The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC ( Kudenchuk et al 2006). There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes.

EMR 130

EMR Coronary Defibrillator Life Support 130

EMS 12-Lead

MARCH 19, 2023

It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. Despite immediate chest compressions, and multiple rounds of defibrillation, he could not be resuscitated. To which the lead paramedic replied, “Not cardiac; his symptoms are atypical. Is this OMI?

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

Dr. Smith's ECG Blog

MAY 19, 2020

She was unable to be defibrillated but was cannulated and placed on ECMO in our Emergency Department (ECLS - extracorporeal life support). After good ECMO flow was established, she was successfully defibrillated. Here is a case of ECMO defibrillation with near shark fin that was due to proximal LAD occlusion. The K was normal.

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

STEMI 98

STEMI Coronary Defibrillator EMS 98

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL. How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later? This caused a type 2 anterior STEMI.

STEMI 110

STEMI Coronary Defibrillator OR 110

EMDocs

JANUARY 8, 2024

With respect to timing, for cardiac arrest with a shockable rhythm, it may be reasonable to administer epinephrine after initial defibrillation attempts have failed. Consider administering epinephrine after defibrillation in those with shockable rhythms. Editorial Comment : Yes to PCI after arrest with STEMI on ECG.

Epinephrine 98

Epinephrine Defibrillator Coronary CPR 98

Dr. Smith's ECG Blog

JULY 14, 2023

He underwent further standard resuscitation EXCEPT that we applied the Inspiratory Threshold Device ( ResQPod ) AND applied Dual Sequential Defibrillation (this simply means we applied 2 sets of pads, had 2 defib machines, and defibrillated with both with only a fraction of one second separating each defibrillation.

E-9-1-1 98

E-9-1-1 Defibrillator CPR STEMI 98

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. He required multiple defibrillations within a period of a few hours. This time, the arrhythmia did not spontaneously terminate — but rather degenerated to VFib, requiring defibrillation. The below ECG was recorded. What do you think?

Defibrillator 131

Defibrillator Coronary ALS STEMI 131

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

Are Some Cardiologists Really Limited by Strict Adherence to STEMI millimeter criteria? He was found in ventricular fibrillation and defibrillated, then brought to a local ED which does not have a cath lab. This is the response he got: Interventionist: "No STEMI, no cath. It is a STEMI equivalent.

STEMI 52

STEMI Defibrillator ED ACS 52

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. Do you think we discussed this patient's 2-3 hour delay to reperfusion in our quarterly "STEMI meeting"?

STEMI 52

STEMI ACS Coronary Epinephrine 52

Dr. Smith's ECG Blog

APRIL 8, 2016

Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? At cath, he immediately had incessant Torsades de Pointes requiring defibrillation 7 times and requiring placement of a transvenous pacer for overdrive pacing at a rate of 80. There is atrial fibrillation.

STEMI 52

STEMI Plasma Defibrillator OR 52

ECG & Echo Learning

JANUARY 18, 2023

STEMI , ST-segment elevation acute myocardial infarction ). 1 Initial diagnosis of STEMI ECG Management Recommendation Level of evidence A 12-lead ECG should be interpreted immediately (within 10 minutes) at first medical contact. I B ECG monitoring should start immediately and a defibrillator must be ready.

STEMI 40

STEMI Coronary Defibrillator OR 40

Dr. Smith's ECG Blog

OCTOBER 4, 2010

He was resuscitated with chest compressions and defibrillation and 1 mg of epinephrine. Thus, this patient had increased ST elevation (current of injury) superimposed on the ST elevation of LVH and simulating STEMI. This young male had ventricular fibrillation during a triathlon. His initial ECG is shown here. He awoke and did well.

ACS 52

ACS Epinephrine Defibrillator STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 25, 2009

RBBB in acute STEMI has a very high mortality. But here there is a large degree of ST elevation in V2-V6, I, and aVL. The paramedics activated the cath lab from the field.

Defibrillator 52

Defibrillator STEMI Paramedic EMS 52

Dr. Smith's ECG Blog

OCTOBER 28, 2013

She was found to be in ventricular fibrillation and was defibrillated 8 times without a single, even transient, conversion out of fibrillation. She was immediately intubated during continued compressions, then underwent a 9th defibrillation, which resulted in an organized rhythm at 42 minutes after initial arrest. see below).

Defibrillator 52

Defibrillator ACS CPR STEMI 52

Dr. Smith's ECG Blog

DECEMBER 23, 2014

He was defibrillated. Anterolateral STEMI. The formula results in 23.43, just above the 23.4 The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Here is his post resuscitation ECG: Now the diagnosis is obvious.

Defibrillator 52

Defibrillator STEMI Coronary 52

Dr. Smith's ECG Blog

OCTOBER 20, 2013

She was never seen to be in ventricular fibrillation and was never defibrillated. Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI. Note that they finally have laid to rest the new or presumably new LBBB as a criteria for STEMI. BP gradually rose. Kurkciyan et al.

STEMI 52

STEMI Coronary ACS Emergency Department 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

Discharge ECG showed antero-inferior reperfusion T wave inversion: Had the initial ECG been signed off as “STEMI negative” the patient could have arrested in the waiting room, with a poor cardiac and neurological outcome.

OR 67

OR STEMI ACS Coronary 67

Dr. Smith's ECG Blog

AUGUST 17, 2019

So there is definitely no STEMI, and the STE is normal. But after reading this blog, you all know that most OMI do NOT meet STEMI criteria. Bedside echo revealed anteroseptal wall motion abnormality at which point I activated a code STEMI. Defibrillated out of v fib in the cath lab. mm in men over age 40.

STEMI 52

STEMI Defibrillator ED OR 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2018

There is a very small amount of STE in some of the anterior, lateral, and inferior leads which do NOT meet STEMI criteria. The case was reviewed by all parties, and it was stated correctly that the ECG does not meet the STEMI criteria. He was defibrillated immediately and had return of normal mental status.

STEMI 52

STEMI Coronary ACS Defibrillator 52

Dr. Smith's ECG Blog

MAY 6, 2019

If it is STEMI, it would have to be RBBB with STEMI. Cardioversion/defibrillation. But — one of the causes of Brugada Phenocopy is acute infarction — so I didn’t know how to distinguish between a preexisting Brugada-1 ECG pattern vs a Brugada ECG pattern developing as a result of acute ongoing anterior STEMI. Hypothermia.

STEMI 52

STEMI Defibrillator OR ALS 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

After the second defibrillation the patient had an organized rhythm: Bradycardic escape/agonal rhythm, with large ST deviations. A repeat ECG was done: Obvious anterolateral wall STEMI. It should have been shocked at least 10 seconds ago. Beats 4, 6, and 7 are narrow, as the rhythm is trying to resume from above the ventricles.

CPR 52

CPR Defibrillator STEMI ED 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

She was defibrillated and resuscitated. STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al.

Emergency Department 52

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

Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. Bicarb 20, Lactate 4.2,

E-9-1-1 52

E-9-1-1 CAD STEMI OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5 Here are other posts on hyperK, large calcium doses for hyperK, and ventricular tachycardia in hyperK Weakness, prolonged PR interval, wide complex, ventricular tachycardia Very Wide and Very Fast, What is it? How would you treat? If the patient is at 1.8,

Plasma 40

Plasma STEMI Defibrillator Overdose 40

Dr. Smith's ECG Blog

JANUARY 23, 2023

When the ICD was finally interrogated, the syncopal events and shocks correlated with two VF events that were defibrillated successfully. Recall that air is a poor conductor of electricity and will, therefore, generate smaller amplitudes on posterior leads (hence why STEMI criteria requires only >0.5

ACS 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

It was reportedly a PEA arrest; there was no recorded V Fib and no defibrillation. He reportedly told his family "I think I'm having a heart attack", then they immediately drove him to the ED, and he was able to ambulate into the triage area before he collapsed and became unresponsive. CPR was initiated immediately.

ACS 52

ACS CPR CAD Heart Attack 52

Dr. Smith's ECG Blog

DECEMBER 22, 2010

After epinephrine, atropine, and defibrillation x 2, there was a return of pulses. There is ST depression in II, III, and aVF that is concerning for reciprocal depression from high lateral STEMI in aVL, where there is some ST elevation. She collapsed and 911 was called; she was found pulseless. Exact rhythm during arrest is uncertain.

STEMI 40

STEMI Epinephrine Defibrillator Emergency Department 40

Dr. Smith's ECG Blog

FEBRUARY 17, 2023

The computer called this Acute STEMI What do you think? STEMI never has a very short QT. There is Bazett, Fridericia, Hodges, Framingham and Rautaharju -- see here at mdcalc: [link] If the ST Elevation here were due to STEMI, it would be an LAD Occlusion. Treatment is by ICD ( implantable cardioverter defibrillator ).

STEMI 52

STEMI Defibrillator OR ED 52

Dr. Smith's ECG Blog

DECEMBER 5, 2019

How well does the computer interpretation perform? -- in this case, the computer diagnosed STEMI but the patient had Fever with Brugada _ _ Fever and Brugada-- Important articles The literature below shows that fever-induced Brugada is indeed a high risk for an arrhythmic event. Syncope and ST Segment Elevation. And another finding.

ALS 52

ALS Defibrillator OR STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 20, 2025

A 12-lead was recorded, showing "STEMI," but is unavailable. Moreover, if you know that catastrophic intracranial hemorrhage can result in an ECG that mimics STEMI, then you know that this patient probably has a severe intracranial hemorrhage. She was BVM ventilated and suctioned. Shortly thereafter, pulses were lost.

STEMI 89

STEMI Paramedic E-9-1-1 Epinephrine 89

Dr. Smith's ECG Blog

DECEMBER 31, 2024

Soon after the witnessed occlusion, the patient suffered ventricular fibrillation arrest, from which he was immediately resuscitated with 1 defibrillation. Final Diagnosis: "STEMI" (of course, as you can see in the ECGs above, this is not true, by definition this was NSTEMI. In other words, millimeters really don't matter!

Coronary 119

Coronary ACS STEMI CAD 119

Dr. Smith's ECG Blog

MARCH 8, 2025

Several 200 J shocks did not terminate the VF, so a second defibrillator was applied for double sequential defibrillation with 400 J. She was defibrillated perhaps 25 times. Propranolol versus Metoprolol for treatment of electrical storm in patients with implantable cardioverter-defibrillator. SanzRuiz, R., Solis, J., &

E-9-1-1 76

E-9-1-1 OR Defibrillator Coronary 76

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Unfortunately, the ECG was interpreted as no significant change from prior , "no STEMI"!! Defibrillation was performed, and ROSC was achieved. Approximately 5 minutes after ROSC, this ECG was obtained (about 45 minutes after arrival): Obvious anterolateral OMI, and STEMI criteria positive for those who care or need it.

STEMI 87

STEMI Defibrillator ACS ED 87

Dr. Smith's ECG Blog

NOVEMBER 29, 2024

Queen : she saw no OMI (no "STEMI Equivalent") either Continued : Now, she says she was walking to the bathroom when she experienced acute onset substernal chest pressure radiating into her neck and left arm. Throughout this process, the patient had repeated VF and was defibrillated 8 times. It is almost certainly not acute.

Defibrillator 67

Defibrillator STEMI Coronary ED 67