Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

male presents to the ED at 6:45 AM with left sided chest dull pressure that woke him up from sleep at 3am. He arrived to the ED at around 6:45am, and stated the pain has persisted. Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. The pain radiated to both shoulders.

Coronary 117

Coronary ACS OR EMR 117

Dr. Smith's ECG Blog

JULY 7, 2024

So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

STEMI 66

STEMI Coronary ALS OR 66

Core EM

NOVEMBER 15, 2023

The Case A 62-year-old male with a history of Hypertension, Hyperlipidemia, Coronary Artery Disease with stents, Pulmonary Embolism on Eliquis, presents with sudden onset, severe, mid-sternal chest pain that started 15 minutes prior to arrival. Serial ECG's should be obtained to assess for evolution to acute STEMI.

Coronary 130

Coronary STEMI ED 130

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He wrote most of it and I (Smith) edited.

OR 109

OR STEMI Coronary ED 109

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 106

ED Coronary CAD STEMI 106

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

But do they represent acute coronary occlusion? But coronaries were normal, and serial high sensitivity troponin was undetectable. Based on ECG changes and echo findings, the patient was diagnosed as coronary vasospasm. Formal echo showed EF 55% with mild inferolateral hypokinesis without any prior for comparison.

STEMI 91

STEMI Coronary OR ED 91

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. It’s unclear if the paramedic ECGs were seen or missed in the ED. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. At this point the emergency physician asked for a stat cardiology consult.

STEMI 76

STEMI Paramedic Coronary EMS 76

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." Transient STEMI is at high risk of re-occlusion.

Coronary 52

Coronary STEMI CAD OR 52

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 this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. Fortunately the patient did not reocclude while awaiting the angiogram.

STEMI 105

STEMI Coronary ACS ED 105

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 124

CAD STEMI Coronary ACS 124

EMS 12-Lead

AUGUST 14, 2022

A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis. Here the ST segments are not so deep, nor are the T waves so wide and bulky, because of improved coronary flow at the level of the occlusion. it has been subsequently deemed a STEMI-equivalent.

STEMI 130

STEMI MICU CAD Coronary 130

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.

STEMI 73

STEMI Paramedic Coronary ED 73

Dr. Smith's ECG Blog

NOVEMBER 19, 2024

He arrived at the ED just shy of two hours after onset, pain free. Here is the initial ED ECG: Here that first ECG is cleaned up by PM Cardio app: What do you think? The Queen of Hearts Diagnosed "STEMI/STEMI equivalent" on that first ECG (she now uses "STEMI Equivalent" rather than OMI).

OR 105

OR STEMI Coronary CAD 105

ACEP Now

APRIL 4, 2024

A 59-year-old male with a past medical history of a repaired ventricular septal defect (VSD), dextrocardia, hypertension, hyperlipidemia, and current smoker presented to the emergency department (ED). This patient had known coronary artery disease (CAD), and previously required drug eluting stents to the obtuse marginal and diagonal arteries.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL. On arrival to the ED, this ECG was recorded: What do you think? How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later?

STEMI 82

STEMI Coronary Defibrillator OR 82

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. It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. Breath sounds were clear in all lung fields.

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

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

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. Cardiac arrest #3: ST depression, Is it STEMI? It also does not uniformly indicate severe coronary disease. sodium bicarbonate.

Defibrillator 113

Defibrillator Coronary Epinephrine ACS 113

Dr. Smith's ECG Blog

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). It is a ssociated with mild dyspnea on exertion. Aspirin given.

Coronary 117

Coronary STEMI ED OR 117

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. The young ED tech immediately suspected LAD OMI.

ED 117

ED STEMI Coronary Paramedic 117

EMDocs

SEPTEMBER 19, 2023

On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Official diagnosis requires EEG, which is not something we can typically obtain in the ED. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

STEMI 73

STEMI Coronary Emergency Department ICU 73

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. Queen of Hearts Diagnosis: Not OMI with High Confidence (but in French!) "Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"."

Coronary 66

Coronary STEMI OR ALS 66

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. The proof of this is that only 5% of patients enrolled had acute coronary occlusion. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. This study failed to do so.

Defibrillator 93

Defibrillator STEMI Coronary ALS 93

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. Clay Smith at @spoonfedEM , and sign up for email updates here. #1:

Coronary 77

Coronary STEMI ED OR 77

Dr. Smith's ECG Blog

JUNE 21, 2023

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). Smith Comment: Is is common for the artery to be open at angiogram in OMI, including full STEMI.

STEMI 98

STEMI Coronary Defibrillator EMS 98

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

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

SEPTEMBER 26, 2023

Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. Having severe pain drives people to the ED for faster treatment! We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7

STEMI 111

STEMI Coronary Emergency Medical Services OR 111

Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI."

E-9-1-1 122

E-9-1-1 ACS Coronary STEMI 122

Dr. Smith's ECG Blog

OCTOBER 1, 2023

He called EMS who brought him to the ED. She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. ED Diagnoses: 1.

OR 126

OR STEMI Coronary CAD 126

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. When EMS found her, she was dyspneic and diaphoretic.

E-9-1-1 113

E-9-1-1 Coronary STEMI ALS 113

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

STEMI 118

STEMI Emergency Department Coronary OR 118

Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? Here it is: Obvious Inferior Posterior STEMI (+) OMI. Then the ED doc would be dependent on that first ECG. Initial troponin was: 3 ng/L We showed that the first troponin in acute STEMI is often negative in at least 27%. have perfect coronary flow by the time of angiogram.

STEMI 82

STEMI Coronary Ambulance ED 82

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

STEMI 92

STEMI Coronary Paramedic OR 92

EMS 12-Lead

JUNE 20, 2022

A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. Here is the final ECG just prior to ED transfer. The pathology is now painfully evident.

ACS 130

ACS Coronary STEMI CAD 130

EMDocs

JANUARY 8, 2024

This post will focus on the key parts of the guideline that affect ED evaluation and management. Percutaneous coronary intervention after cardiac arrest Coronary angiography should be performed emergently for all cardiac arrest patients with suspected cardiac cause of arrest and ST-segment elevation on electrocardiogram.

Epinephrine 83

Epinephrine Defibrillator Coronary CPR 83