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]. Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present."

E-9-1-1 131

E-9-1-1 OR Coronary ACS 131

Dr. Smith's ECG Blog

JANUARY 9, 2024

The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). This patient presented to the ED “after a couple of days of chest discomfort”. Remember that this patient presented to the ED “after a couple of days of chest discomfort”.

Coronary 119

Coronary ACS ED OR 119

Dr. Smith's ECG Blog

OCTOBER 12, 2024

EKG on arrival to the ED is shown below: What do you think? The providers documented concern for ST elevation in the precordial and lateral leads as well as a concern for hyperkalemic T waves in the setting of succinylcholine administration. or basilar ischemia. However, T waves do not appear to be hyperacute or hyperkalemic.

STEMI 116

STEMI Coronary Emergency Department ACS 116

Dr. Smith's ECG Blog

JANUARY 31, 2020

A middle-aged man complained of 15 minutes of classic angina that resolved upon arrival to the ED. But it does prove that the patient has coronary disease and makes the probability that his chest pain is due to ACS very very high. Figure-1: The initial ECG that was done in the ED ( See text ).

ED 52

ED Coronary ACS CAD 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

6] Among 394 emergency department Code STEMI patients with acute culprit lesion requiring coronary interpretation, 16 (4.1%) presented with an ECG labeled ‘normal’ or ‘otherwise normal’ by computer interpretation. have published a number of warnings about the previous reassuring studies.[4,5] minutes).

STEMI 119

STEMI Emergency Department Coronary OR 119

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

It was worse on the evening prior to presentation while lying in bed, then recurred and resolved while at rest just prior to arriving in the ED. Here is the first ED ECG, with no pain: Sinus rhythm. It is well documented with continuous 12-lead monitoring that acute re-occlusion is frequently asymptomatic. Akkerhuis KM, et al.

Coronary 52

Coronary STEMI ALS Emergency Department 52

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. Then what? He survives.

ACS 85

ACS ALS ED Coronary 85

ACEP Now

APRIL 4, 2024

A 59-year-old male with a past medical history of a repaired ventricular septal defect (VSD), dextrocardia, hypertension, hyperlipidemia, and current smoker presented to the emergency department (ED). This patient had known coronary artery disease (CAD), and previously required drug eluting stents to the obtuse marginal and diagonal arteries.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. Then this was recorded in the ED 10 minutes after the first: Now there is massive STE Many inferior MI are associated with RV MI. BOTTOM — 2nd ECG obtained 10 minutes later in the ED ( See text ). She called 911.

Coronary 52

Coronary STEMI ED ALS 52

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 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

JULY 27, 2023

On arrival to the ED, the patient was diaphoretic, tachycardic. I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? I was not worried for a coronary etiology. He had a prehospital ECG that was worrisome to the medics, so they called me to see him at the door. and had dilated pupils.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

JUNE 28, 2019

T he C ASE : The patient is a 60-something who presented to the ED with n ew- o nset c hest p ain. K EY P oints : This patient has known coronary disease. In this patient with documented coronary disease — these q waves could reflect prior lateral infarction ( especially in view of the Q in lead aVL ). It was stented.

Coronary 52

Coronary ACS ED OR 52

Dr. Smith's ECG Blog

MAY 16, 2023

Emergent CT coronary angio also likely has a role in such cases. Like they would for any other acute arterial occlusion syndrome (such as suspicion of acute large vessel stroke), they take the patient across the hall and perform an immediate CT (coronary) angiogram, showing patent coronaries.

Coronary 52

Coronary STEMI ED OR 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. Setting – large, academic, suburban ED. CT aorta negative for dissection.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

MARCH 19, 2023

To realize — Assessment of ECG #1 is complicated by knowing: i ) That today’s patient has a history of documented CAD ; and , ii ) The lack o f a prior tracing for comparison at the time the initial ECG was interpreted. Figure-1: Comparison between the first 3 ECGs in today’s case. What We Learn from the Prior Tracing?

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

JUNE 14, 2017

The P wave is positive in lead aVL of ECG #3, which means it is a low atrial (or probably coronary sinus) rhythm — which of itself is not necessarily “abnormal” in a child if there is no other sign of underlying heart disease. As we see in ECG #3 — the regular rhythm is NOT sinus, because the P wave is negative in lead II.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

A middle-aged man presented with 7-8/10 non-radiating chest tightness to the left chest wall, associated with nausea but no diaphoresis, that began while walking approximately 40 minutes prior to arrival at the ED. He was definitely pain free by the time of arrival at his ED room. What do you think? Chest Pain scores can be misleading.

ED 52

ED STEMI Coronary Emergency Department 52

Dr. Smith's ECG Blog

APRIL 15, 2020

An elderly woman with history of coronary disease presented with CP and SOB and hypotension by EMS. Here is her ED ECG: Here is the ED physician's interpretation: IMPRESSION UNCERTAIN REGULAR RHYTHM, wide complex tachycardia, likely p-waves. The patient was given a small dose of etomidate and electrically cardioverted in the ED.

Coronary 52

Coronary ED OR Overdose 52

Dr. Smith's ECG Blog

APRIL 15, 2019

Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. link] An angiogram was done: It showed no culprit and no coronary disease, but did show a myocardial bridge in the mid LAD.

Coronary 40

Coronary STEMI OR ED 40

ACEP Now

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. Acute myocardial infarction with normal and near normal coronary arteries. Electrical Injuries. 2023 Jul 17. In: StatPearls [Internet].

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JULY 22, 2023

An ECG was performed in the ED at 1554: Original image unavailable, this is the only recorded scanned ECG available. QOH Interpretation: The initial troponin I (older generation) at the first ED was barely positive at 0.06 He denied chest pain or shortness of breath. See below for PM Cardio digitized version of this.

E-9-1-1 92

E-9-1-1 CAD OR STEMI 92

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. At the time of arrival to the ED, the patient reported 1/10 chest pain with normal vital signs. Triage EKG: What do you think?

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. Around 19 hours later, he experienced the same pain, which prompted his presentation to the ED.

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

MARCH 31, 2023

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. What About the Initial ECG?

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

The patient was in his 50s with history of hypertension, diabetes, seizure disorder, and smoking, but no known coronary artery disease. We performed a beside US (shown below) which showed lateral wall hypokinesis as read by an US-boarded ED attending in real time. 418 of these 1788 (23%) had acute coronary occlusion.

STEMI 40

STEMI Coronary ALS OR 40

Dr. Smith's ECG Blog

APRIL 17, 2023

One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

JUNE 27, 2021

They gave him 2 nitroglycerine and transported to the ED. In the ED, the patient was "moaning, writhing in bed, and clutching his chest." Here is the first ED ECG (there was no previous ECG on file for comparison): Sinus rhythm and LVH There is some (less than 1 mm) of STD in V3 and V4. There is no significant ST Elevation.

STEMI 40

STEMI ACS Coronary ED 40

Dr. Smith's ECG Blog

AUGUST 8, 2020

This is a re-posting of a Tweet by Robert Jones (@RJonesSonoEM), reproduced with permission, written by Pendell Meyers A middle aged female with history of smoking presented to the ED with "bad heartburn." Here is her prior baseline ECG (first), and her ED ECG (second): Baseline: ED ECG: What do you think?

STEMI 52

STEMI ED Coronary OR 52

Dr. Smith's ECG Blog

JUNE 30, 2023

Smith and Meyers containing thousands of tracings with documentation of cardiac catheterization results. Along the way to acquiring more experience in recognizing the ECG findings of acute coronary occlusion — is incorporation of a number of KEY ECG Features into one's clinical acumen.

E-9-1-1 52

E-9-1-1 Coronary ED OR 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2019

It is true that other documents occasionally describe "abnormal ST segment elevation" in the posterior leads (commonly accepted criteria is 0.5 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."

STEMI 52

STEMI E-9-1-1 ACS OR 52

Dr. Smith's ECG Blog

JUNE 20, 2018

The medicine note documents that the patient had worsening pain with lying flat and relief with leaning forward. Upwardly Concave ST Segment Morphology Is Common in Acute Left Anterior Descending Coronary Artery Occlusion. Myocarditis is virtually indistinguishable in the ED from MI. 2 comments : 1. 0 0 1 24 140 MMRF 1 1 163 14.0

Overdose 52

Overdose OR STEMI Coronary 52

Dr. Smith's ECG Blog

APRIL 8, 2016

Here is his ED ECG: There is obvious infero-posterior STEMI. Document in the patient's chart that rapid infusion is intentional in response to life-threatening hypokalemia." Over a 13-month period, serum potassium and magnesium levels were measured in 590 patients admitted to a coronary care unit. He appeared to be in shock.

STEMI 52

STEMI Plasma Defibrillator OR 52

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. paramedic transportation to the ED as “chest pain, STEMI negative” 2. Take home 1. Eur Heart J 2019 5.

STEMI 86

STEMI Coronary Paramedic ALS 86

Dr. Smith's ECG Blog

APRIL 8, 2015

Summary of ED Approach to Syncope Please excuse the formatting problems, which I have not been able to fix! Thus, if there is documented sinus bradycardia, and no suspicion of high grade AV block, at the time of the syncope, this is very useful. Any ED systolic blood pressure less than 90 or greater than 180 mm Hg (+1) 4.

Emergency Department 52

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

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. Her history and ECG were interpreted as very concerning for acute coronary syndrome which might benefit from acute reperfusion therapy. KEY Points: DSI does not indicate acute coronary occlusion!

Coronary 119

Coronary ACS STEMI CAD 119

Dr. Smith's ECG Blog

DECEMBER 27, 2024

Documentation lists a diagnosis of "sinus tachycardia." The patient was then sent to the ED for evaluation not by ambulance but driven to the ED by his wife. Finally Dr. Frick details how today's patient was found to have severe, stable coronary disease without evidence of an acute event. He was admitted to cardiology.

Coronary 121

Coronary Defibrillator ACS ED 121