ACEP Now

OCTOBER 29, 2024

Caring for critically ill patients with limited information requires snap assessments and judgements for timely resuscitation and efficient emergency department throughput. In the age of big data, more information sounds like a boon. Knack SKS, Scott N, Driver BE, Pet al. Thiruganasambandamoorthy V, Kwong K, Wells GA, et al.

Emergency Department 59

Emergency Department ALS Emergency Medical Services OR 59

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? In fact, Kosuge et al. Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T Waves - ScienceDirect. Stein et al. Kosuge et al.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

Dr. Smith's ECG Blog

OCTOBER 3, 2024

This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. 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.

E-9-1-1 124

E-9-1-1 Coronary ALS ED 124

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.

Defibrillator 131

Defibrillator Coronary ALS STEMI 131

EMDocs

SEPTEMBER 26, 2024

Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. Baccei SJ et al. Tyler W et al. If you have a story to share click here. Volume 80, no.

Emergency Department 98

Emergency Department ED Coronary ALS 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). Serial ECGs enhance the diagnosis of acute coronary syndrome. Bigger et al. Sadowski ZP, Alexander JH, Skrabucha B, et al. Do not treat AIVR.

STEMI 107

STEMI Coronary Heart Attack ACS 107

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 117

STEMI Coronary ACS ED 117

EMDocs

OCTOBER 30, 2023

while Information technology (IT) helped manage communications about the shortage. This information helped predict how long current ICM inventories would last. 16 In a study conducted by Millet et al. This additional information resulted in a change in management for 1.4% (n=3) of the study population. West J Emerg Med.

E-9-1-1 101

E-9-1-1 Emergency Department ALS CCT 101

Dr. Smith's ECG Blog

MAY 23, 2023

The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. EMS arrived and recorded this ECG: What do you think?

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

JUNE 5, 2023

Any ST Depression Maximal in V1-V4 is OMI until proven otherwise I sent this ECG with no information to Pendell. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.) have perfect coronary flow by the time of angiogram. The large upright T-wave in V2 is consistent with reperfusion.

STEMI 96

STEMI Coronary Ambulance ED 96

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. There is very little information on the methodology of the meta-analysis. Nallamothu, B.

Coronary 66

Coronary CPR OR ICU 66

Dr. Smith's ECG Blog

JANUARY 9, 2023

This was sent to me with no information and I immediately replied that it was diagnostic of LAD OMI. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus.

Coronary 52

Coronary STEMI Heart Attack 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. Do you need to get more information? PLUS — Today's patient is an older woman with known severe coronary disease who presented with new chest pain.

Coronary 111

Coronary OR ALS 111

Dr. Smith's ECG Blog

JUNE 11, 2011

All coronaries were completely normal. Only 5-13% of patients with chest pain and LBBB have MI; many fewer have coronary occlusion. Additionally, appropriate discordance is common in NonSTEMI, but very unusual in coronary occlusion (STEMI). link] Shvilkin et al. link] Shvilkin et al. He was taken to the cath lab.

STEMI 52

STEMI Coronary ALS ED 52

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. Arch Neurol.

EMS 98

EMS ALS OR ACS 98

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. Harhash AA, Huang JJ, Reddy S, et al. Incidence of an acute coronary occlusion. Knotts et al.

Coronary 52

Coronary ACS STEMI ALS 52

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. It can only be seen by IVUS. MINOCA has many etiologies.

Emergency Department 52

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

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. It is not a missed STEMI, but it is a missed coronary occlusion. Fesmire et al.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Coronaries were normal, as was serial troponin. I sent the initial ECG of both cases without any context to my colleague Mazen El-Baba, a senior EM resident with an interest in ECG interpretation, and he responded: “RBBB with first degree AV block” for the first (ie no acute coronary occlusion), and “RBBB and superimposed OMI” for the second.

STEMI 73

STEMI Paramedic Coronary ED 73

Dr. Smith's ECG Blog

FEBRUARY 10, 2023

I don't have any clinical information or any other associated ECGs on this case, but wanted to post it here because it is interesting and it is pathognomonic. NOTE: For illustrative purposes — I’ve adapted Figure-1 from the original manuscript by de Winter et al, published in this 2008 NEJM citation. What is it? See text ).

STEMI 52

STEMI ALS Coronary OR 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

FOAMfrat

JUNE 25, 2024

My hope is that if you’re studying for your certification exams, have a soft spot for wilderness medicine, or even if you like to spend your time off outside, this discussion on high-altitude illness will provide some relevant and exciting information. 2. Jensen JD, Vincent AL. Accessed 22 June 2024. High Altitude Cerebral Edema.

OR 97

OR Coronary ALS 97

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

I sent the first ECG to Dr. Meyers without any information, and he replied, “good one. Meyers et al. Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Aslanger et al. Lemkes et al. Bergmark et al. Will be missed easily.” Eur Heart J 2018 4.

STEMI 52

STEMI Paramedic Coronary ALS 52

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.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

REBEL EM

SEPTEMBER 26, 2022

It provides highly descriptive, real-time information on clot formation, clot strength, platelet function, and fibrinolysis, which is superior to traditional coagulation tests such as INR, aPTT, and platelet count. Article: Kumar M et al. There is no information on interventions or medical therapies outside the transfusion strategy.

FFP 52

FFP E-9-1-1 ICU ALS 52

EMDocs

JANUARY 11, 2024

Evaluate and treat seizures or SE after CA in the context of other available clinical information because other systemic factors may influence the occurrence of seizures or SE and the effectiveness of treatment (90%, 18/20). Reference: Hirsch KG, Abella BS, Amorim E, et al; American Heart Association, Neurocritical Care Society.

Critical Care 98

Critical Care E-9-1-1 OR ICU 98

Dr. Smith's ECG Blog

APRIL 22, 2022

Backus BE, Six AJ, Kelder JC, et al. Moumneh T, Sun BC, Baecker A, et al. Identifying patients with low risk for acute coronary syndrome without troponin testing: validation of the HEAR score. Shah ASV, Anand A, Sandoval Y, et al. Patel J, Alattar F, Koneru J, et al. Gulati M, Levy P, Mukherjee D, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

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%. Kosuge et al. Witting et al. This does not contradict the conclusions of Kosuge et al. , Finally, Stein et al.

E-9-1-1 52

E-9-1-1 ACS ALS OR 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). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Annals of Emergency Medicine Cardiology was called to evaluate the patient immediately for emergent cath, but they stated that the ECG did not meet STEMI criteria and elected to wait for further information before proceeding with cath. Karwowski et al showed that only 64% of 4581 STEMIs had TIMI 0 flow on angiogram. [25] Circulation.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

OCTOBER 13, 2022

I sent this to Dr. Meyers without any other information, and he responded, “do you have a prior to make sure that it is all just because of the delta wave? Rosner et al. What do you think? Would be careful to make sure it’s not inferoposterior OMI superimposed on baseline WPW.” Am J Emerg Med 2000. Goldberger. Am J Emerg Med 1999.

STEMI 52

STEMI Coronary OR ACS 52

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? For clarity in Figure-1 — I've reproduced the initial ECG that was shown above in today's case, which Dr. Meyers ventured to read without the benefit of any clinical information.

OR 52

OR ACS STEMI Coronary 52

AAEM RSA

AUGUST 27, 2020

1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. Nielsen N, Wetterslev J, Cronberg T et al. By the time of the study by Nielsen et al. Kirkegaard et al.

E-9-1-1 52

E-9-1-1 CPR ICU ALS 52

Dr. Smith's ECG Blog

APRIL 20, 2018

If she had no risk factors, it is doubtful that she would have developed such extensive coronary artery disease as we see on the angiogram. However, this additional information was supportive. Her first EKG in isolation has no hard findings that are diagnostic for an acute coronary occlusion.

Coronary 40

Coronary STEMI EMS ACS 40

Dr. Smith's ECG Blog

JUNE 11, 2021

Accordingly, in the algorithm by Cai et al for patients with LBBB and ischemic symptoms ( See below ) — the first indication for PCI is clinical: patients with hemodynamic instability or acute heart failure. This ALONE is very strong evidence of acute coronary occlusion. Any indications for cath lab activation? Learning points 1.

EMR 52

EMR STEMI CPR ED 52

Dr. Smith's ECG Blog

OCTOBER 6, 2023

For lots of information, read this post: Poor Microvascular Reperfusion ("No Reflow"): Best Diagnosed by ECG Next day Echo: EF 20% Regional wall motion abnormality-distal septum anterior and apex akinetic, large Regional wall motion abnormality-distal inferior wall akinetic. de Winter et al in N Engl J Med 359:2071-2073, 2008.

ALS 66

ALS Coronary OR 66

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. The 4-variable formula is based on this paper: Driver, BE et al. He went for Coronary bypass (CABG). 4-variable version still to come. QRS V2 = 12.5

STEMI 52

STEMI Coronary OR ALS 52