Dr. Smith's ECG Blog

AUGUST 9, 2024

Learning points: Both patients and other medical providers can report confusing and often contradictory information that obfuscates the diagnosis (in this case, WPW). Although recognition of OMI was not affected by administration of morphine in this case, use caution with analgesia in ongoing ACS without a definitive plan for angiography.

STEMI 107

STEMI Coronary Heart Attack ACS 107

Dr. Smith's ECG Blog

MARCH 19, 2024

He sent it to me with no other information and I wrote back "100% diagnostic of LBBB with inferior-posterior-lateral OMI" There is atrial paced rhythm with Left Bundle Branch Block (LBBB). The cath report showed: Significant stenosis with subtotal occlusion (99%) in the prox to mid Lcx, culprit of ACS, TIMI flow 1. 2021;23:187.

CAD 111

CAD STEMI ACS ALS 111

EMDocs

AUGUST 31, 2023

2020.09.082 Full prescribing information. link] Full prescribing information. link] Li Z, Krippendorff BF, Sharma S, Walz AC, Lavé T, Shah DK. Unified Treatment Algorithm for the management of crotalid snakebite in the United States: results of an evidence-informed consensus workshop. Bush SP, Ruha AM, Seifert SA, et al.

Allergic Reaction 97

Allergic Reaction Plasma ALS EMS 97

Don't Forget the Bubbles

MAY 17, 2023

Antonaci L, et al. Tritos NA, et al. Levi M, et al. Fishbein MH, et al. Cetinkaya PG, et al. Niu T, et al. Verkuijl SJ, et al. Varni JW, et al. Dias FC, et al. Peter C, et al. Ahlberg R, et al. Shir A, et al. Kuypers KLAM, et al. Hegeman EM, et al.

ALS 72

ALS ACS Emergency Department EMS 72

Emergency Medicine Ireland

JULY 3, 2023

Hopefully in a few minutes you’ll at least have a few morsels more of information to stave off all the trainees who are undoubtedly much smarter than you on the ward round. Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. Today we tackle a somewhat nebulous syndrome. – Mullens, W.,

Critical Care 96

Critical Care ACS OR ALS 96

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

An ECG was texted to me (Smith) without any clinical information: What did I say? This clinical information followed: "The patient had a COPD exacerbation with a prehospital SpO2 of 60%. This clinical information followed: "The patient had a COPD exacerbation with a prehospital SpO2 of 60%. Kosuge et al. Witting et al.

E-9-1-1 52

E-9-1-1 ACS ALS OR 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 117

STEMI Coronary ACS ED 117

EMDocs

OCTOBER 21, 2023

The NIHSS cutoff that predicts outcomes is 4 points higher in AC compared with PC infarctions. While MRI is more resource and time intensive, studies have shown that a 6-minute protocol can give sufficient information to dictate treatment in the right setting. References: Gaillard F, Glick Y, Tatco V, et al. Arch Neurol.

EMS 98

EMS ALS OR ACS 98

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.

Coronary 52

Coronary ACS STEMI ALS 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

NOVEMBER 9, 2023

link] Shvilkin et al. 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.,

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

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

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

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). Paper: Mason JM, et al. These results were corroborated with other another study by Gritensko et al. Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc).

Emergency Department 52

Emergency Department ALS Critical Care ED 52

REBEL EM

JULY 14, 2022

Background Information: Multiple illness severity scores have been developed for use after out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). Unfortunately, these rely on information that is not immediately available to providers in the early hours following return of spontaneous circulation (ROSC).

ICU 52

ICU ALS OR CPR 52

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. greater than 40mS, V1-V2" Meyers interpretation: I was sent this ECG with no clinical information whatsoever, and I responded: "Easily diagnostic of acute LAD occlusion." His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." See text ).

OR 52

OR STEMI ACS Emergency Department 52

ACEP Now

FEBRUARY 11, 2024

Sodhi M, Rezaeianzadeh R, Kezouh A, et al. Ahmann AJ, Capehorn M, Charpentier G, et al. Contrave (naltrexone HCl/bupropion HCl) prescribing information. ACS chemical neuroscience molecule spotlight on Contrave. ACS Chem Neurosci. Bansal AB, Al Khalili Y. JAMA Health Forum. 2023;4(4):e230493. Steatorrhea.

Overdose 52

Overdose ACS Plasma ALS 52

Dr. Smith's ECG Blog

DECEMBER 12, 2022

Written by Pendell Meyers I was reading ECGs in a database (without any clinical information) when I came to this one: What do you think? You must understand this and the dynamic nature of ACS to provide excellent care for such patients. Seeing only this ECG with no context, I thought this ECG was within normal limits.

OR 52

OR ACS STEMI Coronary 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

EMDocs

JANUARY 11, 2024

Evaluate and treat seizures or SE after CA in the context of other available clinical information because other systemic factors may influence the occurrence of seizures or SE and the effectiveness of treatment (90%, 18/20). Reference: Hirsch KG, Abella BS, Amorim E, et al; American Heart Association, Neurocritical Care Society.

Critical Care 98

Critical Care E-9-1-1 OR ICU 98

Dr. Smith's ECG Blog

DECEMBER 6, 2022

I sent this "normal" ECG without any information to a number of ECG enthusiasts, who were all concerned about possible OMI - whether subtle high lateral OMI with inferior reciprocal change, or subtle inferior OMI with high lateral reciprocal change. Take home 1. C ircumflex occlusions can have subtle to no ECG changes 3.

STEMI 52

STEMI ACS Coronary OR 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

3–8 Shi et al. When the ECG is nondiagnostic for coronary occlusion, or the patient is suspected of having a non-occlusion MI, consider echocardiography to inform the decision for angiography. Sandoval Y, Smith SW, Sexter A, et al. Shi S, Qin M, Shen B, et al. Guo T, Fan Y, Chen M, et al. of Cardiology AC, Others.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JULY 11, 2019

Meyers : This ECG was texted to me with no clinical information, and my response was: "That looks like a very subtle LAD OMI. CLICK HERE — for a brief article by Rowlands et al that explains these concepts in more detail. Very very subtle one. What happened?"

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

I sent this to Dr. Meyers without any other information, and he responded, “do you have a prior to make sure that it is all just because of the delta wave? 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. What do you think? What do you think?

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

APRIL 20, 2018

However, this additional information was supportive. Patients like her are the reason we are advocating for a change in the ACS paradigm from STEMI to OMI. Armstrong et al attempted to study it but may have included too many 'obvious' cases - the criteria from that paper would certainly have missed this case.

Coronary 40

Coronary STEMI EMS ACS 40

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. The 4-variable formula is based on this paper: Driver, BE et al. Case 3 I was reading a stack of ECGs yesterday, and saw this one, with no clinical information.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

When I saw this without any other information, I said it was very suspicious for a high lateral MI. The clinicians later stated they had had no suspicion of ACS, but that the faculty wanted a troponin anyway. Sandoval Y et al. He had a triage ECG at time 0 (ECG-1): Computer read, with Physician overread: Sinus rhythm.

STEMI 52

STEMI Emergency Department ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2023

I assumed it was from a patient with symptoms compatible with ACS/OMI. If you are convinced by all the data, including the troponin, that the patient's pain is due to ACS, and he has persistent pain, then he should go to the cath lab. Wereski R, Chapman AR, Lee KK, Smith SW, Lowe DJ, Gray A, et al. What do you think?

ACS 122

ACS ALS STEMI OR 122

Dr. Smith's ECG Blog

JUNE 8, 2023

I sent the ECG to Dr. Meyers without any information, and he immediately replied, “inferior OMI.” As recurrent ischaemia is the principle event reduced by early intervention in NSTE-ACS, these are important endpoint events occurring with delayed angiography and there is a consistent signal for harm now from two data sources.”[5]

STEMI 86

STEMI Coronary Paramedic ALS 86

EMDocs

FEBRUARY 12, 2024

Supplementing information from VBGs Unlike pH, PCO 2 , and HCO 3 , there are no correlations or conversions that reliably determine oxygenation status from a VBG (1, 10). References/Further Reading (1) Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. 11) Webb RK, Ralston AC, Runciman WB. PMID: 11685301. (10)

Emergency Department 98

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

AAEM RSA

DECEMBER 3, 2020

32 Relying on easily and rapidly obtained information, these simple and low-cost tools may be particularly useful in low resource settings and in cases where time or severity of patient presentation does not permit additional workup. Fournier gangrene: an histori9]al reappraisal. Sugihara T, Yasunaga H, Horiguchi H, et al.

Emergency Department 52

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

Dr. Smith's ECG Blog

APRIL 8, 2015

Also consider non-hemorrhagic volume depletion, dehydration : orthostatic vitals may uncover this [see Mendu et al. (3)]. Annotated Bibliography For an excellent overview of ED Syncope management , see this article by Kessler C et al. Del Rosso A, et al. Other studies 1) EGSYS score (full text link). Heart 2008;94(12):1620–6.

Emergency Department 52

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

Don't Forget the Bubbles

OCTOBER 2, 2024

Use of CFTR modulators in pregnancy: new information for neonatal, paediatrics and midwifery teams. Pecenka C, et al. Winkler AE, et al. Bonifacio SL, et al. Brosnan B, et al. Panda PK, et al. Tangwijitsakul H, et al. Gunnarsdottir K, et al. Chong KH, et al. Blaabæk EH, et al.

ALS 52

ALS Emergency Department ED ACS 52

Don't Forget the Bubbles

JULY 5, 2023

Opioids do not cause ACS but they can exacerbate hypoxia in patients with ACS. Older children and adults usually present with ACS 2-3 days after hospitalisation due to pulmonary infarction (in situ sickling), hypoventilation due to rib infarction (which may be exacerbated by recent narcotic administration) or fat embolism.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

REBEL EM

DECEMBER 23, 2024

To assess the clinical impact and relevance of these concerns, Alwang et al. Paper: Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. PMID: 28423290 Kidwell K, Albo C, Pope M, et al. PMID: 24066745 Self WH, Semler MW, Wanderer JP, et al. PMID: 29485926 Semler MW, Self WH, Wanderer JP, et al. JAMA Intern Med.

ALS 129

ALS ED ACS EMR 129

ACEP Now

FEBRUARY 19, 2025

Although technology like electronic health records (EHRs) were initially introduced as tools for improving team communication and streamlining information sharing, they have instead often isolated ED teams, siloing clinicians, who are hunched over keyboards rather than communicating at the bedside. References Edmondson AC.

E-9-1-1 51

E-9-1-1 ALS ED Emergency Department 51

Dr. Smith's ECG Blog

MARCH 3, 2025

I suspect pulmonary edema, but we are not given information on presence of B-lines on bedside ultrasound, or CXR findings. This presentation clearly indicates more than simple ACS ( A cute C oronary S yndrome ). Or I suspect that there is OMI simultaneous with another pathology. We certainly know that there is hypoxia.

E-9-1-1 74

E-9-1-1 Coronary STEMI Emergency Department 74