EMDocs

SEPTEMBER 7, 2024

We’ll keep it short, while you keep that EM brain sharp. 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. Vital signs include BP 90/48, HR 122, T 98.3

EMS 74

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

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 106

EMS CPR ED Coronary 106

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

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

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

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

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 110

Defibrillator Coronary Epinephrine ACS 110

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 73

EMS ALS OR ACS 73

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

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 74

STEMI Paramedic Coronary EMS 74

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

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

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 97

STEMI Coronary Defibrillator EMS 97

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

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

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 122

CAD STEMI Coronary ACS 122

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 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 ACS ED 130

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 74

Emergency Department ED ALS Coronary 74

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

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 ICU 72

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 128

Defibrillator Coronary Epinephrine CPR 128

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 125

OR STEMI Coronary CAD 125

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 116

OR STEMI EMS ED 116

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

EMS arrived and recorded this ECG: What do you think? EMS gave aspirin and nitroglycerin, and the patient noted significant improvement on arrival to the Emergency Department. Here is her ECG on arrival to the ED: Improved, but still some signal of posterior OMI. Queen of hearts explainability image. Overall High confidence OMI.

STEMI 81

STEMI OR ED EMS 81

Dr. Smith's ECG Blog

NOVEMBER 19, 2024

These ECGs were texted to me by one of our previous ultrasound fellows, Will Smoot An elderly male arrived via EMS for acute substernal chest pain with radiation to left shoulder and arm that awakened him from sleep at 0030. He took two full strength aspirin prior to EMS arrival. post OMI with significant multi-vessel coronary disease.

OR 64

OR STEMI Coronary CAD 64

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-9-1-1 109

E-9-1-1 Coronary STEMI ALS 109

EMDocs

OCTOBER 29, 2024

Authors: Rachel Bridwell, MD (EM Attending Physician; Tacoma, WA), Katey DG Osborne, MD (EM Attending Physician; Tacoma, WA) // Reviewed by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) Welcome to emDOCs revamp!

E-9-1-1 86

E-9-1-1 ICU Epinephrine EMS 86

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

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

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 66

STEMI Coronary ALS OR 66

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. Coronaries were normal, as was serial troponin. Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

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

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-9-1-1 118

E-9-1-1 Coronary ACS BLS 118