ACEP Now

APRIL 4, 2024

A 59-year-old male with a past medical history of a repaired ventricular septal defect (VSD), dextrocardia, hypertension, hyperlipidemia, and current smoker presented to the emergency department (ED). The patient initially presented to an outside ED and was subsequently transferred to our facility for continuity of care.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

male presents to the ED at 6:45 AM with left sided chest dull pressure that woke him up from sleep at 3am. He arrived to the ED at around 6:45am, and stated the pain has persisted. Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. The pain radiated to both shoulders.

Coronary 115

Coronary ACS OR EMR 115

Dr. Smith's ECG Blog

MARCH 19, 2024

The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." Most large STEMI have peak troponin I in the 20.0 Next trop in AM. Peak trop 257.97 Smith: This is an enormous myocardial infarction.

CAD 89

CAD STEMI ACS ALS 89

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Ongoing pain noted throughout all documentation, but after nitro drip and prn morphine, "pain improved to 2/10." Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Setting – large, academic, suburban ED. CT aorta negative for dissection.

E-9-1-1 78

E-9-1-1 ACS STEMI Coronary 78

Dr. Smith's ECG Blog

DECEMBER 11, 2023

The neighbor recorded a systolic blood pressure again above 200 mm Hg and advised her to come to the ED to address her symptoms. Triage documented a complaint of left shoulder pain. Immediate versus delayed invasive intervention for non-stemi patients. She contacted her neighbor, a nurse, for help. The case continues.

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

Dr. Smith's ECG Blog

APRIL 17, 2023

One case sent by Dr. Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

MAY 16, 2023

Here is the Queen of Heart's interpretation: The cath lab had been activated for concern of STEMI. Learning Points: This is one of many examples of false positive STEMI criteria, which is distinguishable by expert humans, and now by AI such as QOH. No prior ECG was available.

Coronary 52

Coronary STEMI ED OR 52

Dr. Smith's ECG Blog

JUNE 27, 2021

They gave him 2 nitroglycerine and transported to the ED. In the ED, the patient was "moaning, writhing in bed, and clutching his chest." Here is the first ED ECG (there was no previous ECG on file for comparison): Sinus rhythm and LVH There is some (less than 1 mm) of STD in V3 and V4. It was not a STEMI) 1.

STEMI 52

STEMI ACS Coronary ED 52

Dr. Smith's ECG Blog

MARCH 31, 2023

This was marked as "Not a STEMI" by the physicians. It is not a STEMI, but it is diagnostic of an LAD OMI (Occlusion MI). has outperformed many cardiologists in its ability to recognize with "high confidence" acute OMIs from ECGs not satisfying STEMI-criteria. This was sent to me by a friend.

STEMI 52

STEMI Coronary OR ED 52

ACEP Now

JULY 6, 2023

Of course, the bill for any episode of emergency department (ED) care can be substantial, exceeding the billed charges for equivalent care provided in some primary care offices. Now, many acute pyelonephritis patients receive an IV antibiotic, analgesia, and an antiemetic in the ED. This process required at least a full day.

ALS 52

ALS Emergency Department STEMI ED 52

Dr. Smith's ECG Blog

MARCH 19, 2023

The patient was diagnosed with a"Non-STEMI." Traditionally , Occlusion MI (OMI) myocardial infarctions that are not STEMI are called NonSTEMI. That said — we do know that ECG #2 was the last ECG on file prior to this patient’s presentation to the ED on the day of admission. To me, that is a meaningless diagnosis.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

JULY 19, 2019

He still had active pain on arrival to the ED. This morphology can be cause by or associated with cocaine: A Patient with Cocaine Chest Pain and Prehospital Computer interpretation of STEMI This is OMI of the anterior, lateral, and inferior walls until proven otherwise. His initial ECG in the ED ( = E CG # 1 ) is shown in Figure-1.

STEMI 52

STEMI ED ACS OR 52

Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." The RR ( R espiratory R ate ) in today's case is recorded as 14/minute at the time the patient presented to the ED on the day after their initial presentation. Today's Initial ECG: As per Drs.

E-9-1-1 137

E-9-1-1 ACS Emergency Department Coronary 137

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

JULY 26, 2023

How would YOU interpret ECG #1 if this was the only tracing you saw — and — the only thing you knew about the patient, was that he/she was being seen in the ED? At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010. He presented to the ED for today's visit because of vertigo.

STEMI 52

STEMI ED OR 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. At the time of arrival to the ED, the patient reported 1/10 chest pain with normal vital signs. Triage EKG: What do you think? 1] Wereski, R.,

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). While this may be change that is reciprocal to an Acute/Subacute Inferior STEMI, the problem is that LV aneurysm may also manifest with this reciprocal change. In STEMI, they are generally upright and large in proportion to the QRS.

STEMI 52

STEMI ACS Emergency Department OR 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

He wrote in his note that "The EKG showed early repolarization in I, V2-V3 but no clear STEMI pattern." We performed a beside US (shown below) which showed lateral wall hypokinesis as read by an US-boarded ED attending in real time. See far below for data on 24 troponin T in STEMI and NSTEMI, and correlation with infarct size.

STEMI 52

STEMI Coronary ALS OR 52

Dr. Smith's ECG Blog

JUNE 4, 2019

A 40-something woman presented to the ED having had “heartburn” overnight and then worsening chest pain 1 hour prior to arrival. Here is the ED ECG (no previous ECG was available for comparison). T his is a systematic failure that has been documented in the following study: Garg A, Lehmann MH. The patient looked ill.

STEMI 52

STEMI ED OR 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

This is why it is essential that the OMI/NOMI paradigm replace the STEMI/NonSTEMI paradigm. Under Non-STEMI, this patient would not have intervention until at least 20 hours (next day), after the infarct is completed. Learning Points: 1. 25-30% of OMI are not treated in a timely way.

Critical Care 52

Critical Care STEMI ED OR 52

Dr. Smith's ECG Blog

JULY 11, 2018

This is of course diagnostic of an acute coronary occlusion MI (OMI) that also meets STEMI criteria. Then this was recorded in the ED 10 minutes after the first: Now there is massive STE Many inferior MI are associated with RV MI. BOTTOM — 2nd ECG obtained 10 minutes later in the ED ( See text ). Can you tell from this ECG?

Coronary 52

Coronary STEMI ED ALS 52

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. A near 60 year old male called 911 for increasingly severe fever and SOB.

Coronary 52

Coronary STEMI OR ED 52

Dr. Smith's ECG Blog

JULY 22, 2023

An ECG was performed in the ED at 1554: Original image unavailable, this is the only recorded scanned ECG available. A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. He denied chest pain or shortness of breath.

E-9-1-1 70

E-9-1-1 CAD OR STEMI 70

Dr. Smith's ECG Blog

AUGUST 8, 2020

This is a re-posting of a Tweet by Robert Jones (@RJonesSonoEM), reproduced with permission, written by Pendell Meyers A middle aged female with history of smoking presented to the ED with "bad heartburn." Here is her prior baseline ECG (first), and her ED ECG (second): Baseline: ED ECG: What do you think?

STEMI 52

STEMI ED Coronary OR 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

A middle-aged man presented with 7-8/10 non-radiating chest tightness to the left chest wall, associated with nausea but no diaphoresis, that began while walking approximately 40 minutes prior to arrival at the ED. He was definitely pain free by the time of arrival at his ED room. What do you think? Chest Pain scores can be misleading.

ED 52

ED STEMI Coronary Emergency Department 52

Dr. Smith's ECG Blog

JUNE 8, 2023

STEMI negative : the EMS automated interpretation read, “STEMI negative. 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. Sinus bradycardia.”

STEMI 63

STEMI Coronary Paramedic ALS 63

Dr. Smith's ECG Blog

JUNE 14, 2017

I’ve attached an article and an abstract (that article is in Japanese unfortunately … ) that do document that you CAN however on occasion find AIVR in otherwise healthy children — and I suppose that IS what we have here. Is there STEMI? Most physicians, at first glance, get this wrong. What is it? What is the rhythm? Giant R-waves.

STEMI 52

STEMI Coronary ED OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

They transported to the ED. The history, obtained subsequently, is interesting: The patient had been seen at an outside ED 2 days prior and the K was 2.5 Hospital admission had been recommended, but she left that ED against medical advice. to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5

Plasma 52

Plasma STEMI Defibrillator Overdose 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

JUNE 20, 2018

The medicine note documents that the patient had worsening pain with lying flat and relief with leaning forward. Myocarditis is virtually indistinguishable in the ED from MI. See this case: Pericarditis, or Anterior STEMI? I n the intervening 3 hours, new Q-waves have developed in leads V3 and V4, and deepened in V5 and V6.

Overdose 52

Overdose OR STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 5, 2019

Thus, Brugada is the likely diagnosis _ A very nice explanation of this is given in the document quoted below on current ECG criteria for Brugada pattern. If there are any syncopal or presyncopal events, she should be evaluated immediately in the ED. --All Bayes de Luna, A et al. All 1st degree relatives should have 1 time EGG.

ALS 52

ALS OR Defibrillator STEMI 52