EMDocs

OCTOBER 29, 2024

Chu CK, Delia E, Mograder A, Dwyer EM. 2017;45(1):12-20. 2015;7(9):E365-E369. 2018;12(1). 20594 MOZELL D, SHAH N, CASTILLON JJR, GONUGUNTLA VT, AWERBUCH E. J Saudi Hear Assoc. 2018;30(4):336. doi:10.1016/J.JSHA.2018.07.001 2018.07.001 Sherrid M V., J Am Coll Cardiol. 1993;22(3):816-825. Anaesth Intensive Care.

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E-9-1-1 ICU Epinephrine EMS 87

Dr. Smith's ECG Blog

JUNE 17, 2024

Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. C Examination notable for diaphoresis, 1+ bilateral lower extremity edema, regular heart rate and rhythm, and no signs of respiratory distress with normal breath sounds. What do you think? In fact, Kosuge et al. Stein et al.

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E-9-1-1 ACS Emergency Department Coronary 136

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

ECG & Echo Learning

MARCH 8, 2023

Management must, however, be individualized with respect to the delay to coronary angiography (PCI). Guidelines recommend the use of validated risk models to estimate the risk of acute myocardial infarction , 30-days and 1-year mortality in patients with NSTE-ACS. Circulation. 2000 Oct 24;102(17):2031-7.

STEMI 40

STEMI E-9-1-1 ACS Coronary 40

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. 1 Risk Factors: 1-4 Spontaneous Anticoagulants (Apixaban, Rivaroxaban, etc.)

EMS 74

EMS E-9-1-1 Operating Room OR 74

Dr. Smith's ECG Blog

NOVEMBER 11, 2024

The ECG shows sinus rhythm with a rate of about 78 and 2:1 AV conduction along with right bundle branch block and left anterior fascicular block. 2:1 block is a special case, because the tracing lacks successive PR intervals. I have labeled the P waves below for ease of reference: P waves 8 and 9 both conduct to the ventricles.

OR 71

OR E-9-1-1 Coronary 71

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. The patient proceeded to cath where all coronaries were described as normal with no evidence of any CAD, spasm, or any other abnormality. So maybe she is better than I am.

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EMS 12-Lead

APRIL 28, 2022

Initial vital signs include: NIBP 99/58 HR 150-160 (trend) RR 10 (spontaneous, but shallow) SpO2 86 (RA) BBS CTA The initial rhythm strip is attached: Figure 1 There is a wide complex tachycardia of varying morphology, amplitude, and R-R cycle length. A prominent vertical scar, however, is noted at the sternum.

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EMS 12-Lead

AUGUST 22, 2022

Question 1: What is the rhythm? Beat 1 : Sinus, narrow QRS complex. The assumption is that a premature complex discharged prior to Beat 1, which prolonged its respective refractory period in the same manner as Beat 5. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration.

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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. Learning Point: 1. For examples of such exceptions — See My Comment in the January 9, 2019 — August 22, 2020 — and June 30, 2023 posts in Dr. Smith's ECG Blog ).

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Dr. Smith's ECG Blog

NOVEMBER 30, 2022

mm of ST segment elevation, V2 and V3 have 1 mm of elevation, v4 has 2 mm of elevation and v5 around 1.5 Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy. What do you think?

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

JUNE 30, 2023

Queen: #1: NOT OMI, HIGH CONFIDENCE Queen: #2: NOT OMI, HIGH CONFIDENCE ECG 1 Interpretation: there is terminal T-wave in V3-V6. LEARNING POINT : 1. 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.

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Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. Figure-1: The initial ECG in today's case — obtained after ROSC.

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E-9-1-1 Defibrillator CPR STEMI 89

Dr. Smith's ECG Blog

JULY 24, 2024

Easy LINK — [link] — My New E CG P odcasts ( 5/28/2024 ): These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ( "Making Waves" ) — hosted by Dr. Anthony Kashou. 0:00 — Intro by Dr. ) — published by Mayo Clinic CV Podcast Series on 1/16/2024 ( 33 minutes ). 9:25 — Are there hyperacute T waves?

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E-9-1-1 Coronary STEMI OR 52

Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pain is described as located in the midsternal area, radiating to the right arm, described as 8-9/10 and worse with deep inspirations. In the evening, he became diaphoretic and complained of 9/10 continuous chest pain. If there is NO WMA, then it is not coronary occlusion, but if there IS one, then you still don't have a diagnosis.

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ECG & Echo Learning

OCTOBER 2, 2022

Most agents exhibit both vasopressor and inotropic effects (Figure 1). Below follows a drug manual for use in the CCU (coronary care unit), ICU (intensive care unit) or ER (emergency room). μg/kg/min + + + ++ Low dose dopamine stimulates D1 receptors and induces vasodilation in coronary, renal, cerebral and mesenteric vessels.

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E-9-1-1 ALS Coronary Epinephrine 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. As you take another LOOK at ECG #1 — What is the relevance of the findings that I've labeled in Figure-1 ?

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E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

MARCH 9, 2023

He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. Proven STEMI has an open artery in 19% to 36% of cases, depending on whether it is TIMI −1, −2, or −3 flow. 25] Stone et al found that 72% have TIMI 0 or 1 flow.

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EMDocs

OCTOBER 30, 2023

1 The shortage in supply posed difficulties for hospitals that significantly depend on GE Healthcare as their supplier, which encompassed approximately 50% of hospitals in the United States (US). 11 Table 1. Preparation 9 Hospitals had to prepare for the impending contrast shortage as soon as potential shortage news occurred.

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Dr. Smith's ECG Blog

APRIL 22, 2022

But these cases show the potential dangers of delayed recognition and treatment of inferior reperfusion Take away 1. ECG’s can be labeled as ‘normal’ by the computer (and confirmed by cardiology) even with diagnostic signs of occlusion or reperfusion References 1. JAMA Intern Med 2019 9. Am J Med [Internet] 2017;130(9):1076–83.e1.

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E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

MAY 30, 2023

We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. 1 mg of Atropine was given and the heart rate increased transiently to 60. Atropine usually works in junctional rhythm with a narrow complex 9. What to do? RVMI explains part of the shock.

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E-9-1-1 STEMI Coronary OR 82

REBEL EM

SEPTEMBER 26, 2022

2020;71(1):235-246. Plt 37×10^9/L and 40×10^9/L, SOC and TEG, respectively) All patients enrolled had an upper endoscopy and verified the source of bleeding. Article: Kumar M et al. Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial.

FFP 52

FFP E-9-1-1 ICU ALS 52

Dr. Smith's ECG Blog

MAY 26, 2023

Learning Points: 1. If the situation is not right for acute coronary occlusion, then the ECG findings probably do not represent acute coronary occlusion. Despite the eye-catching ST-T wave changes that came-and-went a number of times — there was no acute coronary occlusion. Figure-1: The first 2 tracings in today's case.

Overdose 88

Overdose E-9-1-1 Coronary OR 88

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

He was taken emergently to the cardiac catheterization lab and found to have multi-vessel coronary artery disease with a near-occlusive culprit lesion in the RCA, possibly reperfused. Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent.

E-9-1-1 52

E-9-1-1 Coronary STEMI Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. Here they are: Learning Points: 1. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. In acute MI, the T-wave is large, and the T/ST ratio is high. This is much more typical of myocarditis.

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E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

MAY 19, 2022

Ct coronary angiogram showed normal coronary arteries. Smith note: I think CT coronary angiogram is reasonable with the elevated troponins and symptoms. Regarding the History: It sounds from the History as if this patient has at least a significant component of EIA ( E xercise- I nduced A sthma ).

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Dr. Smith's ECG Blog

DECEMBER 13, 2019

On review of systems the patient reported back pain for approximately 1 week which he was treating with NSAIDs with minimal relief. I’ve excerpted in Figure-1 , relevant paragraphs from a 2017 ESC ( European Society of Cardiology ) article on this subject by Xanthopoulos & Skoularigis ( ESC: Vol. 15-9/6/2017 ).

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E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

4 important features that indicate acute right hear strain: 1. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with APE (p less than 0.001). They found that only 11% of PE had 1 mm T-wave inversions in both lead III and lead V1, vs. 4.6%

E-9-1-1 52

E-9-1-1 ACS ALS OR 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

The coronaries were clean (this is not the gold standard, however, as some patients with ischemic ST elevation may have clean coronaries). ACTUAL CORONARY ANATOMY: Dominance: Right LM: A 5 mm vessel which bifurcates into the LAD and LCx coronary artery. QRSV2 = 16 RAV4 = 14 Value = 20.24 (The cutoff of 18.2

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

Dr. Smith's ECG Blog

FEBRUARY 8, 2015

Vittinghoff, E. Metoprolol and atenolol are overwhelmingly beta-1 cardioselective. Beta-1 blockade decreases inotropy and chronotropy and has no vasoconstrictive effects. The prohibition against beta blockade in cocaine toxicity, causing "unopposed alpha" stimulation, needs to be re-examined. is intuitive, and not surprising.

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E-9-1-1 Coronary Epinephrine Overdose 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. E CG # 1 = the initial Triage ECG ( TOP ) — As per Dr. . = Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. Why is this important? Thelin et al. Mokhtari et al.

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E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

JANUARY 16, 2020

Angiogram showed a 99% left main thrombotic occlusion with TIMI-1 flow (this is considered "occlusion" even though there is some flow. not left main occlusion == MY Comment by K EN G RAUER, MD ( 1/16/2020 ): == I did not correctly identify the “culprit artery” in this case. mEq/L Her BP with pressors came up to 80, then 100.

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E-9-1-1 STEMI Coronary 52

Dr. Smith's ECG Blog

AUGUST 3, 2017

There are two main etiologies of ischemic ST-depression: 1) subendocardial ischemia 2) reciprocal to ST-elevation in an opposite wall Here there are distinct R-waves with marked ST-depression throughout most of the precordium. Tips for recognizing Acute Posterior STEMI: 1. References: 1. This can help in confirmation.

STEMI 52

STEMI E-9-1-1 Coronary ALS 52

AAEM RSA

AUGUST 27, 2020

1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. Kirkegaard H, Soreide E, de Haas, I et al. De Fazio C, Skrifvars MB, Soreide E et al. 2019;23(1):1–9.

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E-9-1-1 CPR ICU ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

The Differential Diagnosis is: SVT with aberrancy(#) [AVNRT vs. WPW (also called AVRT*)] Atrial flutter with 1:1 conduction, with aberrancy VT coming from the anterior fascicle ( fascicular VT )@ *AVRT = AV Reciprocating Tachycardia (Tachycardic loop that uses both the AV node and an accessory pathway. See Learning point 1 below.

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E-9-1-1 ALS OR Coronary 52

EMDocs

JANUARY 11, 2024

The neurologic section was divided into (1) brain oxygenation, perfusion, edema, and intracranial pressure (ICP); (2) seizures and the ictal-interictal continuum (IIC); and (3) sedation and analgesia. Reference: Hirsch KG, Abella BS, Amorim E, et al; American Heart Association, Neurocritical Care Society. 2023 Dec 1.

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Critical Care E-9-1-1 OR ICU 75

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Is this due to coronary occlusion? The medic activated the cath lab but was refused by the interventionalist, who did not believe that this ECG represented acute coronary occlusion. Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Why did I say this? Look at aVF.

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E-9-1-1 STEMI Coronary CAD 52