Dr. Smith's ECG Blog

NOVEMBER 3, 2023

When Pendell and I are coding ECGs for the Queen's training, this is one category: "Definite ischemia, difficult to differentiate between posterior OMI and subendocardial ischemia." In our opinion it should not be given in ACS unless you are committed to the cath lab. Hayakawa A, Tsukahara K, Miyagawa S, et al. Am J Emerg Med.

ACS 82

ACS Coronary ALS CAD 82

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 101

STEMI Coronary ACS ED 101

Dr. Smith's ECG Blog

AUGUST 9, 2024

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. Sadowski ZP, Alexander JH, Skrabucha B, et al. Bigger JR Jr, Dresdale RJ, Heissenbuttel RH, et al. Leave it alone.

STEMI 84

STEMI Coronary Heart Attack ACS 84

EMS 12-Lead

APRIL 2, 2022

1, 2] The most clinically useful definition to account for this entire constellation is intraventricular conduction delay. Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion. second (ie, with a pure fascicular VT) — so How can you NOT count 0.11

ALS 130

ALS STEMI Coronary OR 130

ACEP Now

NOVEMBER 14, 2023

The definition of massive hemoptysis is variable across publications with expectorated blood volumes ranging from 100 to 1,000 mL per 24 hours, as these volumes are difficult to estimate for any given patient. References Deshwal H, Sinha A, Mehta AC. Atchinson PRA, Hatton CJ, Roginski MA, et al. Li H, Ding X, Zhai S, et al.

E-9-1-1 52

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

ACEP Now

MAY 9, 2024

Taking a different approach than the authors of the AHRQ report, Auerbach et al used a “look back” approach to perform both qualitative and quantitative evaluations of the types and frequencies of errors occurring in hospital settings. References Newman-Toker DE, Peterson SM, Badihian S, et al. Auerbach AD, Lee TM, Hubbard CC, et al.

Emergency Department 52

Emergency Department ICU ALS ACS 52

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The original term " benign early repolarization" has fallen out of favor since the seminal paper by Haïssaguerre et al. In an attempt to clarify language, a consensus definition was developed. mV in 2 or more contiguous leads (excluding V1-V3) The QRS duration should be < 120 ms This definition is not perfect.

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

Dr. Smith's ECG Blog

JANUARY 5, 2024

80%) and definitely too much for hour to hour. However, the Definition of MI requires at least one value above the 99th percentile, which for a male is 34 ng/L (16 ng/L for women). Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. Heitner et al. of the time.

ACS 106

ACS ALS OR STEMI 106

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

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

Don't Forget the Bubbles

JULY 5, 2023

Haemoglobin electrophoresis: To reach a definitive diagnosis, Hb electrophoresis is used. Opioids do not cause ACS but they can exacerbate hypoxia in patients with ACS. The treatment for ACS is mainly supportive: Oxygen : supplemental oxygen should be given only when the patient is hypoxic (saturation of oxygen < 94%).

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

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). Therefore, no definitive conclusions can be made about this trial. Therefore, no definitive conclusions can be made about this trial. 2022 Sep 7.

Emergency Department 52

Emergency Department ALS Critical Care ED 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.

E-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

FOAMfrat

OCTOBER 20, 2023

And according to a paper from Russotto et al. Of note, in the paper by Russotto et al., Likely due to different definitions for hypotension and adverse/major critical events, but the numbers remain higher than we would ever like — Kinda scary when you think about it. Sackles et al. What the hell are you to do?!

E-9-1-1 52

E-9-1-1 ALS ACS OR 52

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 86

STEMI ACS OR ALS 86

EMDocs

SEPTEMBER 24, 2024

Episode 107: Eclampsia Definition: Severe hypertensive disease of pregnancy (HDP) with new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a patient who is pregnant or postpartum and there’s no other causative etiologies. Wilkerson RG, Ogunbodede AC. Brewer J, Owens MY, Wallace K, et al.

ED 82

ED OR ACS ALS 82

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

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. Sensitivity of POCUS even for definite wall motion abnormalities is far from perfect. 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

JANUARY 6, 2023

Lupu L, et al. Smith comment: We have shown that use of opiates is associated with worse outcomes in ACS: Bracey, A. Opioids in ACS may reduce the pain score, but do not provide reperfusion for ongoing ACS. Unfortunately, they follow their own guidelines only 6% of the time!! mg/dL, K 3.5 OMI is not just an ECG diagnosis.

ACS 52

ACS Coronary ICU STEMI 52

AAEM RSA

APRIL 1, 2021

1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 Holcomb JB, Tilley BC, Baraniuk S, et al.

E-9-1-1 52

E-9-1-1 Plasma ACS ALS 52

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

Dr. Smith's ECG Blog

MAY 31, 2023

See this study showing an association between morphine and mortality in ACS: Use of Morphine in ACS is independently associated with mortality, at odds ratio of 1.4. de Winter et al in N Engl J Med 359:2071-2073, 2008. See this case: A man his 50s with chest pain.

STEMI 81

STEMI Coronary ACS OR 81

Dr. Smith's ECG Blog

MAY 8, 2023

The ACC likely made this new recommendation for the MSC in ventricular paced rhythm in large part due to the "PERFECT" Study (Meyers is an author, and Smith was the senior author): Dodd et al. Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STEMI 52

STEMI Coronary ED ACS 52

Don't Forget the Bubbles

JUNE 30, 2023

REBOA increased deaths due to bleeding at three hours and 90 days and substantially delayed time to definitive haemorrhage control. REBOA increased deaths due to bleeding at three hours and 90 days and substantially delayed time to definitive haemorrhage control. Laan DV, Vu TD, Thiels CA et al. c) Or, do both? Emerg Med J.

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

Dr. Smith's ECG Blog

MARCH 6, 2019

She did not receive any opioids (which would mask her pain without affecting any underlying ACS). Lead I has a definitively hyperacute T-wave without STE. Patel et al., Krucoff et al.) Patel et al. Krucoff et al. Schomig et al. What will you do for this asymptomatic patient??? Heart 1996.

STEMI 52

STEMI ALS ACS OR 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Although this is considered a "STEMI equivalent" and the ACC/AHA guidelines even approve of thrombolytics for ACS with this ECG, the usual criteria used to alert the cath lab team of an inbound Code STEMI are not met by this ECG. 6,7 Surgical repair of AS, by either TAVR or SAVR, is the definitive treatment for this condition.

Coronary 52

Coronary ACS ALS STEMI 52

EMDocs

SEPTEMBER 25, 2023

Also known as Facilitated intubation (FI), the use of intubating with only a sedative was an accepted alternative intubation technique prior to those definitive studies in the late 1990s but quickly was abandoned for RSI in all emergent endotracheal intubations (ETI) (8,9). References: Heffner AC et al. Prehosp Emerg Care.

ED 65

ED Emergency Department ALS Paramedic 65

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

3) RV Failure leads to hypotension but NOT pulmonary edema (unlike LV failure) 4) Repeat ECGs, right sided ECG and bedside echo may be helpful in making a diagnosis of ACS. Lead aVL is definitely not normal. Smith's book : Learning points: 1) OMI can be very subtle and RV infarction may manifest poorly on the standard ECG.

STEMI 95

STEMI OR ACS ALS 95

Dr. Smith's ECG Blog

DECEMBER 6, 2022

S yncope is an uncommon presentation of ACS, but anginal equivalents are more likely in older patients with diabetes 2. The highest risk group are patients with a cardiac cause of their syncope, in whom 1-year mortality can reach 33% ( Koene et al: J Arrhythm 33(6):533-544, 2017 ). Take home 1.

STEMI 52

STEMI ACS Coronary OR 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

OCTOBER 3, 2018

Khan AR, Golwala H, Tripathi A, et al. Methods : The PERFECT study (#NCT02765477) is a retrospective, 16 center, international investigation of ED patients from 1/2008 - 12/2016 with VPR on the ECG and symptoms of acute coronary syndrome (ACS). Acute myocardial infarction (AMI) was defined by the Third Universal Definition of AMI.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Findings: - Sinus tachycardia - Poor R wave progression - STD in leads V3 and V4 - there is almost an appearance of STE in V6, but it is not definite - there is also slight STE in aVL with slight reciprocal STD in inferior leads Impression: Diagnostic of posterior OMI [and the subtle lateral involvement (aVL) supports this] until proven otherwise.

STEMI 52

STEMI ACS OR Coronary 52

Dr. Smith's ECG Blog

JULY 11, 2019

B OTTOM L ine : While ECG #1 does not satisfy the definition of a STEMI — as per Dr. Meyers, it really looks like a cute L AD O MI. CLICK HERE — for a brief article by Rowlands et al that explains these concepts in more detail.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

The emergency physician wasn’t sure what to make of the changes from one ECG to the next but was concerned about ACS. Rosner et al. It definitely occurs — and all emergency providers who have practiced for any length of time have seen a series of patients with WPW on ECG. Here’s the third ECG, 30 minutes after the second.

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

FEBRUARY 14, 2020

This pattern in isolation would signify diffuse supply/demand mismatch without focal complete occlusion, which would be a very large differential of anything causing severe global supply demand mismatch, including ACS and various other processes. However, there is STE in V1 with a large area T-wave which is hyperacute.

STEMI 52

STEMI ACS OR ED 52