Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? Second, although there is a lot of ST Elevation which meets STEMI criteria, especially in V3-4, the ST segment is extremely upwardly concave with very large J-waves (J-point notching). With EMS, patient had a GCS of 3 and was saturating 60% on room air. or basilar ischemia.

STEMI 119

STEMI Coronary Emergency Department ACS 119

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI 52

STEMI Coronary EMR ALS 52

EMDocs

SEPTEMBER 19, 2023

Reference: emDOCs – NCSE Journal of Emergency Medicine – Review Case 4: 52-year-0ld male brought in by EMS with “code STEMI” ECG demonstrates ST depressions with rocket like T waves in V2-V4. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

STEMI 86

STEMI Coronary Emergency Department ICU 86

Dr. Smith's ECG Blog

APRIL 4, 2023

This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI? As cardiology documented, “possible STEMI.

STEMI 52

STEMI Coronary OR ACS 52

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 HPI: Abrupt onset of substernal chest pain associated with nausea/vomiting 30 min PTA. ng/mL - 80.0

CAD 115

CAD STEMI ACS ALS 115

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. Confounders to the GCS such as seizure and post-ictal phase, ingestions and drug overdose, as well as medications administered in the prehospital setting that impact GCS score should be documented.

Emergency Medical Services 98

Emergency Medical Services EMS OR Overdose 98

Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." Written by Willy Frick A 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of "chest burning." The following ECG was obtained. ECG 1 What do you think?

ACS 124

ACS ALS OR STEMI 124

Dr. Smith's ECG Blog

APRIL 17, 2023

The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? His HEAR score (before troponin resulted) was documented at 3, with documentation stating "low suspicion for ACS." Physician interpretation: "No STEMI."

OR 52

OR STEMI ACS Emergency Department 52

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 73

STEMI Coronary OR ALS 73

ESO

JANUARY 19, 2024

Gender, race, ethnicity, and socioeconomic disparities are well-documented within the healthcare system. While stroke assessment is documented 38% of the time for patients overall, it is only documented 32% of the time for Hispanic/Latino patients. However, in reality, that’s not always the case.

CPR 52

CPR Advanced Life Support Life Support STEMI 52

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"). Repeat ECG: New developing Q waves in V2 and V3, further confirming evolving OMI.

E-9-1-1 82

E-9-1-1 ACS STEMI Coronary 82

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 C Pain Titrated i.v. IIa C Anxiety Tranquillizer (e.g benzodiazepine) is considered.

STEMI 40

STEMI Coronary OR Defibrillator 40

Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. In both tracings — an exceedingly fast PMVT is documented. The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The below ECG was recorded. What are additional treatment options?

Defibrillator 134

Defibrillator Coronary ALS STEMI 134

Dr. Smith's ECG Blog

OCTOBER 2, 2021

We assume that at some point the patient's pain returned, but it is not documented, so exactly when this happened is uncertain. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities. The first troponin I was less than 0.30 ng/mL (undetectable).

OR 52

OR ACS STEMI Coronary 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

You've read in my previous posts that I have a lot of evidence that Wellens' represents spontaneously reperfused STEMI in which the STEMI went unrecorded. New ST elevation diagnostic of STEMI [equation value = 25.3 It is well documented with continuous 12-lead monitoring that acute re-occlusion is frequently asymptomatic.

Coronary 52

Coronary STEMI ALS Emergency Department 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. This case is tough.

STEMI 52

STEMI ACS Emergency Department OR 52

REBEL EM

MARCH 2, 2023

Based on recent studies, current guidelines recommend that O2 should not be given to non-hypoxemic patients with STEMI or NSTEMI [2,3]. 4159 patients (10% of total population) had STEMI 30d Mortality: High O2 protocol: 8.8% 4159 patients (10% of total population) had STEMI 30d Mortality: High O2 protocol: 8.8%

ACS 52

ACS Coronary STEMI Ambulance 52

NAEMSP

MARCH 5, 2024

Appropriate air medical services utilization and recommendations for integration of air medical services resources into the EMS system of care: a joint position statement and resource document of NAEMSP, ACEP, and AMPA. Air medical transport has been utilized in multiple hospital based programs including trauma, STEMI, and stroke.

Critical Care 52

Critical Care Medical Transportation CPR EMS 52

ACEP Now

APRIL 4, 2024

Figure 1: EKG for Dextrocardia showing STEMI. The second EKG was concerning for STEMI in the precordial leads (see figure 1). This delay in recognition can result in the inadvertent underdiagnosis of STEMIs. Dextrocardia with STEMI is a rare clinical presentation that presents with both diagnostic and technical challenges.

Coronary 40

Coronary STEMI CAD Emergency Department 40

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

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

See many examples of Pseudo STEMI due to hyperkalemia at these two posts: Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life. And, there is no documentation that the tachycardia has resolved. This is diagnostic of hyperkalemia.

STEMI 52

STEMI OR 52

EMDocs

JANUARY 11, 2024

Brain Oxygenation, Perfusion, Edema, and ICP Statements Takeaway: Avoid 100% oxygen saturation. Instead, target 92-98%. Keep hemoglobin > 7 g/dL. Consider lowering ICP if elevated (head of bed elevation, hyperosmolar therapy, etc.). Valproic acid and levetiracetam are reasonable first-line therapies for EEG or clinical seizure activity.

Critical Care 91

Critical Care E-9-1-1 OR ICU 91

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. The interventionalist asked for another troponin, which shortly returned at 66 ng/L. Another ECG was recorded while waiting for the cath team (it was nighttime). Smith and Meyers as “worrisome”?

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

JUNE 27, 2021

Meyers note: notice in their documentation many of the classic mistakes of the STEMI generation: "Non ST Elevation MI" as their reasoning for why the patient did not merit emergent reperfusion, while simultaneously calling it "emergently" (after 8 hours!!!) Because we are hypnotized the STEMI paradigm. "If Here are a few clips.

STEMI 40

STEMI ACS Coronary ED 40

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. Singer sent this to me with just the information: "~40 year old with acute chest pain".

Coronary 52

Coronary STEMI ED 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." See far below for data on 24 troponin T in STEMI and NSTEMI, and correlation with infarct size. This difficulty results in high lateral OMI being the most commonly missed OMIs by the misguided STEMI criteria.

STEMI 40

STEMI Coronary ALS OR 40

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. A previous ECG from 4 years prior was normal: This looks like an anterior STEMI, but it is complicated by tachycardia (which can greatly elevate ST segments) and by the presentation which is of fever and sepsis.

Coronary 40

Coronary STEMI OR ED 40

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? As we see in ECG #3 — the regular rhythm is NOT sinus, because the P wave is negative in lead II.

STEMI 52

STEMI Coronary 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. Comment by KEN GRAUER, MD ( 7/11/2018 ): = Insightful blog post by Dr. Smith regarding ECG criteria for recognizing acute RV involvement in patients with inferior STEMI. But which myocardial walls are affected?

Coronary 52

Coronary STEMI ED ALS 52

Dr. Smith's ECG Blog

FEBRUARY 2, 2017

Discussion See this post: STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes I could find very little literature on the treatment of severe life-threatening hypokalemia. Document in the patient's chart that rapid infusion is intentional in response to life-threatening hypokalemia." Is 40 mEq too much?

Plasma 52

Plasma CPR STEMI ALS 52

ACEP Now

JULY 6, 2023

4 Formerly, chest pain patients without an S-T Elevation Acute Myocardial Infarction (STEMI), whose pain was suspected to be cardiac in nature, became inpatients for sequential monitoring of their lactate dehydrogenase and creatine kinase isozyme profiles. 2 Technological changes have helped emergency physicians become more efficient.

ALS 52

ALS Emergency Department STEMI ED 52

Dr. Smith's ECG Blog

JULY 26, 2023

At this point — I learned a bit more about today's patient: The patient is a man who had an inferior STEMI in 2010. But the well-formed Q-wave and the presence of a normal T-wave in inferior leads led me to believe this was Old Inferior MI with persistent ST Elevation, otherwise known as inferior LV aneurysm. MORE Information is Provided!

STEMI 52

STEMI ED OR 52

Dr. Smith's ECG Blog

APRIL 14, 2023

The triage ECG was interpreted correctly as "No STEMI." This finally prompted a repeat ECG at 1341: 1350: Obviously STEMI(+) OMI. There was associated diaphoresis, but no dyspnea, nausea, or vomiting. He reported having covid 2 weeks ago, but had seemingly fully recovered. Triage 1104: What do you think?

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

Wellens' syndrome represents the aftermath of an unrecorded occlusion (STEMI) with spontaneous reperfusion. Even if troponins are negative and infarction is not documented — dynamic ECG changes in association with new chest discomfort is indication for investigation. The patient is pretty sure that this discomfort was his reflux.

ED 52

ED STEMI Coronary Emergency Department 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. The initial high sensitivity troponin I returned at ＜4 ng/L (below the limit of detection). Learning Points: 1.

Critical Care 52

Critical Care STEMI ED OR 52

Dr. Smith's ECG Blog

AUGUST 8, 2020

This ECG clearly meets STEMI criteria by the way, regardless of age or gender. This is a high troponin (most STEMI are above 10 ng/mL for troponin I). There is STE from V3-V6 (more than 1 mm in V4-V6), and a tiny hint in I and II. There is no STE or STD in III an aVF. There are also new very tiny Q waves in V4-6.

STEMI 52

STEMI ED Coronary 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. See this case: Pericarditis, or Anterior STEMI? Paper published: Terminal QRS distortion not found in any ECG of Early Repolarization TQRSD is defined as the absence of BOTH an S-wave and a J-wave in leads V2 or V3.

Overdose 52

Overdose OR STEMI Coronary 52