syndrome.

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al.

STEMI 122

STEMI Emergency Department Coronary OR 122

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. 3–8 Shi et al. In acute MI, the T-wave is large, and the T/ST ratio is high. This is much more typical of myocarditis. Angiogram was negative.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

MAY 23, 2023

I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. We wrote this Editorial in the Journal of Electrocardiology in 2019. Litell JM, Meyers HP, Smith SW.

STEMI 89

STEMI Coronary Paramedic OR 89

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. PLUS — Today's patient is an older woman with known severe coronary disease who presented with new chest pain. She's had multiple PCI procedures.

Coronary 104

Coronary OR ALS 104

Dr. Smith's ECG Blog

MARCH 9, 2023

Karwowski et al showed that only 64% of 4581 STEMIs had TIMI 0 flow on angiogram. [25] 25] Stone et al found that 72% have TIMI 0 or 1 flow. [26] 26] Finally, Cox et al found that 80% had TIMI 0, 1, or 2.27 Karwowski et al showed that only 64% of 4581 STEMIs had TIMI 0 flow on angiogram. [25] Pol Arch Intern Med.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

SVT misdiagnosed as panic disorder Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Lessmeier et al. I’ll add here 2 more reference links on the subject — by Brugada; Diez — and — by Tondo et al. Not all forms of idiopathic VT are predictable based on their ECG appearance ( Anderson et al, 2019 ).

E-9-1-1 52

E-9-1-1 ALS OR Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2022

This is most consistent with ischemia/infarction in the distribution of the left circumflex coronary artery. Meyers, Bracey, Smith, et al. Echocardiogram: The estimated left ventricular ejection fraction is 34% Regional wall motion abnormality-lateral, akinetic. Next Day ECG: T waves in V2, V3 are larger than they were at baseline.

STEMI 52

STEMI ED Coronary OR 52

REBEL EM

MARCH 30, 2023

The TOMAHAWK (Desch 2021), COACT (Abella 2019), and PEARL (Lemkes 2019) trials examined patients with OHCA without ST elevation with a shockable rhythm, and investigators found no difference in delayed versus emergency angiogram. Article: How-Berlemont C, Lamhaut L, Diehl J, et al. Additionally, the trial had several biases.

Coronary 83

Coronary CPR OR ICU 83

Dr. Smith's ECG Blog

OCTOBER 7, 2019

See this paper by Smith et al. Smith pointed out that while atropine may may result in slightly more oxygen demand, the increase in cardiac output and in blood pressure would increase overall coronary perfusion and decrease ischemia. V4R in Right Ventricular MI As in the Smith study of lead V1 in RVMI, Kosuge et al.

STEMI 52

STEMI EMS Coronary ALS 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. It can only be seen by IVUS. MINOCA has many etiologies.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

ACEP Now

JUNE 14, 2024

In 2019, the global prevalence of COPD was estimated to be 10.3 Some of the critical differentials include pulmonary embolism, acute decompensated heart failure, pneumonia, pneumothorax, and acute coronary syndrome. ECG evaluates for dysrhythmias, acute coronary syndrome, or signs of right heart strain. 2012;16(5):323.

ALS 52

ALS Coronary OR Emergency Department 52

Dr. Smith's ECG Blog

JULY 11, 2019

When in doubt, record serial ECGs and watch out for signs of ischemia despite medical management. == Comment by K EN G RAUER, MD ( 7/11/2019 ): == Our thanks to Drs. This is a h igher - p revalence H istory for acute coronary disease. CLICK HERE — for a brief article by Rowlands et al that explains these concepts in more detail.

STEMI 52

STEMI ACS CAD ED 52

The Skeptics' Guide to EM

AUGUST 7, 2021

She has been very involved with EMRAP’s CorePendium as the cardiovascular section editor and has a chapter coming out soon on women and acute coronary syndrome. She has been very involved with EMRAP’s CorePendium as the cardiovascular section editor and has a chapter coming out soon on women and acute coronary syndrome.

Coronary 101

Coronary Emergency Department ALS 101

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Meyers et al. Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Aslanger et al. DIagnostic accuracy oF electrocardiogram for acute coronary OCClusion resulTing in myocardial infarction (DIFOCCULT study). Lemkes et al. Bergmark et al.

STEMI 52

STEMI Paramedic Coronary ALS 52

EMDocs

MARCH 6, 2024

Post-hoc analysis of patients with LGIB compared a liberal transfusion threshold of 9 g/dL (8 g/dL in those with acute coronary syndrome) with restrictive strategy and found no difference in in-hospital mortality. Triantafyllou K, Gkolfakis P, Gralnek IM, et al. Oakland K, Chadwick G, East JE, et al. 2019 May;68(5):776-789.

ALS 85

ALS OR Coronary ED 85

Dr. Smith's ECG Blog

JANUARY 17, 2024

Using the current paradigm, can you tell which patient had an acute coronary occlusion? STEMI vs OMI Now let’s see the rest of the ECG: can you tell which patient has an acute coronary occlusion, and which ECG has hyperacute T waves? Driver et al. Meyers, Bracey et al. Herman, Meyers, Smith et al.

STEMI 103

STEMI Coronary ALS OR 103

Dr. Smith's ECG Blog

MARCH 6, 2019

I believe this is by far the most common outcome for this patient around the world in 2019. Current practice ranges widely, but based on my short experience and reports from other institutions, most of these patients are not being taken emergently to the cath lab in 2019. Patel et al., Krucoff et al.) Patel et al.

STEMI 52

STEMI ALS ACS OR 52

Don't Forget the Bubbles

AUGUST 21, 2023

It’s worth considering congenital defects such as anomalous left coronary artery from pulmonary artery (ALCAPA) , coarctation of the aorta, and aortic stenosis in neonates and young infants presenting with dilated cardiomyopathy. 38; 4:467 Boer den SL, et al. Harmon, WG et al. 1148-1169 Khan, RS et al. Bouziri A.,

ALS 98

ALS Critical Care ED OR 98

EMDocs

OCTOBER 30, 2023

16 In a study conducted by Millet et al. A retrospective study done in May 2023, by Shaish et al 24 showed a 30 % reduction in accuracy of NCCT compared to CECT in a study done among 201 adult ED patients with abdominal pain. link] Bellolio MF, Heien HC, Sangaralingham LR, et al. link] Published May 26, 2022. West J Emerg Med.

E-9-1-1 73

E-9-1-1 Emergency Department ALS ED 73

Dr. Smith's ECG Blog

MAY 19, 2022

Ct coronary angiogram showed normal coronary arteries. Smith note: I think CT coronary angiogram is reasonable with the elevated troponins and symptoms. The Cardiorespiratory Implications of Ultra-marathon Bjørkavoll‐Bergseth et al. Paana et al. International Journal of Cardiology 2019. ng/L; 3 hours, 38.3

E-9-1-1 52

E-9-1-1 Coronary OR ED 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. The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. Complete heart block is the state of the AV node. The January 30, 2018 post — for PTA.

ALS 94

ALS STEMI Coronary OR 94