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

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 86

STEMI EMS ACS ED 86

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 104

STEMI Coronary ACS ED 104

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

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 72

ACS OR 72

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 92

STEMI Coronary ACS OR 92

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 87

ACS Coronary ALS CAD 87

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 103

Coronary E-9-1-1 STEMI ACS 103

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 82

E-9-1-1 ACS STEMI Coronary 82

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 88

STEMI Coronary Heart Attack ACS 88

Dr. Smith's ECG Blog

AUGUST 10, 2023

So now there was ACS + electrical instability, another indication for emergent angiogram. El-Baba, Austin and McLaren — provides yet another superb example of how " clinical interpretation" of today's initial tracing indicates definite need for prompt cath despite not satisfying STEMI criteria. Shroff, G. & Smith, S.

STEMI 89

STEMI ACS Emergency Department ED 89

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

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 133

Defibrillator Coronary STEMI CPR 133

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 109

ACS ALS OR STEMI 109

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 104

ACS ED STEMI OR 104

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

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-9-1-1 122

E-9-1-1 Coronary ACS BLS 122

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 85

STEMI ACS OR ALS 85

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

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 93

Coronary CAD ACS OR 93

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 89

Coronary ACS Emergency Management Emergency Manager 89

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Despite the seemingly worrisome ST-T wave changes on serial tracings shown in Figure-1 — an acute event was definitively ruled out by 4 consecutive negative hs troponins — with further support provided by an Echo showing excellent LV function without wall motion abnormality. So they looked into the patient's chart. Some patients do this.

E-9-1-1 110

E-9-1-1 Coronary EMS ED 110

Dr. Smith's ECG Blog

JUNE 27, 2021

If it is maximal in V1-V4, and the patient's presentation in consistent with ACS (as this certainly is), then it is DIAGNOSTIC of Occlusion with 90% specificity (We have an upcoming article that proves this). Angiogram: "ACS - Non ST Elevation Myocardial Infarction. STEMI was defined by the 4th universal definition of MI.

STEMI 52

STEMI ACS Coronary ED 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 ALS 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. See this case: A man his 50s with chest pain. What happens when you treat with morphine rather than with reperfusion?

STEMI 79

STEMI Coronary ACS OR 79

Dr. Smith's ECG Blog

APRIL 4, 2023

Most importantly , while waiting for the paradigm to evolve, maintain focus on our true goal for our patients with ACS: to identify and reperfuse patients with acute occlusion MI.” Follow up your patient's cath results to learn which were false-positives or missed occlusions. That’s exactly what happened in this case.

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

This case fits this definition of cardiac memory. == MY Comment , by K EN G RAUER, MD ( 11/9 /2023 ): == I found Dr. Smith's presentation of today's case highly insightful for the changes in ST-T wave appearance that may sometimes be seen, depending on whether or not LBBB ( L eft B undle B ranch B lock ) is present.

E-9-1-1 82

E-9-1-1 ACS ALS OR 82

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

There is definite reperfusion. There was definite evolution of the ECG. Another ECG was recorded at 120 minutes, S-wave reconstituted T-wave and STE are normalizing. The S-wave is reconstituted. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." The ECG is VERY specific for OMI.

Overdose 52

Overdose OR Coronary ACS 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

MAY 8, 2023

10 In 2018, the European Society of Cardiology guidelines 11 and the fourth universal definition of myocardial infarction 12 suggested utilizing the original Sgarbossa criteria (Figures 1A to 1C) for diagnosis of occlusion myocardial infarction in both left bundle branch block 13 , 14 and ventricular paced rhythm.15,

STEMI 52

STEMI Coronary ED ACS 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

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 99

STEMI OR ACS ALS 99

Dr. Smith's ECG Blog

OCTOBER 24, 2013

Therefore, even with a normal or non-diagnostic ECG, a 50 year old male patient should undergo serial ECGs and troponins and be admitted to a monitored bed until MI or ACS can be ruled out. There is no way to tell the difference between GI etiology of chest pain and MI. This is obviously a very big topic in itself.

CPR 52

CPR ACS Coronary OR 52

Dr. Smith's ECG Blog

MAY 3, 2024

RBBB + LAFB in the setting of ACS is very bad. Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Patients with ACS and RBBB/LAFB usually have a left main vs. proximal LAD. Learning Points: 1.

ACS 117

ACS ED Coronary EMS 117

Dr. Smith's ECG Blog

APRIL 26, 2017

I remained unconvinced that this was due to ACS. With the added history, and the entirety of the presentation, it was determined by cardiology that the clinical presentation was not due to ACS. When a heart with LVH is under stress, the ST segments may rise and become convex. When the stress is relieved, it resolves.

STEMI 52

STEMI ACS ED Coronary 52