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 ). Low TMP grade correlates very well with resolution of ST Elevation.

ED 52

ED ACS Coronary Paramedic 52

The Skeptics' Guide to EM

JULY 2, 2022

Case: You are working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain. Background: Chest pain is one of the most common presentations to the ED. In prior decades nearly all patients presenting to EDs with chest pain were admitted to hospital. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

The Skeptics' Guide to EM

JANUARY 18, 2020

You turn to the attending and ask, “do you really think this could be acute coronary syndrome (ACS)?” ACS is usually amongst this differential, as cardiovascular disease is a leading cause of morbidity and mortality in this population. The proportion of patients with ACS at the index visit or within 30 days. *

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. Here is the final ECG just prior to ED transfer. Moreover, he had no pertinent medical history to report in terms of CAD, HTN, HLD, or DM, for example.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

JUNE 17, 2024

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. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with Acute PE (p less than 0.001).

E-9-1-1 139

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

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. The patient is admitted for ACS to a cardiologist who says he will see the patient in the morning.

ACS 85

ACS ALS ED OR 85

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. A 12 Lead ECG was captured on her arrival.

Coronary 130

Coronary ACS CAD ED 130

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. This should prompt immediate investigation into supply-demand mismatching, or ACS. She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease.

EMT 130

EMT EMT ACS Coronary 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. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? The ST depressions in I and aVL have resolved.

CAD 126

CAD STEMI Coronary ACS 126

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. Full case details and outcomes are below. Case 1: Case 2: Case 1: What do you think? Physician: "No STEMI."

OR 52

OR STEMI ACS Emergency Department 52

The Skeptics' Guide to EM

FEBRUARY 27, 2021

Case: A 46-year-old female presents to the emergency department (ED) with sudden onset, severe right flank pain. Delays in providing adequate analgesia leads to poorer patient outcomes, prolonged ED length of stay and reduced patient satisfaction (17, 18). AEM Feb 2021. Reference: Brichko et al.

Emergency Department 130

Emergency Department ALS ACS ED 130

Dr. Smith's ECG Blog

DECEMBER 5, 2023

An ECG was perfomed on arrival to our ED: NSR with ST elevation II,III, aVF with reciprocal depression in aVL Would you refer this pediatric patient for emergent PCI? Pediatric cardiology performed a bedside echo in ED with EF estimation of 60%, no pericardial effusion, and no regional wall motion abnormalities.

Coronary 115

Coronary CAD ACS ALS 115

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

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. At midnight.

E-9-1-1 125

E-9-1-1 ACS Coronary STEMI 125

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). ACE inhibitors, or potassium-sparing diuretics), are particularly susceptible. In the case of ACS, the ECG can rapidly change from this. Chou's Electrocardiography in Clinical Practice, 6th ed.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. Angiogram No obstructive epicardial coronary artery disease Cannot exclude non-ACS causes of troponin elevation including coronary vasospasm, stress cardiomyopathy, microvascular disease, etc. I don't know if her pain was getting better or not.

Coronary 103

Coronary E-9-1-1 STEMI ACS 103

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

NOVEMBER 1, 2022

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." He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival. He awoke with naloxone.

Overdose 52

Overdose OR Coronary ACS 52

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. Click to enlarge.)

Operating Room 52

Operating Room ACS Critical Care Coronary 52

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

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”. This series provides evidence-based updates to previous posts so you can stay current with what you need to know. Other lung fields unremarkable. C or 100.4 mg/kg, max 0.4 C or 100.4

E-9-1-1 75

E-9-1-1 ICU ACS EMS 75

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

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. At the time of arrival to the ED, the patient reported 1/10 chest pain with normal vital signs. There is no age cut-off for ACS.

OR 52

OR 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. Deutch et al.

STEMI 104

STEMI Coronary ACS ED 104

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 131

Defibrillator Coronary Epinephrine CPR 131

Dr. Smith's ECG Blog

AUGUST 10, 2023

So now there was ACS + electrical instability, another indication for emergent angiogram. This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram. However, he began experiencing chest pain with moderate cardiovascular activity (e.g., incline walking on a treadmill) thereafter. Shroff, G.

STEMI 89

STEMI ACS Emergency Department ED 89

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. In EMS2 ECG, the T waves in V5 is possibly hyperacute. So the cath lab was activated. Long term outcome is unavailable.

STEMI 86

STEMI EMS ACS ED 86

The Skeptics' Guide to EM

MAY 29, 2021

Upon arrival in the emergency department (ED), the patient is incoherently speaking, has a pulse of 135 beats per minute, blood pressure of 85/50 mm Hg, and an obvious open wound in their left mid-axillary line at the level of the nipple. Journal of Trauma and Acute Care Surgery. We did the session over zoom as an SGEM Journal Club.

Emergency Medical Services 130

Emergency Medical Services ACS ALS Emergency Department 130

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

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

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.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

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. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated. It’s reported that he regained consciousness after 30 seconds, approximately.

Coronary 130

Coronary ALS Firefighter OR 130

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. A 56 y/o Male called 911 from his hotel room in the early morning hours after abruptly awakening from sleep with crushing chest discomfort and difficulty breathing. However, in this context (i.e.

STEMI 130

STEMI ALS Coronary CAD 130

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 85

STEMI ACS OR ALS 85

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present." As a result, even before looking at this patient's initial ECG — he falls into a high -prevalence likelihood group for ACS ( for an A cute C oronary S yndrome ). Repeat cTnI drawn at around 8 AM was 3.910 ng/mL.

E-9-1-1 119

E-9-1-1 OR Coronary ACS 119

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. He was diagnosed as NSTEMI.

ACS 87

ACS Coronary ALS CAD 87

EMDocs

FEBRUARY 12, 2024

As the only respiratory therapist in the ED has been paged and is starting BiPAP for this patient, an overhead call for two incoming trauma alerts from a multivehicle collision sounds. Because the RT responsible for drawing arterial blood gases is busy caring for these patients, ABGs will be delayed.

Emergency Department 94

Emergency Department E-9-1-1 ED ICU 94