EMS 12-Lead

MAY 20, 2022

Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. Below is the initial ED ECG.

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. They too have dense white masses consistent with coronary atherosclerosis. Annals of Emergency Medicine 2011; Suppl 58(4): S211.

CAD 126

CAD STEMI Coronary ACS 126

EMDocs

SEPTEMBER 19, 2023

On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Official diagnosis requires EEG, which is not something we can typically obtain in the ED. STEMI vs. NSTEMI dichotomy is not sensitive for true occlusion MI or acute coronary occlusion. J Am Coll Cardiol.

STEMI 72

STEMI Coronary Emergency Department EMS 72

EMS 12-Lead

AUGUST 14, 2022

The specific ST/T pattern was not fully appreciated by the attending EMS personnel, yet alarming enough to convince the patient to be seen in the Emergency Department despite his intentions of seeking evaluation on his own accord through his respective family physician. But the lesion is still active! MICU transport was unremarkable.

STEMI 130

STEMI MICU CAD Coronary 130

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). link] ] Outcome The patient emerged neurologically intact. Clinical Cardiology 2019.

STEMI 96

STEMI Coronary Defibrillator EMS 96

Dr. Smith's ECG Blog

OCTOBER 18, 2023

If you were working in a busy emergency department, would you like to be interrupted to interpret these ECGs or can these patients safely wait to be seen because of the normal computer interpretation? Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med.

STEMI 121

STEMI Emergency Department Coronary OR 121

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI 104

STEMI Coronary ACS ED 104

EMS 12-Lead

APRIL 21, 2022

There is appreciable STE aVR with near-global STD that appropriately maximizes in Leads II and V5, and thus suggesting a circumstance of generic, diffusely populated, circumferential subendocardial ischemia versus occlusive coronary thrombus. [1] It’s judicious, then, to arrange for coronary angiogram. link] [1] Mirand, D.

Coronary 130

Coronary ALS OR ACS 130

ALiEM

FEBRUARY 9, 2024

Encourage your ED to set up an algorithm that you can follow based on your laboratory’s assay. Low-risk patients do not routinely require stress testing in the ED. You (or someone in your department) needs to know which assay your ED has, and use the appropriate values for that assay.

E-9-1-1 276

E-9-1-1 ED Coronary ALS 276

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. Kontos et al.

STEMI 62

STEMI Coronary Paramedic ALS 62

EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). Utility of the history and physical examination in the detection of Acute Coronary Syndromes in emergency department patients. Western Journal of Emergency Medicine, 18 (4), 752-760. [2]

ACS 130

ACS Paramedic Coronary ALS 130

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 133

Defibrillator Coronary STEMI CPR 133

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. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. Emerg Med Pract. Electrical Injuries.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. A recent angiogram report indicated a totally occluded left anterior descending artery (LAD) and right coronary artery (RCA), with 30-40% narrowings in the left circumflex artery (LCx).

Coronary 99

Coronary EMR STEMI Emergency Department 99

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). This finding does not alter the need to pursue emergent reperfusion, although it might suggest a poorer prognosis.”[3] Incidence of an acute coronary occlusion.

Coronary 52

Coronary ACS STEMI ALS 52

REBEL EM

FEBRUARY 22, 2023

difficult to see due to corneal edema) Emergency Department Management All patients should get emergency ophthalmologic consultation Start with eye drops (see table below) and add systemic medications if severe or refractory symptoms/IOP. et al, Emergency Medicine Clinical Essentials ed 2. Cup to disc ratio >0.6

Emergency Department 52

Emergency Department ALS ED Coronary 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. He survives.

ACS 85

ACS ALS ED OR 85

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. 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. 2022 Jan;51:384-387.

STEMI 88

STEMI Coronary Paramedic OR 88

Core EM

JULY 23, 2024

Objective: Based on current evidence, this review article aims to guide the Emergency Department (ED) in providing care for patients with blast injuries. Cardiovascular: Injury: cardiac contusion, wall rupture, tamponade, papillary muscle rupture, valve injury, aortic arch injury, and coronary artery dissection.

EMS 100

EMS Emergency Medical Services OR Coronary 100

EMDocs

MARCH 25, 2024

2, 3 Biliary POCUS can help decrease patient length of stay in the Emergency Department. 2, 3 Biliary POCUS can help decrease patient length of stay in the Emergency Department. Utility of common bile duct measurement in ED point of care ultrasound: A prospective study. Am J Emerg Med. 2022;7:188-189.

ALS 87

ALS Coronary Emergency Department ED 87

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. Missing occlusions: quality gaps for ED patients with occlusion MI.

STEMI 74

STEMI Coronary OR ALS 74

Dr. Smith's ECG Blog

MARCH 17, 2023

Submitted by anonymous, written by Pendell Meyers A woman in her 50s presented to the Emergency Department with chest pain and shortness of breath that woke her from sleep, with diaphoresis. She was ultimately discharged home after ED workup. Her vitals were within normal limits.

Coronary 52

Coronary Emergency Department ED OR 52

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. Figure-1: The first 2 tracings in today's case. The Need for Immediate Transport?

OR 131

OR STEMI Coronary Emergency Department 131

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. MINOCA: Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease). 2) overlooked obstructive coronary disease (e.g.,

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Core EM

MARCH 7, 2024

Objective: Based on current evidence, this review article aims to guide the Emergency Department (ED) in providing care for patients with blast injuries. Cardiovascular: Injury: cardiac contusion, wall rupture, tamponade, papillary muscle rupture, valve injury, aortic arch injury, and coronary artery dissection.

EMS 100

EMS Emergency Medical Services OR Coronary 100

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

While in the ED, patient developed acute dyspnea while at rest, initially not associated with chest pain. The patient had no chest symptoms until he had been in the ED for many hours and had been undergoing management of his DKA. The patient was under the care of another ED physician. Another ECG was recorded: What do you think?

ED 105

ED Coronary CAD STEMI 105

Dr. Smith's ECG Blog

OCTOBER 3, 2018

When he showed it to me, I said "Ouch, looks like an acute coronary occlusion. For some reason unknown to me, the interventionalist was in the ED. no LBBB or paced rhythm), acute coronary occlusion MI (OMI) is diagnosed in approximately 75% of cases. What happened?" On arrival, the patient went into ventricular fibrillation.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." 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.

Emergency Department 52

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

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

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG: What do you think?

ACS 52

ACS Coronary Defibrillator STEMI 52

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. The remainder of his Emergency Department stay was uneventful. Full case details and outcomes are below.

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

An ECG was recorded quickly on return to the ED: (sorry for poor quality, cannot get originals) What do you think? On arrival to the PCI center's Emergency Department, the receiving team recorded an ECG on arrival: Persistent atrial flutter, however this time the QRS occurs on a slightly different portion of the flutter wave.

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

MARCH 6, 2023

Study idea: We should look at all OMIs who had a chest CT and compare to all patients with Non-OMI pathology who had a contrast chest CT and have radiologists blindly interpret the perfusion of the myocardium The cardiology fellow came down to the ED and said: "What are you worried about? This ST depression?" 2022.08.750 Section 5.2.2,

OR 52

OR STEMI ED Critical Care 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. And so it is wise to look at the coronary arteries. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. He was moderately hypoxic. Angiogram was negative.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

EMDocs

OCTOBER 21, 2023

A 68-year-old male with a past medical history of hypertension, diabetes mellitus, and coronary artery disease with a drug eluting stent placed 2 months ago presents with dizziness and vomiting that began 3 hours ago. Median time from ED arrival to diagnosis was 8 hours 24 min in one study, with only 19% being diagnosed within the 4.5-hour

EMS 74

EMS ALS OR ACS 74

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

FEBRUARY 4, 2022

Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med. In our case, the emergency physician was well trained in identifying subtle LAD Occlusion MI and ignored the computer. 2022 Jan;51:384-387. doi: 10.1016/j.ajem.2021.11.023. 2021.11.023.

STEMI 52

STEMI Coronary Emergency Department OR 52