Dr. Smith's ECG Blog

NOVEMBER 14, 2023

We who know ischemic ECGs know that really when T-wave inversion is specific for coronary thrombosis that it indicates reperfusion of the artery, not active occlusion. Learning Point: 1. As is often emphasized on Dr. Smith's ECG Blog — the evolution of an acute OMI is not necessarily static — but may be "dynamic".

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E-9-1-1 Coronary EMS ED 116

EMS 12-Lead

APRIL 28, 2022

Initial vital signs include: NIBP 99/58 HR 150-160 (trend) RR 10 (spontaneous, but shallow) SpO2 86 (RA) BBS CTA The initial rhythm strip is attached: Figure 1 There is a wide complex tachycardia of varying morphology, amplitude, and R-R cycle length. A prominent vertical scar, however, is noted at the sternum.

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E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. So maybe she is better than I am.

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E-9-1-1 CAD OR STEMI 92

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. Figure-1: The initial ECG in today's case — obtained after ROSC.

E-9-1-1 98

E-9-1-1 Defibrillator CPR STEMI 98

Dr. Smith's ECG Blog

MAY 26, 2023

This was a very complex case and the details are too much for an ECG Blog, but suffice it to say that, s hortly thereafter, the patient had an asystolic arrest and was resuscitated. Learning Points: 1. If the situation is not right for acute coronary occlusion, then the ECG findings probably do not represent acute coronary occlusion.

Overdose 98

Overdose E-9-1-1 Coronary ICU 98

Dr. Smith's ECG Blog

MAY 30, 2023

We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. 1 mg of Atropine was given and the heart rate increased transiently to 60. Atropine usually works in junctional rhythm with a narrow complex 9. What to do? RVMI explains part of the shock.

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E-9-1-1 STEMI Coronary OR 97

Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pain is described as located in the midsternal area, radiating to the right arm, described as 8-9/10 and worse with deep inspirations. In the evening, he became diaphoretic and complained of 9/10 continuous chest pain. If there is NO WMA, then it is not coronary occlusion, but if there IS one, then you still don't have a diagnosis.

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E-9-1-1 Coronary OR ACS 52

Dr. Smith's ECG Blog

MARCH 1, 2023

It is unclear to me whether this case could represent 1) simple supply/demand mismatch due to increased demand from epinephrine, 2) Kounis syndrome (usually described as mast cell mediated coronary vasospasm during allergic reaction), 3) brief autolysed left main or LAD ACS with no findings on later echo and CT coronary angio, or 4) something else.

Allergic Reaction 52

Allergic Reaction E-9-1-1 Epinephrine Coronary 52

Dr. Smith's ECG Blog

FEBRUARY 8, 2015

Vittinghoff, E. Metoprolol and atenolol are overwhelmingly beta-1 cardioselective. Beta-1 blockade decreases inotropy and chronotropy and has no vasoconstrictive effects. The prohibition against beta blockade in cocaine toxicity, causing "unopposed alpha" stimulation, needs to be re-examined. is intuitive, and not surprising.

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E-9-1-1 Coronary Epinephrine Overdose 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

mm of ST segment elevation, V2 and V3 have 1 mm of elevation, v4 has 2 mm of elevation and v5 around 1.5 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. What do you think?

Emergency Department 52

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

Dr. Smith's ECG Blog

JUNE 30, 2023

Queen: #1: NOT OMI, HIGH CONFIDENCE Queen: #2: NOT OMI, HIGH CONFIDENCE ECG 1 Interpretation: there is terminal T-wave in V3-V6. LEARNING POINT : 1. Along the way to acquiring more experience in recognizing the ECG findings of acute coronary occlusion — is incorporation of a number of KEY ECG Features into one's clinical acumen.

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E-9-1-1 Coronary ED OR 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. As you take another LOOK at ECG #1 — What is the relevance of the findings that I've labeled in Figure-1 ?

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E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

DECEMBER 13, 2019

On review of systems the patient reported back pain for approximately 1 week which he was treating with NSAIDs with minimal relief. As we have described multiple times on this blog, false positive "pericarditis" kills by distracting the clinician from actual emergencies including OMI, dissection, PE, and others. 15-9/6/2017 ).

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E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

He was taken emergently to the cardiac catheterization lab and found to have multi-vessel coronary artery disease with a near-occlusive culprit lesion in the RCA, possibly reperfused. Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent.

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

Dr. Smith's ECG Blog

JULY 24, 2024

Easy LINK — [link] — My New E CG P odcasts ( 5/28/2024 ): These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ( "Making Waves" ) — hosted by Dr. Anthony Kashou. And regarding arrhythmias: For more on the regular WCT — See My Comment in the May 5, 2020 post and in the April 15, 2020 post in Dr. Smith's ECG Blog.

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E-9-1-1 Coronary STEMI OR 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. Here they are: Learning Points: 1. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. In acute MI, the T-wave is large, and the T/ST ratio is high. This is much more typical of myocarditis.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

4 important features that indicate acute right hear strain: 1. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with APE (p less than 0.001). They found that only 11% of PE had 1 mm T-wave inversions in both lead III and lead V1, vs. 4.6%

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

Dr. Smith's ECG Blog

MARCH 9, 2023

He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. Proven STEMI has an open artery in 19% to 36% of cases, depending on whether it is TIMI −1, −2, or −3 flow. 25] Stone et al found that 72% have TIMI 0 or 1 flow.

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E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

APRIL 22, 2022

But these cases show the potential dangers of delayed recognition and treatment of inferior reperfusion Take away 1. ECG’s can be labeled as ‘normal’ by the computer (and confirmed by cardiology) even with diagnostic signs of occlusion or reperfusion References 1. JAMA Intern Med 2019 9. Am J Med [Internet] 2017;130(9):1076–83.e1.

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E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

MAY 19, 2022

Ct coronary angiogram showed normal coronary arteries. Smith note: I think CT coronary angiogram is reasonable with the elevated troponins and symptoms. Regarding the History: It sounds from the History as if this patient has at least a significant component of EIA ( E xercise- I nduced A sthma ).

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E-9-1-1 Coronary ED OR 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

This ECG is quite obvious for long-time readers, and you may think this far too easy to be presented on this blog. mm in just one lead V7-9), but as far as I can tell all of these documents specifically avoid calling this condition STEMI and specifically avoid using any terminology similar to "STEMI equivalent." Comment from K.

STEMI 52

STEMI E-9-1-1 ACS OR 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

The coronaries were clean (this is not the gold standard, however, as some patients with ischemic ST elevation may have clean coronaries). ACTUAL CORONARY ANATOMY: Dominance: Right LM: A 5 mm vessel which bifurcates into the LAD and LCx coronary artery. QRSV2 = 16 RAV4 = 14 Value = 20.24 (The cutoff of 18.2

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

REBEL EM

SEPTEMBER 26, 2022

2020;71(1):235-246. Plt 37×10^9/L and 40×10^9/L, SOC and TEG, respectively) All patients enrolled had an upper endoscopy and verified the source of bleeding. Article: Kumar M et al. Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial.

FFP 52

FFP E-9-1-1 ICU ALS 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

There are two main etiologies of ischemic ST-depression: 1) subendocardial ischemia 2) reciprocal to ST-elevation in an opposite wall Here there are distinct R-waves with marked ST-depression throughout most of the precordium. Tips for recognizing Acute Posterior STEMI: 1. References: 1. This can help in confirmation.

STEMI 52

STEMI E-9-1-1 Coronary ALS 52

Dr. Smith's ECG Blog

JULY 7, 2013

Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. Baseline Q-wave surpasses time from symptom onset as a prognostic marker in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. J Am Coll Cardiol 53(17):1503-9. Very unlikely.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. E CG # 1 = the initial Triage ECG ( TOP ) — As per Dr. . = Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. Why is this important? Thelin et al. Mokhtari et al.

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E-9-1-1 STEMI ACS Coronary 40

Dr. Smith's ECG Blog

JULY 18, 2014

Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. He found 2 ECG patterns of atypical T-wave development in PIRP: 1) persistently positive (upright) T-waves 48 hours after AMI onset. Lessons : 1. Although rupture has a high mortality, it is not uniformly fatal References 1.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Is this due to coronary occlusion? The medic activated the cath lab but was refused by the interventionalist, who did not believe that this ECG represented acute coronary occlusion. Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Why did I say this? Look at aVF.

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E-9-1-1 STEMI Coronary CAD 40

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

The Differential Diagnosis is: SVT with aberrancy(#) [AVNRT vs. WPW (also called AVRT*)] Atrial flutter with 1:1 conduction, with aberrancy VT coming from the anterior fascicle ( fascicular VT )@ *AVRT = AV Reciprocating Tachycardia (Tachycardic loop that uses both the AV node and an accessory pathway. See Learning point 1 below.

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E-9-1-1 ALS OR Coronary 52

Dr. Smith's ECG Blog

JANUARY 16, 2020

Angiogram showed a 99% left main thrombotic occlusion with TIMI-1 flow (this is considered "occlusion" even though there is some flow. not left main occlusion == MY Comment by K EN G RAUER, MD ( 1/16/2020 ): == I did not correctly identify the “culprit artery” in this case. mEq/L Her BP with pressors came up to 80, then 100.

E-9-1-1 40

E-9-1-1 STEMI Coronary 40

Dr. Smith's ECG Blog

APRIL 3, 2019

Learning Points: 1. Smith was asked to interpret without the benefit of any clinical information ( = ECG #1 in Figure-1 ). There are frequent PVCs ( on this tracing — 3 PVCs in the space of 10 seconds = beats #3, 9, 14 ). Thus, the patient may be pain free from infarct alone, even without spontaneous reperfusion.

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E-9-1-1 STEMI OR Coronary 40

Dr. Smith's ECG Blog

JULY 12, 2020

1 week later (about 1 week prior to the tamponade visit) she had a follow up outpatient visit and this ECG was recorded: Appears to show resolving findings. For an excellent review of the pathophysiological explanation of signs and symptoms associated with Pericardial Tamponade SEE this Review by Jensen et al in the e-Journal Card.

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E-9-1-1 ED STEMI OR 40

Dr. Smith's ECG Blog

APRIL 8, 2015

Cardiac Syncope ("True Syncope") Independent Predictors of Adverse Outcomes condensed from multiple studies 1. Palpitations preceding syncope (highest value on EGSYS score) 9. It's complicated, but they derived a score based on these variables: 1. h/o heart disease (+1) 3. Troponin greater than 99th percentile (+1) 5.

Emergency Department 52

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

FOAMfrat

FEBRUARY 20, 2025

Whether your program is primarily 9-1-1, interfacility transport (IFT), or a combination of both, the likelihood of being responsible for the safe and expeditious transport of a STEMI patient is high for anyone in the out-of-hospital care setting. There, we would find two coronary ostias, left and right. Sir Isaac Newton.

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E-9-1-1 STEMI Coronary Interfacility Transport 99

Dr. Smith's ECG Blog

FEBRUARY 20, 2025

Moreover, it does not follow a coronary distribution very well. The coronaries were clean. Today's patient unfortunately developed PEA ( P ulseless E lectrical A ctivity ) arrest shortly after arrival of the medic team. 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

FEBRUARY 12, 2025

I suspect most blog readers did not struggle with this one. Pendell Meyers , Aaron E. Puskarich Abstract Objectives Data suggest patients suffering acute coronary occlusion myocardial infarction (OMI) benefit from prompt primary percutaneous intervention (PPCI). PEARL #2: The above said Remember the rule of "N = 1".

STEMI 82

STEMI E-9-1-1 ACS Coronary 82

Dr. Smith's ECG Blog

MARCH 8, 2025

1:45, case start To orient you to this screen, the top is obviously ECG waveforms. The arterial pressure waveform is transduced using the coronary catheter. But in the case of an ostial lesion, there is little or no space between the outside of the catheter and the wall of the coronary artery.

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E-9-1-1 OR Defibrillator Coronary 75