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. References Tsao CW, et al. Benjamin EJ, et al. Kimblad H, et al.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

EMS 12-Lead

JUNE 1, 2022

Such findings would normally suggest primary ischemia with concomitant surveillance of coronary occlusion, but these ST/T changes might very well be secondary to the Escape mechanism at hand. Evaluation of T-wave morphology in patients with left bundle branch block and suspected acute coronary syndrome. 3] Meyers, H. 4] Dodd, K.

Coronary 130

Coronary ALS Firefighter ED 130

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 91

Defibrillator STEMI Coronary ALS 91

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

Dr. Smith's ECG Blog

APRIL 22, 2024

EKG from triage: Here is his previous ECG: Normal ST Elevation Resident's interpretation: Reperfusion pattern/Wellens' with biphasic T waves in V2 and V3, and in comparison to an EKG in 2020 this is new. Lemkes JS, et al. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J.

Coronary 117

Coronary STEMI ED OR 117

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 November 10, 2020 post — for PTA. The October 17, 2020 post — for a 70-year old woman with " Artifactual VT ". Written by Willy Frick A 57 year old man with was admitted to the hospital with chest pain.

Defibrillator 77

Defibrillator ALS Coronary OR 77

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

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.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

MAY 13, 2020

On echo, OMI has a wall motion abnormality, but SI usually does not. == MY Comment by K EN G RAUER, MD ( 5/13/2020 ): == It’s good to periodically review the differential diagnosis of the diffuse subendocardial ischemia. The artery is open, but flow is insufficient to perfuse the entire myocardial thickness (subendocardial AND subepicardial).

Coronary 52

Coronary ACS EMS 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

Dr. Smith's ECG Blog

JANUARY 9, 2023

Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Finally, coronary angiography was performed (at least 5 days after presentation) which confirmed LAD aneurysm with large thrombus burden, TIMI 0 flow, thrombectomy performed.

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Coronaries were normal, as was serial troponin. I sent the initial ECG of both cases without any context to my colleague Mazen El-Baba, a senior EM resident with an interest in ECG interpretation, and he responded: “RBBB with first degree AV block” for the first (ie no acute coronary occlusion), and “RBBB and superimposed OMI” for the second.

STEMI 73

STEMI Paramedic Coronary ED 73

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. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. So this study is worthless and must be ignored.

STEMI 90

STEMI Coronary Paramedic OR 90

REBEL EM

MARCH 30, 2023

Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Article: How-Berlemont C, Lamhaut L, Diehl J, et al. Early coronary angiography and survival after out-of-hospital cardiac arrest. Nallamothu, B.

Coronary 83

Coronary CPR OR ICU 83

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

NOVEMBER 3, 2023

The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Hayakawa A, Tsukahara K, Miyagawa S, et al. Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients. 2009;95:1701–1706. As per Drs.

ACS 83

ACS Coronary ALS CAD 83

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 97

Coronary EMR STEMI Emergency Department 97

Dr. Smith's ECG Blog

JULY 27, 2023

I was not worried for a coronary etiology. PEARL #3: The pathophysiologic mechanism for producing amphetamine-induced acute MI is unclear ( Bazmi et al — SQUMJ 17(10); e31-37, 2017 — and — Sinha et al — Case Rep Cardiol, 2016 ). The precordial findings are typical for a young AA male See 20 similar cases here.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

A coronary angiogram was done that did not show significant coronary artery disease. I have periodically called attention to examples of the Ashman phenomenon as they occur in Dr. Smith's ECG Blog ( See My Comments in the January 5, 2020 post — the June 17, 2020 post — and the March 30, 2023 post , among others ).

Defibrillator 68

Defibrillator Coronary OR ALS 68

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

EMDocs

FEBRUARY 7, 2024

GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. Shetty R, Basheer FT, Poojari PG, et al. Wilding JPH, Batterham RL, Calanna S, et al; STEP 1 Study Group. 2020 Apr;46(2):100-109.

Allergic Reaction 74

Allergic Reaction ALS CAD OR 74

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]. The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al.

E-9-1-1 117

E-9-1-1 OR Coronary ACS 117

Dr. Smith's ECG Blog

OCTOBER 28, 2022

Learn about the Smith-Modified Sgarbossa Criteria for Diagnosis of OMI Paced Rhythm: Dodd, Meyers, Smith, et al. Electrocardiographic diagnosis of acute coronary Occlusion Myocardial Infarction in ventricular paced rhythm using the modified Sgarbossa criteria. Annals of Emergency Medicine 2021. Figure-1: The 2nd ECG in today's case. (

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. The February 11, 2020 post ( LA-RA reversal ). The March 18, 2020 post ( LA-RA reversal ). The August 28, 2020 post ( LA-LL reversal ). The November 19, 2020 post ( LA-LL reversal ).

ALS 91

ALS STEMI Coronary OR 91

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). Int J Cardiol Heart Vasc 2020 3. Lemkes et al.

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

JANUARY 23, 2024

Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. A DDENDUM: There are many potential causes of AV block.

Coronary 85

Coronary OR Defibrillator ALS 85

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

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

MAY 31, 2023

Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. Academic Emergency Medicine 27(S1): S220; May 2020. de Winter et al in N Engl J Med 359:2071-2073, 2008. Am Heart J. 2005;149:1043–1049. And Another that we wrote: -Bracey, A. Abstract 556.

STEMI 81

STEMI Coronary ACS OR 81

Dr. Smith's ECG Blog

JULY 14, 2023

For example — Baldi et al note a more than doubling in the number of false-positive ECGs for STEMI i f judgments were based on post-resuscitation 12-lead tracings obtained less than 7 minutes after ROSC ( Resuscitation 162:445-446, 2021 ). Many of these patients have preexisting coronary and other forms of severe heart disease.

E-9-1-1 89

E-9-1-1 Defibrillator CPR STEMI 89

Dr. Smith's ECG Blog

APRIL 22, 2022

Backus BE, Six AJ, Kelder JC, et al. Am J Emerg Med 2020 3. Moumneh T, Sun BC, Baecker A, et al. Identifying patients with low risk for acute coronary syndrome without troponin testing: validation of the HEAR score. Shah ASV, Anand A, Sandoval Y, et al. Patel J, Alattar F, Koneru J, et al. Am J Med 2021 5.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 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

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. He was diagnosed with mild AKI which resolved. ng/L; 3 hours, 38.3

E-9-1-1 52

E-9-1-1 Coronary OR ED 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

Herzog et al. Khan et al. ECG interpretation needs to be done in isolation and then applied to the patient, and this way AI can help identify patients at risk of missed occlusions References 1. Clinical characteristics of dialysis patients with acute myocardial infarction in the United States. Circulation 2007 2.

STEMI 86

STEMI ACS OR ALS 86

Dr. Smith's ECG Blog

JANUARY 6, 2023

Lupu L, et al. Immediate and early percutaneous coronary intervention in very high-risk and high-risk Non-STEMI patients. When the patient has ACS, with ongoing ischemic symptoms despite maximal medical management, you must consider ongoing acute coronary occlusion MI regardless of your certainty of the ECG findings. =

ACS 52

ACS Coronary ICU STEMI 52

Dr. Smith's ECG Blog

JUNE 1, 2022

Moreover, the research which appears to confirm this idea was indeed in relation to the circumflex, but they did not study Occlusion ; rather, they studied asymptomatic coronary disease. I showed conclusively that this is a common finding in normal ECGs, though it is more common in LAD Occlusion than in norml variant STE.

STEMI 52

STEMI Coronary OR ALS 52

AAEM RSA

AUGUST 27, 2020

Douglas, MD; Taylor Conrad, MD, MS; Theodore Segarra, MD; Christianna Sim, MD, MPH Editors: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM Originally published: Common Sense July/August 2020 Introduction The ability to obtain good neurological outcomes after cardiac arrest is often limited. Nielsen N, Wetterslev J, Cronberg T et al.

E-9-1-1 52

E-9-1-1 CPR ICU ALS 52