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." Smith comment: we showed that the first troponin, even in full-blown STEMI, is negative 25% of the time. But according to Langlois-Carbonneau et al.,

STEMI 89

STEMI OR Coronary Emergency Department 89

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. It’s unclear if the paramedic ECGs were seen or missed in the ED. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. At this point the emergency physician asked for a stat cardiology consult.

STEMI 100

STEMI Paramedic Coronary EMS 100

EMDocs

FEBRUARY 24, 2024

. #1: How to Treat Infected Kidney Stones Spoon Feed All patients with infected ureteral stones necessitate a urine culture, antibiotics, and urology consultation in the ED, with the majority requiring admission for surgical intervention. 2024 Jan;75:137-142. 2024 Jan;22(1):140-151. Am J Emerg Med. doi: 10.1016/j.ajem.2023.10.049.

Coronary 98

Coronary STEMI ED OR 98

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? EKG on arrival to the ED is shown below: What do you think? Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). or basilar ischemia.

STEMI 115

STEMI Coronary Emergency Department ACS 115

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. 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-9-1-1 127

E-9-1-1 Coronary STEMI ALS 127

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., Here is the bottom line of the article: It is widely believed that hyperacute T-waves are a transitional state preceding ST Elevation 1–4 Thus, it is tempting to postulate that early cases of OMI will eventually evolve to STEMI; yet, our data contradicts that notion. This one is easy for the Queen.

OR 122

OR STEMI ICU Coronary 122

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). It is a ssociated with mild dyspnea on exertion. Aspirin given.

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Coronary STEMI ED OR 117

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

male presents to the ED at 6:45 AM with left sided chest dull pressure that woke him up from sleep at 3am. He arrived to the ED at around 6:45am, and stated the pain has persisted. Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. The pain radiated to both shoulders.

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Coronary ACS OR EMR 121

Dr. Smith's ECG Blog

JULY 25, 2024

The patient was brought to the ED and had this ECG recorded: What do you think? Cardiac arrest #3: ST depression, Is it STEMI? 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. After 1 mg of epinephrine they achieved ROSC.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Learning Points: You cannot trust conventional algorithms even to find STEMI(+) OMI, even when they say "normal ECG." At this point — a STEMI was diagnosed, and cardiac cath with PCI was performed.

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STEMI Coronary Emergency Department OR 113

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. Do either, both, or neither have occlusion MI? Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

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? Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Is it normal STE? This is a "Transient OMI". Am J Cardiol.

STEMI 115

STEMI ACS Critical Care Coronary 115

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

OCTOBER 6, 2024

This patient had the onset of chest pain 24 hours before arrival to the ED. The Non-STEMI, which was an OMI, was diagnosed much faster with AI on the ECG than with troponin. For more on ECG findings in pulmonary disease — Check out My Comment in the May 31, 2024 post in Dr. Smith's ECG Blog ). It had never been described before.

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STEMI Coronary ED 77

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. A healthy 45-year-old female presented with chest pain, with normal vitals. First trop was 90 ng/L (normal <16 in females) and peak was 7,400 ng/L.

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

Later, I found old ECGs: 5 month prior in clinic: V5 and V6 look like OMI 9 months prior in clinic with no chest symptoms: V5 and V6 look like OMI 1 year prior in the ED with chest pain: V5 and V6 sure look like a STEMI For this ECG and chest pain in the ED, the Cath lab activated. But the angiogram was clean. There was no OMI.

STEMI 70

STEMI ED OR 70

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high). Consider the scenario in today's CASE: This 56-year old man with risk factors including diabetes and known coronary disease — presented to the ED on Day #1 with new weakness , fatigue , lethargy and confusion.

Coronary 120

Coronary STEMI Emergency Department OR 120

Dr. Smith's ECG Blog

JULY 14, 2024

Another missed OMI by the False STEMI-NonSTEMI Dichotomy Don't miss them!!! BOTTOM Line for CASE #1: Prompt recognition of the precordial "Swirl" pattern of acute LAD OMI resulted in stent reperfusion in less than 90 minutes from the time of arrival in the ED. Use the Queen of Hearts and save myocardium and lives!

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STEMI OR ED 105

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 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated. Long term outcome is unavailable.

STEMI 121

STEMI EMS ACS ED 121

ESO

APRIL 19, 2024

From April 2-5, ESO brought the hospital industry’s top thought leaders and data analysts together at Wave 2024 to share what trends they’re forecasting for the medical field along with how they’re enacting change within their own organization through the power of data-driven insights. ESO has resources to keep you informed.

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EMS Paramedic Critical Care STEMI 105

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. COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab.

Defibrillator 113

Defibrillator STEMI Coronary ALS 113

Dr. Smith's ECG Blog

JANUARY 20, 2024

Cardiology refused to be the admitting physician because it was "NSTEMI", and forced the ED physician to admit the patient to the hospitalist. Of course, there was terrible boarding and the patient was considered non-emergent (NSTEMI), and so could not leave the ED for some time. YOU TOO CAN HAVE THE PM Cardio AI BOT!!

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STEMI CAD ED ALS 120

Dr. Smith's ECG Blog

OCTOBER 1, 2024

== MY Comment , by K EN G RAUER, MD ( 8/30 /2024 ): == I was sent the ECG shown in Figure-1 — knowing only that the patient was being seen in the ED ( E mergency D epartment ). 2 Informational: I was provided with a repeat ECG on this patient — which was recorded a bit after ECG #1, still in the ED ( Bottom tracing in Figure-3 ).

E-9-1-1 113

E-9-1-1 STEMI ED OR 113

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. Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." The first ECG (10h14) showed TWI in inferior leads."

Coronary 66

Coronary STEMI OR ALS 66

Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." Accessed May 28, 2024. In 2024 — once the diagnosis of acute is contemplated, point of care Echo and/or CTPA ( C omputed T omography P ulmonary A ngiography ) enable expedited confirmation.

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E-9-1-1 ACS Emergency Department Coronary 138

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

The is very small STE in III and aVF which do not meet STEMI criteria, hyperacute T waves, reciprocal TWI in aVL, and maximal STD in V2-V3 showing posterior OMI. The cath lab was activated despite lack of STEMI criteria, around 2 am in the morning. Here is her ECG on arrival to the ED: Improved, but still some signal of posterior OMI.

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STEMI OR ED EMS 81

REBEL EM

FEBRUARY 3, 2025

Background: ST-segment elevation myocardial infarction (STEMI) is a critical condition requiring rapid diagnosis and intervention. While ECGs play a central role in detecting STEMI, misinterpretations often occur, leading to unnecessary catheterization or missed diagnoses. Paper: Lee SH, Jeon KL, Lee YJ, Ko YG, Choi D, Hong MK, et al.

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STEMI Coronary Emergency Department ALS 84

Dr. Smith's ECG Blog

DECEMBER 3, 2024

This was written by one of our fine residents, who will soon be an EMS fellow: Michael Perlmutter Case A mid-50s male came to the ED with a burning sensation that was acutely worse while at home. He came to the ED at the urging of his wife. Note also development of distinct J-point notching in leads V3 , V4 that was not seen earlier.

ED 110

ED Coronary ACS STEMI 110

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This time the Queen of Hearts interpreted: No STEMI or Equivalent.

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STEMI Coronary Critical Care ED 105

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? The Queen of Hearts Diagnosed "STEMI/STEMI equivalent" on that first ECG (she now uses "STEMI Equivalent" rather than OMI).

OR 110

OR STEMI Coronary CAD 110

ACEP Now

FEBRUARY 11, 2025

Around the world, acute pain is the most common reason for patients to present to the emergency department (ED). We propose a novel concept for the implementation of a regional anesthesia service aimed at providing pain relief to both ED patients and those admitted to the hospital. link] Published June 17, 2024. Int Emerg Nurs.

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Emergency Department E-9-1-1 ALS ED 80

Dr. Smith's ECG Blog

JANUARY 9, 2025

Smith : I recognize this as a STEMI mimic. See here for young women with OMI == MY Comment , by K EN G RAUER, MD ( 12/24 /2024 ): == I found today's case challenging and an excellent example of how despite my not being certain of the diagnosis from the history and initial ECG careful follow-up yielded the answer. I was not alarmed.

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ED STEMI OR 106

Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? He arrived in the ED and had this ECG recorded: The first high sensitivity troponin I returned undetectable (3 ng/L). For more on the ECG diagnosis and consequences of acute RV MI Check out My Comment in July 19, 2020 post and the August 2, 2024 post). He called 911.

Coronary 56

Coronary STEMI EMS ALS 56

Dr. Smith's ECG Blog

FEBRUARY 14, 2025

The ECG meets STEMI criteria objectively. The ED physician did not think the ECG represented OMI. One other ECG was obtained during the ED stay: The patient was discharged home. See My Comment in the June 25, 2024 post for changes with LA-LL reversal ). PM Cardio QOH says No signs of OMI. AMI was ruled out.

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STEMI ED Coronary OR 61

Dr. Smith's ECG Blog

NOVEMBER 29, 2024

Queen : she saw no OMI (no "STEMI Equivalent") either Continued : Now, she says she was walking to the bathroom when she experienced acute onset substernal chest pressure radiating into her neck and left arm. Her ECG afterward is shown below: ECG from five days prior Smith : this shows an old inferior MI with persistent ST elevation.

Defibrillator 66

Defibrillator STEMI Coronary ED 66

Dr. Smith's ECG Blog

OCTOBER 30, 2024

He arrived in our ED with the below ECG pain free. All of these findings together makes this ECG diagnostic of inferior and posterior occlusion myocardial infarction (OMI) The patient is this case was treated as if he had an ongoing OMI. Primary PCI was not feasible and therefore the patient was given thrombolytics by EMS.

Coronary 111

Coronary EMS OR STEMI 111