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

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

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

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

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

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 113

Defibrillator Coronary Epinephrine ACS 113

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. The TOMAHAWK Investigators.

EMR 130

EMR Coronary Defibrillator Life Support 130

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 76

STEMI Coronary Paramedic EMS 76

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

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 74

EMS ALS OR ACS 74

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

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!

STEMI 130

STEMI MICU CAD Coronary 130

Dr. Smith's ECG Blog

MARCH 13, 2023

An ED ECG, if recorded with pain, should show LAD OMI. Smith — in the setting of a patient with new chest pain — the initial ECG in today's case ( = ECG #1 — obtained by the EMS team prior to ED arrival ) — is diagnostic of ACS ( A cute C oronary S yndrome ) until proven otherwise.

ED 52

ED ACS Coronary Paramedic 52

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 96

STEMI Coronary Defibrillator EMS 96

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

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

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

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 Firefighter OR 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 131

Defibrillator Coronary Epinephrine CPR 131

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 72

STEMI Coronary Emergency Department EMS 72

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

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 129

OR STEMI Coronary CAD 129

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 119

OR STEMI EMS ED 119

Dr. Smith's ECG Blog

JUNE 8, 2023

Written by Jesse McLaren A 75 year old with a history of CABG called EMS after 24 hours of chest pain. STEMI negative : the EMS automated interpretation read, “STEMI negative. paramedic transportation to the ED as “chest pain, STEMI negative” 2. ED consult for “non-STEMI” when the trop comes back elevated 3.

STEMI 62

STEMI Coronary Paramedic ALS 62

Dr. Smith's ECG Blog

JULY 7, 2024

Written by Jesse McLaren A previously healthy 60 year old developed exertional chest pain with diaphoresis, and called EMS. Here’s the EMS ECG, digitized with PM cardio. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. Take home 1.

STEMI 70

STEMI Coronary ALS OR 70

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

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-9-1-1 122

E-9-1-1 Coronary ACS BLS 122

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

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

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-9-1-1 110

E-9-1-1 Coronary EMS ED 110

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

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 ALS 139

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 138

Coronary OR EMS ED 138

Dr. Smith's ECG Blog

JULY 16, 2022

This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. Apparently, the patient was not satisfied, and came to the ED as he still had pain. It was extremely busy in the ED and things did not get done quickly. Plus he did a 2 year combined EM Cardiology and Critical Care Fellowship.

Coronary 52

Coronary ED EMS Critical Care 52

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. Per EMS, the patient was found at the bottom of a high voltage line with diffuse burns and amputation of his left forearm.

Operating Room 52

Operating Room ACS Critical Care Coronary 52

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. Smith adds to our knowledge of this syndrome.

Coronary 52

Coronary ACS EMS ALS 52