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 116

STEMI ACS Critical Care OR 116

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

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. link] = My Comment by K EN G RAUER, MD ( 11/14 /2023 ): = One of the most helpful clinical clues in support that an acute cardiac event is ongoing — is the finding of " dynamic " ECG changes.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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

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. What do you think? Rhythm : Residents asked me why it is not VT. The QRS is extremely wide.

Defibrillator 132

Defibrillator Coronary Epinephrine CPR 132

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. Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). She contacted her neighbor, a nurse, for help.

E-9-1-1 125

E-9-1-1 ACS Coronary STEMI 125

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. vs. 2.9%; P  = 0.28) in the delayed group.

STEMI 63

STEMI Coronary Paramedic ALS 63

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin.

CAD 52

CAD ACS STEMI Coronary 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! Figure-1: I've labeled the initial ECG in the ED. KEY Point: All patients who present to the ED for new CP should promptly have a triage ECG recorded, that is then immediately interpreted by the ED physician.

STEMI 105

STEMI Coronary ACS ED 105

Dr. Smith's ECG Blog

APRIL 9, 2023

Submitted by Ali Khan MD and James Mantas MD, MS, written by Pendell Meyers A man in his 50s with history of diabetes, hypertension, and tobacco use presented to the ED with 24 hours of worsening left sided chest pain radiating to the back, characterized as squeezing and pinching, associated with shortness of breath.

ACS 52

ACS ED OR EMS 52

EMDocs

JUNE 27, 2024

An 8-year old male with a history of sickle cell anemia presents to the ED for evaluation of fever for 2 days and “feeling like I can’t get a full breath”. 768: Epidemiology of Hospital Based ED Visits due to Sickle Cell Crisis and Acute Chest Syndrome in Kids. Chinawa JM, Ubesie AC, Chukwu BF, Ikefuna AN, Emodi IJ. C or 100.4

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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. Unfortunately — 1.5

ACS 87

ACS Coronary ALS CAD 87

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

male presents to the ED at 6:45 AM with left sided chest dull pressure that woke him up from sleep at 3am. He arrived to the ED at around 6:45am, and stated the pain has persisted. Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. The pain radiated to both shoulders.

Coronary 80

Coronary ACS OR EMR 80

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. This is not the case.

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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? Under most circumstances — this combination of ECG findings would point to an acute event. and had dilated pupils. He was alert and oriented. both here and here ).

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Prior episodes had simply resolved after brief symptoms, but the current episode had lasted for 2 hours without improvement, so she presented to the ED. At triage she stated her pain is still persistent, but it is mildly improved compared to when she decided to come to the ED. No diaphoresis or vomiting.

ACS 105

ACS ED STEMI OR 105

Dr. Smith's ECG Blog

JANUARY 23, 2023

Recall that, in the setting of ACS symptoms, ST depression that are maximal in leads V1-V4 (as opposed to V5 and V6) not attributable to an abnormal QRS complex is specific for OMI. The most recent event had occurred just before being triaged. This pattern is recognizable by the ST depressions maximal in lead V4.

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. Below is the 15 lead ECG.

STEMI 86

STEMI ACS OR ALS 86

Dr. Smith's ECG Blog

MARCH 20, 2023

Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. Since then, I started looking for OMI EKG findings and not just STEMI. Risk Factors: High Cholesterol.

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Corroborating this is the subtle ST depression in V2-V3 which is inappropriate for the normal QRS complex, and in the context of ACS, we have shown this is quite specific for posterior OMI. In the context of ACS, ST depression maximal in V1-V4 (rather than V5-V6) not due to a QRS abnormality is specific for posterior OMI.

ACS 52

ACS EMS STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

An ECG was recorded quickly on return to the ED: (sorry for poor quality, cannot get originals) What do you think? No obvious adverse events were attributed to the thrombolytics. After a negative noncontrast head CT the next step is looking for a hyperdense basilar artery sign AND to perform a CT cerebral angiogram).

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

JUNE 27, 2021

The patient has heart failure as a result of this event. They gave him 2 nitroglycerine and transported to the ED. In the ED, the patient was "moaning, writhing in bed, and clutching his chest." A 2nd ED ECG was done at 3 hours after chest pain onset: ST depression maximal in V2-V4 persists, and is actually a bit more profound.

STEMI 52

STEMI ACS Coronary ED 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. I was shown today’s initial ECG ( that I’ve reproduced in Figure-1 ) — knowing only that this tracing was from a patient in the ED ( therefore — a patient presumably with some kind of chest discomfort, albeit of unstated duration and severity ).

Defibrillator 134

Defibrillator Coronary STEMI CPR 134

EMDocs

SEPTEMBER 25, 2023

The trade off to using FI for these challenging airways is the consideration of an aspiration event, the initial indication for RSI. However, RSI has never been shown to reduce the risk of aspiration in the ED (13) or during emergent OR cases (14). To date, ketamine has been the agent of choice (12).

ED 65

ED Emergency Department ALS OR 65

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

FEBRUARY 6, 2020

Abdominal pain can of course be a symptom of ACS, but it was brief and seemed to have resulted in a vasovagal event. We recorded an ED ECG: The STD, STE, and T-wave inversion are all there, but in this one the voltage is indeed high and diagnostic of LVH. It is certainly possible, but the pretest probability is very low.

ACS 52

ACS ED Coronary STEMI 52

Dr. Smith's ECG Blog

JULY 19, 2019

He still had active pain on arrival to the ED. This is the most important exception to the classic teaching of "diffuse STE without reciprocal depression is less likely ACS, more likely pericarditis". His initial ECG in the ED ( = E CG # 1 ) is shown in Figure-1. Here is his triage ECG: What do you think?

STEMI 52

STEMI ED ACS OR 52

Dr. Smith's ECG Blog

APRIL 17, 2023

One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. He had no symptoms of ACS. CASE #2: I am more disturbed by learning of the events associated with the ECG in Case #2.

OR 52

OR STEMI ACS Emergency Department 52

Don't Forget the Bubbles

JULY 22, 2024

Pre-school wheezers remain a poorly understood cohort of children despite seeing them every day in paediatric EDs. However, there was no difference in LOS (83 minutes for placebo vs 79 minutes for prednisolone) in participants who were discharged straight from the ED ( 32% ). Reattendance to GP/ED was more important.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

Dr. Smith's ECG Blog

JULY 11, 2019

Cardiology was called and the patient was taken for urgent catheterization with the time from ED arrival to cath about 1 hour and 45 minutes. I focus my att ention on the interpretation of the initial ED tracing ( = E CG # 1 in Figure-1 ). Labs were sent and an initial Troponin I resulted at 2.14 It is not normal to see ≥1.5

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

JULY 31, 2018

Subsequent events: Later, before being taken to her room, the 2nd troponin returned at 1.01 Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. The 1st “lesson” is, “All bets are off” — when an adult of any age presents to the ED with new-onset chest discomfort.

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

MAY 27, 2012

A 90 yo with a history of orthostatic hypotension had a near syncopal event followed by chest pain. Chest pain was resolved upon arrival in the ED. Chest pain and possible ischemia were attributed not to ACS, but to transient hypoperfusion from orthostatic hypotension. His previous ECG was normal. What is it? Answer below.

ACS 52

ACS STEMI OR ED 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." After discussing all of the above with ED staff, we have made a decision to get stat echocardiogram and assess overall LV function and wall motion abnormalities and defer cath lab activation at the time."

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

AUGUST 26, 2019

I wouldn't activate the lab for this EKG alone, but if the patient is clinically compatible with ACS you could call a heart alert. BUT — this patient did present to the ED with new non-chest pain symptoms ( including syncope ) that could reflect an acute cardiac event. Let me know what happens."

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

MARCH 8, 2019

Jerry Jones commented: "Any ST depression on the ECG of a patient with chest pain credible for ACS represents a reciprocal change until proved otherwise." For clarity — I show in Figure-1 the i nitial E CG obtained in the ED ( = E CG # 1 ) — together with the p rehospital E CG that I have pieced together ( = E CG # 2 ).

ED 52

ED STEMI ACS OR 52

ACEP Now

AUGUST 12, 2024

FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. Considering hyperacute T-waves have been accepted as STEMI equivalents, it is possible that pseudonormalization could gain more recognition as an indicator of ACS. Click to enlarge.) Click to enlarge.) Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

JUNE 28, 2019

If a patient presents with symptoms of ACS, has an elevated troponin, and has persistent symptoms in spite of medical therapy [antiplatelet, antithrombotic, and anti-ischemic (nitro)], then cath lab activation is indicated regardless of ECG findings. In this case, one might say it is "obvious" MI because of a straight ST segment in aVF.

Coronary 52

Coronary ACS ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

About an hour later, he was then found on the floor in cardiac arrest in the ED. ST depression maximal in V1-V4, in the context of ACS symptoms and unexplained by QRS abnormality or tachydysrhythmia, should be considered posterior OMI until proven otherwise. His initial troponin T was 15 ng/L (only two hours since pain onset).

Coronary 52

Coronary Heart Attack ED CPR 52