The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. Half of these arrests are witnessed with the other half being un-witnessed.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. VF was refractory to amiodarone, lidocaine, double-sequential defibrillation, esmolol, etc. It is unknown when this pain recurred and became constant.

Defibrillator 130

Defibrillator Coronary STEMI CPR 130

EMS 12-Lead

MARCH 19, 2023

He denied any known medical history, specifically: coronary artery disease, hypertension, dyslipidemia, diabetes, heart failure, myocardial infarction, or any prior PCI/stent. Despite immediate chest compressions, and multiple rounds of defibrillation, he could not be resuscitated. Breath sounds were clear in all lung fields.

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

REBEL EM

JUNE 1, 2023

Indication for emergency invasive coronary angiography or had coronary angiography within 1 hour of arrival. Known obstructive coronary artery disease or known coronary stent. Known cardiac defibrillator. Excluded: Obvious cause for OHCA prior to SDCT or on hospital arrival. Pre-existing DNR order.

Coronary 145

Coronary Defibrillator CPR ALS 145

Dr. Smith's ECG Blog

JULY 21, 2024

It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). Upon contrast injection of the LMCA, the patient deteriorated, as the LMCA was severely diseased and flow to all coronary arteries ( LAD, LCx and RCA ) was compromised. He was taken immediately to the cath lab.

Defibrillator 113

Defibrillator Coronary ALS STEMI 113

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 97

STEMI Coronary Defibrillator EMS 97

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 80

STEMI Coronary Defibrillator OR 80

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 89

E-9-1-1 Defibrillator CPR STEMI 89

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 104

Defibrillator Advanced Life Support Coronary Life Support 104

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

EMS 12-Lead

AUGUST 22, 2022

We can, therefore, put down the defibrillation pads, set aside the amiodarone, and look further at the ECG. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Paradoxically, though, the third green arrow identifies a QRS that is more narrow than the RBBB complexes surrounding it.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

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

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

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 77

Defibrillator ALS Coronary OR 77

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

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 127

Defibrillator OR Coronary EMS 127

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

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 84

Coronary OR Defibrillator ALS 84

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 52

Coronary Defibrillator ACS CAD 52

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e

STEMI 40

STEMI Coronary OR Defibrillator 40

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

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

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 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 3, 2017

The assay at my institution, for example, is frequently negative until 4-6 hours after acute coronary occlusion. After the second defibrillation the patient had an organized rhythm: Bradycardic escape/agonal rhythm, with large ST deviations. It should have been shocked at least 10 seconds ago.

CPR 52

CPR Defibrillator STEMI ED 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

It was reportedly a PEA arrest; there was no recorded V Fib and no defibrillation. 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.

ACS 52

ACS CPR CAD Heart Attack 52

ECG & Echo Learning

MARCH 7, 2023

A defibrillator should be immediately available as a precaution. Acute coronary syndrome (including myocardial infarction ) within the last 30 days. A maximum of two infusions can be given. Each infusion should be completed, even if the patient reverts to sinus rhythm. Normal dilution: 4 mg/ml.

Defibrillator 40

Defibrillator Coronary OR 40