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. Edited by Smith He also sent me this great case.

CAD 129

CAD STEMI Coronary ACS 129

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. This is a demonstration of how Wellens' is transient OMI : First ED ECG is Wellens' (pain free). Also see this incredible case of the use of 12-lead ST Segment monitoring. __ Case Continued The Cath lab was activated 70 minutes after ED arrival.

Coronary 121

Coronary STEMI ED OR 121

The Skeptics' Guide to EM

APRIL 10, 2021

JAMA Intern Med 2021 Case: A 60-year-old man presents to the emergency department (ED) after his wife found him to be drowsy and confused at home. On arrival to the ED his vitals are normal aside from a decreased level of consciousness and he is found to have a serum sodium concentration of 118 mmol/L.

Emergency Department 130

Emergency Department Coronary ED OR 130

Dr. Smith's ECG Blog

JANUARY 25, 2024

A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain. Here is his ED ECG: What do you think? Smith offers the unique perspective of assessing the initial ECG of a patient who has had prior events — and, who now presents with new symptoms.

Coronary 79

Coronary ED OR 79

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-9-1-1 119

E-9-1-1 Coronary EMS ED 119

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech. No ECG was ordered on Day #1.

Coronary 124

Coronary STEMI Emergency Department OR 124

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. ECG Features suggesting "Fake" As per Dr. Sam Ghali ( who sent us today's case ) — serial Troponins were clearly indicated since the patient presented to the ED. Negative serial Troponins were needed to rule out an acute event. Sam : "Yes, this case was sent to me. It was a man in his 30s with chest pain.

E-9-1-1 127

E-9-1-1 Coronary ALS ED 127

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

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? The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event.

EMS 117

EMS CPR ED Coronary 117

Dr. Smith's ECG Blog

JANUARY 27, 2024

Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion.

STEMI 120

STEMI Coronary ACS ED 120

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. But I'd be less certain about an acute event without more information and prior and/or serial tracings. It is unknown when this pain recurred and became constant.

Defibrillator 139

Defibrillator Coronary STEMI CPR 139

Dr. Smith's ECG Blog

MAY 10, 2023

A CT Coronary angiogram was ordered. Here are the results: --Minimally obstructive coronary artery disease. --LAD Although a lesion is not visible anatomically on this CT scan, coronary catheter angiography could be considered based on Cardiology evaluation." A repeat troponin returned at 0.45 CAD-RADS category 1. --No

Coronary 52

Coronary STEMI CAD OR 52

EMS 12-Lead

AUGUST 22, 2022

Beats 9-12 : Continuation of the previously described events, all inducible by the pause (and thus, prolongation of refractoriness) created by the PVC of Beat 8. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Chou’s Electrocardiography in Clinical Practice (6th ed). Surawicz, B.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? Then the ED doc would be dependent on that first ECG. It must have re-occluded between the ED and the cath lab) --Lesion was stented. have perfect coronary flow by the time of angiogram. Or had not had a prehospital ECG on the ambulance.

STEMI 96

STEMI Coronary Ambulance ED 96

EMS 12-Lead

APRIL 28, 2022

This particular facility is situated for independent living, thus no medical providers are on site to provide pertinent details for medical history, medication intake, or remarkable events prior to the incident at hand. Josephson’s Clinical Cardiac Electrophysiology: Techniques and Interpretations (6th ed). 2] Viskin, S., 8] Liu, E.,

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

There was no association between moderate to severe chest pain on arrival and major adverse cardiac events at 6 months (20% vs. 14%, p=0.12). Having severe pain drives people to the ED for faster treatment! Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. years old ± 13.7

STEMI 123

STEMI Coronary Emergency Medical Services OR 123

Dr. Smith's ECG Blog

OCTOBER 22, 2024

He reported typical chest pain since 4H AM and arrived at our ED at 10h with ongoing chest pain. The coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Presence of a single coronary lesion: occlusion of the ostial main marginal.

Coronary 69

Coronary STEMI OR ALS 69

Dr. Smith's ECG Blog

SEPTEMBER 7, 2024

ECG 1 at time zero EARLY REPOLARIZATION ABNORMAL ECG ED final official overread: "early repol vs hyperacute T, minimal changes from previous (previous shown below)" What do YOU think? See these casese (and I have many others): First ED ECG is Wellens' (pain free). A 70-something y.o. male presents to triage with shortness of breath.

STEMI 119

STEMI ACS Critical Care Coronary 119

Dr. Smith's ECG Blog

OCTOBER 8, 2024

I interpreted this tracing knowing only that the patient was a woman in her 60s, with a prior history of proximal LAD OMI — who now presented to the ED with a history of new chest discomfort and shortness of breath. For clarity in Figure-1 — I’ve labeled today’s initial tracing. Figure-1: I've labeled the initial ECG in today's case.

OR 126

OR STEMI ICU Coronary 126

Dr. Smith's ECG Blog

OCTOBER 8, 2023

Imagine you just started your ED shift. Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECG s that has not been overread by a physician. R wave V4 9mm) C T of the coronary arteries showed no lesions. That said, this patient did present to the ED with "new CP" — and.

ED 126

ED Coronary OR 126

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This is written by Brooks Walsh.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2010

He subsequently had a syncopal event and was down for 1-2 minutes. Upon arrival to the ED, he had the following 12-lead ECG: There is striking ST segment elevation in V1 and V2, with ST depression in V3-V6 as well as I, II, and aVF. His wife called 911. EMS found him with an irregular heart rate at 200-250 beats per minute.

STEMI 52

STEMI Coronary EMS ED 52

EMS 12-Lead

APRIL 2, 2022

He reported a history of ischemic cardiomyopathy with coronary stent placement approximately 10 years prior, but could not recall the specific artery involved. Whether this represents a potential acute cardiac event would depend on the history, comparison with prior tracings and serial tracings. Attached is the first ECG. 3] Smith, S.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

JULY 22, 2012

Blunt cardiac injury my result in : 1) Acute myocardial rupture with tamponade 2) Valve rupture (tricuspid, aortic, mitral) 3) Coronary thrombosis or dissection (and thus Acute MI) from direct coronary blunt injury 4) Dysrhythmias of all kinds. In the ED, ultrasound showed hemopericardium with tamponade.

Coronary 52

Coronary ICU OR ED 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

About an hour later, he was then found on the floor in cardiac arrest in the ED. The history in today's case — was that of a man in his 70s who presented to the ED for 2 hours of chest pain , that was still present on arrival in the ED. His initial troponin T was 15 ng/L (only two hours since pain onset).

Coronary 52

Coronary Heart Attack ED CPR 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

It was worse on the evening prior to presentation while lying in bed, then recurred and resolved while at rest just prior to arriving in the ED. Here is the first ED ECG, with no pain: Sinus rhythm. Prevalence of Total Coronary Occlusion during the Early Hours of Transmural Myocardial Infarction. Computerized QTc = 419.

Coronary 52

Coronary STEMI ALS Emergency Department 52

Dr. Smith's ECG Blog

JULY 31, 2018

Subsequent events: Later, before being taken to her room, the 2nd troponin returned at 1.01 Next day, t he patient was taken for an angiogram and found to have a reperfused LAD lesion with good flow that appeared to the angiographer as if it was a spontaneous coronary artery dissection. She felt more comfortable being admitted.

Coronary 52

Coronary ACS STEMI OR 52

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. This middle-aged male with known coronary disease presented with new chest pain.

Coronary 52

Coronary ED EMS Critical Care 52

Dr. Smith's ECG Blog

MAY 16, 2023

Emergent CT coronary angio also likely has a role in such cases. Like they would for any other acute arterial occlusion syndrome (such as suspicion of acute large vessel stroke), they take the patient across the hall and perform an immediate CT (coronary) angiogram, showing patent coronaries.

Coronary 52

Coronary STEMI ED OR 52

Dr. Smith's ECG Blog

AUGUST 30, 2023

One more thing that should be mentioned: since there are only Q waves from V1 to V3, it is possible that there was an old anterior wall MI, or that the current event is subacute, or acute on top of an old Q wave. Regardless, V2 with a hyperacute T wave and abnormal T/S ratio means there must be acute OMI, regardless of prior events.

Coronary 74

Coronary OR STEMI ED 74

Dr. Smith's ECG Blog

JULY 27, 2023

On arrival to the ED, the patient was diaphoretic, tachycardic. I did not think it was due to ACS, but we ordered an ED ECG immediately: What do you think? I was not worried for a coronary etiology. Under most circumstances — this combination of ECG findings would point to an acute event. and had dilated pupils.

Coronary 52

Coronary ACS Naloxone Plasma 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Submitted by Dr. George Mastoras (Twitter @georgemastoras), written by Jesse McLaren It’s a busy day in the ED when you’re sent another ECG to sign off from a patient at triage. Here is the post shock ECG: Cardiology was called stat for ischemic VT, query SCAD vs thrombotic occlusion vs coronary vasospasm.

OR 69

OR STEMI ACS Coronary 69

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. 2009;95:1701–1706.

ACS 86

ACS Coronary ALS CAD 86

Dr. Smith's ECG Blog

APRIL 22, 2022

Identifying patients with low risk for acute coronary syndrome without troponin testing: validation of the HEAR score. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. McLaren and Smith — the initial ECG in Case #1 shows that an event did occur.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

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. the presence of J waves from early repolarization doesn’t rule out an acute coronary occlusion 4. link] References 1.

STEMI 73

STEMI Coronary OR ALS 73

Dr. Smith's ECG Blog

OCTOBER 25, 2023

The patient is a man in his 60s with established severe alcohol use disorder — and epidural abscess being treated with longterm Ciprofloxacin — who presented to the ED following a syncopal episode. Instead — it commonly reflects ischemia from severe underlying coronary disease. As per Drs. How to Quickly Estimate the QTc: As per Drs.

Overdose 127

Overdose ACS OR ICU 127

Dr. Smith's ECG Blog

JUNE 17, 2016

Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear. KEY POINTS from this CASE: The presenting history often provides invaluable clues to the likelihood of an acute cardiac event. (

STEMI 52

STEMI OR Coronary EMS 52

ACEP Now

AUGUST 12, 2024

FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. Sequence of events in angina at rest: Primary reduction in coronary flow. The patient had an EKG performed within 10 minutes of arrival while in triage (see Figure 1). Click to enlarge.) Click to enlarge.) Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52