EMS 12-Lead

APRIL 8, 2022

BP 142/100 HR 90 RR 16 (BBS CTA) SpO2 99 (RA) Dstick 110 My colleagues noted the ST-depression in the respective leads, as well, and STEMI activated to the nearest PCI center. 1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

OCTOBER 18, 2023

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. Patient 1 : anterior OMI Compared with baseline (first ECG), the initial ED ECG (second ECG) has mild ST elevation and hyperacute T waves V2-3 and mild ST depression in V6.

STEMI 120

STEMI Emergency Department Coronary OR 120

EMS 12-Lead

MAY 8, 2022

The attending crews were concerned for SVT with corresponding ischemic hyperacute T waves (HATW) and subsequently activated STEMI pre-hospital. The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7 Then, three minutes later… Crews activated STEMI as she deteriorated into PEA arrest.

STEMI 130

STEMI ED EMS Firefighter 130

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. Below is the initial ED ECG. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. Manual of Cardiovascular Medicine (5th ed.). Smith comment : V5 and V6 are excessively discordant!!!!

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

STEMI 52

STEMI Paramedic Coronary ALS 52

EMS 12-Lead

JUNE 20, 2022

A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. Here is the final ECG just prior to ED transfer. The attending crews were concerned for an ACS-equivalent of LAD occlusion and initiated a prehospital STEMI activation to the closest PCI center. References 1] Smith, S.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

JULY 18, 2014

He had walked into the ED (did not use EMS). Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. Raitt et al.), Raitt et al.), Armstrong et al.),

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. Lindahl et al. From Gue at al. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery.

Coronary 100

Coronary E-9-1-1 STEMI ACS 100

Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. J waves can also be induced by Occlusion MI (5), STEMI mimics including takotsubo and myocarditis complicated by ventricular arrhythmias (6, 7), and subarachnoid hemorrhage with VF (8). Take home : Not all STEs are STEMIs or OMIs. What do you think?

STEMI 52

STEMI ALS EMS OR 52

Dr. Smith's ECG Blog

MARCH 4, 2024

Unknown algorithm The Queen gets it right Case 4 How unreliable are computer algorithms in the Diagnosis of STEMI? The patient's prehospital ECG showed that there was massive STEMI and these are hyperacute T-waves "on the way down" as they normalize. The Queen gets it right First ED ECG: Hyperacute T-waves persist.

STEMI 110

STEMI OR ED ALS 110

Dr. Smith's ECG Blog

MARCH 13, 2013

A 36 yo male smoker presented to the ED with chest pain. You can see how V1, V2, aVR, and V4R would have ST elevation in either a right ventricular STEMI or with a septal STEMI, and how lateral leads, and even posterior leads, would have reciprocal ST depression. In a 1999 study by Engelen et al. mm at J-point, 2.5

STEMI 52

STEMI Coronary ALS ACS 52

Dr. Smith's ECG Blog

MARCH 10, 2017

A 61 year-old with chest pain arrived to the ED by ambulance with resolving chest pain. Here is his ED ECG: The computer interpretation was " normal " What do you think? link] Hughes KE et al. The cath lab was activated, as it should be with transient STEMI. This ECG is NOT normal. There is low QRS amplitude.

STEMI 52

STEMI Ambulance ED ALS 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. Do either, both, or neither have occlusion MI? Vitals were normal.

STEMI 77

STEMI Paramedic Coronary ED 77

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

STEMI 95

STEMI Coronary Defibrillator EMS 95

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). Lemkes JS, et al. At times the pain does go to his left neck.

Coronary 119

Coronary STEMI ED OR 119

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. COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab. 5% vs. 58%!!

Defibrillator 92

Defibrillator STEMI Coronary ALS 92

Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." In fact, Kosuge et al. Stein et al. This is a paper worth reading : Marchik et al. Kosuge et al. Witting et al. of patients with PE and 3.3% of patients without PE.

E-9-1-1 138

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

EMS 12-Lead

APRIL 14, 2022

There is mixed overlap of ST-segment elevation (STE), ST-segment depression (STD), Hyperacute T waves (HATW), and deWinter pattern (which the ACC regards as a STEMI-equivalent but is better suited under the blanket of OMI). link] [1] Zachary et al. Chou's Electrocardiography in Clinical Practice, 6th ed. 2] Costanzo, L.

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

APRIL 21, 2022

The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. STEMI was activated and the patient went to Cath on arrival. Chou’s Electrocardiography in Clinical Practice (6th ed). link] [1] Mirand, D. Canadian Journal of Cardiology, 34 ; 132-145. [2]

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? Here it is: Obvious Inferior Posterior STEMI (+) OMI. Then the ED doc would be dependent on that first ECG. Initial troponin was: 3 ng/L We showed that the first troponin in acute STEMI is often negative in at least 27%. Or had not had a prehospital ECG on the ambulance.

STEMI 75

STEMI Coronary ED Ambulance 75

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

STEMI 86

STEMI Coronary Paramedic OR 86

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

male presents to the ED at 6:45 AM with left sided chest dull pressure that woke him up from sleep at 3am. He arrived to the ED at around 6:45am, and stated the pain has persisted. Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. The pain radiated to both shoulders.

Coronary 116

Coronary ACS OR EMR 116

EMS 12-Lead

APRIL 2, 2022

Figure 1-1 My colleague, a faithful student of ECG interpretation, handed me the tracing and said that it warranted STEMI activation because of apparent terminal QRS distortion (TQRSD) in V2. ASA 324mg was administered while a STEMI activation was simultaneously transmitted to the nearest PCI center. 4] Baranchuk, A, et al.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. This time the Queen of Hearts interpreted: No STEMI or Equivalent.

STEMI 86

STEMI Coronary Critical Care ED 86

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. 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

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Herzog et al. Khan et al.

STEMI 82

STEMI ACS OR ALS 82

Dr. Smith's ECG Blog

JUNE 17, 2023

EMS recorded this ECG during active symptoms and transmitted it to the ED: I had no information when I was shown the ECG. I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 Carley et al.

OR 52

OR STEMI ALS EMS 52

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. Type B waves are deeper and symmetric.

ED 52

ED Coronary ALS STEMI 52

Dr. Smith's ECG Blog

MARCH 19, 2024

The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." Most large STEMI have peak troponin I in the 20.0 There are hyperacute T-waves in V5 and V6. Next trop in AM. Peak trop 257.97 ng/mL - 80.0

CAD 90

CAD STEMI ACS ALS 90

Dr. Smith's ECG Blog

DECEMBER 29, 2015

Case history A middle-aged woman with a history of HTN, but no prior CAD, presented to the ED with chest pain. The criteria of Armstrong et al. would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. Can you diagnose an ACO (STEMI) when you also have LVH? One retrospective analysis by Armstrong et al.

STEMI 40

STEMI Coronary ALS CAD 40

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

STEMI 74

STEMI Coronary OR ALS 74

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

ECG 1 at time zero EARLY REPOLARIZATION ABNORMAL ECG ED final official overread: "early repol vs hyperacute T, minimal changes from previous (previous shown below)" What do YOU think? Smith : there is some minimal ST elevation in V2-V6, but does not meet STEMI criteria. Lemkes et al. Is it normal STE? This is a "Transient OMI".

STEMI 114

STEMI ACS Critical Care Coronary 114

Dr. Smith's ECG Blog

OCTOBER 9, 2018

link] In this paper, in a department in which they state they have only 50 STEMI per year, they looked at only 8 days worth of triage ECGs for a total of 538. They did not find one STEMI on their triage ECGs (no surprise! They only looked at ED diagnosis, not at any angiogram or even at discharge diagnosis. October 2018.

STEMI 52

STEMI ED OR Ambulance 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

The precordial ST-depression pattern on this ECG (and in this clinical setting) should immediately raise suspicion of Posterior STEMI! Posterior STEMI occurs in approximately 15-20% of acute MI, but the vast majority of the time it is seen in conjunction with inferior (Infero-Posterior) or lateral (Postero-Lateral) STEMI (1).

STEMI 52

STEMI E-9-1-1 Coronary ALS 52

Dr. Smith's ECG Blog

MARCH 6, 2019

This is technically a STEMI, with 1.5 However, I think many practitioners might not see this as a clear STEMI, and would instead call this "borderline." They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG was recorded on arrival: What do you think?

STEMI 52

STEMI ALS ACS OR 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. Conversely, Matetzky et al.

STEMI 52

STEMI ACS Coronary CAD 52

Dr. Smith's ECG Blog

JUNE 18, 2013

This was my thought: if this patient presented to the ED with chest pain, then this is an LAD occlusion. His ECG was repeated at this point: This shows a well developed anterior STEMI. To not see these findings is very common, and this patient would be given the diagnosis of NonSTEMI, with subsequent development of STEMI.

STEMI 52

STEMI Coronary ALS CAD 52