Dr. Smith's ECG Blog

MAY 19, 2020

She was unable to be defibrillated but was cannulated and placed on ECMO in our Emergency Department (ECLS - extracorporeal life support). After good ECMO flow was established, she was successfully defibrillated. Here is a case of ECMO defibrillation with near shark fin that was due to proximal LAD occlusion. The K was normal.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). The arrhythmia spontaneously converted before defibrillation was achieved. This is an ominous sign.

Coronary 128

Coronary ACS Emergency Department Defibrillator 128

Dr. Smith's ECG Blog

APRIL 24, 2015

Again, it is common to have an ECG that shows apparent subendocardial ischemia after resuscitation from cardiac arrest, after defibrillation, and after cardioversion. Ventricular fibrillation is not only caused by acute coronary syndrome. Much depends on the post resuscitation ECG and its evolution shortly after defibrillation.

Defibrillator 52

Defibrillator ACS CAD STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

Today's case reminds us of the intuitive logic that if a patient has a shockable arrest ( ie, VFib ) — and following successful defibrillation shows evidence of acute OMI ( even if STEMI criteria are not necessarily fulfilled ) — that such patients have much to gain from immediate cath with PCI. (

STEMI 109

STEMI Coronary Defibrillator OR 109

Dr. Smith's ECG Blog

JULY 14, 2023

He underwent further standard resuscitation EXCEPT that we applied the Inspiratory Threshold Device ( ResQPod ) AND applied Dual Sequential Defibrillation (this simply means we applied 2 sets of pads, had 2 defib machines, and defibrillated with both with only a fraction of one second separating each defibrillation.

E-9-1-1 98

E-9-1-1 Defibrillator CPR STEMI 98

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). There is a relatively normal QRS yet there is STD maximal in V2-V4, which resolves from V4 to V6.

STEMI 98

STEMI Coronary Defibrillator EMS 98

Dr. Smith's ECG Blog

OCTOBER 18, 2023

She spontaneously converted (Defibrillation was not performed). Most such rhythms in the setting of ischemia are VF and will not convert without defibrillation. The patient was referred for coronary angiography which did not reveal any atherosclerotic changes. A repeat magnesium level was not drawn prior to coronary angiography.

Defibrillator 122

Defibrillator Advanced Life Support Coronary Life Support 122

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. But artifact is "alive and well" — and learning to recognize it will amaze many of your colleagues ( and may serve to avoid an unnecessary defibrillation or two ).

Defibrillator 81

Defibrillator ALS Coronary OR 81

Dr. Smith's ECG Blog

JANUARY 23, 2024

Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. She was given CRT-D (Cardiac Resynchronization Therapy-Defibrillator).

Coronary 107

Coronary OR Defibrillator ALS 107

Dr. Smith's ECG Blog

SEPTEMBER 27, 2023

After amiodarone and several defibrillations and about 20 minutes after initial arrest, stable ROSC was achieved. Other coronaries were normal. How did the PM Cardio Queen of Hearts perform: Not OMI with low confidence. ECG#3 Resuscitation efforts were ongoing. ROSC was achieved shortly before new episodes of ventricular tachycardia.

Defibrillator 132

Defibrillator OR Coronary EMS 132

Dr. Smith's ECG Blog

SEPTEMBER 16, 2024

After resuscitation and defibrillation , there were no more episodes of TdP. A coronary angiogram was done that did not show significant coronary artery disease. A coronary angiogram was done that did not show significant coronary artery disease. Below is the patient’s 12 lead ECG following defibrillation.

Defibrillator 67

Defibrillator Coronary OR ALS 67

Dr. Smith's ECG Blog

OCTOBER 4, 2010

He was resuscitated with chest compressions and defibrillation and 1 mg of epinephrine. The next day, and angiogram showed normal coronary arteries. This young male had ventricular fibrillation during a triathlon. On his bib it stated that he had a congenital heart disorder. His initial ECG is shown here. He awoke and did well.

ACS 52

ACS Defibrillator Epinephrine STEMI 52

Dr. Smith's ECG Blog

OCTOBER 28, 2013

She was found to be in ventricular fibrillation and was defibrillated 8 times without a single, even transient, conversion out of fibrillation. She was immediately intubated during continued compressions, then underwent a 9th defibrillation, which resulted in an organized rhythm at 42 minutes after initial arrest. References : 1.

Defibrillator 52

Defibrillator ACS CPR STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm. Cath lab was activated: There was no coronary artery disease, but there was spontaneous coronary artery dissection (SCAD) of the distal LAD, which was narrowed by 95%, and treated medically.

OR 66

OR STEMI ACS Coronary 66

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

She was defibrillated and resuscitated. 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. One need not have obstructive coronary disease to have occlusive thrombus!

Emergency Department 52

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

Dr. Smith's ECG Blog

DECEMBER 23, 2014

There are a few subtle signs of coronary occlusion here. He was defibrillated. He had an ECG recorded: Sinus Rhythm. This was read as normal by the emergency physician and by the computer. QTc is 400 ms. What do you think? First , look at V4-V6. The T-wave is almost as tall as the R-wave. This should not be. Anterolateral STEMI.

Defibrillator 52

Defibrillator STEMI Coronary 52

Dr. Smith's ECG Blog

JUNE 19, 2023

The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. During angiogram in the cath lab, the patient suffered two episodes of ventricular fibrillation for which he was successfully defibrillated. Two stents were placed with resultant TIMI 3 flow. Just another NSTEMI.

STEMI 52

STEMI ACS Coronary Defibrillator 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

This is another case written by Pendell Meyers (who is helping to edit the blog and has many great recent posts) Case A 45 year old man was driving to work when he experienced acute onset sharp left sided chest pain with paresthesias of the left arm. He received aspirin en route via EMS, and no EMS ECGs are available.

CPR 52

CPR Defibrillator STEMI ED 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

Acute coronary occlusion is the most common and most treatable cause of this pattern, but it is not the only cause. Takotsubo, spasm, low flow with a preexisting stable coronary lesion, etc. He was defibrillated immediately and had return of normal mental status.

STEMI 52

STEMI Coronary ACS Defibrillator 52

Dr. Smith's ECG Blog

OCTOBER 20, 2013

She was never seen to be in ventricular fibrillation and was never defibrillated. Rather it is due to coronary insufficiency due to a tight left main or 3-vessel disease with inadequate coronary flow. Medics found her apneic and pulseless, began CPR, and she was found to be in asystole. BP gradually rose.

STEMI 52

STEMI Coronary ACS Emergency Department 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

When the ICD was finally interrogated, the syncopal events and shocks correlated with two VF events that were defibrillated successfully. 90% stenosis of the proximal ramus intermedius, pre procedure TIMI II flow The ramus intermedius is a normal variant on coronary anatomy that arises between the LAD and LCX.

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

OCTOBER 26, 2020

12 minutes later, the patient went back into VFib arrest and underwent another 15 minutes of resuscitation followed by successful defibrillation and sustained ROSC. In total, he received approximately 40 minutes of CPR and 7 defibrillation attempts. Coronary spasm causing massive current of injury with shark fin ECG.

Coronary 40

Coronary Defibrillator ACS CAD 40

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Accuracy of OMI findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. DIagnostic accuracy oF electrocardiogram for acute coronary OCClusion resulTing in myocardial infarction (DIFOCCULT study). Transient ST-segment myocardial infarction: a new category of high risk acute coronary syndrome?

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 29, 2020

She was never defibrillated. Angiogram --Minimal coronary atherosclerosis --No obstructive epicardial coronary artery disease or evidence of plaque rupture noted to explain prolonged QT or ventricular fibrillation cardiacarrest, suspect nonischemic mechanism Echo The estimated left ventricular ejection fraction is 45 %.

Defibrillator 52

Defibrillator Epinephrine Coronary Overdose 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

It was reportedly a PEA arrest; there was no recorded V Fib and no defibrillation. NOTE: For more on the ECG diagnosis of acute RV "strain" ( and acute PE ) — Please check out My Comment at the bottom of the page in the March 28, 2022 post in Dr. Smith's ECG Blog. CPR was initiated immediately.

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

APRIL 8, 2016

At cath, he immediately had incessant Torsades de Pointes requiring defibrillation 7 times and requiring placement of a transvenous pacer for overdrive pacing at a rate of 80. Over a 13-month period, serum potassium and magnesium levels were measured in 590 patients admitted to a coronary care unit. Armstrong, MD Arch Intern Med.

STEMI 52

STEMI Plasma Defibrillator OR 52

Dr. Smith's ECG Blog

DECEMBER 31, 2024

Written by Pendell Meyers A woman in her 70s with known prior coronary artery disease experienced acute chest pain and shortness of breath. Her history and ECG were interpreted as very concerning for acute coronary syndrome which might benefit from acute reperfusion therapy. Vital signs were within normal limits. hours since onset.

Coronary 118

Coronary ACS STEMI CAD 118

Dr. Smith's ECG Blog

MARCH 6, 2025

Second , when you have a rhythm problem, you are likely to be able to fix the problem with electricity (cardioversion, defibrillation, pacing). Fifth , potential management actions are in your hands; you do not need to request a coronary interventionalist or cath lab team.

Coronary 95

Coronary ICU OR Defibrillator 95

Dr. Smith's ECG Blog

MARCH 8, 2025

The arterial pressure waveform is transduced using the coronary catheter. Normally, the diameter of the coronary artery ostium is much greater than the diameter of the catheter so that catheter engagement does not significantly impair antegrade coronary perfusion. She was defibrillated perhaps 25 times.

E-9-1-1 75

E-9-1-1 OR Defibrillator Coronary 75

Dr. Smith's ECG Blog

DECEMBER 27, 2024

The submitter started the patient on amiodarone and arranged implantation of a defibrillator. == MY Comment , by K EN G RAUER, MD ( 12/27 /2024 ): == Superb discussion by Dr. Frick in today's case, that highlights a series of important points regarding the ECG recognition of stable VT ( V entricular T achycardia ).

Coronary 121

Coronary Defibrillator ACS ED 121

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. In this case, you should get a second defibrillator and perform double sequential external defibrillation (DSED). The patient was taken to lab for coronary angiography.

Defibrillator 63

Defibrillator ACS Coronary ALS 63

Dr. Smith's ECG Blog

DECEMBER 20, 2024

Written by Willy Frick with edits by Ken Grauer An older man with a history of non-ischemic HFrEF s/p CRT and mild coronary artery disease presented with chest pain. The most common way is by delivering a lead into the coronary sinus ostium in the RA, which wraps around the posterolateral portion of the LV. ECG 1 What do you think?

Defibrillator 102

Defibrillator Coronary ALS Emergency Department 102

Dr. Smith's ECG Blog

FEBRUARY 20, 2025

Moreover, it does not follow a coronary distribution very well. The coronaries were clean. By ECG alone: it is suspicious for stress cardiomyopathy, or takotsubo, due to the diffuse ST Elevation: II, III, aVF AND I and aVL. This is unusual in acute OMI. In addition, there is STE in V3-V6, so there is massive injury. From this site.

STEMI 88

STEMI Paramedic E-9-1-1 Epinephrine 88

Dr. Smith's ECG Blog

NOVEMBER 29, 2024

She underwent coronary angiography which showed thrombotic occlusion of an RPL branch s/p aspiration thrombectomy. Throughout this process, the patient had repeated VF and was defibrillated 8 times. Written by Willy Frick A young woman with a history of paroxysmal nocturnal hemoglobinuria presented with acute substernal chest pain.

Defibrillator 66

Defibrillator STEMI Coronary ED 66

Dr. Smith's ECG Blog

FEBRUARY 6, 2025

The intricacies of the different classes of antiarrhythmics and their mechanism of action extend beyond the scope of this blog. CT coronary angiogram showed a hypoplastic RCA and dominant LCx. I list below links to other cases of idiopathic VT from Dr Smith's ECG blog. Try a different kind of antiarrhythmic. No PVCs are seen.

Plasma 72

Plasma ACS OR Coronary 72