Dr. Smith's ECG Blog

DECEMBER 5, 2023

A final ECG was perfomed on hospital day 2: Persistent ST elevation in the inferior leads with slight reciprocal ST depression in aVL Teaching points - It is essential to consider ACS in all age groups. While ACS may be less common in the pediatric population, it is important to consider risk factors that may make OMI more likely (e.g.,

Coronary 116

Coronary CAD ACS ALS 116

REBEL EM

OCTOBER 23, 2023

Follow up with the dentist in the morning Reinsert the tooth and avoid solid food Reinsert the tooth and stabilize it with a bridge Remove the tooth and repair the gingival laceration Remove the tooth and wrap it in saline-soaked gauze FOR THE RIGHT ANSWER CLICK ON THE ROSH REVIEW LOGO BELOW References Day PF, Flores MT, O’Connell AC, et al.

EMS 59

EMS ACS ALS ED 59

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). ACS and hyperkalemia both have lethal downstream consequences, so it is imperative for the clinician to acclimate to the presentation, or developing, features of each. link] [1] Zachary et al. 2] Costanzo, L.

ACS 130

ACS Paramedic Coronary ALS 130

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Kuttab et al’s findings, constituting 45% of the review’s weight, suggest that administering <30cc/kg IVF is associated with increased odds of mortality, delayed hypotension, and increased ICU utilization. times more intubations and 2.15

E-9-1-1 122

E-9-1-1 ALS ACS ICU 122

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. References: Jaff MR et al. PMID: 21422387 Wan S et al. PMID: 15262836 Sharifi M et al. PMID: 27422214 Wang C et al. PMID: 19741062 Kucher N et al. PMID: 24226805 Piazza G et al. PMID: 26315743 Tapson VF et al.

ALS 137

ALS ACS OR CPR 137

REBEL EM

FEBRUARY 12, 2024

Read More First10EM: Imaging for Renal Colic SGEM : SGEM XTRA: COME TOGETHER, RIGHT NOW – OVER RENAL COLIC References Chang, Helena, et al. Moore CL, Carpenter CR, Heilbrun ME, et al. Smith-Bindman R, Aubin C, Bailitz J, et al. PMID: 25229916 DOI: 10.1056/NEJMoa1404446 Westphalen AC, Hsia RY, Maselli JH, Wang R, Gonzales R.

Emergency Department 85

Emergency Department ALS ACS EMS 85

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. Lindahl et al. From Gue at al. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data.

Coronary 105

Coronary E-9-1-1 STEMI ACS 105

EMS 12-Lead

APRIL 21, 2022

Dedicated followers of the Smith ECG Blog know that the STD of true subendocardial ischemia does not localize, yet some of the examples listed below demonstrate the opposite, and were subsequently labeled “diffuse ischemia” or “generic subendocardial changes” as a diagnosis of convenience. However, the maximal STD in this case is V3.

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Brief aside: "Early repolarization" is a frequently proclaimed and poorly understood electrocardiographic phenomenon which mostly serves to reassure clinicians that not all ST elevations are ischemic (something readers of this blog know well). It relies on an 1 mm cut point, which this blog does not favor as an approach to ECG.

E-9-1-1 122

E-9-1-1 OR Coronary ACS 122

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). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Knotts et al.

ACS 52

ACS Coronary STEMI ALS 52

Dr. Smith's ECG Blog

AUGUST 9, 2024

This has been discussed many times before on this blog. In-depth discussion is beyond the scope of this blog. Similarly, the OMI paradigm respects ACS as a dynamic process in which ECG changes reflect the phase of myocardial injury and risk stratify which patients may benefit from emergent PCI. Bigger et al.

STEMI 88

STEMI Coronary Heart Attack ACS 88

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

In our opinion it should not be given in ACS unless you are committed to the cath lab. Learning Point: Any NSTEMI patient with active ongoing ACS symptoms refractory to medical management is supposed to go to the cath lab within 2 hours if available, per all guidelines in world, regardless of ECG findings. Am J Emerg Med.

ACS 83

ACS Coronary ALS CAD 83

Dr. Smith's ECG Blog

APRIL 18, 2024

Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1] Amsterdam et al. Alencar et al. Lupu et al. Herman, Meyers, Smith et al. But only 6.4% link] References 1.

STEMI 120

STEMI Coronary ALS CAD 120

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. Evidence regarding intervention to non-culprit plaques is mixed and beyond the scope of this blog post. Heitner et al. Thus, one considers a test result that varies by 2 or less to be the same result.

ACS 111

ACS ALS OR STEMI 111

Dr. Smith's ECG Blog

AUGUST 19, 2023

But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Dialysis patients have a high rate of ACS without chest pain and high rate of delayed diagnosis and delayed reperfusion 2.

STEMI 91

STEMI ACS OR ALS 91

FOAMfrat

OCTOBER 20, 2023

Previously, I wrote a blog on pre-oxygenation, referencing my personal “weapon of choice” as chosen from the 7 Ps of RSI. But, putting them both into one blog would make for a read far too long to maintain even my attention span (which honestly is pretty short). And according to a paper from Russotto et al.

E-9-1-1 52

E-9-1-1 ALS ACS OR 52

Dr. Smith's ECG Blog

MARCH 4, 2023

MOREVER, the morphology of the TWI is just not right for ACS. S1Q3T3 This is a paper worth reading : Marchik et al. Kosuge et al. showed that, when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS. inverted T-waves in V1 and V2, 1.8;

ACS 52

ACS ALS OR 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Because there was proven thrombus (ACS) but the troponin never went above the 99% reference range (and therefore cannot be called MI -- definition of MI requires rise and/or fall of troponin with at least one value above the 99% reference range), this is UNSTABLE ANGINA with ST Elevation. A picture is worth 1,000 words.

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS. Kosuge et al. showed that , when T-waves are inverted in precordial leads, if they are also inverted in lead III and V1, then pulmonary embolism is far more likely than ACS.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

REBEL EM

NOVEMBER 6, 2024

PMID: 32644703 Robinson PM, Griffiths E, Watts AC. PMID: 27227986 Glover NM, Black AC, Murphy PB. Commentary on an article by Marc Schnetzke, MD, et al.: “Determination of Elbow Laxity in a Sequential Soft-Tissue Injury Model. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Simple elbow dislocation. 2023 Nov 5.

E-9-1-1 59

E-9-1-1 ACS OR Emergency Department 59

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. I have posted previous such cases, but in searching my own blog, I could not find them. The ECG only tells you there is ischemia, not the etiology of it.

Coronary 52

Coronary ACS EMS STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

link] Shvilkin et al. Thus, the very well informed physician could differentiate these ECGs from those of an LBBB patient with MI: 1) no concordance 2) no excessive discordance 3) LBBB with tachycardia, probably rate related 4) subsequent T wave inversion that, according to Shvilkin et al., is diagnostic of cardiac memory.

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Lindahl et al. From Gue at al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

JANUARY 27, 2024

There were zero patients in this study with a "normal" ECG who had any kind of ACS! Deutch et al. This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value. So this study is actually worthless. West J Emerg Med 2024).

STEMI 107

STEMI Coronary ACS ED 107

ACEP Now

NOVEMBER 14, 2023

References Deshwal H, Sinha A, Mehta AC. Atchinson PRA, Hatton CJ, Roginski MA, et al. Ittrich H, Bockhorn M, Klose H, et al. Li H, Ding X, Zhai S, et al. Kathuria H, Hollingsworth HM, Vilvendhan R, et al. EMCrit blog website. Fekri MS, Hashemi-Bajgani SM, Shafahi A, et al. Semin Respir Crit Care Med.

E-9-1-1 52

E-9-1-1 ALS Emergency Department OR 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

SCAD isn’t rare, especially in women Historically SCAD had been identified in 22% of ACS cases in women. Pregnancy is not a common cause of SCAD When ACS occurs in the peripartum period, SCAD is responsible in 43% of cases. A study by Hassan et al. A study by Hassan et al. Lobo et al. The SCAD cases in Lobo et al.

Coronary 52

Coronary CAD ACS STEMI 52

REBEL EM

FEBRUARY 2, 2023

Paper: Mason JM, et al. These results were corroborated with other another study by Gritensko et al. Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc). References Mason JM, et al. 2018, PMID: 30571262 Gritsenko, Diana, et al. Link to Paper Here Shojaee M, et al. Am J Emerg Med. Am J Emerg Med.

Emergency Department 52

Emergency Department ALS Critical Care ED 52

Dr. Smith's ECG Blog

JUNE 19, 2023

Armstrong et al. ST depression maximal in V1-V4, without a QRS abnormality clearly causing it, in the setting of ACS symptoms, is very concerning for posterior MI until proven otherwise. The Queen of Hearts seems really really good at finding subtle OMI. Stay tuned for upcoming studies showing this.

STEMI 52

STEMI ACS Coronary Defibrillator 52

Dr. Smith's ECG Blog

JANUARY 17, 2023

In the December 5, 2022 post of Dr. Smith's ECG Blog — We show 4 additional cases of this pulse-tap artifact. Additional review of ECG artifacts by Pérez-Riera et al ( Ann Noninvasic Electrocardiol 23:e12494, 2018 ) VT Artifact — by Knight et al: NEJM 341:1270-1274, 1999. This is no longer the case!

ALS 52

ALS ACS OR ED 52

Dr. Smith's ECG Blog

MARCH 12, 2018

It is also true that anterior and inferior T-wave inversion could be consistent with reperfusion of a type III wraparound LAD occlusion, despite the fact that Kosuge et al showed that T-wave inversion in lead III is much more likely to be PE than ACS if your differential contains nothing else. Stein et al. Kosuge et al.

ACS 52

ACS Coronary ALS ICU 52

Dr. Smith's ECG Blog

MARCH 19, 2024

The cath report showed: Significant stenosis with subtotal occlusion (99%) in the prox to mid Lcx, culprit of ACS, TIMI flow 1. Available from: [link] If you are wondering about the Barcelona rule, then you should read the above paper by Khawaja et al. Cardiac catheterization occurred around 1pm (18 hours after arrival). 2021;23:187.

CAD 93

CAD STEMI ACS ALS 93

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." A troponin this high in a patient with no known chronic troponin elevation, and active acute ACS symptoms, has a very high likelihood of type 1 ACS regardless of the ECG.

OR 52

OR STEMI ACS Emergency Department 52

EMS 12-Lead

APRIL 2, 2022

Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. Figure 2-1 The V1 / V2 leads were appropriately placed in this circumstance, and dedicated followers of the Smith ECG Blog will instantly recognize the problem at hand. 4] Baranchuk, A, et al.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

AUGUST 9, 2019

But if they do present: The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion , though it might be due to sub total LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. Widimsky P et al. Knotts et al. TIMI 0/1 flow).(61,62)

Coronary 52

Coronary STEMI ACS ALS 52

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion).

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

It encompasses the complete range of ACS, including OMI, NOMI, and coronary thromboses that have the potential to rapidly propagate and become OMI and therefore has no specificity. References 1. -- Hillinger P, Strebel I, Abacherli R, et al. Int J Cardiol 2019 2. -- Meyers HP, Bracey, Smith et al. J of Emerg Med 2021.

STEMI 52

STEMI Coronary ALS ACS 52

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! There is profound "inferior" ST Depression.

Coronary 52

Coronary ACS Naloxone Plasma 52