Dr. Smith's ECG Blog

JULY 2, 2023

This was texted to me from a former resident, while working at a small rural hospital, with the statement: "I can’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS." I sent it to Pendell, and he said OMI with low confidence without any other information. Thus, Unstable Angina.

ACS 52

ACS Coronary OR 52

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. Each article will take a deeper dive into each recommendation’s supporting evidence and practical implications. The parents of 18-month-old Susie brought her to the Emergency Department after she had a seizure at home.

E-9-1-1 131

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

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). There are no hyperacute T waves. Or does it?

ACS 103

ACS STEMI OR 103

Don't Forget the Bubbles

JULY 5, 2023

It has many useful videos for patients and doctors about sickle cell disease, management and communication scenarios. Sickle cell disease (SCD) is the most common type of haemoglobinopathy followed by thalassaemia. This process of sickling and unsickling goes on and off until the erythrocyte membrane is no longer flexible. Blood culture is pending.

E-9-1-1 126

E-9-1-1 ACS OR ICU 126

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". He reports feeling nauseated with emesis. There is ischemic ST depression in V4-V6.

Defibrillator 131

Defibrillator Coronary STEMI CPR 131

Dr. Smith's ECG Blog

DECEMBER 12, 2022

Written by Pendell Meyers I was reading ECGs in a database (without any clinical information) when I came to this one: What do you think? You must understand this and the dynamic nature of ACS to provide excellent care for such patients. Seeing only this ECG with no context, I thought this ECG was within normal limits.

OR 52

OR ACS STEMI Coronary 52

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. Studies without a clear timeframe for fluid administration.

E-9-1-1 121

E-9-1-1 ALS ACS ICU 121

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 82

E-9-1-1 ACS STEMI Coronary 82

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 ]. The Queen no longer thinks it is OMI.

Coronary 100

Coronary E-9-1-1 STEMI ACS 100

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. Up to 5% of burns occur secondary to electrical injuries, and this rises to 27% in developing countries. Was the voltage high or low (as below)? Was there any syncope ?

ACS 80

ACS Life Support OR CPR 80

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. ng/mL (undetectable).

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 3, 2024

Smith : this was shown to me without any other information, and I said that it is strongly suggestive of inferior OMI, probably reperfused. This dynamic change is diagnostic of ACS. Cardiology was consulted and agreed that his history was high risk for ACS and a next-day angiogram was merited. Another EKG was also obtained.

ED 96

ED Coronary ACS STEMI 96

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. With me so far?

Critical Care 96

Critical Care ACS OR ALS 96

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. greater than 40mS, V1-V2" Meyers interpretation: I was sent this ECG with no clinical information whatsoever, and I responded: "Easily diagnostic of acute LAD occlusion." His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS."

OR 52

OR STEMI ACS Emergency Department 52

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. What a farce.

STEMI 90

STEMI Coronary ACS OR 90

REBEL EM

DECEMBER 23, 2024

Paper: Alwang AK, Law AC, Klings ES, Cohen RT, Bosch NA. Volume of initial Resuscitation: As acknowledged by the authors, this study does not inform the best volume of early fluid resuscitation to provide, nor should the heterogeneity analysis be interpreted to suggest that a higher volume of fluid resuscitation is better.

ALS 82

ALS ED ACS EMR 82

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

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 102

STEMI Coronary ACS ED 102

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%. Some providers were worried about ACS because of this ECG. My answer alleviated their concern for ACS and no further workup was done for ACS.

E-9-1-1 52

E-9-1-1 ACS ALS OR 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. The entry and exit wounds are key indicators, but they can be small or hidden under clothing.

EMT 98

EMT EMT Emergency Medical Technician First Aid 98

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 90

CAD STEMI ACS ALS 90

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 86

STEMI Coronary Heart Attack ACS 86

Dr. Smith's ECG Blog

FEBRUARY 1, 2023

Just so you know this ECG interpretation is not done by the retrospectoscope: I sent it to Dr. Smith without any information, and he immediately responded: "Infero-postero-lateral OMI" The ECG had a computer and final cardiology interpretation of “possible inferior infarct, age undetermined”, because of Q waves.

OR 52

OR STEMI Coronary ACS 52

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

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 87

Coronary ACS Emergency Management Emergency Manager 87

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. Learning Point: 1. If you have old ECGs available, seek them out and compare today's ECGs to those old one. The Queen of Hearts has not yet been trained to compare with previous or with serial ECGs.

E-9-1-1 107

E-9-1-1 Coronary EMS ED 107

Don't Forget the Bubbles

MAY 17, 2023

Patterns of parental online health information-seeking behaviour. De Alwis AC, et al. De Alwis AC, et al. We suggest this list can help you discover relevant or interesting articles for your local journal club or allow you to keep a finger on the pulse of paediatric research. Pruccoli J, et al. Eur J Pediatr. 2023 Apr 13.

ALS 72

ALS ACS Emergency Department EMS 72

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., But the patient has active chest pain. Is it Wellens' syndrome?

E-9-1-1 82

E-9-1-1 ACS ALS OR 82

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

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. Note 2 other similar cases at the bottom that come from my book, The ECG in Acute MI.

STEMI 52

STEMI ACS ED Coronary 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! Clear lungs.

STEMI 52

STEMI ACS CAD OR 52

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

EMDocs

JANUARY 11, 2024

Brain Oxygenation, Perfusion, Edema, and ICP Statements Takeaway: Avoid 100% oxygen saturation. Instead, target 92-98%. Keep hemoglobin > 7 g/dL. Consider lowering ICP if elevated (head of bed elevation, hyperosmolar therapy, etc.). Valproic acid and levetiracetam are reasonable first-line therapies for EEG or clinical seizure activity.

Critical Care 76

Critical Care E-9-1-1 OR ICU 76

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. 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

JULY 31, 2018

I saw this before any other information and knew immediately that it represented an LAD occlusion. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. There is ST depression in II, III, and aVF, and V3 to V6. There is 1 mm of STE in lead V2.

Coronary 52

Coronary ACS STEMI 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

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