Dr. Smith's ECG Blog

AUGUST 9, 2024

He had no previously documented medical problems except polysubstance use. Serial ECGs enhance the diagnosis of acute coronary syndrome. Bigger et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the Crusade Quality Improvement Initiative. Leave it alone.

STEMI 107

STEMI Coronary Heart Attack ACS 107

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present."

E-9-1-1 131

E-9-1-1 OR Coronary ACS 131

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

It is well documented with continuous 12-lead monitoring that acute re-occlusion is frequently asymptomatic. It shows that on a 7 day angiogram, only 58% of re-occlusions were symptomatic: Ohman EM, Califf RM, Topol EJ et al. Akkerhuis KM, et al. Gottlieb SO, et al. Jernberg T, et al. Patel DJ, et al.

Coronary 52

Coronary STEMI ALS Emergency Department 52

REBEL EM

MARCH 2, 2023

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient ’ s oxygen saturation. More recent evidence, however, demonstrates that too much oxygen could be harmful ( AVOID Trial ) by causing coronary vasoconstriction and increasing oxidative stress. Low O2 protocol: 3.1%

ACS 52

ACS Coronary STEMI Ambulance 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

Dr. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al. Smith’s ECG Blog has published a growing list of over 40 cases of ECGs falsely labeled ‘normal’ by the computer which are diagnostic of Occlusion MI, and Smith et al.

STEMI 119

STEMI Emergency Department Coronary OR 119

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. References Hansen MS, et al. Rogers AM, et al. Cecconi M, et al. Then what?

ACS 85

ACS ALS ED Coronary 85

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published. P.S.: Our September 3, 2020 post features Dr.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

STEMI criteria is bad at differentiating between normal variant and acute coronary occlusion or reperfusion, and initial troponin levels don't differentiate between occlusive and non-occlusive MI 3. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4. McLaren et al, including Meyers/Smith.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

JULY 27, 2023

I was not worried for a coronary etiology. PEARL #3: The pathophysiologic mechanism for producing amphetamine-induced acute MI is unclear ( Bazmi et al — SQUMJ 17(10); e31-37, 2017 — and — Sinha et al — Case Rep Cardiol, 2016 ). The precordial findings are typical for a young AA male See 20 similar cases here.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. The condition of the coronary artery at the time of angiogram may be different than it was 30 minutes prior during recording of the ECG. A 40-something woman had sudden chest pain. She called 911. The proposed mechanism is complex.

Coronary 52

Coronary STEMI ED ALS 52

Dr. Smith's ECG Blog

JULY 22, 2023

The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. Our patient had a Brugada Type 1 pattern elicited by an elevated core temperature, which is also a documented phenomenon. In the largest study looking at this topic by Mizusawa et al.,

E-9-1-1 92

E-9-1-1 CAD OR STEMI 92

EMDocs

JANUARY 11, 2024

Early coronary angiography in post-CA patients with no ST-segment elevation on the presenting ECG may still be of benefit by potentially salvaging myocardium and decreasing the incidence of systolic heart failure in survivors (95.7%, 22/23). Individualize RBCTs to the clinical situation (81%, 17/21).

Critical Care 97

Critical Care E-9-1-1 OR ICU 97

ACEP Now

MARCH 14, 2024

Tintinalli JE, Stapczynski J, Ma O, et al. Acute myocardial infarction with normal and near normal coronary arteries. Documentation with coronary arteriography within 12 1/2 hours of the onset of symptoms in two cases (three episodes). Arnoldo BD, Purdue GF, Kowalske K, et al. 2023 Jul 17. McGraw Hill; 2016.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

APRIL 17, 2023

His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Chest pain is documented as ongoing. NOTE: For illustrative purposes — I’ve adapted Figure-1 from the original manuscript by deWinter et al, published in this 2008 NEJM citation. QOH: "OMI High confidence".

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

The patient was in his 50s with history of hypertension, diabetes, seizure disorder, and smoking, but no known coronary artery disease. No patient should have to be "lucky" by having a positive troponin to be taken seriously as a possible acute coronary occlusion. See the proof for yourself in the literature below: Schmitt et al.

STEMI 40

STEMI Coronary ALS OR 40

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. Significant coagulopathy: INR > 1.8

FFP 52

FFP E-9-1-1 ICU ALS 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Kosuge et al. Witting et al. This does not contradict the conclusions of Kosuge et al. , Finally, Stein et al. This is a paper worth reading : Marchik et al. Finally — Note that the S1Q3T3 pattern is missing in ECG #2 , despite documentation of a massive PE. of controls.

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e III A Primary percutaneous coronary intervention strategy Management Recommendation Level of evidence Primary PCI of the infarct related artery (IRA) is indicated.

STEMI 40

STEMI Coronary OR Defibrillator 40

Dr. Smith's ECG Blog

APRIL 8, 2016

Document in the patient's chart that rapid infusion is intentional in response to life-threatening hypokalemia." the associated loss is double, at 200-400 mEq.* [ Sterns RH, et al. Over a 13-month period, serum potassium and magnesium levels were measured in 590 patients admitted to a coronary care unit. 1987;147(3):465-469.

STEMI 52

STEMI Plasma Defibrillator OR 52

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. Cardiology documented “late presentation STEMI but likely aborted given resolution of ST changes from EMS to hospital.”

STEMI 86

STEMI Coronary Paramedic ALS 86

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)]. Thus, if there is documented sinus bradycardia, and no suspicion of high grade AV block, at the time of the syncope, this is very useful. Del Rosso A, et al. Other studies 1) EGSYS score (full text link).

Emergency Department 52

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

Dr. Smith's ECG Blog

MARCH 17, 2025

There is very scarce documentation, but the next ECG was obtained around 1 PM. A recent meta-analysis by Stone et al. In fact, this incredible study by Heiter et al. There was no repeat ECG. There was repeat troponin about an hour after that, and it trended down, from 41 ng/L to 30 ng/L, now within the reference range.

ACS 81

ACS STEMI Coronary ALS 81

Dr. Smith's ECG Blog

MARCH 25, 2025

ONLY give opiates if the pain is intolerable or you will activate the cath lab at the first objective evidence of coronary ischemia. Documentation indicates that the patient was shocked 4 times (with no comment on energy level) and received amiodarone 300 mg IV and magnesium 2 g IV. In fact, in this elegant study by Heitner et al.

Defibrillator 63

Defibrillator ACS Coronary ALS 63