EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. It’s judicious, then, to arrange for coronary angiogram.

Coronary 130

Coronary ACS CAD ED 130

The Skeptics' Guide to EM

JANUARY 18, 2020

Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Reference: Wang et al.

ACS 130

ACS Coronary Emergency Department OR 130

EMS 12-Lead

JUNE 20, 2022

Although the attending crews did not consider the ECG pathognomonic for occlusive thrombosis, they nonetheless considered the patient high-risk for ACS and implored him to reconsider. One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. They too have dense white masses consistent with coronary atherosclerosis. Edited by Smith He also sent me this great case.

CAD 126

CAD STEMI Coronary ACS 126

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP). She arrives in the emergency department (ED) with decreased level of consciousness and shock.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

MARCH 13, 2023

This is acute ACS, but it almost always seen in a pain free state. An ED ECG, if recorded with pain, should show LAD OMI. That said — severe chest pain was present at the time the patient arrived in the ED ( corresponding to the time ECG #2 was recorded ).

ED 52

ED ACS Coronary Paramedic 52

EMS 12-Lead

JULY 30, 2023

David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath. She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease. This should prompt immediate investigation into supply-demand mismatching, or ACS.

EMT 130

EMT EMT ACS Coronary 130

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. In fact, Kosuge et al. Kosuge et al.

E-9-1-1 139

E-9-1-1 ACS Emergency Department ALS 139

Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. For the same reason, you should not delay coronary angiography because pain resolves with morphine. But pain is a critical signal for urgency in the context of acute coronary syndrome. Mukherjee, D.,

E-9-1-1 125

E-9-1-1 ACS Coronary STEMI 125

Dr. Smith's ECG Blog

APRIL 2, 2024

He was unidentified and there were no records available After 7 shocks, he was successfully defibrillated and brought to the ED. Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. Here is the initial ED ECG. So a dual chamber pacer is placed with one lead through the coronary sinus to the LV.

Defibrillator 131

Defibrillator Coronary Epinephrine CPR 131

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. ECG's are difficult. 2] Costanzo, L.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

MARCH 1, 2023

Sent by anonymous, written by Pendell Meyers A man in his late 40s presented to the ED with concern for allergic reaction after accidentally eating a potential allergen, then developing an itchy full body rash and diarrhea. In the ED he received methylprednisolone, diphenhydramine, and epinephrine for possible anaphylaxis.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 52

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. Anything more on history?

Coronary 52

Coronary ACS STEMI ALS 52

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. He survives.

ACS 85

ACS ALS ED OR 85

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 76

STEMI Coronary Paramedic EMS 76

EMS 12-Lead

JUNE 1, 2022

He advises, however, recurrent syncopal episodes for the past six months, some of which have resulted in ED admission, yet no identifying mechanism could be determined. 3,4] The final 12 Lead ECG does not meet any Smith-modified Sgarbossa criteria, so the T wave signatures are characteristic of improved coronary flow, but not necessarily MI.

Coronary 130

Coronary ALS Firefighter OR 130

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! 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 this study is actually worthless.

STEMI 104

STEMI Coronary ACS ED 104

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram.

Coronary 130

Coronary ALS OR ACS 130

EMDocs

JANUARY 8, 2024

This post will focus on the key parts of the guideline that affect ED evaluation and management. Editorial Comment: ECPR may be considered in patients refractory to standard ACS in the right situation. Major Updates Avoid routine use of calcium in patients with cardiac arrest. COR 2a, LOE B-R. COR 1, LOE B-NR. COR 2a, LOE B-NR.

Epinephrine 82

Epinephrine Defibrillator Coronary CPR 82

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 122

E-9-1-1 Coronary ACS BLS 122

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. paramedic transportation to the ED as “chest pain, STEMI negative” 2. Take home 1. Eur Heart J 2019 5.

STEMI 62

STEMI Coronary Paramedic ALS 62

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative.

E-9-1-1 82

E-9-1-1 ACS STEMI Coronary 82

ACEP Now

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. 2,3,5 Except for laundry or electrical car outlets (240 V AC), all U.S. household outlets are rated at 120 V AC. 2023 Jul 17.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

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. In our opinion it should not be given in ACS unless you are committed to the cath lab. 2009;95:1701–1706. Morris N, Body R.

ACS 87

ACS Coronary ALS CAD 87

ALiEM

FEBRUARY 9, 2024

Encourage your ED to set up an algorithm that you can follow based on your laboratory’s assay. Low-risk patients do not routinely require stress testing in the ED. You (or someone in your department) needs to know which assay your ED has, and use the appropriate values for that assay. Otherwise, apply a simplified approach.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

Dr. Smith's ECG Blog

JULY 27, 2023

On arrival to the ED, the patient was diaphoretic, tachycardic. I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? I was not worried for a coronary etiology. He had a prehospital ECG that was worrisome to the medics, so they called me to see him at the door. and had dilated pupils.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. It is unknown when this pain recurred and became constant.

Defibrillator 133

Defibrillator Coronary STEMI CPR 133

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? No wall motion abnormality This shows that significant ACS can have ZERO WMA!! A 70-something y.o. male presents to triage with shortness of breath.

STEMI 115

STEMI ACS Critical Care OR 115

EMS 12-Lead

APRIL 8, 2022

1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. Cardiology admitted him for observation with plans for next-day coronary angiogram. However, in this context (i.e. V2 – in the final EMS ECG the ST segment was baseline. 1] Driver, B.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. I cannot be anything else.

STEMI 52

STEMI Coronary ED ACS 52

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 94

Coronary ED ACS OR 94

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. Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main."

Coronary 52

Coronary ACS EMS 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

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. Some patients do this.

E-9-1-1 110

E-9-1-1 Coronary EMS ED 110

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

Now, it is true that shortly after a non-ACS cardiac arrest, there can be transient diffuse ST depression, but not ST elevation in a coronary distribution, and there should not be a wall motion abnormality. There was faint filling of the distal branches of the RCA by collaterals from the left coronary system.

Coronary 52

Coronary STEMI ACS ED 52

Dr. Smith's ECG Blog

JUNE 27, 2021

They gave him 2 nitroglycerine and transported to the ED. In the ED, the patient was "moaning, writhing in bed, and clutching his chest." Here is the first ED ECG (there was no previous ECG on file for comparison): Sinus rhythm and LVH There is some (less than 1 mm) of STD in V3 and V4. There is no significant ST Elevation.

STEMI 52

STEMI ACS Coronary ED 52

Dr. Smith's ECG Blog

JULY 31, 2018

Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. Next day, t he patient was taken for an angiogram and found to have a reperfused LAD lesion with good flow that appeared to the angiographer as if it was a spontaneous coronary artery dissection.

Coronary 52

Coronary ACS STEMI OR 52