EMDocs

OCTOBER 30, 2023

” – Musings of an American ED resident in July 2022 when US healthcare was affected simultaneously by supply chain issues from GE Healthcare (contrast media) and Abbott Laboratories (Similac baby formula). A baby formula milk shortage for adults.” 11 Table 1.

E-9-1-1 101

E-9-1-1 Emergency Department ALS CCT 101

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

Dr. Smith's ECG Blog

MARCH 10, 2025

But like many similar studies, the study was small (one year at one centre with no indication of the incidence of acute coronary occlusion), and it used as the gold standard the final cardiologist interpretation of the ECG - not the patient outcome! 2022 ; 51 : 384 - 387. Smith comment: this is even more stupid. Take home 1.

STEMI 89

STEMI OR Coronary Emergency Department 89

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. In October 2022, the American College of Cardiology released an updated expert consensus decision regarding the evaluation of chest pain in the emergency department.

STEMI 119

STEMI Coronary Emergency Department OR 119

ALiEM

OCTOBER 20, 2023

A 50-year-old Caucasian female with a history of hypertension, coronary artery disease, and insulin-dependent diabetes mellitus presents to the emergency department with a complaint of painful sores on the top of her left foot. Updated 2022 Dec 1]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Necrobiosis Lipoidica.

Plasma 161

Plasma Coronary Emergency Department OR 161

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 121

STEMI Coronary ALS CAD 121

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Inferior hyperacute T waves, which have been added to the 2022 ACC consensus on chest pain as a “STEMI equivalent”[3] 3. J Am Coll Cardiol 2022 4. De Alencar Neto. Int J Cardiol 2024 2.

STEMI 123

STEMI Coronary ALS Emergency Department 123

EMDocs

JULY 1, 2023

Upon further research in the 1970’s, retrospective data from autopsies of those patients showed coronary aneurysms 5 Pathophysiology: Kawasaki Disease is a vasculitis of medium sized arteries. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967.

EMS 94

EMS Coronary ED OR 94

Dr. Smith's ECG Blog

APRIL 22, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Pattern A evolves into Pattern B. Am Heart J. 2000;139:430–436. Am J Cardiol.

Coronary 118

Coronary STEMI ED OR 118

Dr. Smith's ECG Blog

OCTOBER 8, 2024

In the context of this woman in her 60s who has known coronary disease ( and who is now presenting with acute chest discomfort ) — I interpreted neighboring leads V1 and V2 as part of the same acute process suggested by the QRST in lead V3. 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

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 125

OR STEMI EMS ED 125

EMDocs

SEPTEMBER 19, 2023

NSTEMI dichotomy is not sensitive for true occlusion MI or acute coronary occlusion. “The application of STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant miry of patients who have acute coronary occlusion.” NCSE is likely more common than we think.

STEMI 100

STEMI Coronary Emergency Department ICU 100

Dr. Smith's ECG Blog

JUNE 23, 2024

The patient was treated as possible NSTEMI and underwent coronary angiography about 4 hours after presentation. TIMI 3 means the rate of passage of dye through the coronary artery is normal by angiography.) Initial hsTnI was 384 ng/L. The report describes a 60% proximal LAD lesion with TIMI 3 flow.

Coronary 118

Coronary CAD CPR Critical Care 118

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

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

Coronary 139

Coronary OR EMS ED 139

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-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

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 ). What do you do clinically when the ECG looks like this?

E-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

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

SEPTEMBER 29, 2024

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. See Discussion in the June 29, 2024 post of Dr. Smith' ECG Blog ).

STEMI 110

STEMI Coronary Defibrillator OR 110

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. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

MAY 23, 2023

2022 Jan;51:384-387. 2022 May;55:180-182. 2022 May;55:180-182. Epub 2022 Mar 17. 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. by being interrupted??? 2021.11.023.

STEMI 98

STEMI Coronary Paramedic OR 98

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 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

You can easily imagine this patient getting one of several diagnoses -- vasospasm, MINOCA , pericarditis, or maybe even no diagnosis at all beyond "non-obstructive coronary artery disease." Another option would be to use Optical Coherence Tomography for Coronary Imaging ). That plaque is at risk of thrombosing again.

OR 66

OR Coronary ACS EMS 66

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. 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. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization. Real or just fake?"

E-9-1-1 124

E-9-1-1 Coronary ALS ED 124

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

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

As per Dr. McLaren — today's patient was lucky in that the acute coronary occlusion spontaneously reperfused — and the patient remained pain-free. There’s clear T wave inversion in III/aVF, which is reciprocal to subtle ST elevation and hyperacute T waves in I/aVL (broad, symmetric, and larger than the entire QRS in aVL).

OR 130

OR STEMI Coronary Emergency Department 130

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 131

Defibrillator Coronary ALS STEMI 131

Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI 66

STEMI Coronary ALS OR 66

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. Written by Jesse McLaren Four patients presented with chest pain. minutes).

STEMI 119

STEMI Emergency Department Coronary OR 119

Dr. Smith's ECG Blog

DECEMBER 12, 2022

Comment by K EN G RAUER, MD ( 12/12 /2022 ): = I will summarize in 4 words the important message conveyed by Dr. Meyers in today's post = "Be Aware of Pseudo-Normalization!" 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

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Other cardiac-related causes for syncope associated with acute MI may include malignant ventricular arrhythmias and bradyarrhythmias including AV block. The "good news" — is that a cardiac-related cause of syncope is unlikely if the initial ECG is normal, and cardiac monitoring in the ED fails to reveal significant arrhythmia.

EMS 114

EMS CPR ED Coronary 114

EMDocs

FEBRUARY 7, 2024

American Gastroenterological Association issued a practice guideline in November 2022 recommending that semaglutide 2.4 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. How do they work?

Allergic Reaction 98

Allergic Reaction ALS CAD OR 98

EMDocs

SEPTEMBER 26, 2024

Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. 3 : September 2022. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. Plaintiff : You told me you would call me if the radiology report was “different.” Tyler W et al.

Emergency Department 98

Emergency Department ED Coronary ALS 98

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

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 104

Coronary OR STEMI EMS 104

Dr. Smith's ECG Blog

MAY 31, 2023

And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. Am Heart J.

STEMI 96

STEMI Coronary ACS OR 96

Dr. Smith's ECG Blog

JUNE 15, 2023

Thus, this does NOT meet STEMI criteria (though, as of 2022, it is a formal "STEMI equivalent", assuming everyone agrees that this is de Winter morphology, for which there is currently no objective definition). Also, if you use the LAD OMI formula : QT = 420, RAV4 = 5 mm, QRSV2 = 6 mm, STE60V3 = 2.5 mm, the value is 22.2 (LAD What a farce.

STEMI 98

STEMI Coronary ACS OR 98

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 123

EMR Coronary OR STEMI 123