EMS 12-Lead

JUNE 1, 2022

He advises, however, recurrent syncopal episodes for the past six months, some of which have resulted in ED admission, yet no identifying mechanism could be determined. 3,4] The final 12 Lead ECG does not meet any Smith-modified Sgarbossa criteria, so the T wave signatures are characteristic of improved coronary flow, but not necessarily MI.

Coronary 130

Coronary ALS Firefighter ED 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! However, when the Troponin I returned 8.4

MICU 130

MICU STEMI CAD Coronary 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. 2] Aslanger, E., 3] deWinter, R.

Coronary 130

Coronary ALS OR ACS 130

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

Dr. Smith's ECG Blog

AUGUST 11, 2024

The machine indicated STEMI (but it barely meets STEMI criteria, if at all) and the patient was brought to the ED: On arrival 20 minutes later the pain had reduced to 1/10 after aspirin, and the patient had repeat ECG at triage: Now the ST segments and T waves have normalized, and the only abnormality is sinus bradycardia and loss of R waves.

STEMI 74

STEMI Paramedic Coronary EMS 74

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. Circulation. 2019;139(12):e530-e552.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

JANUARY 31, 2020

A middle-aged man complained of 15 minutes of classic angina that resolved upon arrival to the ED. But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. Figure-1: The initial ECG that was done in the ED ( See text ).

ED 52

ED Coronary ACS CAD 52

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. This study failed to do so.

Defibrillator 91

Defibrillator STEMI Coronary ALS 91

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

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

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. Coronaries were normal, as was serial troponin. Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. 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. So this study is worthless and must be ignored.

STEMI 90

STEMI Coronary Paramedic OR 90

EMDocs

SEPTEMBER 7, 2024

A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. A 25-year-old man presents to the ED via EMS after he sustained a gunshot wound to the left flank.

EMS 74

EMS E-9-1-1 Operating Room OR 74

Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. For the same reason, you should not delay coronary angiography because pain resolves with morphine. But pain is a critical signal for urgency in the context of acute coronary syndrome. Mukherjee, D.,

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

JANUARY 8, 2024

She went to angio and had normal coronaries. She was briefly resuscitated and made it to the ED alive, long enough to have another ECG: This could be all due to RV strain or the STE in inferor leads could also be due to supply demand mismatch (type II STEMI) She was given 100 mg of tPA but arrested again and could not be resuscitated.

Coronary 71

Coronary STEMI EMS OR 71

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

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

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

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

JANUARY 9, 2024

The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). This patient presented to the ED “after a couple of days of chest discomfort”. Remember that this patient presented to the ED “after a couple of days of chest discomfort”.

Coronary 99

Coronary ACS ED OR 99

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

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

MAY 24, 2022

Here is the report: Cath lab activation at 3 am by the ED for atypical CP, and elevated troponin with diffuse STT changes. No angiographically significant obstructive coronary artery disease. CT coronary angiogram is excellent , but is rarely available outside of business hours, and hardly ever at night.

Coronary 52

Coronary OR ED 52

Dr. Smith's ECG Blog

JULY 27, 2023

On arrival to the ED, the patient was diaphoretic, tachycardic. I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? I was not worried for a coronary etiology. He had a prehospital ECG that was worrisome to the medics, so they called me to see him at the door. and had dilated pupils.

Coronary 52

Coronary ACS Naloxone Plasma 52

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

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. Apparently, the patient was not satisfied, and came to the ED as he still had pain. It was extremely busy in the ED and things did not get done quickly. He had been at a clinic that day where he had complained of worsening GERD.

Coronary 52

Coronary ED EMS Critical Care 52

Dr. Smith's ECG Blog

APRIL 12, 2023

An ECG was recorded: ED ECG 1: The findings are still present but not nearly as profound now. Mild Plaque no angiographically significant obstructive coronary artery disease. There is STE and hyperacute T-waves in V2 and V3, with significant STE in I and aVL, and inferior reciprocal STD. The estimated ejection fraction is 38%.

STEMI 52

STEMI Coronary ED OR 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

JUNE 11, 2024

To add to this complexity ( as per My Comment in the August 22, 2020 post in Dr. Smith's ECG Blog ) — the ST-T wave appearance in repolarization variants may be dynamic ! It is clearly missed by the conventional algorithm. There is no way the ST-T wave appearance in lead aVL can be normal ( within the RED rectangle in this lead ).

STEMI 111

STEMI Coronary Emergency Department OR 111

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. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS.

Emergency Department 52

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

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. The angiogram showed completely normal coronary arteries. Triage ECG: What do you think? NOTE: Automatic junctional tachycardia is not common.

STEMI 119

STEMI ED OR Coronary 119

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. 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. He was moderately hypoxic. Angiogram was negative.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 29, 2023

A 50-something with no previous cardiac history and no risk factors presented to the ED with acute chest pain (pressure) that radiated to the left arm. The cardiology fellow came to the ED. Clinicallly — this would be consistent with the less-than-total coronary occlusion seen on cath. There is ST depression in V1-V3.

Critical Care 52

Critical Care Coronary ED OR 52

Dr. Smith's ECG Blog

MARCH 19, 2023

To EMPHASIZE: ST-T wave abnormalities are also present in most other leads in ECG #1 — but they are clearly more subtle, and difficult to declare as “acute” in this patient with known coronary disease in the absence of a prior ECG for comparison. Figure-1: Comparison between the first 3 ECGs in today’s case. What Do We Learn from ECG #3 ?

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear. STE at 60 ms after the J-point is substantially higher than at the J-point.

STEMI 52

STEMI Coronary EMS ED 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. 2009;95:1701–1706.

ACS 83

ACS Coronary ALS CAD 83

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. The February 11, 2020 post ( LA-RA reversal ).

E-9-1-1 82

E-9-1-1 STEMI Coronary OR 82