Core EM

JANUARY 25, 2024

Differentiating between the two is difficult as multiple proposed diagnostic criteria have yet to demonstrate sufficient sensitivity or specificity for a definitive diagnosis. Risk factors that increase the likelihood of VT include history of previous myocardial infarction, known coronary artery disease, and structural heart disease.

Coronary 246

Coronary Emergency Department ED OR 246

EMDocs

NOVEMBER 6, 2023

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association 2023 Guideline for managing cardiac arrest or life-threatening toxicity due to poisoning was recently released. This post will focus on the key parts of the guideline that affect ED evaluation and management. Top 10 Take Home Pearls 1.

Naloxone 94

Naloxone OR Overdose BLS 94

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. This included the addition several new STEMI equivalents [4] on ECG that warrant “prompt evaluation for emergency coronary angiography.”

STEMI 110

STEMI Coronary Emergency Department OR 110

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

This new ECG was still interpreted as STEMI and the patient was taken to the cath lab where the angiogram showed completely normal coronary arteries throughout. Smith : this ECG is definitely not OMI, but could be mistaken for Swirl pattern, which is a septal OMI with STE in V1 and STD in V6. Unfortunately no echo was available.

OR 120

OR STEMI EMS ED 120

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. Definitive diagnosis that ECG #1 is in fact VT is more than academic.

Coronary 139

Coronary OR EMS ED 139

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion. Deutch et al.

STEMI 105

STEMI Coronary ACS ED 105

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." He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival.

Overdose 52

Overdose OR Coronary ACS 52

Dr. Smith's ECG Blog

APRIL 9, 2024

Before the lab values returned this patient had a n emergent coronary CT angiogram done that ruled out CAD. A false positive cath lab activation is also off course acceptable for this diagnosis if you cannot get an emergent coronary CT angiogram. Each main coronary artery (LAD, RCA and LCx) are shown in separate images.

Coronary 94

Coronary CAD ACS OR 94

The Skeptics' Guide to EM

OCTOBER 20, 2018

The acute coronary syndrome work-up is negative but she is Well’s high and needs a CTPA to rule-out a pulmonary embolism. Part of the difficulty with this topic is the inconsistent definition of contrast-induced nephropathy. A common definition is an increase in creatinine level by 25% or an absolute increase of 0.3

Coronary 171

Coronary Emergency Department ALS OR 171

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

OCTOBER 24, 2018

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. You can see the deficiency of the definition of MI. Because there is reciprocal ST depression in aVL, this should not be called early repol. But maybe not.

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

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. He reports feeling nauseated with emesis.

Defibrillator 134

Defibrillator Coronary STEMI CPR 134

Dr. Smith's ECG Blog

JUNE 15, 2023

Thus, this does NOT meet STEMI criteria (though, as of 2022, it is a formal "STEMI equivalent", assuming everyone agrees that this is de Winter morphology, for which there is currently no objective definition). Even if a patient's ECG does meet STEMI criteria, it may not be perceived so. What a farce.

STEMI 93

STEMI Coronary ACS OR 93

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. We’ll keep it short, while you keep that EM brain sharp. Vital signs include BP 90/48, HR 122, T 98.3

EMS 75

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

Dr. Smith's ECG Blog

MARCH 17, 2024

Although radiation into the left arm is most classic for coronary ischemia, radiation into both arms is actually modestly more predictive ). Answer: This is MINOCA -- Myocardial Infarction with Non-Obstructive Coronary Arteries. His troponin peaked at 10.310 ng/mL and trended down. The name is self-explanatory.

Coronary 75

Coronary OR 75

Dr. Smith's ECG Blog

OCTOBER 18, 2023

When I saw the ECG of this patient I saw that there was definitely something "off". The patient was referred for coronary angiography which did not reveal any atherosclerotic changes. A formal echo at the PCI center after coronary angiography revealed a large septal and apical WMA. Troponin I peaked at 769 ng/L.

Defibrillator 108

Defibrillator Advanced Life Support Coronary Life Support 108

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

As per Dr. McLaren — today's patient was lucky in that the acute coronary occlusion spontaneously reperfused — and the patient remained pain-free. There’s clear T wave inversion in III/aVF, which is reciprocal to subtle ST elevation and hyperacute T waves in I/aVL (broad, symmetric, and larger than the entire QRS in aVL).

OR 131

OR STEMI Coronary Emergency Department 131

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

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. Coronary arteries cannot be assessed because the scan was not gated, but proximal segments of the coronary arteries seem to be open with some contrast. Again nothing diagnostic.

STEMI 52

STEMI EMR Coronary OR 52

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. There is no definite evidence of acute ischemia. (ie,

Defibrillator 117

Defibrillator Coronary ALS STEMI 117

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

Dr. Smith's ECG Blog

AUGUST 9, 2024

Serial ECGs enhance the diagnosis of acute coronary syndrome. Although recognition of OMI was not affected by administration of morphine in this case, use caution with analgesia in ongoing ACS without a definitive plan for angiography. This can occur due to scar ( e.g. post infarct VT) or anatomical variants ( e.g. AVNRT or AVRT).

STEMI 88

STEMI Coronary Heart Attack ACS 88

EMDocs

JULY 1, 2023

Upon further research in the 1970’s, retrospective data from autopsies of those patients showed coronary aneurysms 5 Pathophysiology: Kawasaki Disease is a vasculitis of medium sized arteries. Tomisaku Kawasaki, who noticed 50+ similar pediatric presentations between the years 1961 and 1967.

EMS 66

EMS Coronary ED OR 66

Dr. Smith's ECG Blog

JULY 2, 2023

A delta of 3 ng/L definitely would not rule-in MI for any assay, but it does raise the possibility that further measurements would result in a 4- or 6-hour troponin above the URL and thus make the diagnosis of acute MI. We don't know if he had a stress test, a CT Coronary angiogram, or they just decided to do an angiogram.

ACS 52

ACS Coronary OR 52

Dr. Smith's ECG Blog

APRIL 17, 2023

Verouden, Wellens, and Wilde ) submitted a Letter to the Editor to the New England Journal of Medicine ( N Engl J Med 359:2071-2073, 2008 ) — in which they described a “new ECG pattern” without ST elevation that signifies acute occlusion of the proximal LAD ( L eft A nterior D escending ) coronary artery. QOH: "Not OMI, High confidence."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

AUGUST 20, 2024

Record serial ECGs == MY Comment , by K EN G RAUER, MD ( 8/16 /2024 ): == It is always a challenge to interpret an ECGs from a patient with known coronary disease, but no prior tracing for comparison. Given the known history of coronary disease — multiple previous ECGs certainly were done. Use the Queen of Hearts 2.

Coronary 67

Coronary OR 67

EMS 12-Lead

AUGUST 22, 2022

They are not premature, by definition. A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside. From afar, there is gross tachycardia, cadence irregularities, and narrow QRS complexes that may, or may not, be Sinus in origin; and finally – a cacophony of wide complexes that might very well be ventricular in origin.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event. The "good news" — is that a cardiac-related cause of syncope is unlikely if the initial ECG is normal, and cardiac monitoring in the ED fails to reveal significant arrhythmia.

EMS 108

EMS CPR ED Coronary 108

Dr. Smith's ECG Blog

JULY 31, 2020

Yet despite this remarkable flaw in the STEMI-paradigm — a substantial number ( if not a frank majority ) of clinicians continue to apply outdated criteria when interpreting ECGs, by refusing to consider prompt cath for definitive diagnosis and reperfusion therapy just because a millimeter-based definition for acute STEMI is not satisfied.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

OCTOBER 12, 2023

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. with the important message that sometimes ( especially in retrospect! ) — a definite diagnosis can not be made. The ECG shows sinus rhythm.

Coronary 106

Coronary OR ED 106

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. Am J Emerg Med 2023 2.

STEMI 74

STEMI Coronary OR ALS 74

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. First, many on Twitter said "Pericarditis". Medical Rx.

Coronary 52

Coronary STEMI ALS OR 52

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

APRIL 4, 2023

Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. As he documented, “This patient is experiencing chest pain consistent with an acute coronary syndrome. Start using the terms acute coronary occlusion and occlusion MI. This is diagnostic of OMI, either proximal LAD or first diagonal. OMI or STEMI?

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. In an attempt to clarify language, a consensus definition was developed. Back to the case. ECG 2 What do you think?

E-9-1-1 120

E-9-1-1 OR Coronary ACS 120

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. As per Drs.

ACS 87

ACS Coronary ALS CAD 87

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. that is, show a pattern of labile ST-T wave changes not due to an acute coronary event. I personally can hardly wait for that future version! Learning Point: 1.

E-9-1-1 111

E-9-1-1 Coronary EMS ED 111