Dr. Smith's ECG Blog

MARCH 13, 2023

An ED ECG, if recorded with pain, should show LAD OMI. So this ECG was immediately recorded: Indeed, as predicted, a patient with previous Wellens' waves who now definitely has chest pain has acute Occlusion, with new ST elevation in I, aVL, V2-V5. The Cath lab was activated.

ED 52

ED ACS Coronary Paramedic 52

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Initial ED ECG: What do you think? Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Coronary angiogram shows diffuse severe three-vessel disease.

Coronary 139

Coronary OR EMS ED 139

EMDocs

JULY 1, 2023

A 3-year-old male with no past medical history presents to the ED with one week of daily fevers >102°F associated with four days of rash on the trunk. We’ll keep it short, while you keep that EM brain sharp. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967. C) for the past week.

EMS 66

EMS Coronary ED OR 66

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. A 25-year-old man presents to the ED via EMS after he sustained a gunshot wound to the left flank.

EMS 75

EMS E-9-1-1 Operating Room OR 75

Dr. Smith's ECG Blog

MARCH 1, 2023

Sent by anonymous, written by Pendell Meyers A man in his late 40s presented to the ED with concern for allergic reaction after accidentally eating a potential allergen, then developing an itchy full body rash and diarrhea. In the ED he received methylprednisolone, diphenhydramine, and epinephrine for possible anaphylaxis.

Allergic Reaction 52

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

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 123

E-9-1-1 Coronary ACS BLS 123

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. Suppose the OMI had been recognized, or suppose another ECG had been recorded and it showed definite OMI. It is unknown when this pain recurred and became constant.

Defibrillator 134

Defibrillator Coronary STEMI CPR 134

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. I cannot be anything else.

STEMI 52

STEMI Coronary ED ACS 52

EMS 12-Lead

MAY 8, 2022

They are definitely high in amplitude and, intermittently, appear to disproportionately tower over the respective QRS. This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2]

STEMI 130

STEMI ED EMS Firefighter 130

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. Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL. Some patients do this.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111

Dr. Smith's ECG Blog

APRIL 25, 2023

But the stuttering pain and sudden onset suggest acute coronary occlusion (Occlusion MI, or OMI). Cath lab activation by the ED and I agree with coronary angiography emergently." Result: no angiographically significant obstructive coronary artery disease. Smith and Meyers to diagnose both obvious (STEMI) and subtle OMI.

Coronary 52

Coronary STEMI ALS OR 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Both were awake and alert with normal vital signs.

OR 120

OR STEMI EMS ED 120

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. Apparently, the patient was not satisfied, and came to the ED as he still had pain. It was extremely busy in the ED and things did not get done quickly. He had been at a clinic that day where he had complained of worsening GERD.

Coronary 52

Coronary ED EMS Critical Care 52

Dr. Smith's ECG Blog

OCTOBER 12, 2023

As part of her work up in the ED an ECG was recorded. There is maybe no definite answer and arguments can be made for the different scenarios. An MRi was not done for this patient and a definite answer maybe cannot be obtained. The patient is a 60 something female. She was febrile and hypotensive at presentation.

Coronary 106

Coronary OR ED 106

EMS 12-Lead

AUGUST 22, 2022

They are not premature, by definition. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Takotsubo should be a diagnosis of exclusion after angiography reveals no obstructive coronary disease, and repeat Echo displays left ventricular recovery. Furthermore, pertinent electrolyte values (e.g.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. 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. So this study is worthless and must be ignored.

STEMI 89

STEMI Coronary Paramedic OR 89

REBEL EM

FEBRUARY 22, 2023

Open angle Closed angle Definitions Increased resistance to aqueous outflow through the trabecular meshwork. et al, Emergency Medicine Clinical Essentials ed 2. Ophthalmology, in Marx J et al (eds): Rosens Emergency Medicine: Concepts and Practice, ed 9. Transient vision loss defined as vision loss <24 hours.

Emergency Department 52

Emergency Department ALS ED Coronary 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. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. 2009;95:1701–1706.

ACS 87

ACS Coronary ALS CAD 87

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

Keep in mind the presenting History ( ie, a 50yo presenting to a rural ED with a 1-hour history of CP radiating to the back and jaw — and an initial ECG labeled as "normal" by the computer interpretation ). As you comtemplate the above issues to address — Take another LOOK at these first 2 ECGs in today's case.

OR 131

OR STEMI Coronary Emergency Department 131

Dr. Smith's ECG Blog

MAY 19, 2020

Angiography showed normal coronaries. A followup ECG was recorded 2 days later: No definite evidence of infarction. MINOCA: Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease). Here is my comment on MINOCA: "Non-obstructive coronary disease" does not necessarily imply "no plaque rupture with thrombus."

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

Imagine you just started your ED shift. Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECG s that has not been overread by a physician. R wave V4 9mm) C T of the coronary arteries showed no lesions. That said, this patient did present to the ED with "new CP" — and.

ED 113

ED Coronary OR 113

Dr. Smith's ECG Blog

DECEMBER 9, 2023

On arrival in the ED, the patient denied any symptoms at all. No chest pain, no shortness of breath, no back pain, no numbness, weakness, tingling, no seizures or history of seizures, First ED ECG This still shows apparent inferior OMI. The patient was g iven full dose aspirin and the medics activated the Cath Lab.

STEMI 111

STEMI Coronary ED OR 111

Dr. Smith's ECG Blog

AUGUST 30, 2023

Mark Hellerman's OMI Pocket Guide ) — will immediately recognize the other critical piece of information in the history from today's patient = The patient's CP improved — and then returned , at which time she presented to the ED. What About Today's ECG?

Coronary 75

Coronary OR STEMI ED 75

Dr. Smith's ECG Blog

DECEMBER 29, 2023

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. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4. link] References 1.

STEMI 74

STEMI Coronary OR ALS 74

Dr. Smith's ECG Blog

MARCH 31, 2023

It is definitely not normal. The 2 clinical areas of most potential benefit to emergency care from computerized interpretations are: i ) Cardiac arrhythmias; and , ii ) Rapid detection of acute coronary O cclusion ( ie, detection of acute O MI ) in cases for which easily recognizable STEMI-criteria are not present.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

MAY 13, 2020

Here is the ED ECG on arrival: Less STE/STD Provider's Clinical Impression: "findings concerning for myocardial infarction, likely proximal LAD or Left main." Sensitivity of POCUS even for definite wall motion abnormalities is far from perfect. Nevertheless, the clinical situation made other etiologies unlikely.

Coronary 52

Coronary ACS EMS ALS 52

REBEL EM

MARCH 22, 2023

REBEL Core Cast 98.0 – AVNRT Click here for Direct Download of the Podcast Definition: A regular, narrow-complex rhythm with a ventricular rate that is typically > 160 bpm. Serum troponin testing in patients with paroxysmal supraventricular tachycardia: outcome after ED care. Serum troponins should not routinely be obtained.

ALS 52

ALS EMS ED OR 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. For some reason unknown to me, the interventionalist was in the ED. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. What happened?" On arrival, the patient went into ventricular fibrillation.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

MARCH 9, 2023

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. Relationship between an in-farct related artery, acute total coronary occlusion, and mortality in patients with ST-segment and non-ST-segment myocardial infarction.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 6, 2011

He presented to the ED after 30 minutes, now also feeling weak. Thus, there are some suspicious abnormalities, but no definite signs of ischemia. But the definition misses the point. It is a coronary occlusion with a substantial myocardial territory at risk, that showed only very subtle ST changes. He was diaphoretic.

Coronary 52

Coronary STEMI ED OR 52

Dr. Smith's ECG Blog

MARCH 19, 2023

To EMPHASIZE: ST-T wave abnormalities are also present in most other leads in ECG #1 — but they are clearly more subtle, and difficult to declare as “acute” in this patient with known coronary disease in the absence of a prior ECG for comparison. Figure-1: Comparison between the first 3 ECGs in today’s case. What Do We Learn from ECG #3 ?

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. There is definite reperfusion. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." This alone could be due to LVH, but V4 could NOT be due to LVH. He awoke with naloxone.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. The patient had no chest symptoms until he had been in the ED for many hours and had been undergoing management of his DKA. The patient was under the care of another ED physician. Another ECG was recorded: What do you think?

ED 106

ED Coronary CAD STEMI 106

Dr. Smith's ECG Blog

APRIL 8, 2022

The ECG is diagnostic for acute transmural infarction of the anterior and lateral walls, with LAD OMI being the most likely cause (which has various potential etiologies for the actual cause of the acute coronary artery occlusion, the most common of which is of course type 1 ACS, plaque rupture with thrombotic occlusion). Aspirin 81 mg daily.

STEMI 52

STEMI Coronary ACS ED 52

Dr. Smith's ECG Blog

JULY 12, 2023

Turns out that it was a 50-something patient with no previous cardiac history who had called 911 for chest pain and had presented 75 minutes earlier by ambulance to triage (as the entire ED was overloaded). All triage ECGs are immediately shown to triage ED faculty. POINT #3: How does ECG #2 confirm our suspicion about ECG #1?

ED 74

ED Coronary Ambulance OR 74

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. The angiogram showed completely normal coronary arteries. Triage ECG: What do you think? Note that the Tp is oppositely directed to the P wave.

STEMI 123

STEMI ED OR Coronary 123

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." A repeat troponin returned at 0.45 CAD-RADS category 1. --No

Coronary 52

Coronary STEMI CAD OR 52