Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. Back to the case. Guagliumi, G.,

E-9-1-1 125

E-9-1-1 OR Coronary ACS 125

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. Regular readers of this ECG Blog will be well familiar with many of these points. No ECG was ordered on Day #1.

Coronary 116

Coronary STEMI Emergency Department OR 116

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. They too have dense white masses consistent with coronary atherosclerosis. Annals of Emergency Medicine 2011; Suppl 58(4): S211.

CAD 129

CAD STEMI Coronary ACS 129

Dr. Smith's ECG Blog

OCTOBER 18, 2023

If you were working in a busy emergency department, would you like to be interrupted to interpret these ECGs or can these patients safely wait to be seen because of the normal computer interpretation? Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med.

STEMI 123

STEMI Emergency Department Coronary OR 123

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). From there you can link to other great websites (including Dr. Smith's ECG Blog) that provide multiple case studies of both subtle and overt hyperkalemia. Western Journal of Emergency Medicine, 18 (4), 752-760. [2]

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." 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.

Emergency Department 52

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

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. But STEMI criteria is only 43% sensitive for OMI.[1] Int J Cardiol 2024 2.

STEMI 125

STEMI Coronary ALS Emergency Department 125

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. A recent angiogram report indicated a totally occluded left anterior descending artery (LAD) and right coronary artery (RCA), with 30-40% narrowings in the left circumflex artery (LCx).

Coronary 105

Coronary EMR STEMI Emergency Department 105

Dr. Smith's ECG Blog

JUNE 11, 2024

Many systems now refrain from showing computer "normal" ECGs to the busy emergency physicians at triage because of very poorly conceived articles that say that if the computer algorithm says "normal," the emergency physician should not be bothered. We have shown many examples of this on this blog.

STEMI 116

STEMI Coronary Emergency Department OR 116

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI 110

STEMI Coronary ACS ED 110

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. The Need for Immediate Transport?

OR 133

OR STEMI Coronary Emergency Department 133

Dr. Smith's ECG Blog

JANUARY 9, 2024

She presented to the emergency department after a couple of days of chest discomfort. The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). I have emphasized on many occasions in Dr. Smith's ECG Blog how AFlutter is by far (!)

Coronary 107

Coronary ACS ED OR 107

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?" Chris Mondie of the Newark Beth Israel Emergency Medicine Residency sent case 1 below of a 100% LM occlusion. Widimsky P et al.

Coronary 52

Coronary STEMI ACS ALS 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

Angiogram: Severe two-vessel coronary artery disease with possible co-culprits (90% proximal circumflex, 70% mid/distal RCA) in the setting of non-ST elevation myocardial infarction. Marked ST depression from multi-vessel coronary disease serves to attentuate what would have been ST elevation in leads II and aVF ).

ED 111

ED Coronary CAD STEMI 111

Dr. Smith's ECG Blog

OCTOBER 12, 2024

A man in his 90s with a history of HTN, CKD, COPD, and OSA presented to the emergency department after being found unresponsive at home. Vital signs were within normal limits on arrival to the Emergency Department. Written by Bobby Nicholson What do you think of this “STEMI”? Blood glucose was not low at 162 mg/dL.

STEMI 106

STEMI Coronary Emergency Department OR 106

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.

Defibrillator 137

Defibrillator Coronary STEMI CPR 137

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). link] ] Outcome The patient emerged neurologically intact. Clinical Cardiology 2019.

STEMI 98

STEMI Coronary Defibrillator EMS 98

Dr. Smith's ECG Blog

MAY 23, 2023

Am J Emerg Med. I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. 2022 Jan;51:384-387.

STEMI 93

STEMI Coronary Paramedic OR 93

Dr. Smith's ECG Blog

MAY 13, 2024

Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain. 4) Lastly, the QRS amplitude in V2 (both the R- and S- waves) are measured.

OR 116

OR STEMI Heart Attack Coronary 116

Dr. Smith's ECG Blog

MARCH 14, 2024

According to this data a triage ECG labeled ‘normal’ rules out the possibility of acute coronary occlusion. This is obviously unreliable data, as Dr. Smith’s Blog has published 51 cases of OMI with ECGs labeled ‘normal’ , 35 of which were identified by the Queen of Hearts – with 10 examples here. It should never have been published.

STEMI 116

STEMI ACS Coronary Emergency Department 116

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. This has been discussed many times before on this blog. In-depth discussion is beyond the scope of this blog. link] Fesmire, F.

STEMI 92

STEMI Coronary Heart Attack ACS 92

EMS 12-Lead

APRIL 28, 2022

Upon arrival at the receiving emergency department, however, she precipitously degenerated into VF and could not be resuscitated. In most cases, rather, the culprit is gross ischemia due to myocardial infarction, cardiomyopathy, or advanced coronary artery disease. Unfortunately, a post-conversion 12 Lead was not acquired.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

OCTOBER 25, 2023

A man in his 60s with a history of severe alcohol use disorder and epidural abscess on long-term ciprofloxacin presented to the emergency department after an episode of syncope while standing in line at a grocery store. Instead — it commonly reflects ischemia from severe underlying coronary disease. He did not have chest pain.

Overdose 120

Overdose OR ACS ICU 120

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Hgb 11g/dL (110g/L) and leukocytosis, and a mildly elevated troponin (36 ng/L, with normal 1mm STE in aVR due to ACS will require coronary artery bypass surgery for revascularization, the infarct artery is often not the LM, but rather the LAD or severe 3-vessel disease. Incidence of an acute coronary occlusion. Left main?

Coronary 52

Coronary ACS STEMI ALS 52

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). Angiography showed normal coronaries. MINOCA: Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease). 2) overlooked obstructive coronary disease (e.g.,

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. The Smith-Modified Sgarbossa Criteria Accurately Diagnose Acute Coronary Occlusion in Emergency Department Patients With Ventricular Paced Rhythm.

Coronary 52

Coronary STEMI Paramedic ALS 52

ECG Medical Training

SEPTEMBER 4, 2016

He is transported to the Emergency Department where care is transferred to a nurse. Assuming the patient has signs and symptoms of an acute coronary syndrome (you always want clinical correlation), you should consider the T-waves in example A. Further Reading Take a look at these blog posts from Dr. Smith’s ECG Blog.

STEMI 52

STEMI Paramedic Coronary Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Also see this incredible case of the use of 12-lead ST Segment monitoring.

Coronary 52

Coronary STEMI ALS Emergency Department 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

He arrived in the emergency department hemodynamically stable. The next day, and angiogram showed normal coronary arteries. He was resuscitated with chest compressions and defibrillation and 1 mg of epinephrine. 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

MARCH 17, 2023

Submitted by anonymous, written by Pendell Meyers A woman in her 50s presented to the Emergency Department with chest pain and shortness of breath that woke her from sleep, with diaphoresis. A very similar case to the one presented today appears in the January 17, 2023 post of Dr. Smith’s ECG Blog.

Coronary 52

Coronary Emergency Department ED OR 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 65

STEMI Coronary Critical Care ED 65

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. 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. Am J Emerg Med 2023 2. What do you think?

STEMI 74

STEMI Coronary OR ALS 74

Dr. Smith's ECG Blog

OCTOBER 26, 2010

He presented to the Emergency Department with a blood pressure of 111/66 and a pulse of 117. An angiogram showed no acute coronary lesions. This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain.

ACS 52

ACS STEMI OR Critical Care 52

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. What do you think? Just another NSTEMI.

STEMI 52

STEMI ACS Coronary Defibrillator 52

REBEL EM

FEBRUARY 22, 2023

difficult to see due to corneal edema) Emergency Department Management All patients should get emergency ophthalmologic consultation Start with eye drops (see table below) and add systemic medications if severe or refractory symptoms/IOP. Decreased visual acuity, Cup to disc ratio >0.6 Cup to disc ratio >0.6

Emergency Department 52

Emergency Department ALS ED Coronary 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. Ann Emerg Med 1998;31(1):3-11.

STEMI 52

STEMI Coronary ALS CAD 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. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52