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. He was diagnosed as NSTEMI.

ACS 82

ACS Coronary ALS CAD 82

REBEL EM

SEPTEMBER 11, 2023

ACS surgeons appeared to select surgery as their initial choice substantially more frequently than other subspecialties. ACS surgeons would have sent 6/43 patients for ERCP or MRCP (14%), whereas surgical oncologists would have sent a higher percentage of patients for ERCP or MRCP (7/18 or 38.9%).

ED 68

ED ACS Emergency Department OR 68

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. 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.

Coronary 52

Coronary ACS EMS ALS 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

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Do not let your consultants diagnose takotsubo when it is clearly OMI.

Emergency Department 52

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

REBEL EM

FEBRUARY 2, 2023

This could have biased the results in favor of amiodarone as we’ve covered this before on REBEL EM before The IV amiodarone group required less additional HR control agents to control increased heart rate. Sepsis, hyperthyroidism, dehydration, heart failure, ACS, etc).

Emergency Department 52

Emergency Department ALS Critical Care ED 52

Dr. Smith's ECG Blog

APRIL 9, 2023

Only if you are uncertain about the diagnosis of ACS. The EM physicians activated their "heart alert" pathway, which immediately summons the cardiology fellow to bedside to evaluate for potential emergent cardiac catheterization lab activation. Bedside POCUS revealed inferior wall motion abnormality (images not available).

ACS 52

ACS ED OR EMS 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. En route, EMS administered aspirin 325mg by mouth, but withheld nitroglycerin due to initial hypotension. Answer below in the still shot.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

AUGUST 15, 2019

He had multiple cardiovascular risk factors and the EM physician strongly suspected ACS. A millimeter definition of acute STEMI should not be needed to justify the need for prompt cardiac catheterization. Written by Pendell Meyers A male in his early 50s presented with waxing and waning chest pain starting at rest.

STEMI 52

STEMI ACS OR EMS 52

Dr. Smith's ECG Blog

DECEMBER 16, 2019

The provider, and former HCMC EM resident, was exceedingly perceptive and able to accurately diagnose LAD occlusion from this very subtle ECG. If a patient has symptoms of ACS, and they are persistent, and a diagnostic troponin, then cath lab activation is indicated. Often this would include resolution of the LBBB.

ED 52

ED ACS OR ALS 52

Dr. Smith's ECG Blog

DECEMBER 15, 2023

The patient contacted EMS after a few hours of chest pain that started 5:30 AM. There is slight but definite ST elevation with an inverted T wave in lead aVL. Learning Points : Serial ECG are very valuable when it comes to identifying a dynamic process such as ACS. He is otherwise healthy. The ECG is live fed to our institution.

ACS 60

ACS STEMI Coronary EMS 60

REBEL EM

MARCH 2, 2023

REBEL Cast Ep114 – High Flow O2, Suspected ACS, and Mortality? PMID: 33653685 Clinical Question: Is there an association between high flow supplementary oxygen and 30-day mortality in patients presenting with a suspected acute coronary syndrome (ACS)? Click here for Direct Download of the Podcast Paper: Stewart, RAH et al.

ACS 52

ACS Coronary STEMI Ambulance 52

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Written by Pendell Meyers A man in his 40s called EMS for acute chest pain that awoke him from sleep, along with nausea and shortness of breath. 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.

STEMI 121

STEMI EMS ACS ED 121

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 126

ACS ED Coronary EMS 126

Dr. Smith's ECG Blog

AUGUST 9, 2024

About 2 hours later the patient arrived at a PCI-capable center and repeat ECG was obtained: The transferring EMS crew noted “runs of VT” during transport. 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.

STEMI 107

STEMI Coronary Heart Attack ACS 107

REBEL EM

JANUARY 29, 2024

Click here for Direct Download of the Podcast Paper: Aykan AC et al. PMID: 23102885 Aykan AC et al. appeared first on REBEL EM - Emergency Medicine Blog. 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].

ALS 136

ALS ACS OR CPR 136

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. We don’t want to go backwards!

ED 94

ED Emergency Department ALS Paramedic 94

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. c) Or, do both? 2014 Sep;45(9):1287-95. Trauma Surg Acute Care Open.

E-9-1-1 139

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

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. Bourke Tillmann and Scott Weingart for their expertise on the EM Cases podcast that inspired this column. 2021;42(1):145-159.

E-9-1-1 52

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

Don't Forget the Bubbles

MAY 3, 2023

Garabon JJW, Gunz AC, Ali A, Lim R. EMS Use and Success Rates of Intraosseous Infusion for Pediatric Resuscitations: A Large Regional Health System Experience. Based on this study, further prospective research with more stringent outcome definitions may help to expand and clarify (e.g. Prehosp Emerg Care. 2023;27(2):221-226.

CPR 52

CPR Emergency Department ALS ICU 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

One must always be careful when looking for "baseline" ECGs, because the prior ECG on file may have been during another ACS event, as this one clearly was. The EM physicians at the outside hospital appropriately activated the cath lab transfer protocol but that order was subsequently negated by others.

STEMI 52

STEMI Coronary ACS Defibrillator 52

FOAMfrat

OCTOBER 20, 2023

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. Dr. Jarvis of The EMS Lighthouse Project podcast also covers this paper in detail here: [link] ^^^ I highly recommend listening! Is there a targeted SI?

E-9-1-1 52

E-9-1-1 ALS ACS OR 52

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. J of National Association of EMS Physicians 2014. She was asymptomatic at the time of this ECG recorded on arrival to our ED: What do you think? II, III, aVF, and V6 have STD.

STEMI 52

STEMI ALS ACS ICU 52

EMDocs

OCTOBER 7, 2023

We’ll keep it short, while you keep that EM brain sharp. A 17-year-old girl, in moderate distress, is brought in by EMS after a motor vehicle collision. EMS reports that she was “pinned” underneath the dashboard, and it took several hours to extricate her. Goodman AD, Got CJ, Weiss AC. J Emerg Med. 2014;46(2):313-319.

EMS 98

EMS E-9-1-1 Emergency Department ALS 98

EMDocs

JANUARY 6, 2024

Authors: Christian Gerhart, MD (EM Resident Physician, Washington University School of Medicine, St. Louis, MO); Jessica Pelletier, DO (EM Education Fellow, Washington University School of Medicine, St. We’ll keep it short, while you keep that EM brain sharp. A 64-year-old male presents by EMS to the ED with shortness of breath.

EMS 92

EMS E-9-1-1 ACS Coronary 92

EMDocs

FEBRUARY 12, 2024

Authors: Rachel Kelly, MD ( EM Resident Physician, Stony Brook University Hospital); Robert Nocito, MD (EM Attending Physician, Stony Brook University Hospital) // Reviewed by: Jessica Pelletier, DO (EM Education Fellow, Washington University in St. 11) Webb RK, Ralston AC, Runciman WB. proning patients, ECMO) (12).

Emergency Department 98

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

Dr. Smith's ECG Blog

APRIL 8, 2015

Approach to Syncope Syncope definition: Brief loss of consciousness with loss of postural tone and complete spontaneous recovery without medical intervention. This San Fran definition, however, is too non-specific , so I list more specific ECG abnormalities below: b. It is NOT a structured review or meta-analysis. Quinn et al.

Emergency Department 52

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

Core EM

NOVEMBER 30, 2024

The Case An 88-year-old woman with a history of dementia, major depressive disorder, and hyperlipidemia presented to the ED via EMS after a near syncopal episode. ECG approach to takotsubo syndrome: ECG cases: EM cases. She was weaned off of pressors and discharged four days after presentation to the ED with close cardiology follow up.

Coronary 130

Coronary STEMI MICU ACS 130

Dr. Smith's ECG Blog

MARCH 23, 2025

Written by Pendell Meyers, sent by anonymous, with additions by Smith A man in his 40s had acute chest pain and called EMS. EMS arrived and recorded this ECG: What do you think? Here is the PMcardio Queen of Hearts interpretation of the ECG: STEMI equivalent detected. Inferior and posterior OMI without STEMI criteria.

STEMI 82

STEMI ACS Coronary EMS 82

Dr. Smith's ECG Blog

APRIL 13, 2025

Despite the poor resolution of the 2 EMS ECGs the diagnosis of acute RCA OMI is immediately established by these EMS ECGs until proven otherwise. The Unmistakeable Conclusion: By the definition I suggested above today's patient manifests MINOCA. The cardiac cath was "normal".

Coronary 84

Coronary STEMI EMS ALS 84

Dr. Smith's ECG Blog

DECEMBER 3, 2024

This was written by one of our fine residents, who will soon be an EMS fellow: Michael Perlmutter Case A mid-50s male came to the ED with a burning sensation that was acutely worse while at home. This dynamic change is diagnostic of ACS. This was also non-diagnostic for OMI, although the dynamic changes are diagnostic of ACS.

ED 110

ED Coronary ACS STEMI 110

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

EMS arrived and recorded this ECG: What do you think? 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. Figure-1: Comparison between the initial EMS ECG and the repeat ECG in the ED.

STEMI 81

STEMI OR ED EMS 81

REBEL EM

FEBRUARY 3, 2025

In the validation dataset, some cases lacked coronary angiography and relied on less definitive methods like CT or echo, adding variability and reducing the reliability of training and validation processes. Furthermore, the model was not trained on all comers in the emergency department, many of whom do not have ACS.

STEMI 84

STEMI Coronary Emergency Department ALS 84

EMDocs

NOVEMBER 25, 2024

link] Differential Diagnosis Dermatologic manifestations Hypersensitivity reaction Food allergy Filariasis Ocular manifestations Loa loa infection Vitamin A deficiency Diagnosis The diagnosis of onchocerciasis typically requires tissue biopsy; thus, it is unlikely that the definitive diagnosis will be made in the emergency department.

E-9-1-1 75

E-9-1-1 ALS Emergency Department OR 75

EMDocs

JANUARY 6, 2025

link] Hummell AC, Cummings M. Cholera Case Definitions and Diagnosis.; Accessed October 5, 2024. link] Centers for Disease Control and Prevention (U.S.). History and Physical: Refugee Health Domestic Guidance.; Accessed October 5, 2024. Nutr Clin Pract Off Publ Am Soc Parenter Enter Nutr. 2022;37(1):41-49. doi:10.1002/ncp.10797

ED 75

ED E-9-1-1 ALS Emergency Department 75