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. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

The Skeptics' Guide to EM

JANUARY 18, 2020

Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? AEM January 2020 Guest Skeptics: Dr. James VandenBerg: James has a master’s degree in clinical investigation from Washington University in St.

ACS 130

ACS Coronary Emergency Department OR 130

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 120

OR STEMI EMS ED 120

Dr. Smith's ECG Blog

APRIL 9, 2024

Before the lab values returned this patient had a n emergent coronary CT angiogram done that ruled out CAD. A false positive cath lab activation is also off course acceptable for this diagnosis if you cannot get an emergent coronary CT angiogram. Each main coronary artery (LAD, RCA and LCx) are shown in separate images.

Coronary 96

Coronary CAD ACS OR 96

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 120

STEMI Coronary ALS CAD 120

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

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." On the other hand, stable EKG over an hour in the setting of ongoing acute coronary syndrome is again unusual.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

DECEMBER 12, 2022

Here is the OMI progression of ECG findings for review: You can see that OMI ECG findings must "deflate" and pass through normal or near-normal in order to get to reperfusion findings. In other words, to get from hyperacute T waves and STE to terminal T wave inversion, the ST and T wave must pass transiently through a state of near-normal.

OR 52

OR ACS STEMI Coronary 52

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. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated. Crew members note residual pallor and clammy skin.

Coronary 130

Coronary ALS Firefighter ACS 130

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. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Pattern A evolves into Pattern B.

Coronary 118

Coronary STEMI ED OR 118

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-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. When I see this, I always look at V2 for any evidence of posterior OMI (STD, or loss or inversion of T-wave, or downsloping ST segment: there is a negative T-wave ), and V6 for any STE (normal). So I would be worried about inferior OMI.

E-9-1-1 122

E-9-1-1 ACS Coronary STEMI 122

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

Dr. Smith's ECG Blog

JUNE 27, 2024

The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. A patient like this one would not be enrolled because no clinician (ER doc or cardiologist) would enroll such a patient. This study failed to do so. 5% vs. 58%!!

Defibrillator 95

Defibrillator STEMI Coronary ALS 95

Dr. Smith's ECG Blog

AUGUST 11, 2024

Despite many ECG signs of OMI being missed the door-to-cath time was still fast, because all the healthcare providers were focused on the pathology of acute coronary occlusion and not were distracted by the lack of STEMI criteria. Start using the terms acute coronary occlusion and occlusion MI.

STEMI 78

STEMI Paramedic Coronary EMS 78

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 118

Defibrillator Coronary ALS STEMI 118

Dr. Smith's ECG Blog

MAY 3, 2024

See the variety of Left Main Occlusion ECGs here: How does Acute Total Left Main Coronary occlusion present on the ECG? == MY Comment , by K EN G RAUER, MD ( 5/3 /2024 ): == Most patients with acute LMain Occlusion do not survive to make it to the hospital. There is STE in aVR. Thus, there is high lateral OMI with diffuse ST depression.

ACS 119

ACS ED Coronary EMS 119

Dr. Smith's ECG Blog

DECEMBER 13, 2023

Knowing the patient has a history of coronary disease could be relevant to today's case — as it should add to our suspicion of a new acute event. If this is the case — this size of a Qr wave in lead III, as well as the seemingly wide Q in lead aVF — would seem to suggest prior inferior infarction a t some point in the past.

EMR 117

EMR Coronary OR STEMI 117

Dr. Smith's ECG Blog

AUGUST 6, 2024

All coronary arteries were patent without atherosclerotic change. Dr. Myocarditis can be very difficult to separate from OMI on ECG, and often some form of coronary artery imaging will need to be done to rule out OMI. In any case, the ECG is diagnostic of severe ischemia and probably OMI. Concordant STE of 1 mm in just one lead or 2a.

Coronary 90

Coronary OR STEMI EMS 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. We’ll keep it short, while you keep that EM brain sharp. Vital signs include BP 90/48, HR 122, T 98.3

EMS 74

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

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. No similar symptoms in the past. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack OR 52

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? Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial.

Coronary 83

Coronary CPR OR ICU 83

Dr. Smith's ECG Blog

JANUARY 8, 2024

She went to angio and had normal coronaries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. I discussed all results with patient. What was the actual diagnosis?

Coronary 71

Coronary STEMI EMS OR 71

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 79

Defibrillator ALS Coronary OR 79

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-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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. by being interrupted???

STEMI 93

STEMI Coronary Paramedic OR 93

Dr. Smith's ECG Blog

JULY 24, 2024

And regarding arrhythmias: For more on the regular WCT — See My Comment in the May 5, 2020 post and in the April 15, 2020 post in Dr. Smith's ECG Blog. Many ( if not most ) NSTEMIs are actually OMIs ( = acute coronary O cclusion MI s ). 4:35 — I’m sent a tracing. 6:40 — The need for a relevant History ( Clinical examples! ).

E-9-1-1 52

E-9-1-1 Coronary STEMI 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 finding of dynamic ST-T wave changes on serial tracings in association with a change in chest pain symptoms ( SEE My Comment in the July 21, 2020 post ).

STEMI 52

STEMI Coronary EMR ALS 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

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

JUNE 17, 2016

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 OR Coronary EMS 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. Cath lab activated Dual antiplatelet therapy and heparin given. NTG drip started. Pain better still.

Coronary 52

Coronary ACS EMS STEMI 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Coronaries were normal, as was serial troponin. Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. Do either, both, or neither have occlusion MI? Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths.

STEMI 73

STEMI Paramedic Coronary ED 73

Dr. Smith's ECG Blog

MAY 24, 2022

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. Given the young age, they were also suspicious of myocarditis, and ordered a CRP. The Cath lab was activated.

Coronary 52

Coronary OR ED 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. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). V1 has 0.5 mm of elevation.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 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 ). However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. Is this: 1. In either case, prompt cardioversion is indicated.

Coronary 103

Coronary ACS ED OR 103

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. For the majority of the tracing there are two P waves for each QRS. There is a LBBB. Mobitz type II AV block was suspected.

Coronary 88

Coronary OR Defibrillator ALS 88