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

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 87

Emergency Medical Services Coronary Emergency Department EMS 87

EMDocs

SEPTEMBER 26, 2024

Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. If you have a story to share click here. Who is responsible for notifying patients of post discharge findings?

Emergency Department 98

Emergency Department ED Coronary ALS 98

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." Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy.

Emergency Department 52

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

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

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. Serial ECGs enhance the diagnosis of acute coronary syndrome. Annals of Emergency Medicine , 31 (1), 3–11. Do not treat AIVR.

STEMI 107

STEMI Coronary Heart Attack ACS 107

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. while Information technology (IT) helped manage communications about the shortage. West J Emerg Med. 2017;18(5):835-845.

E-9-1-1 101

E-9-1-1 Emergency Department ALS CCT 101

Dr. Smith's ECG Blog

MAY 23, 2023

The chest pain started about 24 hours ago, but there was no detailed information available about whether his pain had come and gone, or what prompted him to be evaluated 24 hours after onset. Am J Emerg Med. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. 2022 Jan;51:384-387. 2021.11.023.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

OCTOBER 4, 2010

He arrived in the emergency department hemodynamically stable. ACS would be highly unusual in a young athlete, and given the information on his race bib, one must first suspect that the abnormal ST elevation is due to demand ischemia, not ACS. The next day, and angiogram showed normal coronary arteries.

ACS 52

ACS Defibrillator Epinephrine STEMI 52

Dr. Smith's ECG Blog

MARCH 17, 2023

Submitted by anonymous, written by Pendell Meyers A woman in her 50s presented to the Emergency Department with chest pain and shortness of breath that woke her from sleep, with diaphoresis. I sent the first ECG with no information at all, and without the old ECG, to Steve Smith who immediately just texted back: "pulse tapping."

Coronary 52

Coronary Emergency Department ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. This finding does not alter the need to pursue emergent reperfusion, although it might suggest a poorer prognosis.”[3]

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. It is not a missed STEMI, but it is a missed coronary occlusion. Ann Emerg Med 1998;31(1):3-11.

STEMI 52

STEMI Coronary ALS CAD 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

OCTOBER 2, 2021

Because the patient's pain had resolved completely and cardiology had declined immediate intervention, the patient was admitted but continued to board in the emergency department. Approximately 4 hours after arrival, the patient was re-examined by the emergency physician. The iStat POC assay is 0.08 Do NOT use them.

OR 52

OR ACS STEMI Coronary 52

EMDocs

OCTOBER 21, 2023

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. Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department.

EMS 98

EMS ALS OR ACS 98

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

SEPTEMBER 30, 2019

Meyers comment: Ryan texted me this ECG with no information and my response was "Tough one. The patient’s ECG on arrival at the emergency department is shown below. Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent. He was in obvious discomfort.

E-9-1-1 52

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

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

NOVEMBER 3, 2017

Here is a video lecture of subtle LAD occlusion: One hour lecture on Subtle ECG Findings of Coronary Occlusion The 3-variable formula comes from this paper: Smith SW et al. Case 3 I was reading a stack of ECGs yesterday, and saw this one, with no clinical information. He went for Coronary bypass (CABG). the more accurate.

STEMI 52

STEMI Coronary OR ALS 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

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 screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG: What do you think?

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

MARCH 6, 2023

I sent this to Pendell without any information at all, and he replied "Postero-lateral Reperfusion." 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department: A report of the American college of cardiology solution set oversight committee. •

OR 52

OR STEMI ED Critical Care 52

Dr. Smith's ECG Blog

APRIL 17, 2023

The remainder of his Emergency Department stay was uneventful. greater than 40mS, V1-V2" Meyers interpretation: I was sent this ECG with no clinical information whatsoever, and I responded: "Easily diagnostic of acute LAD occlusion." He had no symptoms of ACS. There are hyperacute T waves in V2-V5, I, II, aVL.

OR 52

OR STEMI ACS Emergency Department 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

With no other information other than the first ECG above, I texted this to Dr. Smith and he responded: ST elevation in lead V2 and terminal QRS distortion in V3. Despite having acute coronary occlusion by cath, his ECGs never met STEMI criteria. Lead aVL, for example, has a definite J-wave. LAD occlusion. Great case.

ACS 52

ACS STEMI Coronary CAD 52

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

Also, note that it is possible to derive a formula that indicates when each formula disagrees with the rule-of-thumb, but doing it graphically is more informative, so that is the approach taken here. 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

Dr. Smith's ECG Blog

OCTOBER 13, 2023

This ECG was texted to me with no other information, with this quote: "You will see this in the Queen of Hearts." 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. I assumed it was in real time.

STEMI 116

STEMI OR Coronary Emergency Department 116

Dr. Smith's ECG Blog

APRIL 8, 2015

2) Boston syncope rule: J Emerg Med. 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

JANUARY 17, 2024

Using the current paradigm, can you tell which patient had an acute coronary occlusion? Patient 1 Patient 2 STEMI criteria is based only ST elevation millimeter criteria measured in isolation from the QRS and stratified by age/sex, so this is the only information provided above. Patient 1 (from top ECG on the left): what do you think?

STEMI 118

STEMI Coronary ALS OR 118

Dr. Smith's ECG Blog

JUNE 8, 2023

I sent the ECG to Dr. Meyers without any information, and he immediately replied, “inferior OMI.” 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. Take home 1.

STEMI 86

STEMI Coronary Paramedic ALS 86

Don't Forget the Bubbles

DECEMBER 5, 2023

Data was collected at 2 emergency departments in America and included assessment by both clinicians and patients for a total of 31 patients. The device was assessed by the clinicians (emergency medicine doctors) using it on ease of use, speed of use and the appearance of the closed wound. Why does it matter?

Coronary 111

Coronary Epinephrine CPR Emergency Department 111

AAEM RSA

DECEMBER 31, 2020

Sincerely, Alex Gregory, MD Editor-in-Chief AAEM/RSA Modern Resident Blog Top 10 Most Read Posts of 2020 Should ST elevation in lead aVR with concern for acute coronary syndrome prompt emergent coronary angiography?

EMT 52

EMT EMT Coronary Emergency Department 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

Dr. Smith's ECG Blog

JANUARY 28, 2012

The differential includes hemopericardium from myocardial rupture, or from coronary artery rupture from PCI, or Dressler's syndrome of post-MI pericardial effusion. Emergency Department Two-Dimensional Echocardiography in the Diagnosis of Nontraumatic Cardiac Rupture. 300-450 ml of serosanguinous fluid was drained.

STEMI 40

STEMI Coronary Critical Care Emergency Department 40

EMDocs

NOVEMBER 13, 2023

The use of CTA (computed tomography angiography) in the emergency department (ED) has increased dramatically in the past 20 years. Pearls and Pitfalls CT Angiography has become a more readily available tool for diagnosis in the emergency department though requires an understanding of its specific uses and indications.

E-9-1-1 105

E-9-1-1 ALS Emergency Department ED 105

Dr. Smith's ECG Blog

MARCH 9, 2025

A 62 year old man with hyperlipidemia presented to a rural emergency department with 7 hours of 3/10 chest pain. Heitner et al found that in 14% of patients with NSTEMI, a blinded interventional cardiologist interpreting coronary angiograms identified a different culprit artery than CMR ( [link] ). This is surprisingly common.

Coronary 88

Coronary STEMI ED ALS 88