EMS 12-Lead

JULY 30, 2023

She was known to have a history of poorly controlled COPD, AFib, and multivessel coronary disease. Pharmacology Review Digoxin is probably one of those medications vaguely recalled from paramedic school. David Didlake, FF/EMT-P, AG-ACNP @DidlakeDW An elder female presented to the ED with worsening shortness of breath.

EMT 130

EMT EMT ACS Coronary 130

EMS 12-Lead

JUNE 20, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith @SmithECGblog I was conducting QA/QI on two very recent cases and was struck by the uniqueness of both. Moreover, he had no pertinent medical history to report in terms of CAD, HTN, HLD, or DM, for example.

ACS 130

ACS Coronary STEMI CAD 130

EMS 12-Lead

AUGUST 22, 2022

A 12 Lead ECG was recorded secondary to bizarre telemetry findings at bedside. From afar, there is gross tachycardia, cadence irregularities, and narrow QRS complexes that may, or may not, be Sinus in origin; and finally – a cacophony of wide complexes that might very well be ventricular in origin. Said differently, it’s a mess.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Dr. Smith's ECG Blog

MAY 23, 2023

But the paramedic and the ED physician in this case did not subscribe to this idea. It is far too premature to say that paramedics and physicians should not be bothered to interpret ECGs labelled as "normal" or "otherwise normal" by the computer algorithm. EMS arrived and recorded this ECG: What do you think? by being interrupted???

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

JUNE 17, 2016

Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear. Outcome "I later found out that this is a patient who regularly calls paramedics to c/o chest pains and he had fooled many of them.

STEMI 52

STEMI OR Coronary EMS 52

EMS 12-Lead

APRIL 2, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Expert commentary provided by Dr. Ken Grauer CASE 1 An 82 y/o Male called 911 for sudden onset dizziness while at rest. Upon arrival he was found alert and oriented, and without gross distress. He denied difficulty breathing, epigastric pain, or chest discomfort.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Coronaries were normal, as was serial troponin. Vitals were normal. Take away 1.

STEMI 73

STEMI Paramedic Coronary ED 73

Dr. Smith's ECG Blog

JULY 7, 2024

First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion. The new ACC expert consensus explains that: “STEMI ECG criteria on a standard 12-lead ECG alone will miss a significant minority of patients who have acute coronary occlusion. Take home 1.

STEMI 66

STEMI Coronary ALS OR 66

Dr. Smith's ECG Blog

DECEMBER 9, 2023

link] Case continued The conventional algorithm diagnosed STEMI and so did the paramedics. A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA. He had a prehospital ECG. He was ambulatory at the scene. It is all but diagnostic of OMI.

STEMI 115

STEMI Coronary ED Paramedic 115

Dr. Smith's ECG Blog

JANUARY 8, 2024

She went to angio and had normal coronaries. Paramedics found her semi-conscious, pale, cool, diaphoretic, tachypneic, very hypotensive. No d-dimer or CT pulmonary angiogram was done when they discovered that she had normal coronary arteries. I discussed the case with Cardiology will admit to their service."

Coronary 71

Coronary STEMI EMS Paramedic 71

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. V1 has 0.5 mm of elevation. ng/mL [IQR: 0.46, 2.35]. It can only be seen by IVUS.

Emergency Department 52

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

Dr. Smith's ECG Blog

OCTOBER 28, 2022

Cortland Ashbrook from Spokane County, Washington, sent this message: Hey doctor Smith, I wondered if you’d give me your opinion on these ECG tracings I took as a paramedic in the field? Electrocardiographic diagnosis of acute coronary Occlusion Myocardial Infarction in ventricular paced rhythm using the modified Sgarbossa criteria.

Coronary 52

Coronary Paramedic ICU EMS 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

Written by Jesse McLaren Two 70 year olds had acute chest pain with nausea and shortness of breath, and called paramedics. But these ECGs were from the same patient: #1 on paramedic arrival and #2 thirty minutes later. Thankfully this patient’s second ECG met STEMI criteria, so paramedics brought them as a code STEMI.

STEMI 52

STEMI Paramedic Coronary ALS 52

ECG Medical Training

SEPTEMBER 4, 2016

The ECG is determined to be non-diagnostic by the treating paramedic. The treating paramedic withholds aspirin. The paramedic, feeling a bit sheepish, asked me to review the case. RR: 24 HR: 104 NIBP: 145/95 Temp: 98.5 C SpO2: 99% on room air Breath sounds are clear bilaterally. The cardiac monitor is attached. Is this a STEMI?

STEMI 52

STEMI Paramedic Coronary Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. The diagnostic coronary angiogram identified only minimal coronary artery disease, but there was a severely calcified, ‘immobile’ aortic valve. Look at the aortic outflow tract.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

AUGUST 9, 2018

This case was sent by Lou B, a paramedic and RN. The coronaries were clean (this is not the gold standard, however, as some patients with ischemic ST elevation may have clean coronaries). ACTUAL CORONARY ANATOMY: Dominance: Right LM: A 5 mm vessel which bifurcates into the LAD and LCx coronary artery.

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

Dr. Smith's ECG Blog

JUNE 24, 2016

The paramedic recorded a series of ECGs; the initial ECG is representative here: Computer read: “ Normal ECG ” What do you think? The paramedic interpreted this as a STEMI. The Subtle STEMI calculation is used to differentiate a subtle anterior acute coronary occlusion from early repolarization (ER). or LAD occlusion?

STEMI 40

STEMI Coronary Paramedic ED 40

Dr. Smith's ECG Blog

DECEMBER 19, 2018

The symptoms improved somewhat after the paramedic gave her nitroglycerin. In combination with the subtle ST depression in aVL , these changes are diagnostic for, or at least nearly so, for acute occlusion of a coronary artery, probably with some reperfusion, as inferior T-waves are inverted and the T-wave in aVL is reciprocally upright.

ED 52

ED Coronary OR Paramedic 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The paramedics found the patient with ROSC and a GCS 7, and an ECG showing LBBB with possible lateral ST elevation. This ALONE is very strong evidence of acute coronary occlusion. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Learning points 1.

EMR 52

EMR STEMI CPR ED 52

Dr. Smith's ECG Blog

MARCH 30, 2014

My most talented blog readers are paramedics because they have to put themselves on the line every time they activate the cath lab. In any case, these further support the diagnosis of coronary occlusion or near occlusion. The minute this medical student saw the first ECG, he knew the diagnosis without any further information.

STEMI 52

STEMI Coronary Paramedic OR 52

Dr. Smith's ECG Blog

MARCH 13, 2023

Unfortunately — the paramedics did not write down whether today's patient was ( or was not ) having chest pain at the time they recorded ECG #1. This may be seen on angiogram as poor "blush" or a low "TIMI Myocardial Perfusion (TMP) Grade." Low TMP grade correlates very well with resolution of ST Elevation.

ED 52

ED ACS Coronary Paramedic 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2020

Her initial 12-lead ECG that was obtained by paramedics in the field is shown in Figure-1. Figure-1: The initial ECG in todays case, obtained by paramedics in the field. ( NOTE: Because LBBB changes the sequence of LV repolarization it may be more difficult to recognize acute coronary occlusion on ECG. See text ). (

STEMI 52

STEMI Paramedic ED OR 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

Pretest probability: Especially when there is no Chest pain, or there are very atypical symptoms, one should be very suspicious of the diagnosis of coronary occlusion unless the ECG is crystal clear. Outcome "I later found out that this is a patient who regularly calls paramedics to c/o chest pains and he had fooled many of them.

STEMI 52

STEMI Coronary EMS ED 52

EMS 12-Lead

JUNE 1, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith [link] @SmithECGblog A 72 y/o Male experiences a syncopal episode while seated. It’s reported that he regained consciousness after 30 seconds, approximately. Crew members note residual pallor and clammy skin.

Coronary 130

Coronary ALS ED ACS 130

EMS 12-Lead

APRIL 8, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review by Dr. Stephen Smith @smithECGblog I was reviewing ECG’s in our LifeNet database and happened upon this one without any knowledge of clinical circumstances. Cardiology admitted him for observation with plans for next-day coronary angiogram.

STEMI 130

STEMI ALS Coronary CAD 130

Dr. Smith's ECG Blog

JUNE 8, 2023

Here’s the paramedic ECG (digitized by PMcardio). 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. HR 40, BP 135/70, RR16, O2 100%. What do you think?

STEMI 86

STEMI Coronary Paramedic ALS 86

EMS 12-Lead

AUGUST 14, 2022

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic @DidlakeDW A 50 y/o Male was taking his dog for a leisurely stroll through the park when he suddenly experienced new onset chest discomfort. A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis.

MICU 130

MICU STEMI CAD Coronary 130

EMS 12-Lead

MAY 8, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith [link] @SmithECGBlog An adult female called 911 for chest discomfort and difficulty breathing. Cardiology was consulted, who advised to surveil a metabolic process as this did not strike them as acute coronary syndrome.

STEMI 130

STEMI ED EMS Firefighter 130

EMT Training Station

JUNE 18, 2023

In this five-part series, we will journey through the intricacies of the cardiovascular system, delve into the most common heart conditions you’ll encounter as an EMT, review essential interventions, and underline the importance of patient education in preventing cardiovascular disease.

EMT 52

EMT EMT Heart Attack Emergency Medical Technician 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

This was shown to me by a very astute Hennepin paramedic. Although this comes from a Hennepin paramedic, the patient was not brought to Hennepin County Medical Center. It is important for cardiologists to realize that a paramedic may see something they do not. of this post. This is my reponse. This is not tribalism.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

When the paramedics arrived, they obtained a 12 lead ECG and confirmed the unstable vital signs. Smith pointed out that while atropine may may result in slightly more oxygen demand, the increase in cardiac output and in blood pressure would increase overall coronary perfusion and decrease ischemia. Why is the patient in shock?

STEMI 40

STEMI EMS Coronary ALS 40

Dr. Smith's ECG Blog

NOVEMBER 14, 2024

This was texted to me by a paramedic while I was out running one day: "54 yo male chest pain started at 1pm. The patient is a 54yo man with diabetes and a known history of coronary diseae ( prior stent placement ) — who presented with new CP ( C hest P ain ) — therefore very high likelihood for having an acute coronary event.

ED 126

ED Coronary Paramedic OR 126

Dr. Smith's ECG Blog

MARCH 19, 2025

Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. He presented to a rural ED at approximately 0630hrs.

STEMI 116

STEMI Coronary ED Paramedic 116

Dr. Smith's ECG Blog

MARCH 3, 2025

She was found by paramedics with an oxygen saturation of 64%, but could not tolerate BiPAP during transport due to claustrophobia. The scan showed a bicuspid aortic valve with severe stenosis and coronary artery disease. She awoke in the morning with sharp chest pain which worsened throughout the morning.

E-9-1-1 74

E-9-1-1 Coronary STEMI Emergency Department 74

FOAMfrat

DECEMBER 4, 2024

You’re me, and you’re in paramedic school, in the thick of the cardiology section. The ultimate goal is to optimize coronary perfusion pressure (CPP)—in other words, the amount of blood flow into the coronary arteries. When the heart is full, it puts pressure on the myocardium, compressing the coronary microvasculature.

Coronary 64

Coronary STEMI Epinephrine Critical Care 64

Dr. Smith's ECG Blog

JANUARY 15, 2025

Pretty impressive for someone who has not yet attended med school, or even been a nurse or paramedic yet. En route to the next hospital, the paramedics recorded another 12-lead tracing. Although normal variant STE can have reciprocal STD in aVL I want to mention that Hans saw this immediately. Another EKG was eventually taken.

Coronary 68

Coronary ED CAD Paramedic 68

Dr. Smith's ECG Blog

APRIL 9, 2025

The paramedics diagnosis was "Possible Anterolateral STEMI." Lidocaine had been used for the prevention of VF since the 1960s after coronary care units became a standard setting for the treatment of AMI. There is sinus rhythm with RBBB and obvious LAD OMI (proximal LAD occlusion): hyperacute T-waves in I, aVL and minimal STE in V1, V2.

Defibrillator 63

Defibrillator STEMI ED Coronary 63