The Skeptics' Guide to EM

JUNE 14, 2017

Thank you to Dr. Manrique Umana for inviting me and the conference organizers for putting on such an amazing and educational event. Thank you to Dr. Manrique Umana for inviting me and the conference organizers for putting on such an amazing and educational event.

Coronary 130

Coronary Emergency Department ALS 130

The Skeptics' Guide to EM

MAY 19, 2018

Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial.

Emergency Department 130

Emergency Department ALS Coronary OR 130

Dr. Smith's ECG Blog

OCTOBER 1, 2023

This patient in today's case was a man in his 60s with a known history of coronary disease, including prior stents. This history immediately places this patient in a high -prevalence population for having an acute event. It's OK not to be certain from the initial ECG as to whether or not an acute event is occurring.

OR 127

OR STEMI Coronary CAD 127

Dr. Smith's ECG Blog

JUNE 23, 2024

The patient was treated as possible NSTEMI and underwent coronary angiography about 4 hours after presentation. TIMI 3 means the rate of passage of dye through the coronary artery is normal by angiography.) Initial hsTnI was 384 ng/L. The report describes a 60% proximal LAD lesion with TIMI 3 flow.

Coronary 106

Coronary CAD CPR Critical Care 106

Dr. Smith's ECG Blog

DECEMBER 19, 2023

The commonest causes of MINOCA include: atherosclerotic causes such as plaque rupture or erosion with spontaneous thrombolysis, and non-atherosclerotic causes such as coronary vasospasm (sometimes called variant angina or Prinzmetal's angina), coronary embolism or thrombosis, possibly microvascular dysfunction. This is not the case.

E-9-1-1 117

E-9-1-1 Coronary ACS BLS 117

Dr. Smith's ECG Blog

APRIL 22, 2024

A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty. Total coronary occlusion, if very brief, may have minimal infarction and yet be very dangerous. Am Heart J. 2000;139:430–436.

Coronary 118

Coronary STEMI ED OR 118

Dr. Smith's ECG Blog

APRIL 2, 2024

For this reason we did not believe this was an acute coronary event and did not activate the cath lab. Here is the troponin profile overnight: This is consistent with cardiac arrest without acute coronary occlusion. So a dual chamber pacer is placed with one lead through the coronary sinus to the LV. Cardiology agreed.

Defibrillator 128

Defibrillator Coronary Epinephrine CPR 128

Dr. Smith's ECG Blog

DECEMBER 7, 2023

I quickly reviewed the patient’s records and saw that she was a 53 year old woman with a history of BMI 40, but no other identifiable risk factors for coronary artery disease. In this patient with stuttering symptoms and rising troponin, there is no other option but to perform emergent coronary angiography. Hers is shown below.

Coronary 104

Coronary OR 104

Dr. Smith's ECG Blog

OCTOBER 15, 2024

Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion. Patient # 1: Assessment of the Initial ECG in the ED … The History for Patient #1 — is clearly concerning for a higher -risk likelihood of having an acute event.

OR 104

OR STEMI Coronary ED 104

Dr. Smith's ECG Blog

MAY 20, 2024

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). They too have dense white masses consistent with coronary atherosclerosis. The blue circle shows the LCx.

CAD 123

CAD STEMI Coronary ACS 123

Critical Care Scenarios

OCTOBER 11, 2023

Takeaway lessons * Type B dissections do not involve the heart or coronaries, but Type A vs B nomenclature is falling out of favor versus more anatomically specific labeling; this system helps characterize the gray area between the innominate and the left subclavian. * Find us on Patreon here! Buy your merch here!

Naloxone 100

Naloxone Coronary OR 100

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

The Skeptics' Guide to EM

APRIL 10, 2021

This has been to prevent the horrible adverse event called osmotic demyelination syndrome (ODS). There is a high mortality associated with hyponatremia [1-3]. Symptomatic hyponatremia has traditionally been treated with a careful slow continuous infusion of hypertonic saline.

Emergency Department 130

Emergency Department Coronary ED OR 130

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. This is another case sent by the undergraduate (who is applying to med school) who works as an EKG tech. No ECG was ordered on Day #1.

Coronary 106

Coronary STEMI Emergency Department OR 106

Dr. Smith's ECG Blog

DECEMBER 11, 2023

For the same reason, you should not delay coronary angiography because pain resolves with morphine. A few hours later, the patient underwent coronary angiography, which showed complete occlusion of her mid left circumflex artery. But pain is a critical signal for urgency in the context of acute coronary syndrome. Mukherjee, D.,

E-9-1-1 122

E-9-1-1 Coronary ACS STEMI 122

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

More past history: hypertension, tobacco use, coronary artery disease with two vessel PCI to the right coronary artery and circumflex artery several years prior. But I'd be less certain about an acute event without more information and prior and/or serial tracings. It is unknown when this pain recurred and became constant.

Defibrillator 129

Defibrillator Coronary STEMI CPR 129

EMS 12-Lead

AUGUST 22, 2022

Beats 9-12 : Continuation of the previously described events, all inducible by the pause (and thus, prolongation of refractoriness) created by the PVC of Beat 8. The coronary angiogram revealed no critical stenosis, or acute plaque ulceration. Beat 4 abruptly halts this repetitious cycle via Peel Back.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

We who know ischemic ECGs know that really when T-wave inversion is specific for coronary thrombosis that it indicates reperfusion of the artery, not active occlusion. that is, show a pattern of labile ST-T wave changes not due to an acute coronary event. I personally can hardly wait for that future version!

E-9-1-1 105

E-9-1-1 Coronary EMS ED 105

Dr. Smith's ECG Blog

DECEMBER 3, 2024

He had ongoing pain following the syncopal event but went to bed and awoke in the morning with ongoing pain. It is therefore important to realize that even IF this patient was having an ongoing cardiac event — We might not necessarily see obviously acute changes. He came to the ED at the urging of his wife.

ED 94

ED Coronary ACS STEMI 94

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 94

STEMI Coronary OR EMS 94

Dr. Smith's ECG Blog

OCTOBER 22, 2024

The coronary angiography showed a 100% ostial main (obtuse) marginal occlusion!" Dominant right coronary, atherosclerotic and calcified. Presence of a single coronary lesion: occlusion of the ostial main marginal. Clinically — this means we need to pay even more attention to seemingly subtle ECG changes.

Coronary 69

Coronary STEMI OR ALS 69

Dr. Smith's ECG Blog

JUNE 27, 2024

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 is a primary ST-T wave change , that in a patient with chest pain ( or cardiac arrest ) — indicates an ongoing acute event until proven otherwise. 5% vs. 58%!!

Defibrillator 91

Defibrillator STEMI Coronary ALS 91

Dr. Smith's ECG Blog

OCTOBER 3, 2024

Coronaries were clean. Negative serial Troponins were needed to rule out an acute event. If a final test was perceived as "needed" — perhaps a normal coronary CT angiogram could have helped to avoid cardiac catheterization. Sam : "Yes, this case was sent to me. It was a man in his 30s with chest pain.

E-9-1-1 109

E-9-1-1 Coronary ALS ED 109

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 the patient had a transient acute coronary occlusion that spontaneously reperfused but is at risk for reocclusion.

STEMI 100

STEMI Coronary ACS ED 100

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 most common way is by delivering a lead into the coronary sinus ostium in the RA, which wraps around the posterolateral portion of the LV. ECG 1 What do you think?

Defibrillator 74

Defibrillator Coronary ALS Emergency Department 74

REBEL EM

SEPTEMBER 12, 2022

Background: Coronary artery disease can result in hibernating myocardium (chronic myocardial contractile dysfunction) due to ischemia. The theory is that there is reduced coronary blood flow and increased myocardial demand resulting in impaired contractility. Paper: Perera D et al. OMT: 38.0% HR 0.99; 95% CI 0.78 to 1.27; p = 0.96

Coronary 52

Coronary ALS OR EMS 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The biphasic T wave is consistent with recent reperfusion of an occluded coronary artery supplying the inferior region. Here’s the angiogram of the RCA : No thrombus or plaque rupture in the RCA (or any coronary artery) was found. This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

JANUARY 9, 2023

Repeat CT angio chest (not CT coronary, unclear what protocol) showed possible LAD aneurysm and thrombus. Finally, coronary angiography was performed (at least 5 days after presentation) which confirmed LAD aneurysm with large thrombus burden, TIMI 0 flow, thrombectomy performed.

Coronary 52

Coronary STEMI Heart Attack OR 52

Dr. Smith's ECG Blog

DECEMBER 13, 2023

Knowing the patient has a history of coronary disease could be relevant to today's case — as it should add to our suspicion of a new acute event. If this is the case — this size of a Qr wave in lead III, as well as the seemingly wide Q in lead aVF — would seem to suggest prior inferior infarction a t some point in the past.

EMR 111

EMR Coronary OR STEMI 111

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

There was no association between moderate to severe chest pain on arrival and major adverse cardiac events at 6 months (20% vs. 14%, p=0.12). Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7

STEMI 106

STEMI Coronary Emergency Medical Services OR 106

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Takotsubo is a sudden event, not one with crescendo angina. 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. An angiogram is a "lumenogram;" most plaque is EXTRALUMINAL!!

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 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. 1] The morphology of PVT closely mirrors that of TdP but the underlying mechanism differs from reversible QT prolongation.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event. LV Aneurysm vs New Infarction?

EMS 104

EMS CPR ED Coronary 104

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. Coronary arteries cannot be assessed because the scan was not gated, but proximal segments of the coronary arteries seem to be open with some contrast. Again nothing diagnostic.

STEMI 52

STEMI EMR Coronary OR 52

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 61

Emergency Medical Services Coronary Emergency Department EMS 61

Dr. Smith's ECG Blog

JULY 22, 2012

Blunt cardiac injury my result in : 1) Acute myocardial rupture with tamponade 2) Valve rupture (tricuspid, aortic, mitral) 3) Coronary thrombosis or dissection (and thus Acute MI) from direct coronary blunt injury 4) Dysrhythmias of all kinds. Finally, this may just be an incredibly rare event that none of us will ever see again.

Coronary 52

Coronary ICU OR ED 52

EMDocs

FEBRUARY 7, 2024

GLP-1 agonists are also associated with improved ejection fraction, coronary blood flow, and cardiac output while reducing the risk of cardiovascular events, infarction size, and all-cause mortality. Adverse events are common in those using GLP-1 agonists, but the vast majority of these are minor. What are the complications?

Allergic Reaction 76

Allergic Reaction ALS CAD OR 76