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. It is clearly missed by the conventional algorithm.

STEMI 113

STEMI Coronary Emergency Department OR 113

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Adult cardiac arrest in the emergency department – A Swedish cohort study. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. Circulation.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

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 129

OR STEMI Coronary Emergency Department 129

Dr. Smith's ECG Blog

JANUARY 9, 2024

She presented to the emergency department after a couple of days of chest discomfort. However , this patient is having chest discomfort, and by definition then she should be considered not to be stable. She had a single chamber ICD/Pacemaker implanted several years prior due to ventricular tachycardia. What is your assessment?

Coronary 119

Coronary ACS ED OR 119

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 98

STEMI Coronary Paramedic OR 98

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. A followup ECG was recorded 2 days later: No definite evidence of infarction. An elderly woman had sudden ventricular fibrillation.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

REBEL EM

FEBRUARY 22, 2023

Open angle Closed angle Definitions Increased resistance to aqueous outflow through the trabecular meshwork. Transient vision loss defined as vision loss <24 hours. Persistent vision loss defined as loss of vision >24 hours. Bagheri 2015 ). 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

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 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

DECEMBER 14, 2018

The pain resolved as he arrived to the emergency department. He was definitely pain free by the time of arrival at his ED room. The 4th Universal Definition of MI calls this Cardiac Procedural Myocardial Injury. He had 2 episodes over the past 2 days of similar chest tightness. BP was 200/100. Here was his triage ECG.

ED 52

ED STEMI Coronary Emergency Department 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. 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

APRIL 22, 2022

A prospective validation of the HEART score for chest pain patients at the emergency department. External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Am J Emerg Med 2020 3. Backus BE, Six AJ, Kelder JC, et al. Int J Cardiol 2013 2. Lancet 2015 6.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

AUGUST 26, 2019

She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? There is definite STE inferior and lateral but it just doesn't look like true positive STE to me. No baseline was available for comparison.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

JULY 3, 2018

There is perhaps a tiny J-wave in several of the QRS complexes in V3, but it would not be enough to definitively say there is a J-wave. Lead aVL, for example, has a definite J-wave. Despite having acute coronary occlusion by cath, his ECGs never met STEMI criteria. Stat echo would also be helpful. mV compared to 0.05-0.1

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The remainder of his Emergency Department stay was uneventful. Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours. He had no symptoms of ACS.

OR 52

OR STEMI ACS ALS 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. He went for Coronary bypass (CABG). above which one should definitely be worried and get serial ECGs. 4-variable version still to come. the more accurate.

STEMI 52

STEMI Coronary OR ALS 52

The Skeptics' Guide to EM

OCTOBER 20, 2018

Lauren is currently funded by an NHLBI K12 grant (1K12HL138049-01) studying the implementation of evidence-based diagnosis of pulmonary embolism in the emergency department. She presents to the emergency department with chest pain and some shortness of breath. Case: A 64-year-old woman with type-2 diabetes.

Coronary 181

Coronary Emergency Department ALS OR 181

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. Serial ECGs enhance the diagnosis of acute coronary syndrome. Annals of Emergency Medicine , 31 (1), 3–11. Leave it alone.

STEMI 107

STEMI Coronary Heart Attack ACS 107

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 135

Defibrillator Coronary STEMI CPR 135

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 120

OR STEMI Heart Attack Coronary 120

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 20, 2013

Rather it is due to coronary insufficiency due to a tight left main or 3-vessel disease with inadequate coronary flow. Data collected included demographics, initial rhythm, EKG, emergency department (ED) CT and outcomes. Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI.

STEMI 52

STEMI Coronary ACS Emergency Department 52

Dr. Smith's ECG Blog

MARCH 24, 2023

But the bradycardia and the infero-posterior OMI is definitely new: Smith : this also has many abnormalities suggestive of ischemia: many leads have ischemic appearing ST depression The emergency provider followed the sequential steps of the current paradigm: 1.

STEMI 52

STEMI Coronary CAD 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. 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

Dr. Smith's ECG Blog

NOVEMBER 24, 2017

However, none of the formulas have proven to be definitively better than another and none are well correlated with outcomes or events! But the QT is definitely greater than half the RR interval. None is considered definitive due to the paucity of data (and conflicting data) relating QTc to outcomes. which is 0.6

ALS 52

ALS OR ED Coronary 52

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. This San Fran definition, however, is too non-specific , so I list more specific ECG abnormalities below: b. 2) Boston syncope rule: J Emerg Med. 2007 Oct; 33(3): 233–239.

Emergency Department 52

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

EMDocs

JANUARY 6, 2024

3,10 Coronary Allograft Vasculopathy Nicknamed “The Achilles Heel of Heart Transplantation,” this accounts for the majority of patient mortality in the 5-10 year range. 10 It affects the whole length of the vessel and all layers of the coronary vasculature rather than just the intima, which is seen in non-transplant atherosclerosis.

EMS 93

EMS E-9-1-1 ACS Coronary 93

REBEL EM

FEBRUARY 3, 2025

Annals of Emergency Medicine. PMID: 39066765 What They Did: The study involved the development of a deep ensemble AI model using ECG data from a prospective percutaneous coronary intervention registry in Korea. Two board-certified cardiologists reviewed and classified the ECGs, and their consensus served as the gold standard.

STEMI 87

STEMI Coronary Emergency Department ALS 87

EMDocs

NOVEMBER 13, 2023

The use of CTA (computed tomography angiography) in the emergency department (ED) has increased dramatically in the past 20 years. 63 This is because their definition of CI-AKI is an AKI that ensues within 48 hours of receiving IV contrast in the absence of any “other nephrotoxic factors.” Forman, H. Yaesoubi, R. 21.26543. (3)

E-9-1-1 106

E-9-1-1 ALS Emergency Department ED 106

Dr. Smith's ECG Blog

JANUARY 15, 2025

Case A 68 year old man with a medical history of hypertension, hyperlipidemia, and CAD with stent deployment in the RCA presented to the emergency department with chest pain. Also : See Ken Grauer's excellent comments at the bottom. He developed it only 20 minutes prior to presentation while cutting branches outside.

Coronary 67

Coronary ED CAD Paramedic 67

Dr. Smith's ECG Blog

FEBRUARY 8, 2025

Written by Jesse McLaren An 80 year old with a history of CHF, ESRD on dialysis, and multiple prior cardiac stents presented to the emergency department with 3 days of intermittent chest pain and shortness of breath that resolved after nitro, which felt like prior episodes of angina. So which was the culprit?

OR 64

OR Coronary STEMI ED 64

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

EMS gave aspirin and nitroglycerin, and the patient noted significant improvement on arrival to the Emergency Department. The cath lab was activated despite lack of STEMI criteria, around 2 am in the morning. Here is her ECG on arrival to the ED: Improved, but still some signal of posterior OMI.

STEMI 81

STEMI OR ED EMS 81

EMDocs

FEBRUARY 3, 2025

While acute cutaneous lupus lesions are highly characteristic of SLE, subacute and chronic skin changes may occasionally develop in individuals without a definitive SLE diagnosis (1,5). SLE is considered an atypical risk factor for cardiovascular disease and acute coronary syndrome(8,9,11).

ED 73

ED E-9-1-1 ALS OR 73

Dr. Smith's ECG Blog

DECEMBER 31, 2024

Written by Pendell Meyers A woman in her 70s with known prior coronary artery disease experienced acute chest pain and shortness of breath. She presented to the Emergency Department at around 3.5 She was emergently transferred to a PCI center. KEY Points: DSI does not indicate acute coronary occlusion!

Coronary 118

Coronary ACS STEMI CAD 118