ACEP Now

JULY 7, 2023

14 A more recent review article looked at two retrospective studies with a combined total of 66 patients who were given esmolol in the treatment of refractory VT or VF. References Tsao CW, et al. Benjamin EJ, et al. Kimblad H, et al. Sakai T, et al. Kudenchuk PJ, et al. Lee YH, et al. Hajjar K, et al.

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Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

JUNE 17, 2024

In fact, Kosuge et al. showed that among patients with either acute coronary syndrome or acute pulmonary embolism and negative T waves in the precordial leads (V1-V4), that inverted T waves in leads III and V1 were present in only 1% of patients with acute coronary syndrome and 88% of patients with pulmonary embolism. “The

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

Core EM

JULY 23, 2024

Objective: Based on current evidence, this review article aims to guide the Emergency Department (ED) in providing care for patients with blast injuries. Cardiovascular: Injury: cardiac contusion, wall rupture, tamponade, papillary muscle rupture, valve injury, aortic arch injury, and coronary artery dissection. Nowadly C.D.,

EMS 100

EMS Emergency Medical Services OR Coronary 100

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

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Defibrillator Coronary ALS STEMI 118

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. ng/mL [IQR: 0.46, 2.35]. It can only be seen by IVUS.

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

Core EM

MARCH 7, 2024

Objective: Based on current evidence, this review article aims to guide the Emergency Department (ED) in providing care for patients with blast injuries. Cardiovascular: Injury: cardiac contusion, wall rupture, tamponade, papillary muscle rupture, valve injury, aortic arch injury, and coronary artery dissection. Nowadly C.D.,

EMS 100

EMS Emergency Medical Services OR Coronary 100

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion. Deutch et al.

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STEMI Coronary ACS ED 107

Dr. Smith's ECG Blog

JUNE 14, 2024

He underwent coronary angiography which showed severe multivessel disease, and he agreed to proceed with workup for CABG. The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. The rhythm terminated before it could be captured on 12-lead.

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Defibrillator ALS Coronary OR 79

Dr. Smith's ECG Blog

MAY 13, 2020

Smith presented results from a 2019 article by Harhash et al, that confirm how the ECG pattern shown in Figure-1 does not represent acute LMain occlusion — but rather the differential diagnosis that I show above. Today’s Post by Dr. Smith adds to our knowledge of this syndrome.

Coronary 52

Coronary ACS EMS STEMI 52

REBEL EM

MARCH 30, 2023

Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Article: How-Berlemont C, Lamhaut L, Diehl J, et al. Early coronary angiography and survival after out-of-hospital cardiac arrest. Voskuil, M.,

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Coronary CPR OR ICU 83

Dr. Smith's ECG Blog

APRIL 25, 2023

But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

Coronary 52

Coronary STEMI ALS OR 52

Dr. Smith's ECG Blog

NOVEMBER 5, 2023

By Magnus Nossen, edits by Grauer and Smith The patient is a 70-something female with DMII, HTN and an extensive prior history of coronary artery disease and myocardial infarctions. PLUS — Today's patient is an older woman with known severe coronary disease who presented with new chest pain. She's had multiple PCI procedures.

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Coronary OR ALS 105

EMDocs

OCTOBER 21, 2023

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. References: Gaillard F, Glick Y, Tatco V, et al. 61.4.496 Navi BB, Kamel H, Shah MP, et al. Lancet Neurol.

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EMS ALS OR ACS 72

EMDocs

OCTOBER 30, 2023

The primary aim of this article is to examine the clinical insights derived from scarcity and its consequences. 16 In a study conducted by Millet et al. A retrospective study done in May 2023, by Shaish et al 24 showed a 30 % reduction in accuracy of NCCT compared to CECT in a study done among 201 adult ED patients with abdominal pain.

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E-9-1-1 Emergency Department ALS CCT 72

Dr. Smith's ECG Blog

FEBRUARY 15, 2018

This ECG is diagnostic of an acute coronary occlusion of an artery supplying the inferior and posterior walls. Even at ~4 hours into her acute coronary occlusion there is barely any ST Elevation. 2) Contemporary troponins only start to rise 4-6 hours after the onset of acute coronary occlusion.

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Coronary Critical Care STEMI ED 52

Dr. Smith's ECG Blog

JULY 14, 2023

Non-randomized trials show better outcomes (neurologic survival) using this device; see this article in Resuscitation: Head and Thorax Elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Many of these patients have preexisting coronary and other forms of severe heart disease.

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E-9-1-1 Defibrillator CPR STEMI 93

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. 3–8 Shi et al. In acute MI, the T-wave is large, and the T/ST ratio is high. This is much more typical of myocarditis. Angiogram was negative.

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E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JUNE 2, 2023

When I teach important syncope ECG patterns to my residents, I have always had to find case reports and review articles to show them the rare epsilon waves in the past. It is especially unusual looking in leads V2 and V3, where it is clear that this is not a routine J wave, or incomplete RBBB. The diagnosis is not easy (see below).

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ED OR ALS CAD 83

Dr. Smith's ECG Blog

FEBRUARY 8, 2015

The data in the paper by Rangel et al. Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. McCord J, Jneid H, Hollander JE, et al. is intuitive, and not surprising. style='mso-element:field-begin'> ADDIN EN.CITE Rangel 1853 1853 17 Rangel, C.

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E-9-1-1 Coronary Epinephrine Overdose 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

The diagnostic coronary angiogram identified only minimal coronary artery disease, but there was a severely calcified, ‘immobile’ aortic valve. Author continued : STE in aVR is often due to left main coronary artery obstruction (OR 4.72), and is associated with in-hospital cardiovascular mortality (OR 5.58).

Coronary 52

Coronary ACS ALS STEMI 52

REBEL EM

SEPTEMBER 26, 2022

Article: Kumar M et al. References De Pietri L, Bianchini M, Montalti R, et al. PMID: 31229583 Kumar M, Ahmad J, Maiwall R, et al. PMID: 31148204 Rout G, Shalimar, Gunjan D, et al. PMID: 20335313 Wang SC, Shieh JF, Chang KY, et al. Hepatology. 2020;71(1):235-246. Hepatology. 2016;63(2):566-573. Hepatology.

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FFP E-9-1-1 ICU ALS 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2014

See this paper by Widimsky et al, which shows the high association of RBBB, especially with LAFB, with LAD occlusion. Furthermore, among 35 patients with acute left main coronary artery occlusion, 9 presented with RBBB (mostly with LAH) on the admission ECG. New RBBB + LAFB is a very bad sign.

CPR 52

CPR STEMI Coronary ALS 52

Dr. Smith's ECG Blog

MAY 19, 2022

Ct coronary angiogram showed normal coronary arteries. Smith note: I think CT coronary angiogram is reasonable with the elevated troponins and symptoms. The Cardiorespiratory Implications of Ultra-marathon Bjørkavoll‐Bergseth et al. Paana et al. He was diagnosed with mild AKI which resolved. He was discharged.

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E-9-1-1 Coronary OR ED 52

Dr. Smith's ECG Blog

MARCH 12, 2018

Wellens pattern is a term which refers to coronary reperfusion morphology in the anterior leads) The best answer is because the entire gestalt of the ECG shows acute right heart strain instead, and just does not look like Wellens after you've seen Wellens hundreds of times. Stein et al. This is a paper worth reading : Marchik et al.

ACS 52

ACS Coronary ALS ICU 52

Dr. Smith's ECG Blog

JUNE 28, 2018

Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. de Zwaan C et al. Am Heart J. 1982 Apr;103(4 Pt 2):730-6. Am Ht J 117(3): 657-665; March 1989. Wehrens XH, Doevendans PA, Ophuis TJ, Wellens HJ.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

JUNE 12, 2017

Comment A recently published article (1) found that a computer-interpreted “normal” ECG has a 99% NPV (95% CI: 97-99) for a clinically significant finding. According to 2 recent articles (2, 3), the computer misses one third of STEMI, but misses many more subtle MI that do not meet STEMI criteria. Mawri S, Michaels A, Gibbs J, et al.

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STEMI CAD Coronary ALS 52

Dr. Smith's ECG Blog

JANUARY 6, 2024

Therefore the impulse must have originated somewhere lower in the atria, perhaps near the coronary sinus. The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity. Complete heart block is the state of the AV node. The January 30, 2018 post — for PTA.

ALS 95

ALS STEMI Coronary OR 95

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Although not striking, this is clearly a diagnostic ECG for infero"posterior" myocardial infarction due to coronary occlusion (OMI), most likely due to left circumflex (LCx) artery occlusion. He denies any illicit drug use. His ECG is shown below. What do you think ? There is clear ST-segment depression in V2-5, which peaks around V4.

EMR 52

EMR OR ALS Coronary 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

In the Marchik article, (assuming they defined it the same way, and the methods do not specify this), among patients with suspicion for PE, S1Q3T3 was found in 8.5% Kosuge et al. Witting et al. This does not contradict the conclusions of Kosuge et al. , Finally, Stein et al. What is an S1Q3T3? of controls.

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E-9-1-1 ACS ALS OR 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Here is full text of this article. See this paper by Smith et al. Smith pointed out that while atropine may may result in slightly more oxygen demand, the increase in cardiac output and in blood pressure would increase overall coronary perfusion and decrease ischemia. It was about a 7 minute transport time.

STEMI 52

STEMI EMS Coronary ALS 52

Dr. Smith's ECG Blog

JULY 11, 2019

This is a h igher - p revalence H istory for acute coronary disease. CLICK HERE — for a brief article by Rowlands et al that explains these concepts in more detail. By this, I mean that the onus is on us to rule out that even subtle ECG changes may be acute — rather than the other way around.

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STEMI ACS CAD ED 52

Don't Forget the Bubbles

DECEMBER 5, 2023

With millions of journal articles published yearly, it is impossible to keep up. Our team have scoured the literature, so you don’t have to… or it might spark an interest to go and have a look at the full article. Article 1: What is adherence like in young people with ulcerative colitis? Crocker, B.C.S.,

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Coronary Epinephrine CPR Emergency Department 111

EMDocs

MARCH 6, 2024

Post-hoc analysis of patients with LGIB compared a liberal transfusion threshold of 9 g/dL (8 g/dL in those with acute coronary syndrome) with restrictive strategy and found no difference in in-hospital mortality. Review article: the management of lower gastrointestinal bleeding. Triantafyllou K, Gkolfakis P, Gralnek IM, et al.

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ALS OR Coronary ED 84

Dr. Smith's ECG Blog

DECEMBER 20, 2013

Without seeing the patient, my interpretation of the first ECG was: likely normal variant ST-elevation (early repolarization), with a small possibility of pericarditis, and almost no possibility of acute coronary occlusion (STEMI). How do we know that the benefits outweigh the risks of anticoagulation?

STEMI 52

STEMI OR Coronary ED 52

EMDocs

NOVEMBER 4, 2024

Medication dosages detailed in this article are suggestions; local institutional pharmacy dosage policies should be followed. 54 It is vital to consider dangerous epigastric pain mimickers like acute coronary syndrome (ACS), hepatobiliary disease, or pancreatitis. 2014.01.015 Motov S, Strayer R, Hayes BD, et al. J Emerg Med.

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ED E-9-1-1 Emergency Department ALS 97

EMDocs

NOVEMBER 13, 2023

2 Outcomes of patients presenting with ischemic stroke who received MRI as initial imaging modality have demonstrated similar outcomes to those with initial CTA, with Kim et al. In a study of 17,903 CTAs ordered in the ED, Tu et al. 8 The data in Mayer et al. 9 A later assessment of the VAN score in Beume et al.

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E-9-1-1 ALS Emergency Department ED 85

Dr. Smith's ECG Blog

APRIL 8, 2015

Also consider non-hemorrhagic volume depletion, dehydration : orthostatic vitals may uncover this [see Mendu et al. (3)]. Annotated Bibliography For an excellent overview of ED Syncope management , see this article by Kessler C et al. Del Rosso A, et al. starts at end of article on p. Heart 2008;94(12):1620–6.

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Emergency Department E-9-1-1 ED ALS 52