JEMS

APRIL 9, 2025

Mike Doss provides a firsthand account of the long-term health impacts of a career in EMS.

EMS 97

EMS Coronary Ambulance Paramedic 97

Emergency Medicine Cases

SEPTEMBER 12, 2023

Jesse MacLaren guides us through 10 cases of patients who present with generalized weakness or acute neurologic symptoms and discusses how to look for ECG signs of dysrhythmias, electrolyte emergencies, acute coronary occlusion, and demand ischemia in patients with generalized weakness and in patients with neurologic symptoms, to consider predisposing (..)

Coronary 329

Coronary OR EMS 329

EMDocs

JULY 1, 2023

We’ll keep it short, while you keep that EM brain sharp. Upon further research in the 1970’s, retrospective data from autopsies of those patients showed coronary aneurysms 5 Pathophysiology: Kawasaki Disease is a vasculitis of medium sized arteries.

EMS 92

EMS Coronary ED OR 92

Dr. Smith's ECG Blog

JANUARY 2, 2025

Dodd KW, Elm KD, Dodd EM, Smith SW. Among patients with left bundle branch block, T-wave peak to T-wave end time is prolonged in the presence of acute coronary occlusion. Finally, do a coronary angiogram Possible alternative to pacing is to give a beta-1 agonist to increase heart rate. Heart Rhythm [Internet]. 2014;11:22732277.

Coronary 116

Coronary OR Defibrillator ALS 116

EMergucate

MAY 17, 2016

Cardiovascular Introduction Acute Coronary Syndrome Adult Cardiac Arrest Arrhythmias Atrial Fibrillation Cardiac Tumours and Transplantation Cardiomyopathies Chest Pain Disorders of … Continue reading →

EMS 100

EMS Coronary 100

Emergency Medicine Cases

DECEMBER 20, 2023

ST/T changes: consider the differential including demand ischemia, associated electrolyte abnormalities, Brugada pattern from sodium channel blockade, and acute coronary occlusion vs vasospasm from cocaine. The post ECG Cases 47 – ECG Interpretation in Toxicology appeared first on Emergency Medicine Cases.

Coronary 239

Coronary OR Overdose EMS 239

EMDocs

SEPTEMBER 7, 2024

We’ll keep it short, while you keep that EM brain sharp. A 70-year-old female with a past medical history of hypertension, coronary artery disease s/p 2x drug eluting stent placement one month ago, atrial fibrillation on apixaban presents to the ED with weakness and lightheadedness. Available from: [link] Guldner GT, Smith T, Magee EM.

EMS 97

EMS E-9-1-1 Operating Room OR 97

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. The TOMAHAWK Investigators.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Here is the case: Report from EMS was witnessed syncope, his son did CPR, but the patient had pulses when EMS arrived. When the patient arrived in the ED, he was still hypotensive in 70s, slowly improving with EMS fluids. Hope you’re doing well! How excited would you have been about this case?" No Chest Pain, but somnolent.

EMS 114

EMS CPR ED Coronary 114

EMDocs

OCTOBER 21, 2023

We’ll keep it short, while you keep that EM brain sharp. 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. Lancet Neurol 2009; 8:724-730.

EMS 97

EMS ALS OR ACS 97

Dr. Smith's ECG Blog

JULY 25, 2024

EMS arrived and found him in Ventricular Fibrillation (VF). 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! This patient was witnessed by bystanders to collapse.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

REBEL EM

OCTOBER 25, 2023

Take Home Points: A CCTA is an anatomic test to determine if a patient has normal coronary arteries, non-obstructive disease, or obstructive disease. Take Home Points: A CCTA is an anatomic test to determine if a patient has normal coronary arteries, non-obstructive disease, or obstructive disease.

Coronary 103

Coronary EMS OR 103

EMS 12-Lead

MAY 20, 2022

Fire/EMS personnel find her laying supine on the kitchen floor, awake and verbal, although acutely ill. 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. It is spread to V2 and V3.

Coronary 130

Coronary STEMI ED Firefighter 130

EMergucate

JANUARY 10, 2023

The following ECG was obtained from a 61 year old man with coronary artery disease and previous coronary stents. Please … Continue reading →

Coronary 130

Coronary EMS 130

EMS 12-Lead

JULY 24, 2023

Category 1 : Sudden narrowing of a coronary artery due to ACS (plaque rupture with thrombosis and/or downstream showering of platelet-fibrin aggregates. It’s judicious, then, to arrange for coronary angiogram. Supply-demand mismatch (non-occlusive coronary disease, or exacerbation of preexisting flow insufficiency) a.

Coronary 130

Coronary ACS CAD ED 130

EMS 12-Lead

MARCH 19, 2023

Fire/EMS crews found him clammy and uncomfortable. 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.

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

EMS 12-Lead

JUNE 20, 2022

According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician. One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. Here is the LAD after stent placement.

ACS 130

ACS Coronary STEMI CAD 130

EMS 12-Lead

SEPTEMBER 6, 2022

Coronary thrombosis is a dynamic process of platelet aggregation and subsequent coagulation. During spontaneous reperfusion -- whether via thrombolysis, or recruitment of collateral circulation -- there exists characteristic ST/T changes on the ECG. Case Review: [link]

Coronary 130

Coronary OR 130

Dr. Smith's ECG Blog

APRIL 18, 2024

The ECG is just a test: a Bayesian approach to acute coronary occlusion If a patient with a recent femur fracture has sudden onset of pleuritic chest pain, shortness of breath, and hemoptysis, the D-dimer doesn’t matter: the patient’s pre-test likelihood for PE is so high that they need a CT. But does this matter? Amsterdam et al. Lupu et al.

STEMI 121

STEMI Coronary ALS CAD 121

Dr. Smith's ECG Blog

DECEMBER 19, 2023

EMS obtained the following vital signs: pulse 50, respiratory rate 16, blood pressure 96/49. It appears EMS obtained two EKGs, but unfortunately these were not saved in the medical record. The EMS crew was only BLS certified, so EKG interpretation is not within their scope of practice. This is not the case.

E-9-1-1 127

E-9-1-1 Coronary ACS BLS 127

Dr. Smith's ECG Blog

JUNE 21, 2023

EMS was called, and they recorded the following ECG on scene at 13:16: What do you think? 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). Clinical Cardiology 2019.

STEMI 98

STEMI Coronary Defibrillator EMS 98

Dr. Smith's ECG Blog

AUGUST 11, 2024

Despite many ECG signs of OMI being missed the door-to-cath time was still fast, because all the healthcare providers were focused on the pathology of acute coronary occlusion and not were distracted by the lack of STEMI criteria. Start using the terms acute coronary occlusion and occlusion MI.

STEMI 100

STEMI Paramedic Coronary EMS 100

Dr. Smith's ECG Blog

JUNE 7, 2024

The most likely would be #2) initially normal, then #3) subtle OMI, then #4) obvious STEMI, and then #1) reperfusion: In other words, the patient with an initially normal ECG develops an acute coronary occlusion, with ECGs that progress from subtle to obvious, and then reperfuse after angiography. But that’s not always the case.

STEMI 112

STEMI Coronary OR EMS 112

Emergency Medicine Cases

NOVEMBER 19, 2019

Can you identify which ones had acute coronary occlusion? In this ECG Cases blog we look at 8 patients with potentially ischemic symptoms, to highlight pearls and pitfalls of inferior MI. The post ECG Cases 3: Can you find the subtle inferior MI? appeared first on Emergency Medicine Cases.

Coronary 130

Coronary STEMI EMS 130

EMDocs

DECEMBER 11, 2023

Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG. This included the addition several new STEMI equivalents [4] on ECG that warrant “prompt evaluation for emergency coronary angiography.”

STEMI 119

STEMI Coronary Emergency Department OR 119

Emergency Medicine Cases

MARCH 10, 2020

Which had acute coronary occlusion? 10 patients presented with the "STEMI-equivalent" ST elevation in aVR with diffuse ST depression. Jesse McLaren guides us through the differential diagnosis of ST elevation in aVR with diffuse ST depression in this ECG Cases blog. The post ECG cases 7: ST elevation in aVR, STEMI-equivalent?

STEMI 130

STEMI Coronary EMS 130

EMS 12-Lead

SEPTEMBER 5, 2022

Another spurious finding is a QS pattern that mimics Anterior MI, and in the acute setting this may elicit compulsory urge to pursue invasive coronary intervention that is entirely unwarranted. Tom Bouthillet demonstrates appropriate electrode application when capturing the pre-hospital 12 Lead ECG: [link]

Coronary 130

Coronary OR 130

Emergency Medicine Cases

AUGUST 16, 2022

Which patients with ECG evidence of coronary occlusion require a CT scan to rule out aortic dissection? What are the range of ECG findings in acute aortic dissection and how do they change management? Dr. Jesse McLaren guides us through 9 cases to answer these and other questions on ECG interpretation in aortic dissection.

Coronary 130

Coronary STEMI EMS 130

EMS 12-Lead

AUGUST 31, 2022

This finding should be assumed new, until proven otherwise, during suspected Acute Coronary Syndrome. A possible normal variant is lateral ST elevation (i.e., I/aVL/V5/V6) with bulky T waves when subsequent to a large, slurred S wave. Combination RBBB/LAFB has a high mortality rate in the setting of LAD occlusion.

Coronary 130

Coronary 130

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.

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.

Coronary 130

Coronary ED EMS OR 130

EMS 12-Lead

AUGUST 18, 2024

Ultimately the patient went to Cath and was found to have multi-vessel obstructive coronary disease with an acute LCX culprit vessel, which was stented. Here is the ECG after 200J. Readers of the Smith ECG Blog will probably recognize this a very subtle inferior OMI.

CAD 147

CAD EMT EMT ACS 147

Emergency Medicine Cases

SEPTEMBER 15, 2020

Which had an acute coronary occlusion? Signs of occlusion MI in patients with LVH include: new Q waves/loss of R waves, disproportionate and dynamic ST elevation (or ST depression from posterior MI), and hyperacute T waves. In this ECG Cases blog we look at 6 patients who presented with potentially ischemic symptoms and LVH on their ECG.

STEMI 130

STEMI Coronary OR EMS 130

EMDocs

SEPTEMBER 19, 2023

Episode 86: Tricky Cases Part 2 Case 3: 56-year-old female with history of seizures, actively seizing, EMS called. Patient seized for approximately 20 minutes prior to EMS arrival. NSTEMI dichotomy is not sensitive for true occlusion MI or acute coronary occlusion. They administer two doses of 10 mg midazolam IM.

STEMI 98

STEMI Coronary Emergency Department ICU 98

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

When EMS found her, she was dyspneic and diaphoretic. Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1 128

E-9-1-1 Coronary STEMI ALS 128

Dr. Smith's ECG Blog

OCTOBER 1, 2023

He called EMS who brought him to the ED. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. This patient in today's case was a man in his 60s with a known history of coronary disease, including prior stents. And the pace only quickens.

OR 127

OR STEMI Coronary CAD 127

Dr. Smith's ECG Blog

MAY 20, 2024

He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic. The scan also showed “scattered coronary artery plaques”. __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand).

CAD 126

CAD STEMI Coronary ACS 126