REBEL EM

SEPTEMBER 21, 2023

What Your Gut Says: The patient has a tachydysrhythmia which may be the presentation of acute coronary syndrome (ACS) even though the patient has no ischemic symptoms. Essentially, we are using the troponin assay to find patients with ACO who may be benefited by coronary interventions or risk factor modification. Cardiol Rev.

Coronary 143

Coronary ACS ED OR 143

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Here is the case: Report from EMS was witnessed syncope, his son did CPR, but the patient had pulses when EMS arrived. When the patient arrived in the ED, he was still hypotensive in 70s, slowly improving with EMS fluids. Here is the ED ECG (a photo of the paper printout) What do you think?

EMS 114

EMS CPR ED Coronary 114

EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. It’s judicious, then, to arrange for coronary angiogram.

Coronary 130

Coronary ACS CAD ED 130

EMS 12-Lead

MAY 20, 2022

Fire/EMS personnel find her laying supine on the kitchen floor, awake and verbal, although acutely ill. 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. Below is the initial ED ECG.

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

JULY 25, 2024

EMS arrived and found him in Ventricular Fibrillation (VF). The patient was brought to the ED and had this ECG recorded: What do you think? The patient was brought to the ED and had this ECG recorded: What do you think? But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

EMS 12-Lead

AUGUST 14, 2022

EMS personnel found him seated on a bench, uncomfortable, but without gross distress. A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis. He waited for it to subside, but after 30 minutes of persistence he called 911. But the lesion is still active!

MICU 130

MICU STEMI CAD Coronary 130

EMDocs

OCTOBER 21, 2023

We’ll keep it short, while you keep that EM brain sharp. 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. Post TW, ed. hour IV thrombolytic window.

EMS 97

EMS ALS OR ACS 97

Core EM

SEPTEMBER 16, 2024

The Case A 96-year-old female with a history of coronary artery disease, hypertension, and complete heart block status post dual-chamber pacemaker (remote) presents to the ED by EMS with generalized weakness and lethargy. This rhythm will not result in cessation with magnet application.

Coronary 130

Coronary ED EMS OR 130

Core EM

SEPTEMBER 11, 2024

The Case A 96-year-old female with a history of coronary artery disease, hypertension, and complete heart block status post dual-chamber pacemaker (remote) presents to the ED by EMS with generalized weakness and lethargy. This rhythm will not result in cessation with magnet application.

Coronary 130

Coronary ED EMS OR 130

EMS 12-Lead

AUGUST 18, 2024

David Didlake EMT-P, RN, ACNP @DidlakeDW An adult male self-presented to the ED with palpitations and the following ECG. Ultimately the patient went to Cath and was found to have multi-vessel obstructive coronary disease with an acute LCX culprit vessel, which was stented.

CAD 147

CAD EMT EMT ACS 147

EMS 12-Lead

JUNE 20, 2022

According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician. One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. Here is the LAD after stent placement.

ACS 130

ACS Coronary STEMI CAD 130

EMS 12-Lead

JUNE 1, 2022

EMS finds him supine, alert and oriented, and without any gross distress. He advises, however, recurrent syncopal episodes for the past six months, some of which have resulted in ED admission, yet no identifying mechanism could be determined. It’s reported that he regained consciousness after 30 seconds, approximately.

Coronary 130

Coronary ALS ED ACS 130

EMS 12-Lead

MAY 8, 2022

EMS found her acutely ill, mottled, dry mucous membranes, modestly hypotensive, and lethargic. This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2]

STEMI 130

STEMI ED EMS Firefighter 130

EMS 12-Lead

MARCH 19, 2023

Fire/EMS crews found him clammy and uncomfortable. He denied any known medical history, specifically: coronary artery disease, hypertension, dyslipidemia, diabetes, heart failure, myocardial infarction, or any prior PCI/stent. Learning points 1] Acute Coronary Syndrome has many shades of clinical manifestation.

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

Dr. Smith's ECG Blog

APRIL 2, 2024

He was unidentified and there were no records available After 7 shocks, he was successfully defibrillated and brought to the ED. Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. Here is the initial ED ECG. Patient received 11 shocks by ICD and was in V-fib when EMS arrived.

Defibrillator 133

Defibrillator Coronary Epinephrine CPR 133

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. He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic.

CAD 126

CAD STEMI Coronary ACS 126

Dr. Smith's ECG Blog

AUGUST 11, 2024

The machine indicated STEMI (but it barely meets STEMI criteria, if at all) and the patient was brought to the ED: On arrival 20 minutes later the pain had reduced to 1/10 after aspirin, and the patient had repeat ECG at triage: Now the ST segments and T waves have normalized, and the only abnormality is sinus bradycardia and loss of R waves.

STEMI 100

STEMI Paramedic Coronary EMS 100

Dr. Smith's ECG Blog

OCTOBER 1, 2023

He called EMS who brought him to the ED. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. ED Diagnoses: 1. This patient in today's case was a man in his 60s with a known history of coronary disease, including prior stents.

OR 127

OR STEMI Coronary CAD 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

JUNE 21, 2023

EMS was called, and they recorded the following ECG on scene at 13:16: What do you think? 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). Clinical Cardiology 2019.

STEMI 98

STEMI Coronary Defibrillator EMS 98

EMS 12-Lead

APRIL 8, 2022

He reported to EMS a medical history of GERD only. 1] Here is the admitting ED ECG after cancellation of Code STEMI. V2 – in the final EMS ECG the ST segment was baseline. V3 – in the final EMS ECG the ST segment was still slightly depressed. The patient continued to verbalize cessation of symptoms while in the ED.

STEMI 130

STEMI ALS Coronary CAD 130

EMDocs

SEPTEMBER 19, 2023

Episode 86: Tricky Cases Part 2 Case 3: 56-year-old female with history of seizures, actively seizing, EMS called. Patient seized for approximately 20 minutes prior to EMS arrival. On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Every airway requires a plan and backups.

STEMI 98

STEMI Coronary Emergency Department ICU 98

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. 5] Surawicz, B.

Coronary 130

Coronary ALS OR ACS 130

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

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

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-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

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

EMS 12-Lead

APRIL 14, 2022

He presented to EMS with extreme pallor, Levine sign, diaphoresis, bilateral arm pain, and an apprehensive sense of doom. It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). Chou's Electrocardiography in Clinical Practice, 6th ed. link] [1] Zachary et al.

ACS 130

ACS Paramedic Coronary ALS 130

The Skeptics' Guide to EM

MAY 28, 2022

AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms.

Emergency Department 100

Emergency Department ACS ALS Coronary 100

EMDocs

SEPTEMBER 26, 2024

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits , a monthly email newsletter for ED physicians. Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Someone should have – either the first ED doc, the second ED doc, or my PCP.

Emergency Department 97

Emergency Department ED Coronary ALS 97

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Past medical history includes coronary stenting 17 years prior. Initial ED ECG: What do you think? Cardiology was consulted and the patient underwent coronary angiogram which showed diffuse severe three-vessel disease. Coronary angiogram shows diffuse severe three-vessel disease. How Can We Prove that ECG #1 is VT?

Coronary 139

Coronary OR EMS ED 139

EMS 12-Lead

JULY 30, 2023

David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath. She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease.

EMT 130

EMT EMT ACS Coronary 130

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Coronary artery disease in patients with out-of-hospital refractory ventricular fibrillation cardiac arrest. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. Circulation. 2019;139(12):e530-e552.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

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. Here is the first ED ECG recorded, now pain free after sublingual Nitro: There is what appears to be a reperfusion T-wave in I and aVL.

E-9-1-1 116

E-9-1-1 Coronary EMS ED 116

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

MARCH 9, 2013

He awoke from sleep with crushing central chest pain and called ems. EMS recorded a 12-lead, then gave 2 sublingual nitros with complete relief of pain. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. de Zwaan C.,

ED 52

ED Coronary ALS STEMI 52

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. Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T Waves - ScienceDirect. What do you think? In fact, Kosuge et al. Accessed May 28, 2024.

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139