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. Even before looking at the initial ECG — this patient is in a high prevalence group for having an acute event. Long term outcome is unavailable.

STEMI 95

STEMI EMS ACS ED 95

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

DECEMBER 11, 2023

Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). So I would be worried about inferior OMI. At midnight.

E-9-1-1 125

E-9-1-1 ACS Coronary STEMI 125

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. Even in patients whose moderate stenosis undergoes thrombosis, most angiograms show greater than 50% stenosis after the event.

Coronary 104

Coronary E-9-1-1 STEMI ACS 104

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 90

STEMI ACS Emergency Department ED 90

Dr. Smith's ECG Blog

MAY 20, 2024

Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? If you are worried about aortic dissection, you also want the BP to be lowered, though you would do it first with esmolol to decrease the dP/dT (change in pressure over change in time). The ST depressions in I and aVL have resolved. Probably the latter.

CAD 127

CAD STEMI Coronary ACS 127

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

No wall motion abnormality This shows that significant ACS can have ZERO WMA!! There are also subtly hyperacute T-wave in I, aVL, and V2-V6. There is also a very negative (reciprocally inverted) T-wave in lead III, and a down-up T-wave in aVF, both of which are highly suggestive of occlusion of the LAD or D1. The S-wave is reconstituted.

STEMI 116

STEMI ACS Critical Care OR 116

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Furthermore, if this occurs at all, it is a rare event. It is not small but rather large plaques, which may not be producing significant stenosis, that undergo rupture with acute occlusive thrombosis, resulting in myocardial infarction and other ischemic events. years, with the interval as long as 12 or 18 years in some studies.

Coronary 80

Coronary ACS OR EMR 80

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival. He awoke with naloxone. This EKG was recorded as part of a standing order for critical care. He denied any CP or SOB. It does not radiate.

Overdose 52

Overdose OR Coronary ACS 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

NOVEMBER 14, 2023

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. The emergency physician was skeptical and believed the ECG to be a mimic, a false positive. So they looked into the patient's chart. Learning Point: 1.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

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. Fortunately, that is exactly what happened.

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

Dr. Smith's ECG Blog

JANUARY 5, 2024

Thus, these troponins are very concerning for ACS, and subsequent ones will probably be diagnostic of acute MI. Smith comment: No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matter how normal the ECG. His angiogram is shown below. Heitner et al.

ACS 110

ACS ALS OR STEMI 110

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. As a result — the onset of any acute event that may have occurred is uncertain. Any cause of pulmonary hypertension.

STEMI 100

STEMI OR ACS ALS 100

EMDocs

JUNE 27, 2024

Left lower lung field end demonstrates expiratory wheezing on auscultation. Other lung fields unremarkable. smoke, high ozone levels, smog) Asthma/reactive airway disease (RAD) Diagnostic criteria 7,8 Respiratory symptoms +/- fever (at least 38.0 C or 100.4 mg/kg, max 4 mg per dose q20-30min) or hydromorphone (0.01-0.02 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

APRIL 2, 2024

I was there and said, "No, I think this is all due to severe chronic cardiomyopathy and cardiac arrest due to primary ventricular fibrillation, not due to ACS." _ Why did I say that? For this reason we did not believe this was an acute coronary event and did not activate the cath lab. Here is the initial ED ECG. What do you think?

Defibrillator 132

Defibrillator Coronary Epinephrine CPR 132

Dr. Smith's ECG Blog

APRIL 14, 2023

It is easy to say this in retrospect, especially not being the one in charge of this overcrowded waiting room full of unseen patients, but an elderly patient with known CAD and ongoing ACS-sounding chest pain despite medical management with positive troponin is already an indication for emergent cath, regardless of the ECG!

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

In our opinion it should not be given in ACS unless you are committed to the cath lab. Learning Point: Any NSTEMI patient with active ongoing ACS symptoms refractory to medical management is supposed to go to the cath lab within 2 hours if available, per all guidelines in world, regardless of ECG findings. He was diagnosed as NSTEMI.

ACS 87

ACS Coronary ALS CAD 87

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. 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. Potassium was normal.

STEMI 86

STEMI ACS OR ALS 86

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. But I'd be less certain about an acute event without more information and prior and/or serial tracings. He reports feeling nauseated with emesis. He denies taking aspirin or antihypertensive medications for the last year and a half.

Defibrillator 134

Defibrillator Coronary STEMI CPR 134

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

JANUARY 27, 2024

There were zero patients in this study with a "normal" ECG who had any kind of ACS! This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value. So this study is actually worthless. Deutch et al. West J Emerg Med 2024).

STEMI 105

STEMI Coronary ACS ED 105

Dr. Smith's ECG Blog

DECEMBER 26, 2020

No obvious adverse events were attributed to the thrombolytics. Second, the increased demand created by extreme tachycardia may exceed the ability of the coronary arteries to supply sufficient blood (due to preexisting three vessel or left main disease, with or without ACS). Christmas Eve Special Gift!! Serial troponins were negative.

STEMI 52

STEMI ACS Coronary Emergency Department 52

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. There was no associated diaphoresis, nausea, vomiting, arm pain, jaw pain, syncope, lightheadedness or other acute symptoms.

ACS 52

ACS ED OR EMS 52

Dr. Smith's ECG Blog

JUNE 8, 2023

There were trends toward larger infarct size with delayed angiography, both by cMR and integral high-sensitivity troponin concentration, as well as toward higher rate of major adverse cardiovascular events (MACE) (8.5 In addition, short-term MACE was low and not different between the treatment groups."[4]

STEMI 63

STEMI Coronary Paramedic ALS 63

Dr. Smith's ECG Blog

JULY 27, 2023

I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? But in this case the clinical scenario is not right for acute ACS with OMI, and there is very high voltage, and the patient is very young, (though beware of young patients , even 29 year olds!! There is profound "inferior" ST Depression.

Coronary 52

Coronary ACS Naloxone Plasma 52

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

ACEP Now

FEBRUARY 11, 2024

Given the fact that he has not had these headaches before and has diffuse symptoms including weakness, lab work and head imaging are obtained. There were no acute findings on head CT. His lab values demonstrate no anemia, leukocytosis, or electrolyte abnormalities except for an elevated creatinine.

Overdose 52

Overdose ACS Plasma ALS 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

The app also states that there is "suspected" ACS without ST elevation (NSTEMI), posterior fascicular block, sinus bradycardia, and LVH) Note on version 1 of the Queen: she will diagnose "OMI" whether it is an active or reperfused OMI. Translation from French: Acute Occlusion Myocardial Infarction with High Confidence.

STEMI 105

STEMI ACS OR 105

Dr. Smith's ECG Blog

JUNE 27, 2021

The patient has heart failure as a result of this event. 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 52

STEMI ACS Coronary ED 52

EMT Training Station

FEBRUARY 11, 2024

Assessing the Severity The severity of an electrical burn depends on several factors: the type of current (AC or DC), voltage, the pathway of the current through the body, the duration of contact, and the victim’s overall health. Flame Burns These are secondary burns caused when an electrical event ignites clothing or nearby materials.

EMT 98

EMT EMT Emergency Medical Technician First Aid 98

Dr. Smith's ECG Blog

OCTOBER 24, 2018

The patient would not have been diagnosed with acute coronary syndrome and would not have had an angiogram, would have been discharged (or perhaps had a stress test, which would be negative), and would be at great risk of another event, possibly resulting in death or heart failure. Suppose you had used the formula? Mokhtari et al.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 24, 2023

Guidelines say that if a patient has ACS but refractory pain, the patient should go emergently to the cath lab. In today's case — the disproportionate ( hyperacute ) limb lead ST-T wave changes described above largely persisted after conversion to sinus rhythm, confirming an acute event and the need for prompt cath.

STEMI 90

STEMI Coronary ACS OR 90

Dr. Smith's ECG Blog

OCTOBER 15, 2023

In addition to the small size of the ECG complexes on this tracing — I did not think the ECG features of an acute event were at all obvious. 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. No diaphoresis or vomiting.

ACS 105

ACS ED STEMI OR 105

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

MARCH 12, 2018

It is also true that anterior and inferior T-wave inversion could be consistent with reperfusion of a type III wraparound LAD occlusion, despite the fact that Kosuge et al showed that T-wave inversion in lead III is much more likely to be PE than ACS if your differential contains nothing else. Stein et al.

ACS 52

ACS Coronary ALS ICU 52

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.” This is accompanied by minimal ST elevation in aVL/V1-V2 and more pronounced inferior reciprocal ST depression, and minimal ST depression V5-6. OMI or STEMI?

STEMI 52

STEMI Coronary OR ACS 52