Dr. Smith's ECG Blog

OCTOBER 27, 2024

The cath lab was deactivated by cardiologist on arrival at ED because it was "not a STEMI". Initial 4th generation troponin I was 10 ng/mL is consistent with large MI due to acute coronary occlusion (OMI). He presented to the ED for evaluation chest pain. There are moderate coronary artery calcifications.

STEMI 116

STEMI ED Coronary EMS 116

EMS 12-Lead

APRIL 9, 2024

At the time of ED arrival he was alert, oriented, and verbalizing only a headache with a normalized BP. The ED activated trauma services, and a 12 Lead ECG was captured. This was deemed “non-specific” by the ED physicians. Thus, the ED admission ECG changes cannot be blamed on LVH. The fall was not a mechanical etiology.

Coronary 290

Coronary ACS CAD ED 290

The Skeptics' Guide to EM

JULY 2, 2022

Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Case: You are working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain.

Coronary 100

Coronary Heart Attack ACS CAD 100

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Note that as many as 7% of patients with acute coronary syndrome have chest pain reproducible on palpation [Lee, Solomon]. which reduces the pre-test probability of acute coronary syndrome by less than 30% [McGee]. Cardiology consult note written around that time documents that "Pain improved with NTG, morphine in ED but still present."

E-9-1-1 116

E-9-1-1 OR Coronary ACS 116

Dr. Smith's ECG Blog

DECEMBER 5, 2023

Acute coronary syndrome in a pediatric patient? An ECG was perfomed on arrival to our ED: NSR with ST elevation II,III, aVF with reciprocal depression in aVL Would you refer this pediatric patient for emergent PCI? He denied drug or alcohol use. He did have a family history notable for early CAD. mg/L and a normal WBC of 8.8.

Coronary 112

Coronary CAD ACS ALS 112

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 102

ED Coronary CAD STEMI 102

The Skeptics' Guide to EM

SEPTEMBER 28, 2024

Case: You are working a busy shift in a rural emergency department (ED) and your excellent Family Medicine trainee presents a case of a 63-year-old woman with chest pain and some intermittent radiation into the inter-scapular region. The patient has no specific risk factors for acute coronary syndrome (ACS) or dissection.

Emergency Department 201

Emergency Department ACS Coronary ALS 201

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. amiodarone or lidocaine).

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

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. What do you think? But which one is it?

OR 66

OR STEMI ACS Coronary 66

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. A 12 Lead ECG was captured on her arrival.

Coronary 130

Coronary ACS CAD ED 130

The Skeptics' Guide to EM

NOVEMBER 25, 2023

A 12-lead electrocardiogram (ECG) demonstrates ST elevations in leads II, III, and aVF with ST depressions in leads I and aVL and the team begins transport to the nearest percutaneous coronary intervention (PCI) capable hospital. We looked at 101 STEMI patients from two rural EDs. Reference: Stopyra et al.

Heart Attack 278

Heart Attack STEMI Emergency Medical Services Coronary 278

Dr. Smith's ECG Blog

OCTOBER 1, 2023

He called EMS who brought him to the ED. ED Diagnoses: 1. The basic principles of emergency ECG interpretation in patients who present to an ED with new symptoms include the following: Respect the History. 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

Core EM

JANUARY 25, 2024

The Case A 41-year-old male presents to the ED with constant palpitations for one day. Risk factors that increase the likelihood of VT include history of previous myocardial infarction, known coronary artery disease, and structural heart disease. Discussion Fascicular VT is a distinct subgroup of idiopathic VT. Brady WJ, Skiles J.

Coronary 246

Coronary Emergency Department ED OR 246

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

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

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

Dr. Smith's ECG Blog

JULY 25, 2024

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. Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! sodium bicarbonate.

Defibrillator 110

Defibrillator Coronary Epinephrine ACS 110

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? As per Dr. Smith — today's patient is a 40-something year old patient with severe diabetes, renal failure and known coronary disease — who presents with “acute crushing CP”.

Coronary 75

Coronary ED OR 75

EMDocs

NOVEMBER 6, 2023

This post will focus on the key parts of the guideline that affect ED evaluation and management. Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association 2023 Guideline for managing cardiac arrest or life-threatening toxicity due to poisoning was recently released. COR Harm, LOE B-R.

Naloxone 94

Naloxone OR Overdose BLS 94

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Both were awake and alert with normal vital signs.

OR 116

OR STEMI EMS ED 116

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 107

OR STEMI ICU Coronary 107

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). This patient is actively dying from a left main coronary artery OMI and cardiac arrest from VT/VF or PEA is imminent!

Coronary 125

Coronary ACS Emergency Department Defibrillator 125

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 116

Coronary STEMI ED OR 116

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 122

CAD STEMI Coronary ACS 122

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP). She arrives in the emergency department (ED) with decreased level of consciousness and shock.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

Here is her ECG on arrival to the ED: Improved, but still some signal of posterior OMI. Angiogram was done rapidly after arrival to the ED: Culprit mid LCX 90% TIMI 3 flow, PCI performed with resultant TIMI 3 flow. Figure-1: Comparison between the initial EMS ECG and the repeat ECG in the ED. Just not yet. Very frustrating.

STEMI 81

STEMI OR ED EMS 81

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

AUGUST 9, 2019

Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.

Coronary 52

Coronary STEMI ACS ALS 52

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

EMS 12-Lead

JUNE 1, 2022

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. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated. It’s reported that he regained consciousness after 30 seconds, approximately.

Coronary 130

Coronary ALS ACS ED 130

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. Does the ECG normalize?

Coronary 130

Coronary ALS OR ACS 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

MARCH 19, 2023

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. Breath sounds were clear in all lung fields. No appreciable skin pallor.

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. which would suggest reduced rates of major adverse cardiac events with coronary artery bypass grafting." On the other hand, stable EKG over an hour in the setting of ongoing acute coronary syndrome is again unusual.

Overdose 52

Overdose OR Coronary ACS 52

EMDocs

FEBRUARY 24, 2024

1: How to Treat Infected Kidney Stones Spoon Feed All patients with infected ureteral stones necessitate a urine culture, antibiotics, and urology consultation in the ED, with the majority requiring admission for surgical intervention. . #3: Originally published at JournalFeed , a site that provides daily or weekly literature updates.

Coronary 76

Coronary STEMI ED OR 76

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. So a dual chamber pacer is placed with one lead through the coronary sinus to the LV.

Defibrillator 128

Defibrillator Coronary Epinephrine CPR 128