EMDocs

JULY 1, 2023

A 3-year-old male with no past medical history presents to the ED with one week of daily fevers >102°F associated with four days of rash on the trunk. We’ll keep it short, while you keep that EM brain sharp. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. C) for the past week.

EMS 94

EMS Coronary ED OR 94

Dr. Smith's ECG Blog

OCTOBER 15, 2024

He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. Patient 2 , EKG 1: What do you think? He went to the cath lab at 0900 the next morning.

OR 116

OR STEMI Coronary ED 116

EMDocs

SEPTEMBER 19, 2023

On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Official diagnosis requires EEG, which is not something we can typically obtain in the ED. NSTEMI dichotomy is not sensitive for true occlusion MI or acute coronary occlusion. Every airway requires a plan and backups.

STEMI 100

STEMI Coronary Emergency Department ICU 100

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

Dr. Smith's ECG Blog

MARCH 10, 2025

Our data corroborate that immediate management of a patient with a normal automated triage ECG reading is not modified by real-time ED physician ECG interpretation." But troponin is a rear-view mirror which shows damage that has already occurred, and is often within the normal range within only 2 hours of onset of acute coronary occlusion.

STEMI 89

STEMI OR Coronary Emergency Department 89

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

When the patient arrived in the ED, he was still hypotensive in 70s, slowly improving with EMS fluids. Here is the ED ECG (a photo of the paper printout) What do you think? QOH ( Q ueen O f H earts ) and Dr. Smith's former resident immediately diagnosed acute OMI — but providers in the ED thought the ECG findings "looked old".

EMS 114

EMS CPR ED Coronary 114

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-9-1-1 131

E-9-1-1 OR Coronary ACS 131

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Heart disease and stroke statistics-2022 update: A report from the American Heart Association. Published December 19, 2022. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. Circulation.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Initial ED ECG: What do you think? Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Coronary angiogram shows diffuse severe three-vessel disease. IV Diltiazem was Contraindicated!

Coronary 139

Coronary OR EMS ED 139

EMDocs

SEPTEMBER 26, 2024

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits , a monthly email newsletter for ED physicians. Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Someone should have – either the first ED doc, the second ED doc, or my PCP.

Emergency Department 98

Emergency Department ED Coronary ALS 98

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. ECG Features suggesting "Fake" As per Dr. Sam Ghali ( who sent us today's case ) — serial Troponins were clearly indicated since the patient presented to the ED. There ARE Signs of a Repolarization Variant: Among the many posts in which we've reviewed cases of repolarization variants — is the May 23, 2022 post.

E-9-1-1 124

E-9-1-1 Coronary ALS ED 124

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 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

On arrival to the ED, this ECG was recorded: What do you think? Although predicting the "culprit" artery of acute coronary occlusion is often straightforward ( ie, based on the distribution of leads with ST elevation and leads with reciprocal ST depression ) — this is not always the case. The April 8, 2022 post by Drs.

STEMI 110

STEMI Coronary Defibrillator OR 110

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. 2022 Jan;51:384-387. 2022 May;55:180-182. 2022 May;55:180-182. Epub 2022 Mar 17. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. Am J Emerg Med. doi: 10.1016/j.ajem.2021.11.023.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." A repeat troponin returned at 0.45 CAD-RADS category 1. --No

Coronary 52

Coronary STEMI CAD OR 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. Chou’s Electrocardiography in Clinical Practice (6th ed). Saini, A., Raymond-Paquin, A.,

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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-9-1-1 123

E-9-1-1 Coronary ACS STEMI 123

Dr. Smith's ECG Blog

JUNE 2, 2023

Despite otherwise normal vital signs, she was appropriately triaged to the critical care area of the ED. They are rare and hard to find in normal practice in the ED. For review of a case of RVOT VT — Please see My Comment at the bottom of the page in the February 14, 2022 post in Dr. Smith's ECG Blog.

ED 96

ED OR ALS CAD 96

Dr. Smith's ECG Blog

OCTOBER 18, 2023

6] Among 394 emergency department Code STEMI patients with acute culprit lesion requiring coronary interpretation, 16 (4.1%) presented with an ECG labeled ‘normal’ or ‘otherwise normal’ by computer interpretation. 2022 ; 51 : 384 - 387 3. 2022 ; 55 : 180 - 182 6. minutes). Am J Emerg Med. J Electrocardiol. 2019 ; 54 : 79 - 81.

STEMI 119

STEMI Emergency Department Coronary OR 119

Dr. Smith's ECG Blog

JULY 7, 2024

They arrived in the ED 30 minutes later to meet the cardiology team, where an ECG was repeated: Again no STEMI criteria, and there has been improvement in the deWinter and swirl pattern. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

STEMI 66

STEMI Coronary ALS OR 66

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-9-1-1 116

E-9-1-1 Coronary EMS ED 116

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 125

OR STEMI EMS ED 125

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

Keep in mind the presenting History ( ie, a 50yo presenting to a rural ED with a 1-hour history of CP radiating to the back and jaw — and an initial ECG labeled as "normal" by the computer interpretation ). As you comtemplate the above issues to address — Take another LOOK at these first 2 ECGs in today's case.

OR 130

OR STEMI Coronary Emergency Department 130

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 Paramedic 71

Dr. Smith's ECG Blog

OCTOBER 8, 2024

I interpreted this tracing knowing only that the patient was a woman in her 60s, with a prior history of proximal LAD OMI — who now presented to the ED with a history of new chest discomfort and shortness of breath. For more on Precordial Swirl — See the October 15, 2022 post in Dr. Smith's ECG Blog ).

OR 123

OR STEMI ICU Coronary 123

Dr. Smith's ECG Blog

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. Problem #1: As I emphasized in My Comment in the December 6, 2022 post — Not all patients with acute MI report chest pain.

STEMI 98

STEMI ACS OR ALS 98

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? What Happens with the Emery Phenomenon?

STEMI 130

STEMI ED OR Coronary 130

Dr. Smith's ECG Blog

OCTOBER 22, 2024

He reported typical chest pain since 4H AM and arrived at our ED at 10h with ongoing chest pain. The coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Presence of a single coronary lesion: occlusion of the ostial main marginal.

Coronary 66

Coronary STEMI OR ALS 66

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 April 17, 2022 post ( Leads V1,V2 misplacement ).

E-9-1-1 97

E-9-1-1 STEMI Coronary OR 97

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. There is pericardial tamponade.

STEMI 60

STEMI Coronary CAD ED 60

Emergency Medicine Education

APRIL 12, 2023

There is always a debate in the ED that should we send a patient status post ROSC to cath lab or not. JAMA in July 2022 published a French national multicenter study regarding OHCA patient who had a ROSC to assess cerebral performance category. Link to article Early versus deferred coronary angiography following cardiac arrest.

Coronary 40

Coronary ED OR 40

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

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

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol 2013;46:240-8 2.

Coronary 52

Coronary ACS STEMI ALS 52

EMDocs

OCTOBER 21, 2023

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. Median time from ED arrival to diagnosis was 8 hours 24 min in one study, with only 19% being diagnosed within the 4.5-hour

EMS 98

EMS ALS OR ACS 98

ACEP Now

AUGUST 12, 2024

FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. Sequence of events in angina at rest: Primary reduction in coronary flow. 2022 Nov, 80 (20) 1925–1960. The patient had an EKG performed within 10 minutes of arrival while in triage (see Figure 1). Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52