Dr. Smith's ECG Blog

JUNE 5, 2024

The ECG does not show any definite signs of ischemia. The patient presented due to chest pain that was typical in nature, retrosternal and radiating to the left arm and neck. He denied any exertional chest pain. The below ECG was recorded. It is unclear if the patient was pain free at this time.

Coronary 106

Coronary ACS ALS OR 106

FOAMcast

OCTOBER 17, 2023

Apple Podcasts , Spotify , Listen Here Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive way of providing resuscitative aortic occlusion in severe hemorrhage to gain temporary hemorrhage control as a bridge to definitive procedures. ” As a result, Jansen et al.

ACS 52

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! Over the years — various definitions have been proposed for what should constitute a " significant " Q wave , based on width and/or depth of the Q wave. So this study is actually worthless.

STEMI 101

STEMI Coronary ACS ED 101

Dr. Smith's ECG Blog

DECEMBER 27, 2023

In an attempt to clarify language, a consensus definition was developed. The definition requires the following three components: An end QRS notch (sometimes called a J wave) or slur, in the case of a slur it must lie entirely above the isoelectric baseline The peak amplitude of the notch or slur should be ≥ 0.1 ECG 2 What do you think?

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

EMS 12-Lead

JULY 24, 2023

Category 1 : Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates. Smith : This is ACS even if the troponin returns normal, and the first troponin especially might return normal. It is accelerated angina, which is by definition not stable.

Coronary 130

Coronary ACS CAD ED 130

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Because the most severe LAD OMIs can cause ischemic failure of the RBB and LAF, any patient with ACS symptoms and new RBBB and LAFB with any concordant STE has LAD OMI until proven otherwise. Post cath EF was estimated at 15% with severe global hypokinesis, and akinesis of the apex. Long term outcome is unavailable.

STEMI 116

STEMI EMS ACS ED 116

Dr. Smith's ECG Blog

JUNE 15, 2023

Thus, this does NOT meet STEMI criteria (though, as of 2022, it is a formal "STEMI equivalent", assuming everyone agrees that this is de Winter morphology, for which there is currently no objective definition). Everywhere I'm aware of (only about 5 systems), the ECGs are not even recorded in the "STEMI database." What a farce.

STEMI 93

STEMI Coronary ACS OR 93

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. In my opinion, I think it looks more like subendocardial ischemia.

ACS 82

ACS Coronary ALS CAD 82

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. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. References: 1.

Coronary 101

Coronary E-9-1-1 STEMI ACS 101

Dr. Smith's ECG Blog

MARCH 26, 2024

Moreover, what I call "domed" T-wave inversion in V1-V3 is typical for acute PE and NOT typical of ACS (i.e., Moreover, T-wave inversion in V1-V3 due to ACS is typically seen in reperfusion states when the patient is symptom free. Wellens'), presumably because the source of the T-wave inversion is RV strain, not LV ischemia.

ACS 68

ACS OR 68

Emergency Medicine Ireland

JUNE 21, 2021

This week we’re looking at the other ACS, the surgical ACS, the old abdominal compartment syndrome. This week we’re looking at the other ACS, the surgical ACS, the old abdominal compartment syndrome. These are all very nice and should all be reflected upon and followed when appropriate in your ACS.

Critical Care 52

Critical Care ACS OR 52

Dr. Smith's ECG Blog

MARCH 1, 2023

This pattern occurs regardless of whether the cause is ACS (decreased supply) or any other cause of decreased supply or increased demand. You must understand that this pattern does not differentiate ACS from other causes of supply/demand mismatch. Figure-1: The initial ECG in today's case. (

Allergic Reaction 52

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

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. Link to abstract Link to full text 2) Use of Morphine in Non-STE-ACS is independently associated with mortality, at odds ratio of 1.4

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

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

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. PMID: 23102885 Aykan AC et al. Because the lungs receive 100% of cardiac output, it has been hypothesized that a lower dose of thrombolytic therapy may still be effective with a better safety profile [3][4]. Clin Exp Emerg Med 2023. JACC Cardiovasc Interv 2018.

ALS 137

ALS ACS OR CPR 137

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. Although tiny in size — the BLUE arrows highlight definite ST elevation in leads I and aVL. In fact, use of antidyrhythimcs (e.g., Leave it alone.

STEMI 84

STEMI Coronary Heart Attack ACS 84

REBEL EM

NOVEMBER 6, 2024

PMID: 32644703 Robinson PM, Griffiths E, Watts AC. PMID: 27227986 Glover NM, Black AC, Murphy PB. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Simple elbow dislocation. Shoulder Elbow. 2017 Jul;9(3):195-204. PMID: 28588660 Donohue KW, Mehlhoff TL. Chronic Elbow Dislocation: Evaluation and Management. J Am Acad Orthop Surg.

E-9-1-1 59

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

ACEP Now

MAY 9, 2024

The diagnostic error was therefore classified as relating to the delays associated with testing and its effect on subsequent definitive management. Therefore, it may be reasonable to consider the profuse rate of diagnostic error comprising the current state of clinical practice directly informs the legal definition of the “standard of care.”

Emergency Department 52

Emergency Department ICU ALS ACS 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. 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. Kosuge et al.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. Suppose the OMI had been recognized, or suppose another ECG had been recorded and it showed definite OMI. The 3rd inferior lead ( = lead II ) — shows definite ST-T wave flattening. In aVF it is "coved" (upwardly convex).

Defibrillator 130

Defibrillator Coronary STEMI CPR 130

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

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. 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. Most studies examine undifferentiated ACS cohorts, with only a handful providing separate data. Do not let your consultants diagnose takotsubo when it is clearly OMI.

Emergency Department 52

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

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Definition: Technically, for the tracing in ECG #1 to truly “qualify” as Wellens’ Syndrome — there should be no CP at the time the ECG is recorded. However, in the chest leads — there has definitely been evolution , in that ST segments are more coved and slightly more elevated in virtually all chest leads.

ACS 101

ACS ED STEMI OR 101

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. He is the founder and host of Emergency Medicine Cases podcast and website.

E-9-1-1 52

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

Dr. Smith's ECG Blog

MARCH 13, 2023

This is acute ACS, but it almost always seen in a pain free state. So this ECG was immediately recorded: Indeed, as predicted, a patient with previous Wellens' waves who now definitely has chest pain has acute Occlusion, with new ST elevation in I, aVL, V2-V5. An ED ECG, if recorded with pain, should show LAD OMI.

ED 52

ED ACS Coronary Paramedic 52

Don't Forget the Bubbles

JULY 22, 2024

This is a broad definition of “pre-school” wheeze , and whilst this addresses a large population, the aforementioned concerns of including children under two prevail. Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, et al. Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, et al.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

JANUARY 9, 2024

However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? If the patient is hemodynamically stable, iv amiodarone could be considered in such a clinical situation. Is this: 1.

Coronary 98

Coronary ACS ED OR 98

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

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. 2022;226(2S):S1237-S1253.

ED 82

ED OR ACS ALS 82

Dr. Smith's ECG Blog

JANUARY 6, 2023

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. It was difficult to tell if the nitroglycerin was helping, but 1mg Dilaudid did resolve or nearly resolve the pain.

ACS 52

ACS Coronary ICU STEMI 52

Dr. Smith's ECG Blog

APRIL 9, 2023

Only if you are uncertain about the diagnosis of ACS. The interventional cardiologist was not initially convinced this was ACS and recommended CT pulmonary angiography to rule out pulmonary embolism. The culprit lesion with the ECGs above make me almost certain that this case meets the conceptual definition of OMI. =

ACS 52

ACS ED OR EMS 52

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

The ECG was transmitted to the Emergency Medicine physician who recognized inferior and posterior OMI findings, and confirmed that the patient has potential ACS symptoms. The T waves in V5-6 are likely also hyperacute. The cath lab was activated despite lack of STEMI criteria, around 2 am in the morning.

STEMI 81

STEMI OR ED EMS 81

Dr. Smith's ECG Blog

APRIL 9, 2024

ACS then becomes less likely. BOTTOM Line: There clearly is enough on this initial ECG to support Dr. Nossen's concern that a definitive diagnosis needed to be made on this young man with new, persistent chest pain. On arrival patient was slightly tachycardic. HR about 90-100/min. Other vital signs normal. at ~100/minute ).

Coronary 91

Coronary CAD ACS OR 91

The Curious Clinicians

JANUARY 31, 2024

If you like the types of questions we answer on The Curious Clinicians, you’ll definitely want to check that out and subscribe. Listen to the episode [link] Credits & Citatio n Episode written by Avi Cooper Show notes written by Giancarlo Buonomo and Avi Cooper Audio edited by Clair Morgan of nodderly.com Cooper AZ, Breu AC, Abrams HR.

ACS 111

ACS OR 111

Dr. Smith's ECG Blog

MARCH 13, 2024

The patient has ACS by history, active pain, and an elevated troponin. By definition , this is acute myocardial infarction, the only question now is the etiology. It is impossible to overstate the importance of putting the ECG and troponin into the context of the clinical history. Smith : at this point, the ECG becomes irrelevant.

Coronary 85

Coronary ACS Emergency Management Emergency Manager 85