Dr. Smith's ECG Blog

MAY 20, 2024

He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic. The cardiologist recognized that there were EKG changes, but did not take the patient for emergent catheterization because the EKG was “not meeting criteria for STEMI”. The ST depressions in I and aVL have resolved.

CAD 125

CAD STEMI Coronary ACS 125

EMS 12-Lead

APRIL 14, 2022

He presented to EMS with extreme pallor, Levine sign, diaphoresis, bilateral arm pain, and an apprehensive sense of doom. It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). In the case of ACS, the ECG can rapidly change from this. ECG's are difficult.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? With EMS, patient had a GCS of 3 and was saturating 60% on room air. He improved to 100% with the addition of non-rebreather, however remained altered and was intubated by EMS with ketamine and succinylcholine. The patient is unconscious and hypoxic. ng/mL and 0.10

STEMI 115

STEMI Coronary Emergency Department ACS 115

ECG & Echo Learning

MARCH 8, 2023

All patients with NSTE-ACS ( NSTEMI or unstable angina) are treated similarly with respect to anti-ischemic and anti-thrombotic drugs. Guidelines recommend the use of validated risk models to estimate the risk of acute myocardial infarction , 30-days and 1-year mortality in patients with NSTE-ACS.

STEMI 40

STEMI E-9-1-1 ACS Coronary 40

Dr. Smith's ECG Blog

AUGUST 15, 2019

He had multiple cardiovascular risk factors and the EM physician strongly suspected ACS. Over the next few hours, four other general cardiologists "signed off on the initial ECG without recognizing STEMI." Learning Points: STEMI criteria misses 25-40% of OMI, like this case for example. mm of the "required" 1.0

STEMI 52

STEMI ACS OR EMS 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

EMS obtained the following vital signs: pulse 50, respiratory rate 16, blood pressure 96/49. It appears EMS obtained two EKGs, but unfortunately these were not saved in the medical record. The EMS crew was only BLS certified, so EKG interpretation is not within their scope of practice.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

DECEMBER 26, 2020

Is this inferor STEMI? Atrial Flutter with Inferior STEMI? Inferolateral ST elevation, vomiting, and elevated troponin The treating team did not identify the flutter waves and they became worried about possible "STEMI" (despite the unusual clinical scenario). The EM provider asked if the cardiologist thought it was a "STEMI."

STEMI 52

STEMI ACS Coronary Emergency Department 52

EMS 12-Lead

APRIL 2, 2022

Figure 1-1 My colleague, a faithful student of ECG interpretation, handed me the tracing and said that it warranted STEMI activation because of apparent terminal QRS distortion (TQRSD) in V2. Anecdotally, had there been symptoms unequivocally consistent with ACS then one could justifiably make the case for a potential D1 occlusion.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The ECG was read as "No STEMI" and the patient was treated like an average chest pain patient (despite the fact that a chest pain patient with active pain and active subendocardial ischemia is very high risk). 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

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. Is this OMI?

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below). In a study last year, 14.4%

STEMI 52

STEMI Coronary ALS ACS 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. From Gue at al.

Emergency Department 52

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

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

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. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. What do you see?

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

He had received aspirin and nitroglycerin by EMS, with some improvement. 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. His vitals were within normal limits.

ACS 52

ACS EMS STEMI Coronary 52

Emergency Medicine Cases

FEBRUARY 28, 2023

Jesse McLaren on when to consider Spontaneous Coronary Artery Dissection (SCAD), which patients are at risk for reocclusion, and the challenges of diagnosing SCAD in patients who have nonischemic ECGs despite silent occlusion, occlusions perfused by collaterals, or from non-occlusive MI on this ECG Cases.

Coronary 130

Coronary OR ACS STEMI 130

Dr. Smith's ECG Blog

APRIL 20, 2018

This post was written by Tarissa Lai, one of our outstanding EM residents at Hennepin County Medical Center, with comments by Steve Smith and Dan Lee. female with HTN, HLD, diabetes, ESRD on dialysis is brought in by EMS with sudden onset, left -sided chest pain for the past four hours. Case A 30 something y.o.

Coronary 40

Coronary STEMI EMS ACS 40

Dr. Smith's ECG Blog

DECEMBER 15, 2023

The patient contacted EMS after a few hours of chest pain that started 5:30 AM. ECG #2 QoH interpretation of ECG #2 Generally when patients are accepted for emergent evaluation in the cath lab, the EMS service keeps the patient connected to the twelve lead ECG during transport. He is otherwise healthy.

ACS 60

ACS STEMI Coronary EMS 60

Dr. Smith's ECG Blog

DECEMBER 12, 2022

You must understand this and the dynamic nature of ACS to provide excellent care for such patients. Failure to do so may result in overlooking subtle ST-T wave changes in a patient "in passage" from a frank STEMI toward reperfusion changes. Serial ECGs are important to perform and incredibly helpful at all stages of expertise.

OR 52

OR ACS STEMI Coronary 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

JUNE 8, 2023

Written by Jesse McLaren A 75 year old with a history of CABG called EMS after 24 hours of chest pain. STEMI negative : the EMS automated interpretation read, “STEMI negative. Even if the patient had presented acutely with STEMI criteria, the ST elevation resolved on arrival though the pain continued.

STEMI 86

STEMI Coronary Paramedic ALS 86

REBEL EM

MARCH 2, 2023

Based on recent studies, current guidelines recommend that O2 should not be given to non-hypoxemic patients with STEMI or NSTEMI [2,3]. REBEL Cast Ep114 – High Flow O2, Suspected ACS, and Mortality? 4159 patients (10% of total population) had STEMI 30d Mortality: High O2 protocol: 8.8% Low O2 protocol: 3.1%

ACS 52

ACS Coronary STEMI Ambulance 52

EMS 12-Lead

APRIL 8, 2022

He reported to EMS a medical history of GERD only. BP 142/100 HR 90 RR 16 (BBS CTA) SpO2 99 (RA) Dstick 110 My colleagues noted the ST-depression in the respective leads, as well, and STEMI activated to the nearest PCI center. 1] Here is the admitting ED ECG after cancellation of Code STEMI. However, in this context (i.e.

STEMI 130

STEMI ALS Coronary CAD 130

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. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Is there STEMI? I suspect the EMS crew misdiagnosed AIVR as VT.

STEMI 107

STEMI Coronary Heart Attack ACS 107

Dr. Smith's ECG Blog

JUNE 17, 2024

Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." looked at consecutive patients with PE, ACS, or neither. What do you think?

E-9-1-1 138

E-9-1-1 ACS Emergency Department Coronary 138

EMS 12-Lead

APRIL 21, 2022

STEMI was activated and the patient went to Cath on arrival. Such aggressive investigation was particularly warranted in this case because of symptoms compatible with ACS, as well as an equally frightening revelation of family history. Conjecture aside, I believe the lesson here, ultimately, is serial ECG’s.

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Pain largely resolved prior to EMS arrival but completely subsided after prehospital NTG and aspirin. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities.

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

There is a very small amount of STE in some of the anterior, lateral, and inferior leads which do NOT meet STEMI criteria. 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. This ECG is highly suspicious for LAD OMI.

STEMI 52

STEMI Coronary ACS Defibrillator 52

Dr. Smith's ECG Blog

MARCH 6, 2019

This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline." They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG was recorded on arrival: What do you think?

STEMI 52

STEMI ALS ACS ICU 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

It may be difficult to read STEMI in the setting of RBBB. There is, however, a long QT also, with abnormal T-waves, but this is not STEMI. This ECG was recorded prehospital, and the computer read STEMI, so the medics activated the cath lab: What do you think? The ECG is consistent with high lateral STEMI. Called 911.

STEMI 40

STEMI CPR CAD Coronary 40

Dr. Smith's ECG Blog

OCTOBER 10, 2022

If this is ACS with Aslanger's pattern , the ST depression vector of subendocardial ischemia (due to simultaneous 3 vessel or left main ACS) is directed toward lead II (inferior and lateral). Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

ACS 52

ACS CPR CAD Heart Attack 52

REBEL EM

JULY 14, 2022

PMID: 30060961 Koller AC, et al. As above, we take the PCAC score into account when we order our interventions and may prioritize Neuroresuscitation in a PCAC 4 over a cath without a hard indication (STEMI). Epub 2016 Jun 28. PMID: 27368428 Elmer J, et al. Ann Emerg Med. Epub 2018 Jul 4. Resuscitation.

ICU 52

ICU ALS OR CPR 52

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

MARCH 14, 2025

He has a history of coronary artery disease and a STEMI two years prior that was treated with primary PCI. He contacted EMS due to acute onset chest pain and feeling unwell and fatigued. These are obvious OMI findings that do not meet STEMI criteria. He was given ASA and sublingual NTG and taken to the ED.

ACS 106

ACS STEMI Coronary OR 106

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. EKG is concerning for acute STEMI with STE in lead I and aVL with reciprocal changes. EKG is concerning for acute STEMI with STE in lead I and aVL with reciprocal changes.

Coronary 130

Coronary STEMI MICU ACS 130

REBEL EM

FEBRUARY 3, 2025

Background: ST-segment elevation myocardial infarction (STEMI) is a critical condition requiring rapid diagnosis and intervention. While ECGs play a central role in detecting STEMI, misinterpretations often occur, leading to unnecessary catheterization or missed diagnoses. 5991 ECGs with Normal annotation and 79 STEMI ECGs.

STEMI 87

STEMI Coronary Emergency Department ALS 87

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

EMS arrived and recorded this ECG: What do you think? The is very small STE in III and aVF which do not meet STEMI criteria, hyperacute T waves, reciprocal TWI in aVL, and maximal STD in V2-V3 showing posterior OMI. The cath lab was activated despite lack of STEMI criteria, around 2 am in the morning. Very frustrating.

STEMI 81

STEMI OR ED EMS 81