The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Date: September 8th, 2021 Reference: Desch et al. Date: September 8th, 2021 Reference: Desch et al. He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP).

EMR 130

EMR Coronary Defibrillator Life Support 130

ACEP Now

DECEMBER 6, 2024

A 45-year-old male with a history of chronic obstructive pulmonary disease (COPD), asthma, amphetamine and tetrahydrocannabinol (THC) use, and coronary vasospasm presented to triage with chest pain. During assessment, the patient reported that a left heart catheterization six months prior indicated spasms but no coronary artery disease.

Coronary 52

Coronary Life Support ALS Emergency Department 52

REBEL EM

SEPTEMBER 21, 2023

What Your Gut Says: The patient has a tachydysrhythmia which may be the presentation of acute coronary syndrome (ACS) even though the patient has no ischemic symptoms. Essentially, we are using the troponin assay to find patients with ACO who may be benefited by coronary interventions or risk factor modification. Cardiol Rev.

Coronary 143

Coronary ACS ED OR 143

The Skeptics' Guide to EM

OCTOBER 22, 2017

[display_podcast] Date: October 19th, 2017 Reference: Hofmann et al. display_podcast] Date: October 19th, 2017 Reference: Hofmann et al. Studies have shown that oxygen can cause vasoconstriction, increase blood pressure and decrease coronary artery blood flow ( Kones et al AM J Med 2011). NEJM Sept 2017. NEJM Sept 2017.

Emergency Medical Services 130

Emergency Medical Services Coronary ALS STEMI 130

EMS 12-Lead

MAY 20, 2022

Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. Below is the initial ED ECG.

Coronary 130

Coronary STEMI Firefighter ED 130

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

The Skeptics' Guide to EM

JANUARY 18, 2020

Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? Reference: Wang et al.

ACS 130

ACS Coronary Emergency Department ALS 130

EMS 12-Lead

JUNE 1, 2022

He advises, however, recurrent syncopal episodes for the past six months, some of which have resulted in ED admission, yet no identifying mechanism could be determined. 3,4] The final 12 Lead ECG does not meet any Smith-modified Sgarbossa criteria, so the T wave signatures are characteristic of improved coronary flow, but not necessarily MI.

Coronary 130

Coronary ALS ED ACS 130

EMS 12-Lead

JUNE 20, 2022

One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. Here is the final ECG just prior to ED transfer. Attached below is the initial ED tracing upon hospital arrival, approximately 25 minutes after the prehospital ECG. No serial ECG’s were recorded.

ACS 130

ACS Coronary STEMI CAD 130

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. 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. Benjamin EJ, et al. Hajjar K, et al. Circulation.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. This is a demonstration of how Wellens' is transient OMI : First ED ECG is Wellens' (pain free). Lemkes JS, et al. It is a ssociated with mild dyspnea on exertion. At times the pain does go to his left neck. Am Heart J. 2000;139:430–436.

Coronary 119

Coronary STEMI ED OR 119

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

E-9-1-1 138

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

EMS 12-Lead

AUGUST 22, 2022

The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. Chou’s Electrocardiography in Clinical Practice (6th ed). References Chiale, P. Saini, A.,

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

EMS 12-Lead

APRIL 8, 2022

1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. Cardiology admitted him for observation with plans for next-day coronary angiogram. However, in this context (i.e. V2 – in the final EMS ECG the ST segment was baseline. 1] Driver, B.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.

Coronary 52

Coronary STEMI ACS ALS 52

EMS 12-Lead

APRIL 28, 2022

In most cases, rather, the culprit is gross ischemia due to myocardial infarction, cardiomyopathy, or advanced coronary artery disease. Josephson’s Clinical Cardiac Electrophysiology: Techniques and Interpretations (6th ed). Chou’s Electrocardiography in Clinical Practice (6th ed). Wolters-Kluwer: Philadelphia, PA. [2]

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

The Skeptics' Guide to EM

MAY 28, 2022

Date: May 24th, 2022 Reference: Broder et al. Date: May 24th, 2022 Reference: Broder et al. The writing group of GRACE-2 wanted to look at clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED. Reference: Broder et al.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). link] [1] Zachary et al. Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. Chou's Electrocardiography in Clinical Practice, 6th ed.

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

MAY 8, 2022

This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2] The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7 An ECG is recorded.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1 115

E-9-1-1 Coronary STEMI ALS 115

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.

STEMI 102

STEMI Coronary ACS ED 102

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Not OMI with High Confidence Click here to sign up for Queen of Hearts Access We showed that the Queen of Hearts decreases false positive cath lab activations: 1) Published recently in Prehospital Emergency Care Baker PO et al. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al.

E-9-1-1 111

E-9-1-1 Coronary ALS ED 111

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). Most OMI have a peak Troponin T over 1000 ng/L [reference: Baro R et al. Clinical Cardiology 2019.

STEMI 95

STEMI Coronary Defibrillator EMS 95

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 119

E-9-1-1 Coronary ACS BLS 119

Dr. Smith's ECG Blog

MARCH 9, 2013

He arrived in the ED and had this ECG recorded:  There are Wellens' waves, type A (upsloping ST segment then inversion of the terminal part of the T-wave - terminal T-wave inversion, or biphasic T-waves) in V2-V4, and aVL. This male in his 40's had been having intermittent chest pain for one week. de Zwaan C., Janssen J.H.A., de Zwaan C.,

ED 52

ED Coronary ALS STEMI 52

EMDocs

SEPTEMBER 26, 2024

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits , a monthly email newsletter for ED physicians. Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Someone should have – either the first ED doc, the second ED doc, or my PCP.

Emergency Department 75

Emergency Department ED Coronary ALS 75

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

When the patient arrived in the ED, he was still hypotensive in 70s, slowly improving with EMS fluids. Here is the ED ECG (a photo of the paper printout) What do you think? QOH ( Q ueen O f H earts ) and Dr. Smith's former resident immediately diagnosed acute OMI — but providers in the ED thought the ECG findings "looked old".

EMS 106

EMS CPR ED Coronary 106

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Lemkes JS, Janssens GN, van der Hoeven NW, et al. This study failed to do so. 5% vs. 58%!! 5% vs. 58%!!

Defibrillator 92

Defibrillator STEMI Coronary ALS 92

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. Chou’s Electrocardiography in Clinical Practice, 6th ed. 4] Baranchuk, A, et al. Goldberger’s Clinical Electrocardiography: A Simplified Approach, 9th ed.

ALS 130

ALS STEMI Coronary OR 130

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 120

STEMI Emergency Department Coronary OR 120

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. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. Rogers AM, et al.

ACS 85

ACS ALS ED Coronary 85

Dr. Smith's ECG Blog

JULY 7, 2024

They arrived in the ED 30 minutes later to meet the cardiology team, where an ECG was repeated: Again no STEMI criteria, and there has been improvement in the deWinter and swirl pattern. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

STEMI 70

STEMI Coronary ALS OR 70

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-9-1-1 117

E-9-1-1 OR Coronary ACS 117

EMDocs

JULY 1, 2023

A 3-year-old male with no past medical history presents to the ED with one week of daily fevers >102°F associated with four days of rash on the trunk. We’ll keep it short, while you keep that EM brain sharp. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. C) for the past week.

EMS 66

EMS Coronary ED OR 66

EMDocs

MARCH 25, 2024

Video 3: Coronary approach to the gallbladder POCUS Findings Sonographically, the gallbladder is situated in the right upper quadrant as an elongated pear-shaped organ on the inferior surface of the liver. Ross M, Brown M, McLaughlin K, et al. Dumbrava BD, Bass GA, Jumean A, et al. Al-Khouja F, Mazumder P, Moeller J, Lahham S.

ALS 88

ALS Coronary Emergency Department ED 88

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

It was worse on the evening prior to presentation while lying in bed, then recurred and resolved while at rest just prior to arriving in the ED. Here is the first ED ECG, with no pain: Sinus rhythm. It shows that on a 7 day angiogram, only 58% of re-occlusions were symptomatic: Ohman EM, Califf RM, Topol EJ et al. de Wood et al.

Coronary 52

Coronary STEMI ALS Emergency Department 52

Dr. Smith's ECG Blog

DECEMBER 16, 2024

Cardiology wanted a CT of the aorta to rule out dissection, presumably partly due to the very high blood pressure readings, but also because it is hard for people to believe that a 20-something woman could have acute thrombotic coronary artery. Coronary malperfusion due to type A aortic dissection: mechanism and surgical management.

STEMI 86

STEMI Coronary Critical Care ED 86