The Skeptics' Guide to EM

JULY 2, 2022

Case: You are working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain. Background: Chest pain is one of the most common presentations to the ED. In prior decades nearly all patients presenting to EDs with chest pain were admitted to hospital. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

Dr. Smith's ECG Blog

DECEMBER 5, 2023

He did have a family history notable for early CAD. An ECG was perfomed on arrival to our ED: NSR with ST elevation II,III, aVF with reciprocal depression in aVL Would you refer this pediatric patient for emergent PCI? He denied drug or alcohol use. The workup at the transferring hospital yielded elevated troponin I at 18.1

Coronary 112

Coronary CAD ACS ALS 112

EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. A 12 Lead ECG was captured on her arrival.

Coronary 130

Coronary ACS CAD ED 130

Dr. Smith's ECG Blog

MARCH 19, 2024

The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. HPI: Abrupt onset of substernal chest pain associated with nausea/vomiting 30 min PTA. This was stented with a 2.25

CAD 89

CAD STEMI ACS ALS 89

EMS 12-Lead

AUGUST 14, 2022

Otherwise, no admission of CAD, HLD, or family history of sudden cardiac death. The ST changes went overlooked by both the ED physician and the on-call cardiologist, and the patient was subsequently admitted to telemetry. There was no obvious pallor, diaphoresis, or dyspnea, and he denied any prior episodes of vomiting.

MICU 130

MICU STEMI CAD Coronary 130

Dr. Smith's ECG Blog

JUNE 2, 2023

Despite otherwise normal vital signs, she was appropriately triaged to the critical care area of the ED. They are rare and hard to find in normal practice in the ED. She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? Or it could simply still be classic VT. RVEF 100 ml/m2.

ED 79

ED OR ALS CAD 79

Dr. Smith's ECG Blog

JANUARY 20, 2024

Cardiology refused to be the admitting physician because it was "NSTEMI", and forced the ED physician to admit the patient to the hospitalist. Of course, there was terrible boarding and the patient was considered non-emergent (NSTEMI), and so could not leave the ED for some time. Scattered other nonobstructive CAD.

STEMI 114

STEMI CAD ED ALS 114

Dr. Smith's ECG Blog

DECEMBER 16, 2018

The case An older woman presented to the ED with dyspnea, diaphoresis, and chest pressure. She had a normal EF, and no significant CAD, and was taking flecainide to suppress the AF. Wide-complex tachycardia: VT or aberrant, or "other?" This case is contributed by Brooks Walsh , an EM physician and ECG expert from Connecticut.

OR 52

OR ED CAD Overdose 52

EMS 12-Lead

JUNE 20, 2022

Moreover, he had no pertinent medical history to report in terms of CAD, HTN, HLD, or DM, for example. Here is the final ECG just prior to ED transfer. Attached below is the initial ED tracing upon hospital arrival, approximately 25 minutes after the prehospital ECG. A 12 Lead ECG was recorded. No serial ECG’s were recorded.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

CAD 52

CAD ACS STEMI Coronary 52

EMS 12-Lead

APRIL 8, 2022

Furthermore, there was no family history of early CAD, MI, or sudden cardiac death. 1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. He reported to EMS a medical history of GERD only. However, in this context (i.e. ST-elevation, etc.)

STEMI 130

STEMI ALS Coronary CAD 130

EMDocs

NOVEMBER 29, 2023

Reyes LF, Garcia E, Ibáñez-Prada ED, et al. Included 584 patients > 18 years admitted to ICU with severe PNA based on IDSA/ATS criteria Primary Outcome: 60-day all-cause mortality Hydrocortisone 16% vs. placebo 18%, adjusted OR 0.90 (95% CI 0.57-1.40) 1.40) Trial likely underpowered.

ICU 80

ICU CAD ALS OR 80

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. Another blood pressure was checked.

STEMI 60

STEMI Coronary CAD ED 60

Dr. Smith's ECG Blog

JANUARY 31, 2020

A middle-aged man complained of 15 minutes of classic angina that resolved upon arrival to the ED. So I made an ED diagnosis of Non-Occlusion Myocardial Infarction (NOMI), and his next day angiogram confirmed NOMI. Figure-1: The initial ECG that was done in the ED ( See text ). Here is his initial ECG: What do you think?

ED 52

ED Coronary ACS CAD 52

EM Literature of Note

OCTOBER 18, 2021

Patients were then were randomized to receive CTCA in the ED or “standard of care only” The primary outcome was, naturally, the glorious typical cardiology trial outcome of death or non-fatal myocardial infarction at one year. Other differences in medical or preventive management did not differ by study arm.

Coronary 40

Coronary CAD ED OR 40

Dr. Smith's ECG Blog

JULY 22, 2023

An ECG was performed in the ED at 1554: Original image unavailable, this is the only recorded scanned ECG available. QOH Interpretation: The initial troponin I (older generation) at the first ED was barely positive at 0.06 He denied chest pain or shortness of breath. See below for PM Cardio digitized version of this. There was a 0.9%

E-9-1-1 70

E-9-1-1 CAD OR STEMI 70

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. However, a smooth tapering of the mid-RCA was seen, highlighted in red below: How do we explain the MI if no sign of CAD was found? This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA. This is written by Brooks Walsh.

Coronary 52

Coronary CAD ACS STEMI 52

ACEP Now

APRIL 4, 2024

A 59-year-old male with a past medical history of a repaired ventricular septal defect (VSD), dextrocardia, hypertension, hyperlipidemia, and current smoker presented to the emergency department (ED). This patient had known coronary artery disease (CAD), and previously required drug eluting stents to the obtuse marginal and diagonal arteries.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

MAY 19, 2020

Diagnosis of MINOCA should be made according to the Fourth Universal Definition of MI, in the absence of obstructive coronary artery disease (CAD) (no lesion ≥50%). The authors recommend using optical coherence tomography or intravascular ultrasound imaging in patients with evidence of nonobstructive CAD by angiogram. The K was normal.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

He reportedly told his family "I think I'm having a heart attack", then they immediately drove him to the ED, and he was able to ambulate into the triage area before he collapsed and became unresponsive. CPR was initiated immediately. It was reportedly a PEA arrest; there was no recorded V Fib and no defibrillation.

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

MAY 10, 2023

CAD-RADS category 1. --No That said — I did not feel the history we were given pointed to any particular diagnosis ( ie, 3 episodes of CP and dyspnea of uncertain duration over the past day — with pain on deep breathing — but with symptoms apparently resolved by the time the patient arrived in the ED ).

Coronary 52

Coronary STEMI CAD OR 52

Dr. Smith's ECG Blog

MARCH 19, 2023

Concerning history, known CAD" Recorded 2 hours after pain onset: What do you think? To realize — Assessment of ECG #1 is complicated by knowing: i ) That today’s patient has a history of documented CAD ; and , ii ) The lack o f a prior tracing for comparison at the time the initial ECG was interpreted.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

JUNE 1, 2012

This was a middle aged female with a h/o CAD who presented to the ED by EMS sudden onset of central chest pressure 45 min prior to ED arrival with associated diaphoresis and SOB.  There is LVH and there are ST-T abnormalities (large inferior T-waves and ST elevation, with reciprocal findings in aVL).

STEMI 52

STEMI CAD ED EMS 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

A formal echocardiogram was completed the next day and again showed a normal ejection fraction without any focal wall motion abnormalities to suggest CAD. Schick is a PGY3 at the Brown Emergency Medicine Residency in Rhode Island. I remember Allie well from her days in the Research volunteer program at Hennepin. F (rectal). There was a 0.9%

E-9-1-1 52

E-9-1-1 CAD STEMI OR 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

No family history of sudden cardiac death, cardiomyopathy, premature CAD, or other cardiac issues. No similar symptoms in the past. No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of breath. He denied headache or neck pain associated with exertion. No further troponins were measured. Pericarditis?

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. Written by Nathanael Franks MD, reviewed by Meyers, Smith, Grauer, etc. He was diagnosed as NSTEMI.

ACS 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

JUNE 12, 2017

He had a family history of early CAD and occasional drug and tobacco use. The ECG was alarming to the ED physician who did indeed review it. An ECG is recorded and the computer reads it as "normal". Do you want to see it? Or would you rather not be bothered? I'd rather be bothered.

STEMI 52

STEMI CAD Coronary ALS 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

J Electrocardiol [Internet] 2022;Available from: [link] Cardiology opinion: Takotsubo Cardiomyopathy (EF 30-35%) V Fib Cardiac arrest Prolonged QTC NSTEMI (Smith comment: is it NSTEMI or is it Takotsubo? -- these are entirely different) Moderate single-vessel CAD. V1 has 0.5 mm of elevation. ng/mL [IQR: 0.46, 2.35]. Learning Points: 1.

Emergency Department 52

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

Dr. Smith's ECG Blog

DECEMBER 13, 2019

They found non-obstructive CAD, with only a 20% stenosis of OM2 and 10% RCA. Pericarditis? . == MY Comment by K EN G RAUER, MD ( 12/13/2019 ): == I LOVE this post — as it explores the important decision-making process associated with the ED diagnosis of a cute P ericarditis. No acute culprit. He was admitted to cardiology.

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

JANUARY 28, 2018

A man is his late 50’s presents to the ED with 1 hour of post exertional chest pressure associated with diaphoresis and nausea. He has a history of known CAD, diabetes, and dyslipidemia. The ED ECG in the context of the prehospital ECGs was indeed diagnostic of acute coronary occlusion. Leads II, III, aVF show about 0.5

Coronary 52

Coronary STEMI CAD ED 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

A middle-aged male with h/o CAD and stents presented with typical chest pressure. The patient arrived in the ED and had this ECG recorded: Interpretation? Here is his ECG: The resident was alarmed at the "ST elevation in III with reciprocal ST depression in aVL" Are you alarmed? This is a very common misread.

STEMI 52

STEMI CPR CAD Coronary 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded. Beware crescendo angina in patient with known CAD ST Elevation in aVR Case 7. Total LM occlusion can present with STE or STD in aVR. The pattern seen may, or may not, be unique to left main occlusion.

Coronary 52

Coronary STEMI ACS ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

His ED cardiac ultrasound (which is not at all ideal for detecting wall motion abnormalities, and is also very operator dependent for this finding) was significant for depressed global EF. In this study of dialysis patients with severe CAD, 77% had an abnormal resting EKG and the most common abnormality was LVH. Herzog et al.

CAD 52

CAD OR ED ALS 52

Dr. Smith's ECG Blog

JULY 11, 2019

Cardiology was called and the patient was taken for urgent catheterization with the time from ED arrival to cath about 1 hour and 45 minutes. He also had non-acute CAD of the RCA (50%) and LCX (50%). I focus my att ention on the interpretation of the initial ED tracing ( = E CG # 1 in Figure-1 ).

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

A woman in her 60s with no prior history of CAD presented with 3 hours of sharp, centrally located chest pain with radiation to the anterior neck, with associated nausea. Medics recorded 2 ECGs, one before and one after sublingual NTG, and both are similar to the first ED ECG. Use ED Echo if available 4. Why did I say this?

E-9-1-1 52

E-9-1-1 STEMI Coronary CAD 52

Dr. Smith's ECG Blog

JULY 31, 2018

She had zero CAD risk factors. Post by Smith, with short article by Angie Lobo ( [link] ), a third year intermal medicine resident at Abbott Northwestern Hospital Case A 30-something woman with no past history, who is very fit and athletic, presented with 1.5 hours of substernal chest pressure. There is 1 mm of STE in lead V2.

Coronary 52

Coronary ACS STEMI 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. There is no ST elevation.

STEMI 52

STEMI ACS Coronary CAD 52