EMDocs

SEPTEMBER 7, 2024

A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. 1 Risk Factors: 1-4 Spontaneous Anticoagulants (Apixaban, Rivaroxaban, etc.)

EMS 98

EMS E-9-1-1 Operating Room OR 98

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.

E-9-1-1 92

E-9-1-1 CAD OR STEMI 92

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. Therefore, this does not meet the definition of myocardial infarction ( 4th Universal Definition of MI ), which requires at least one troponin above the 99% reference range. But maybe not. Thelin et al.

E-9-1-1 40

E-9-1-1 STEMI ACS Coronary 40

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

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.

E-9-1-1 97

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. QRS onset is the best location for ST segment comparison, and is the location recommended by Universal Definition of MI. He was treated with Ceftriaxone and azithromycin. He was admitted.

E-9-1-1 52

E-9-1-1 Coronary OR ACS 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

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 ?

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

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.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 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. Hyperacute T waves do not yet have a formal research definition, but are likely defined best by an increased ratio of area under the curve compared to their QRS complex.

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

FEBRUARY 16, 2019

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." I find this definition problematic because the maximal STD in posterior OMI frequently extends out to V4 rather than V3. Comment from K.

STEMI 52

STEMI E-9-1-1 ACS OR 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

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 ).

E-9-1-1 52

E-9-1-1 Coronary ED OR 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. 0:00 — Intro by Dr. ) — published by Mayo Clinic CV Podcast Series on 1/16/2024 ( 33 minutes ). 9:25 — Are there hyperacute T waves?

E-9-1-1 52

E-9-1-1 Coronary STEMI OR 52

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.

E-9-1-1 40

E-9-1-1 STEMI OR Coronary 40

Dr. Smith's ECG Blog

JULY 12, 2020

More specific information such as definitive RV diastolic collapse was not indicated or available at this time given the obvious clinical context. 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. mm STE depression in aVL.

E-9-1-1 40

E-9-1-1 ED STEMI OR 40

EMDocs

JANUARY 6, 2024

1 Indications for transplant include: Non-ischemic cardiomyopathy (49%) Ischemic cardiomyopathy (35%) Restrictive cardiomyopathy (4%) Retransplantation following failed prior transplant (3%) Hypertrophic cardiomyopathy (3%) Congenital heart disease (3%) Valvular cardiomyopathy (3%) The median survival after heart transplant is over 12 years.

EMS 91

EMS E-9-1-1 ACS Coronary 91

Dr. Smith's ECG Blog

APRIL 8, 2015

Approach to Syncope Syncope definition: Brief loss of consciousness with loss of postural tone and complete spontaneous recovery without medical intervention. Cardiac Syncope ("True Syncope") Independent Predictors of Adverse Outcomes condensed from multiple studies 1. Palpitations preceding syncope (highest value on EGSYS score) 9.

Emergency Department 52

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

EMDocs

NOVEMBER 13, 2023

1 One study found that CTA head and neck was ordered for 2.5% 8 The VAN (vision, aphasia, neglect) score ( Figure 1 ), first proposed by Teleb et al. 9 A later assessment of the VAN score in Beume et al. 8 The VAN (vision, aphasia, neglect) score ( Figure 1 ), first proposed by Teleb et al.

E-9-1-1 105

E-9-1-1 ALS Emergency Department ED 105

Dr. Smith's ECG Blog

JANUARY 5, 2025

Beats 1-2 and 7-10 are wider, uniform, and regular. I doubt retrograde conduction because the RP interval is variable between 8 and 9. It was hand written in two places in the note, so definitely not an accident. Wrong vessel PCI is very common, it happens in about 1 in 4 NSTEMIs. Yes, you read that right.

E-9-1-1 77

E-9-1-1 Coronary OR Ambulance 77

Dr. Smith's ECG Blog

NOVEMBER 11, 2024

The ECG shows sinus rhythm with a rate of about 78 and 2:1 AV conduction along with right bundle branch block and left anterior fascicular block. 2:1 block is a special case, because the tracing lacks successive PR intervals. I have labeled the P waves below for ease of reference: P waves 8 and 9 both conduct to the ventricles.

OR 71

OR E-9-1-1 Coronary 71

EMDocs

FEBRUARY 3, 2025

Although these autoantibodies may be present in a variety of individuals, the development of clinical disease is thought to require exposure to an environmental risk factor such as certain viruses, cigarette smoke or other environmental toxins (1). million have been diagnosed with lupus, with 90% of cases occurring in females (1).

ED 71

ED E-9-1-1 ALS OR 71