Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." Takotsubo is a sudden event, not one with crescendo angina. Such cases are classified as MINOCA (Myocardial Infarction with Non-Obstructed Coronary Arteries). It can only be seen by IVUS.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

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. The undergraduate is now willing to identify himself: Hans Helseth. No ECG was ordered on Day #1.

Coronary 120

Coronary STEMI Emergency Department OR 120

EMDocs

SEPTEMBER 15, 2023

ST segment elevation, or even an isoelectric ST segment, in these leads is abnormal and should make us concerned for ischemia Source Acute Coronary Occlusion in a Patient With Prior Known Right Bundle Branch Block: Another Chink in the Armor for the ST-Elevation Myocardial Infarction Criteria. Ann Emerg Med. 2023 Aug;82(2):219-221.

Emergency Medical Services 83

Emergency Medical Services Coronary Emergency Department EMS 83

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI 117

STEMI Coronary ACS ED 117

EMDocs

OCTOBER 30, 2023

Background and Context Contrast-enhanced computed tomography (CECT) is of paramount importance in the emergency department (ED) due to its indispensable role in facilitating precise diagnostic outcomes. Increased Computed Tomography Utilization in the Emergency Department and Its Association with Hospital Admission.

E-9-1-1 99

E-9-1-1 Emergency Department ALS CCT 99

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Also see this incredible case of the use of 12-lead ST Segment monitoring.

Coronary 52

Coronary STEMI ALS Emergency Department 52

ACEP Now

AUGUST 12, 2024

A 35-year-old male presented to the emergency department complaining of chest pain that started 1.5 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking. Dr. Young is an emergency physician at Saint Francis Hospital and Medical Center, Hartford, Conn.

Emergency Department 52

Emergency Department STEMI ACS ED 52

Dr. Smith's ECG Blog

APRIL 22, 2022

A prospective validation of the HEART score for chest pain patients at the emergency department. External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Am J Emerg Med 2020 3. Backus BE, Six AJ, Kelder JC, et al. Int J Cardiol 2013 2. Lancet 2015 6.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. 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. Am J Emerg Med 2023 2. What do you think?

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

DECEMBER 26, 2020

On arrival to the PCI center's Emergency Department, the receiving team recorded an ECG on arrival: Persistent atrial flutter, however this time the QRS occurs on a slightly different portion of the flutter wave. No obvious adverse events were attributed to the thrombolytics. There was again no intracranial hemorrhage.

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The most recent event had occurred just before being triaged. Triage EKG: What do you think?

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. Relationship between an in-farct related artery, acute total coronary occlusion, and mortality in patients with ST-segment and non-ST-segment myocardial infarction.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JULY 3, 2018

While in the emergency department, he undergoes an additional ECG: 00:49 - Not much change Second ECG with measurements and calculations Magnified view of second ECGs measurements and calculation It is still "negative" for LAD occlusion (less than 23.4) Despite having acute coronary occlusion by cath, his ECGs never met STEMI criteria.

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

The patient’s ECG on arrival at the emergency department is shown below. He was taken emergently to the cardiac catheterization lab and found to have multi-vessel coronary artery disease with a near-occlusive culprit lesion in the RCA, possibly reperfused. In the available view, the RCA appears fully occluded.

E-9-1-1 52

E-9-1-1 Coronary STEMI Emergency Department 52

Dr. Smith's ECG Blog

AUGUST 26, 2019

She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? The patient went emergently to the cath lab, where all coronary arteries were found to be normal.

STEMI 52

STEMI Coronary OR ED 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The remainder of his Emergency Department stay was uneventful. Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours. CASE #2: I am more disturbed by learning of the events associated with the ECG in Case #2.

OR 52

OR STEMI ACS Emergency Department 52

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. Unfortunately, a post-conversion 12 Lead was not acquired. This finding might favor a diagnosis of ischemic-driven PVT.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.

Defibrillator 135

Defibrillator Coronary STEMI CPR 135

Dr. Smith's ECG Blog

JUNE 8, 2023

According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. STEMI criteria, and automated interpretations based on it, will miss acute coronary occlusion. Take home 1.

STEMI 86

STEMI Coronary Paramedic ALS 86

Dr. Smith's ECG Blog

OCTOBER 25, 2023

A man in his 60s with a history of severe alcohol use disorder and epidural abscess on long-term ciprofloxacin presented to the emergency department after an episode of syncope while standing in line at a grocery store. Instead — it commonly reflects ischemia from severe underlying coronary disease. He did not have chest pain.

Overdose 123

Overdose ACS OR ICU 123

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

And so it is wise to look at the coronary arteries. This ECG certainly looks like myocarditis, and was due to myocarditis, but missing acute coronary occlusion is not acceptable. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

MARCH 24, 2023

But the bradycardia and the infero-posterior OMI is definitely new: Smith : this also has many abnormalities suggestive of ischemia: many leads have ischemic appearing ST depression The emergency provider followed the sequential steps of the current paradigm: 1.

STEMI 52

STEMI Coronary CAD OR 52

EM Didactic

JANUARY 27, 2019

If there is no defined injury or event that could have led to a soft tissue injury, we should be reluctant to render a diagnosis of musculoskeletal pain. Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med 2002; 40:180–6.

ACS 52

ACS ALS Coronary Emergency Department 52

ECG & Echo Learning

JANUARY 18, 2023

This page summarises the most current recommendations for the management of acute coronary syndromes with persistent ST-segment elevations (i.e I B Patients transferred to PCI centres can bypass the emergency department to undergo primary PCI without delay. STEMI , ST-segment elevation acute myocardial infarction ).

STEMI 40

STEMI Coronary OR Defibrillator 40

AAEM RSA

AUGUST 27, 2020

1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. Interventions during the acute phase of treatment post return of spontaneous circulation (ROSC) are therefore critical.

E-9-1-1 52

E-9-1-1 CPR ICU ALS 52

Dr. Smith's ECG Blog

NOVEMBER 24, 2017

However, none of the formulas have proven to be definitively better than another and none are well correlated with outcomes or events! Among patients with left bundle branch block, T-wave peak to T-wave end time is prolonged in the presence of acute coronary occlusion.

ALS 52

ALS OR ED Coronary 52

EMDocs

JANUARY 20, 2024

The catheterization lab is activated, but catheterization shows no coronary artery occlusion. ECG shows ST-segment elevation in V3-V6 only with depression in aVR. Initial troponin is mildly elevated. On further questioning, the patient denies recent illness but does mention that her daughter passed away in a car accident yesterday.

E-9-1-1 100

E-9-1-1 EMS Coronary ACS 100

Dr. Smith's ECG Blog

APRIL 8, 2015

(full text link) Presence of any one of these 8 criteria had 97% sensitivity and specificity of 62% for adverse outcomes: 1) Signs of Acute Coronary Syndrome (ACS), 2) conduction disease, 3) worrisome cardiac history, (eg. The ROSE (Risk Stratification of syncope in the emergency department) Study.

Emergency Department 52

Emergency Department E-9-1-1 ED ALS 52

Dr. Smith's ECG Blog

OCTOBER 13, 2023

Here is a more detailed history: Presented to the emergency department with chest pain. NEVER diagnose chest discomfort as due to GERD without a coronary workup. Final Thoughts: Dr. Smith instantly recognized that today's initial ECG would clearly be suspicious of a possible acute event, depending on the History.

STEMI 116

STEMI OR Coronary Emergency Department 116

Dr. Smith's ECG Blog

DECEMBER 20, 2024

Written by Willy Frick with edits by Ken Grauer An older man with a history of non-ischemic HFrEF s/p CRT and mild coronary artery disease presented with chest pain. The following ECG was obtained in the emergency department during active chest pain. He said he had had three episodes of chest pain that day while urinating.

Defibrillator 102

Defibrillator Coronary ALS Emergency Department 102

Dr. Smith's ECG Blog

MARCH 3, 2025

A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. The scan showed a bicuspid aortic valve with severe stenosis and coronary artery disease. She was discharged again from the emergency department without a second EKG or troponin.

E-9-1-1 73

E-9-1-1 Coronary STEMI Emergency Department 73

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

EMS gave aspirin and nitroglycerin, and the patient noted significant improvement on arrival to the Emergency Department. The history in today's case is classic for an acute cardiac event — as this older woman was awakened from sleep by chest pain radiating to her left arm with nausea.

STEMI 81

STEMI OR ED EMS 81

Dr. Smith's ECG Blog

JANUARY 15, 2025

Case A 68 year old man with a medical history of hypertension, hyperlipidemia, and CAD with stent deployment in the RCA presented to the emergency department with chest pain. It may or may not represent early findings in a new acute event. Also : See Ken Grauer's excellent comments at the bottom. EKG 1, 1646: What do you think?

Coronary 67

Coronary ED CAD Paramedic 67

EMDocs

FEBRUARY 3, 2025

Specifically, patients with SLE face an elevated risk of vascular disease due to higher rates of hypertension and hyperlipidemia, predisposing them to both macrovascular and microvascular events, such as TIA, stroke, and neuropathy (7-9). SLE is considered an atypical risk factor for cardiovascular disease and acute coronary syndrome(8,9,11).

ED 69

ED E-9-1-1 ALS OR 69

ACEP Now

NOVEMBER 7, 2024

1 It is important to pick up this diagnosis early, as emergency treatment with percutaneous coronary intervention (PCI) to restore blood from to the heart can be lifesaving. TCAD occurs as a result of rapid deceleration, which increases shear forces on the endothelium of the coronary artery.

Coronary 52

Coronary ALS ED Emergency Department 52

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

He presented to the emergency department for evaluation. Rates of occurrence of PIRP have decreased drastically in the era of percutaneous coronary intervention. Incidence and Prognosis of Pericarditis After ST-Elevation Myocardial Infarction (from the Acute Coronary Syndrome Israeli Survey 2000 to 2013 Registry Database).

STEMI 89

STEMI ALS OR Coronary 89