Dr. Smith's ECG Blog

JULY 25, 2024

The patient was brought to the ED and had this ECG recorded: What do you think? But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. or is he an ACCESS Trial Candidate? == MY Comment , by K EN G RAUER, MD ( 7/5 /2024 ): == Clinical ECG interpretation is a 2-Step process.

Defibrillator 110

Defibrillator Coronary Epinephrine ACS 110

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

On arrival to the ED, this ECG was recorded: What do you think? In other words: 1) infarct of the LAD territory (much of which could be old) and 2) inferior-posterior-lateral infarct. == MY Comment , by K EN G RAUER, MD ( 9/27 /2024 ): == I found today's case insightful for a number of reasons. This prompted cath lab activation.

STEMI 80

STEMI Coronary Defibrillator OR 80

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Click here to sign up for Queen of Hearts Access == MY Comment , by K EN G RAUER, MD ( 10/1 /2024 ): == I looked at the ECG in today’s case knowing only that the patient was a younger male adult with CP ( C hest P ain ). Sam : "Yes, this case was sent to me. It was a man in his 30s with chest pain. 27 post ).

E-9-1-1 111

E-9-1-1 Coronary ALS ED 111

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-9-1-1 110

E-9-1-1 Coronary STEMI ALS 110

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. This is a demonstration of how Wellens' is transient OMI : First ED ECG is Wellens' (pain free). Also see this incredible case of the use of 12-lead ST Segment monitoring. __ Case Continued The Cath lab was activated 70 minutes after ED arrival.

Coronary 117

Coronary STEMI ED OR 117

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 106

EMS CPR ED Coronary 106

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

OCTOBER 12, 2024

EKG on arrival to the ED is shown below: What do you think? Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) or basilar ischemia. On my initial interpretation, the patient has normal sinus rhythm with a narrow QRS complex, and LVH. ng/mL and 0.10 J Electrocardiol.

STEMI 98

STEMI Coronary Emergency Department OR 98

Dr. Smith's ECG Blog

JUNE 17, 2024

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. Accessed May 28, 2024.

E-9-1-1 137

E-9-1-1 ACS Emergency Department Coronary 137

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

Here is her ECG on arrival to the ED: Improved, but still some signal of posterior OMI. Angiogram was done rapidly after arrival to the ED: Culprit mid LCX 90% TIMI 3 flow, PCI performed with resultant TIMI 3 flow. Figure-1: Comparison between the initial EMS ECG and the repeat ECG in the ED. Very frustrating.

STEMI 81

STEMI OR ED EMS 81

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

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 19, 2024

He arrived at the ED just shy of two hours after onset, pain free. Here is the initial ED ECG: Here that first ECG is cleaned up by PM Cardio app: What do you think? post OMI with significant multi-vessel coronary disease. The pain was relieved by one prehospital NTG spray. No prior similar symptoms or known CAD.

OR 69

OR STEMI Coronary CAD 69

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech. No ECG was ordered on Day #1.

Coronary 108

Coronary STEMI Emergency Department OR 108

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

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. Click here to sign up for Queen of Hearts Access == == MY Comment , by K EN G RAUER, MD ( 10/6 /2024 ): == Today's case provides an excellent example of how prompt recognition of acute OMI worked as it should to expedite cardiac cath and coronary reperfusion.

STEMI 77

STEMI Coronary ED 77

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

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. West J Emerg Med 2024).

STEMI 102

STEMI Coronary ACS ED 102

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

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

Dr. Smith's ECG Blog

JULY 11, 2024

He sent the patient to the ED for further evaluation. A chest x-ray in the ED found bilateral pleural effusions. The scan did not find PE, but showed evidence of coronary plaque: There are areas of dense white in the LAD (red and blue circles) and in the first diagonal (green circle).

Coronary 91

Coronary ED ACS OR 91

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Submitted by Dr. George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm.

OR 66

OR STEMI ACS Coronary 66

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. Treasure Island (FL): StatPearls PublishingCopyright © 2024, StatPearls Publishing LLC.; 4 Benefits of Biliary POCUS?

ALS 87

ALS Coronary Emergency Department ED 87

Dr. Smith's ECG Blog

JANUARY 9, 2024

*Temporarily decreasing the LRL of the ICD/Pacemaker can promote intrinsic depolarization which is beneficial when assessing ST segments and T waves for ischemia. == MY Comment , by K EN G RAUER, MD ( 1/10 /2024 ): == Highly insightful post by Dr. Magnus Nossen — that brings home a number of very important points.

Coronary 99

Coronary ACS ED OR 99

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. It is already approved in Europe.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Available from: [link] Click here to sign up for Queen of Hearts Access == MY Comment , by K EN G RAUER, MD ( 10/8 /2024 ): == It’s always easier to look back at a case from the comfort of one’s home — and to criticize decisions that were made. High T waves in the earliest stage of myocardial infarction. Am Heart J [Internet].

OR 108

OR STEMI ICU Coronary 108

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

JUNE 11, 2024

Acad Emerg Med 2024;31:296-300 == MY Comment , by K EN G RAUER, MD ( 6/6 /2024 ): == Recognition of repolarization variants can be challenging. It is clearly missed by the conventional algorithm. Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.

STEMI 111

STEMI Coronary Emergency Department OR 111

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

ECG 1 at time zero EARLY REPOLARIZATION ABNORMAL ECG ED final official overread: "early repol vs hyperacute T, minimal changes from previous (previous shown below)" What do YOU think? See these casese (and I have many others): First ED ECG is Wellens' (pain free). A 70-something y.o. male presents to triage with shortness of breath.

STEMI 113

STEMI ACS Critical Care OR 113

Dr. Smith's ECG Blog

OCTOBER 30, 2024

He arrived in our ED with the below ECG pain free. However, there was no thrombotic component and there was TIMI III flow in all coronaries and their main branches. And, even if there was acute aortic dissection — the dissection could result in occlusion of a coronary artery. There is now reperfusion of the artery.

Coronary 89

Coronary EMS OR STEMI 89

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 Queen of Hearts AI app will hopefully be FDA approved in Q1 of 2024. I have not yet seen any case report of this combination.

ACS 83

ACS Coronary ALS CAD 83

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. Signs and symptoms of systemic infection (e.g.,

ALS 52

ALS Coronary OR Emergency Department 52

EMDocs

NOVEMBER 4, 2024

Jafar Mahmood, MD (Pain Medicine Attending, Paincare Medical Practice) // Reviewed by: Jessica Pelletier, DO, MHPE (EM Attending, APD, University of Missouri-Columbia), Marina Boushra, MD (EM-CCM Attending, Cleveland Clinic); Brit Long, MD (@long_brit) Introduction: Pain management in the ED can be a unique challenge.

ED 98

ED E-9-1-1 Emergency Department ALS 98

Don't Forget the Bubbles

DECEMBER 5, 2023

A very Merry Christmas from the BW team, and all the Best Wishes for 2024! Sex ed” sucks. They believe that Sex Ed programs are irrelevant to real-life experience and contain inadequate discussion of important issues, including consent or positive sexual relationships. Why does it matter?

Coronary 111

Coronary Epinephrine CPR Emergency Department 111