Dr. Smith's ECG Blog

JUNE 17, 2024

If this EKG were handed to you to screen from triage without any clinical information, what would you think? 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. looked at consecutive patients with PE, ACS, or neither.

E-9-1-1 138

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

Dr. Smith's ECG Blog

DECEMBER 11, 2023

What would you do at this time with this information? But pain is an important signal in MI and informs the clinician of the urgency. Smith : As Willy states, ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). At midnight. A few notes: Morphine treats ALL forms of pain.

E-9-1-1 123

E-9-1-1 ACS Coronary STEMI 123

Dr. Smith's ECG Blog

DECEMBER 22, 2023

This is a particularly informative link: 2 Examples of Posterior Reperfusion T-waves So one might think that, with active pain, there is anterior OMI. Comment : ACS with persistent symptoms is a guideline recommended indication for ＜2 hour angio (both ACC/AHA and ESC). I think the ECG is normal.

ACS 116

ACS STEMI OR 116

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

If there were diffuse ischemic STD, with precordial STDmaxV5-6 and reciprocal STE-aVR, this would be non-specific subendocardial ischemia from ACS or supply-demand mismatch. The new ESC guidelines has for the first time merged both STEMI and non-STEMI in the same guideline because they are both on the spectrum of ACS.

STEMI 114

STEMI ACS Coronary OR 114

ALiEM

FEBRUARY 9, 2024

119.042891 Ashburn NP, Snavely AC, O’Neill JC, et al. 2018.05.040 Featured image adapted from Adobe Firefly Author information Matthew J.W. 2021 Jun 22;143(25):e1118]. Circulation. 2019;140(19):1543-1556. doi: 10.1161/CIRCULATIONAHA.119.042891 J Am Coll Cardiol. 2018;72(6):620-632. doi: 10.1016/j.jacc.2018.05.040

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

Don't Forget the Bubbles

SEPTEMBER 13, 2023

An expert committee appraised the evidence behind recommendations to avoid imaging to inform the 2022 NICE guidance. Discussion may be supported by patient information materials, particularly the provision of information in multiple languages. doi:10.1177/0883073818786086 Young AC, Costanzi JB, Mohr PD, Forbes WS.

E-9-1-1 131

E-9-1-1 Emergency Department ALS OR 131

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This is diagnostic of ACS; it appears to be a reperfused acute inferior OMI. I sent it to 5 of my OMI friends without any clinical information or outcome and all 5 independently responded with exactly the same diagnosis: "reperfused inferior OMI". There is ischemic ST depression in V4-V6.

Defibrillator 135

Defibrillator Coronary STEMI CPR 135

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. Optical coherence tomography, due to its high resolution, may provide additional information [ 10,13 ]. References: 1.

Coronary 109

Coronary E-9-1-1 STEMI ACS 109

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. It’s not mentioned whether the authors attempted to identify additional studies by checking the references of the selected articles or by contacting the original paper authors for more information.

E-9-1-1 121

E-9-1-1 ALS ACS ICU 121

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

SEPTEMBER 10, 2023

I texted this ECG with no information to Dr. Smith, who immediately said: "If CP, then anterior OMI until proven otherwise." 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. Am Heart J.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

MARCH 19, 2024

He sent it to me with no other information and I wrote back "100% diagnostic of LBBB with inferior-posterior-lateral OMI" There is atrial paced rhythm with Left Bundle Branch Block (LBBB). The cath report showed: Significant stenosis with subtotal occlusion (99%) in the prox to mid Lcx, culprit of ACS, TIMI flow 1.

CAD 111

CAD STEMI ACS ALS 111

Dr. Smith's ECG Blog

JUNE 15, 2023

Written by Pendell Meyers Both of these cases were sent to me with no information other than adults with acute chest pain. What would be your response? Case 1: Case 2: What if I told you that Case 1 has an abnormal initial troponin, and Case 2 has a normal initial troponin? Case 1 An elderly male presented with chest pain.

STEMI 98

STEMI Coronary ACS OR 98

Dr. Smith's ECG Blog

AUGUST 9, 2024

Learning points: Both patients and other medical providers can report confusing and often contradictory information that obfuscates the diagnosis (in this case, WPW). Although recognition of OMI was not affected by administration of morphine in this case, use caution with analgesia in ongoing ACS without a definitive plan for angiography.

STEMI 107

STEMI Coronary Heart Attack ACS 107

Don't Forget the Bubbles

OCTOBER 7, 2024

This is supplied via alternating current (AC), increasing the risk of titanic contraction of skeletal muscle, leading to kids holding on to the electrical power source. AC and DC shocks may result in different injury patterns. Significant injuries can occur even in the absence of extensive burns or other signs of external injury.

ACS 80

ACS Life Support OR CPR 80

GEDC

AUGUST 7, 2024

The measure, developed in collaboration with the American College of Surgeons (ACS), the Institute for Healthcare Improvement (IHI) and the American College of Emergency Physicians (ACEP), aims to improve older adult patient care and outcomes. Read this CMS fact sheet for more information about the rule (see p.

Emergency Department 52

Emergency Department ACS 52

Medgadget

FEBRUARY 14, 2023

Urine tests are an effective, simple, and non-invasive method because the urine contains many informative biomolecules that can be traced back to identify the disease.” Study in ACS Nano : All-in-one nanowire assay system for capture and analysis of extracellular vesicles from an ex vivo brain tumor model Via: Nagoya University

ACS 75

ACS OR 75

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

An ECG was texted to me (Smith) without any clinical information: What did I say? This clinical information followed: "The patient had a COPD exacerbation with a prehospital SpO2 of 60%. This clinical information followed: "The patient had a COPD exacerbation with a prehospital SpO2 of 60%. This is NOT Wellens. Kosuge et al.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

Emergency Medicine Ireland

JULY 3, 2023

Hopefully in a few minutes you’ll at least have a few morsels more of information to stave off all the trainees who are undoubtedly much smarter than you on the ward round. Type 1 is the acute deterioration in kidney function seen in cardiogenic shock from ACS. Today we tackle a somewhat nebulous syndrome.

Critical Care 96

Critical Care ACS OR ALS 96

EMDocs

AUGUST 31, 2023

2020.09.082 Full prescribing information. link] Full prescribing information. link] Li Z, Krippendorff BF, Sharma S, Walz AC, Lavé T, Shah DK. Unified Treatment Algorithm for the management of crotalid snakebite in the United States: results of an evidence-informed consensus workshop. Ann Emerg Med. 2020;76(4):S29.

Allergic Reaction 97

Allergic Reaction Plasma ALS EMS 97

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.

STEMI 117

STEMI Coronary ACS ED 117

Dr. Smith's ECG Blog

MARCH 13, 2024

The patient has ACS by history, active pain, and an elevated troponin. Fortunately, ECG is not the only diagnostic information to clue you into the possibility OMI! It is impossible to overstate the importance of putting the ECG and troponin into the context of the clinical history. Smith : at this point, the ECG becomes irrelevant.

Coronary 108

Coronary ACS Emergency Management Emergency Manager 108

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

Dr. Smith's ECG Blog

JULY 3, 2018

With no other information other than the first ECG above, I texted this to Dr. Smith and he responded: ST elevation in lead V2 and terminal QRS distortion in V3. See this study showing an association between morphine and mortality in ACS: Use of Morphine in ACS is independently associated with mortality, at odds ratio of 1.4

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. We do not know whether a better assay would have given better information, but it is very likely. There is no age cut-off for ACS. Do NOT use them.

OR 52

OR ACS STEMI Coronary 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. It helps in making informed decisions for the next steps in treatment.

EMT 98

EMT EMT Emergency Medical Technician First Aid 98

Dr. Smith's ECG Blog

MARCH 4, 2023

MOREVER, the morphology of the TWI is just not right for ACS. 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. S1Q3T3 This is a paper worth reading : Marchik et al. They found that S1Q3T3 had a Positive Likelihood Ratio of 3.7,

ACS 52

ACS ALS OR 52

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). Also, ACS does not cause hypoxemia out of proportion to hemodynamic compromise, as PE can.

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

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

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Don't Forget the Bubbles

MAY 17, 2023

Patterns of parental online health information-seeking behaviour. De Alwis AC, et al. Premenarchal anorexia nervosa: clinical features, psychopharmacological interventions, and rehospitalization analysis in a 1-year follow-up, controlled study. Pruccoli J, et al. Eur J Pediatr. 2023 Apr 13. Yudianto B, et al. J Paediatr Child Health.

ALS 72

ALS ACS Emergency Department EMS 72

ESO

OCTOBER 18, 2024

Now, any agency unit (not aiding agency units) can be re-dispatched from the Units Report page with separate information (times, personnel, actions) completed for each re-dispatched unit report. Injury Prevention Summary ACS PRQ- Hospice ACS PRQ – Solid organ injuries PtReg: 2.5 Neurosurgeon Response PRQ- 2.12

Mobile Integrated Health 52

Mobile Integrated Health Community Paramedicine Critical Care MIH 52

Dr. Smith's ECG Blog

APRIL 26, 2017

I did not have more information at the time. I remained unconvinced that this was due to ACS. With the added history, and the entirety of the presentation, it was determined by cardiology that the clinical presentation was not due to ACS. Is there a formula to help with this? See discussion at the bottom.

STEMI 52

STEMI ACS ED Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

Remember that the ECG reports what is happening to the myocytes , then you must use that information to make inferences about what the patient needs. 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.

STEMI 52

STEMI Coronary ACS Defibrillator 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2018

The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenic shock" is not applicable outside of sinus rhythm. This case represents the same physiologic event as OMI in terms of the result on the myocardium, therefore with identical ECG features, however there may not be ACS!

STEMI 52

STEMI ACS CAD OR 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. I sent the ECG with no information to Dr. McLaren, who instantly replied: "RCA?" (he he means, "inferoposterior OMI, so probably RCA occlusion?").

ACS 52

ACS EMS STEMI Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

Thus, the very well informed physician could differentiate these ECGs from those of an LBBB patient with MI: 1) no concordance 2) no excessive discordance 3) LBBB with tachycardia, probably rate related 4) subsequent T wave inversion that, according to Shvilkin et al., link] Shvilkin et al. mm, and T-wave inversion in lead III is only 2.5

E-9-1-1 78

E-9-1-1 ACS ALS OR 78

Dr. Smith's ECG Blog

APRIL 9, 2023

Meyers : I was sent this ECG with zero clinical information (and without the prior ECG below), and at that time I said that I did not see evidence of OMI. Only if you are uncertain about the diagnosis of ACS. Initial vitals: Temp 36.7 C, BP 161/79, RR 16, HR 70, Pulse Ox 97% Initial ECG (during "minimal" pain): What do you think?

ACS 52

ACS ED OR EMS 52