Dr. Smith's ECG Blog

DECEMBER 19, 2023

EMS obtained the following vital signs: pulse 50, respiratory rate 16, blood pressure 96/49. It appears EMS obtained two EKGs, but unfortunately these were not saved in the medical record. The EMS crew was only BLS certified, so EKG interpretation is not within their scope of practice. This is not the case.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Written by Pendell Meyers Two adult patients in their 50s called EMS for acute chest pain that started within the last hour. Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

OR 125

OR STEMI EMS ED 125

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

When EMS found her, she was dyspneic and diaphoretic. Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1 127

E-9-1-1 Coronary STEMI ALS 127

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. 1, 2] The most clinically useful definition to account for this entire constellation is intraventricular conduction delay. Attached is the first ECG. Isn’t VT ALWAYS “wide”?

ALS 130

ALS STEMI Coronary OR 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. EMS arrived — and recorded 2 ECGs. 14 minutes later — ECG #2 was recorded by EMS. I personally can hardly wait for that future version! Some patients do this.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

Dr. Smith's ECG Blog

AUGUST 6, 2024

All ECGs were recorded by EMS, and transferred to a PCI capable center for evaluation. It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. All coronary arteries were patent without atherosclerotic change. To the uninitiated — this ECG may appear normal.

Coronary 104

Coronary OR STEMI EMS 104

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

ACEP Now

JULY 7, 2023

Extracorporeal membrane oxygenation Of patients with out-of-hospital cardiac arrest presenting to the ED in refractory VF, a majority have significant coronary artery disease, much of which is amenable to percutaneous coronary intervention. Circulation. 2019;139(12):e530-e552. Yannopoulos D, et al. J Am Coll Cardiol.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

SEPTEMBER 27, 2023

This was written by Magnus Nossen, from Norway, with comments and additions by Smith A 50 something smoker with no previous medical hx contacted EMS due to acute onset chest pain. Upon EMS arrival the patient appeared acutely ill and complained of chest pain. Other coronaries were normal. How do you interpret the ECG?

Defibrillator 132

Defibrillator OR Coronary EMS 132

Dr. Smith's ECG Blog

MAY 23, 2023

EMS arrived and recorded this ECG: What do you think? 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. Litell JM, Meyers HP, Smith SW.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

JANUARY 8, 2024

She went to angio and had normal coronaries. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. Think of this diagnosis when a patient with CP and SOB + elevated troponin — has normal coronary arteries on cardiac cath. I discussed all results with patient.

Coronary 71

Coronary STEMI EMS OR 71

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS.

Coronary 52

Coronary ACS EMS ALS 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

When Pendell and I are coding ECGs for the Queen's training, this is one category: "Definite ischemia, difficult to differentiate between posterior OMI and subendocardial ischemia." The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. He was diagnosed as NSTEMI. Eur J Emerg Med.

ACS 82

ACS Coronary ALS CAD 82

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. 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

DECEMBER 9, 2023

A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA. Figure-1: The initial ECG in today's case — obtained by the EMS team. ( Regional wall motion abnormality- inferior and inferolateral. Why ECG #1 Looks Acute.

STEMI 115

STEMI Coronary ED Paramedic 115

Dr. Smith's ECG Blog

JULY 16, 2022

This illustration comes from Charles Bruen's great blog, Resus Review Coronary Artery Diagramming – Resus Review Charles is another illustrious graduate of the Hennepin EM Residency; actually, the EM/IM combined residency. Plus he did a 2 year combined EM Cardiology and Critical Care Fellowship.

Coronary 52

Coronary ED EMS Critical Care 52

Dr. Smith's ECG Blog

JANUARY 20, 2017

The case below was contributed by Pendell Meyers, an EM G1 at Mt. Here is a link to the case report: Dynamic T-wave inversions in the setting of left bundle branch block Though Wellens' syndrome was described in the LAD territory, I have shown cases demonstrating that it occurs in any coronary distribution. Sinai though!) Limkakeng AT.

STEMI 52

STEMI Coronary OR ALS 52

REBEL EM

FEBRUARY 22, 2023

Open angle Closed angle Definitions Increased resistance to aqueous outflow through the trabecular meshwork. 790-819 EM docs: Central Retinal Artery Occlusion CanadiEM: Medical Concepts – Acute Angle Closure Glaucoma Post Created By: Anand Swaminathan MD, MPH Post Peer Reviewed By: Salim R. Bagheri 2015 ).

Emergency Department 52

Emergency Department ALS ED Coronary 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. Amal Mattu’s ECG Blog has an excellent review of AVNRT vs. VT and REBEL EM reviews the sensitivity and specificity of various algorithms.

ALS 52

ALS EMS ED OR 52

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

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. En route, EMS administered aspirin 325mg by mouth, but withheld nitroglycerin due to initial hypotension. Answer below in the still shot.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

APRIL 20, 2019

EMS showed us their ECG on arrival at her house: What do you think? However, this STE is definitively abnormal in the setting of a normal QRS complex and hyperacute T-wave morphology in V2. The cardiologist arrived quickly and was skeptical about these findings on EMS ECG. We called for emergent cath lab activation.

STEMI 52

STEMI EMS Coronary OR 52

Dr. Smith's ECG Blog

MARCH 13, 2023

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. Since the patient has active pain now, if this is indeed Wellens,' she must be re-occluded at this moment. The Cath lab was activated.

ED 52

ED ACS Coronary Paramedic 52

Dr. Smith's ECG Blog

DECEMBER 19, 2018

In combination with the subtle ST depression in aVL , these changes are diagnostic for, or at least nearly so, for acute occlusion of a coronary artery, probably with some reperfusion, as inferior T-waves are inverted and the T-wave in aVL is reciprocally upright.

ED 52

ED Coronary OR Paramedic 52

Dr. Smith's ECG Blog

APRIL 29, 2020

EMS arrived and found her in a wide complex PEA rhythm. The ultimate reason for the long QT was never definitively determined. Drug-induced QT interval cannot be completely ruled out, but the tox consult found the she had definitely not overdosed and did not believe that therapeutic doses would do this.

Defibrillator 52

Defibrillator Epinephrine Coronary Overdose 52

Dr. Smith's ECG Blog

DECEMBER 15, 2023

The patient contacted EMS after a few hours of chest pain that started 5:30 AM. There is slight but definite ST elevation with an inverted T wave in lead aVL. Eventually with more training the QoH will outperform any human in the detection of acute coronary occlusion. He is otherwise healthy.

ACS 60

ACS STEMI Coronary EMS 60

Dr. Smith's ECG Blog

JUNE 20, 2020

The QRS duration is 118 ms , so by definition it is not Left Bundle Branch Block (which must be 120 ms at a minimum and is usually longer) Thus, LVH on the ECG does not always correlate with anatomic LVH. Discussion Thus, no further ECGs were recorded and there was no angiogram or stress test or CT coronary angiogram. There is LVH.

STEMI 52

STEMI CAD OR Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Coronary angiogram shows diffuse severe three-vessel disease. Read this post: Idiopathic Ventricular Tachycardias for the EM Physician 2.

Coronary 138

Coronary OR EMS ED 138

Dr. Smith's ECG Blog

AUGUST 9, 2024

About 2 hours later the patient arrived at a PCI-capable center and repeat ECG was obtained: The transferring EMS crew noted “runs of VT” during transport. Serial ECGs enhance the diagnosis of acute coronary syndrome. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Bigger et al.

STEMI 107

STEMI Coronary Heart Attack ACS 107

EMS 12-Lead

APRIL 28, 2022

David Didlake, NRP, APRN, ACNP-BC @DidlakeDW Expert analysis provided by Dr. Ken Grauer [link] @ekgpress EMS is called to the main reception area of a retirement center where an elderly female is found down, unconscious and unresponsive. She has a palpable pulse at the radial arteries, bilaterally, with shallow respirations.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

MAY 3, 2024

See the variety of Left Main Occlusion ECGs here: How does Acute Total Left Main Coronary occlusion present on the ECG? == MY Comment , by K EN G RAUER, MD ( 5/3 /2024 ): == Most patients with acute LMain Occlusion do not survive to make it to the hospital. Left Main Non-Occlusive ACS presents with widespread ST Depression and STE in aVR.

ACS 126

ACS ED Coronary EMS 126

EMS 12-Lead

MAY 8, 2022

EMS found her acutely ill, mottled, dry mucous membranes, modestly hypotensive, and lethargic. They are definitely high in amplitude and, intermittently, appear to disproportionately tower over the respective QRS. Example 1 EMS is called to the residence of an elderly male experiencing profound weakness. The serum K returned 8.7,

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. It shows a proximal LAD occlusion, in conjunction with a subtotally occluded LMCA ( Left Main Coronary Artery ). There is no definite evidence of acute ischemia. (ie, The below ECG was recorded.

Defibrillator 131

Defibrillator Coronary ALS STEMI 131

REBEL EM

MARCH 2, 2023

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient ’ s oxygen saturation. More recent evidence, however, demonstrates that too much oxygen could be harmful ( AVOID Trial ) by causing coronary vasoconstriction and increasing oxidative stress. Low O2 protocol: 3.1%

ACS 52

ACS Coronary STEMI Ambulance 52

REBEL EM

JANUARY 29, 2024

appeared first on REBEL EM - Emergency Medicine Blog. Background: Massive pulmonary embolism defined as sustained hypotension (SBP <90mmHg) has a high mortality which is why early recognition and thrombolytic therapy is typically recommended (AHA Class IIA; ESC Class IB) [1].

ALS 136

ALS ACS OR CPR 136

Dr. Smith's ECG Blog

OCTOBER 7, 2019

This is by one of our outstanding 3rd year residents , Aaron Robinson, with some edits and comments by Smith EMS responded to a reported seizure in a 42 year old male. One of our EMS Fellows along with a Senior EM Resident were on duty that evening, and arrived on the scene with the Fire Department.

STEMI 40

STEMI EMS Coronary ALS 40

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

Acute coronary occlusion is the most common and most treatable cause of this pattern, but it is not the only cause. Takotsubo, spasm, low flow with a preexisting stable coronary lesion, etc. The myocytes do not know why they are dying, they can only report their death and hope you can see it and figure it out.

STEMI 52

STEMI Coronary ACS Defibrillator 52