2024, ALS and Coronary - Paramedicine Now

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Studies such as those by Moise et al 14 and Ellis et al 39 have shown that the relative risk of developing an acute myocardial infarction in the territory supplied by an artery with a 70%. years, with the interval as long as 12 or 18 years in some studies. Unfortunately, vascular remodeling is variable and inconsistent.

Coronary

Coronary ACS OR EMR

SGEM#454: I Just Died in Your Arms Tonight – Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes

The Skeptics' Guide to EM

SEPTEMBER 28, 2024

Date: September 23, 2024 Reference: Essat et al. Annals of Emergency Medicine, May 2024 Guest Skeptic: Dr. Casey Parker is a Rural Generalist from Australia who is also an ultrasounder. The patient has no specific risk factors for acute coronary syndrome (ACS) or dissection. Reference: Essat et al.

Emergency Department

Emergency Department ACS Coronary ALS

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

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. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. Int J Cardiol 2024 2. Nikus et al. Kontos et al.

STEMI

STEMI Coronary ALS Emergency Department

Is OMI an ECG Diagnosis?

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. Amsterdam et al. Alencar et al.

STEMI

STEMI Coronary ALS CAD

Acute artery occlusion -- which one?

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

E-9-1-1 Coronary STEMI ALS

A 30-something with acute chest pain

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Not OMI with High Confidence Click here to sign up for Queen of Hearts Access We showed that the Queen of Hearts decreases false positive cath lab activations: 1) Published recently in Prehospital Emergency Care Baker PO et al. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al.

E-9-1-1

E-9-1-1 Coronary ALS ED

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Dr. Smith's ECG Blog

JUNE 17, 2024

In fact, Kosuge et al. showed that among patients with either acute coronary syndrome or acute pulmonary embolism and negative T waves in the precordial leads (V1-V4), that inverted T waves in leads III and V1 were present in only 1% of patients with acute coronary syndrome and 88% of patients with pulmonary embolism. “The

E-9-1-1

E-9-1-1 ACS Emergency Department Coronary

Prehospital activation: De-activated on ED arrival by Cardiologist because "It's not a STEMI"

Dr. Smith's ECG Blog

OCTOBER 27, 2024

Initial 4th generation troponin I was 10 ng/mL is consistent with large MI due to acute coronary occlusion (OMI). There are moderate coronary artery calcifications. Lupu et al. Reference : Lupu L, Taha L, Banai A, Shmueli H, Borohovitz A, Matetzky S, Gabarin M, Shuvy M, Beigel R, Orvin K, et al.

STEMI

STEMI ED Coronary EMS

Palpitations while awaiting CABG

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 native QRS may be more obvious in one lead or another. == MY Comment , by K EN G RAUER, MD ( 5/30 /2024 ): == I was not taught about artifact in medical school. Take advantage of all the telemetry leads.

Defibrillator

Defibrillator ALS Coronary OR

60 year old with chest pain, STEMI negative. What should the discharge diagnosis be?

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

STEMI Coronary ALS OR

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

Dr. Smith's ECG Blog

OCTOBER 22, 2024

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

Coronary STEMI OR ALS

Guidelines would (erroneously) say that this patient who was defibrillated and resuscitated does not need emergent angiography

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

Defibrillator STEMI Coronary ALS

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

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. Lemkes JS, et al. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436. Eur Heart J [Internet].

Coronary

Coronary STEMI ED OR

Two patients with chest pain and RBBB: do either have occlusion MI?

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

STEMI Paramedic Coronary ED

Using Point-of-Care Ultrasound to Identify the Gallbladder

EMDocs

MARCH 25, 2024

Video 3: Coronary approach to the gallbladder POCUS Findings Sonographically, the gallbladder is situated in the right upper quadrant as an elongated pear-shaped organ on the inferior surface of the liver. Ross M, Brown M, McLaughlin K, et al. Dumbrava BD, Bass GA, Jumean A, et al. Al-Khouja F, Mazumder P, Moeller J, Lahham S.

ALS

ALS Coronary Emergency Department ED

What are treatment options for this rhythm, when all else fails?

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

Defibrillator Coronary ALS STEMI

Texted from a former EM resident: 70 yo with syncope and hypotension, but no chest pain. Make their eyes roll!

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Click here to sign up for Queen of Hearts Access == MY Comment , by K EN G RAUER, MD ( 9/11 /2024 ): == Among the important concepts brought out by today's case are the following: #1) — Is acute OMI a common cause of syncope ? #2) Former resident: "The biggest piece for me was the size of the T waves in relation to everything else.

EMS

EMS CPR ED Coronary

46 year old with chest pain develops a wide complex rhythm -- see many examples

Dr. Smith's ECG Blog

AUGUST 9, 2024

Serial ECGs enhance the diagnosis of acute coronary syndrome. Bigger et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the Crusade Quality Improvement Initiative. Sadowski ZP, Alexander JH, Skrabucha B, et al. Bigger JR Jr, Dresdale RJ, Heissenbuttel RH, et al.

STEMI

STEMI Coronary Heart Attack ACS

The High Life: an Altitude Illness Guidebook

FOAMfrat

JUNE 25, 2024

Other risk factors include heavy physical exertion, alcohol consumption, dehydration, and existing co-morbidities that may affect acclimatization such as coronary artery disease, COPD, hypertension, obesity, and sickle cell trait/anemia. High Elevation Travel & Altitude Illness | CDC Yellow Book 2024.” Accessed 22 June 2024.

OR

OR Coronary ALS

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion. Deutch et al.

STEMI

STEMI Coronary ACS ED

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Hayakawa A, Tsukahara K, Miyagawa S, et al. I have not yet seen any case report of this combination. It is already approved in Europe. As per Drs.

ACS

ACS Coronary ALS CAD

emDOCs Podcast – Episode 94: GLP-1 Agonist Complications

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. Available online 12 January 2024. Shetty R, Basheer FT, Poojari PG, et al. Capehorn MS, Catarig AM, Furberg JK, et al.

Allergic Reaction

Allergic Reaction ALS CAD OR

Why the sudden shock after a few days of malaise?

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

A Short Comment on PIRP and T Waves: Oliva et al found a strong association of myocardial rupture with postinfarction regional pericarditis. Another possible cause of pseudonormalization of T waves mentioned many times on this blog is the pseudonormalization caused by re-occlusion of an infarct related reperfused coronary artery.

STEMI

STEMI Coronary OR ALS

How a pause can cause cardiac arrest

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

A coronary angiogram was done that did not show significant coronary artery disease. Most Torsades is the result of a pause-dependent effect that predisposes to development of the malignant arrhythmia ( Dohadwala et al — Heart Rhythm Case Rep 3(2):115-119, 2017 ). Post ROSC the patient was alert and cooperative.

Defibrillator

Defibrillator Coronary OR ALS

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. The Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. She's had multiple PCI procedures. It is already approved in Europe.

Coronary

Coronary OR ALS

An elderly male with shortness of breath

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

Lemkes et al. A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. PubMed PMID: 7778540. == MY Comment , by K EN G RAUER, MD ( 9/7 /2024 ): == The KEY to comparing to ECGs — is to put both ECGs next -to-each-other!

STEMI

STEMI ACS Critical Care OR

What kind of AV block is this? And why does she develop Ventricular Tachycardia?

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. Vaso or inotropic medications are not harmless, and can precipitate life threatening arrhythmias.

Coronary

Coronary OR Defibrillator ALS

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Dr. Smith's ECG Blog

JANUARY 5, 2024

Heitner et al. Sometimes it can take 12 or 24 hours to see ECG evidence of reperfusion. == MY Comment , by K EN G RAUER, MD ( 1/4/ 2024 ): == Superb and thorough discussion by Dr. Frick of today's case! The PDA plaque was also bulky, but was not described as inflamed or ulcerated. DOI:10.1161/CIRCINTERVENTIONS.118.007305),

ACS

ACS ALS OR STEMI

Evaluating Chronic Obstructive Pulmonary Disease

ACEP Now

JUNE 14, 2024

Some of the critical differentials include pulmonary embolism, acute decompensated heart failure, pneumonia, pneumothorax, and acute coronary syndrome. Anginal chest pain, chest heaviness, or evidence of fluid overload suggest acute coronary syndrome or acute decompensated heart failure. Adeloye D, Song P, Zhu Y, et al.

ALS

ALS Coronary OR Emergency Department

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

Dr. Smith's ECG Blog

JANUARY 17, 2024

Using the current paradigm, can you tell which patient had an acute coronary occlusion? STEMI vs OMI Now let’s see the rest of the ECG: can you tell which patient has an acute coronary occlusion, and which ECG has hyperacute T waves? Driver et al. Meyers, Bracey et al. Herman, Meyers, Smith et al.

STEMI

STEMI Coronary ALS OR

A man in his 80s with chest pain and ventricular paced rhythm

Dr. Smith's ECG Blog

JULY 19, 2024

Lupu et al. Immediate and early percutaneous coronary intervention in very high risk and high risk non-ST segment elevation myocardial infarction patients. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. 2015;170:1255–1264.

Coronary

Coronary STEMI OR ALS

The 76th Bubble Wrap

Don't Forget the Bubbles

DECEMBER 5, 2023

A very Merry Christmas from the BW team, and all the Best Wishes for 2024! Nizami T, Beaudoin F, Suner S, et al. The goal of chest compressions during neonatal resuscitation is to increase cerebral and coronary blood flow with the intention to achieve a return of spontaneous circulation (ROSC). Crocker, B.C.S.,

Coronary

Coronary Epinephrine CPR Emergency Department

Pain Management of Common Chief Complaints in the ED

EMDocs

NOVEMBER 4, 2024

54 It is vital to consider dangerous epigastric pain mimickers like acute coronary syndrome (ACS), hepatobiliary disease, or pancreatitis. 2014.01.015 Motov S, Strayer R, Hayes BD, et al. 2018.01.020 Motov S, Rockoff B, Cohen V, et al. 0b013e328348bf6f Murphy CE, Raja AS, Baumann BM, et al. May 2014;32(5):421-31.

ED

ED E-9-1-1 Emergency Department ALS

Paramedicine Now

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

SGEM#454: I Just Died in Your Arms Tonight – Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes

Trending Sources

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Is OMI an ECG Diagnosis?

Acute artery occlusion -- which one?

A 30-something with acute chest pain

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Prehospital activation: De-activated on ED arrival by Cardiologist because "It's not a STEMI"

Palpitations while awaiting CABG

60 year old with chest pain, STEMI negative. What should the discharge diagnosis be?

Why you should use the Queen of Hearts and record serial ECGs more often. If you wait for troponin.

Guidelines would (erroneously) say that this patient who was defibrillated and resuscitated does not need emergent angiography

Chest pain, resolved. Does it need emergent cath lab activation (some controversy here)? And much much more.

Two patients with chest pain and RBBB: do either have occlusion MI?

Using Point-of-Care Ultrasound to Identify the Gallbladder

What are treatment options for this rhythm, when all else fails?

Texted from a former EM resident: 70 yo with syncope and hypotension, but no chest pain. Make their eyes roll!

46 year old with chest pain develops a wide complex rhythm -- see many examples

The High Life: an Altitude Illness Guidebook

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

See this "NSTEMI" go unrecognized for what it really is, how it progresses, and what happens

emDOCs Podcast – Episode 94: GLP-1 Agonist Complications

Why the sudden shock after a few days of malaise?

How a pause can cause cardiac arrest

Wide complex and apparent hyperacute T-waves. Does absence of change from previous ECG mean that it is not New?

An elderly male with shortness of breath

What kind of AV block is this? And why does she develop Ventricular Tachycardia?

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Evaluating Chronic Obstructive Pulmonary Disease

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

A man in his 80s with chest pain and ventricular paced rhythm

The 76th Bubble Wrap

Pain Management of Common Chief Complaints in the ED

Stay Connected