Dr. Smith's ECG Blog

MARCH 1, 2023

Sent by anonymous, written by Pendell Meyers A man in his late 40s presented to the ED with concern for allergic reaction after accidentally eating a potential allergen, then developing an itchy full body rash and diarrhea. In the ED he received methylprednisolone, diphenhydramine, and epinephrine for possible anaphylaxis.

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Allergic Reaction E-9-1-1 Epinephrine Coronary 52

Dr. Smith's ECG Blog

JANUARY 19, 2020

There is STE in III and aVF which does not meet STEMI criteria due to insufficient STE in lead aVF. On arrival in the ED, she was profoundly hypotensive, nearly obtunded, and bradycardic. Another ECG was obtained during pacing: Mostly paced rhythm with PVCs (#3, #6, #9, #12). This is an obvious inferoposterior OMI.

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E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

MAY 30, 2023

Here is his ED ECG: There is bradycardia with a junctional escape. There is an obvious inferior posterior STEMI(+) OMI. We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. Atropine usually works in junctional rhythm with a narrow complex 9.

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E-9-1-1 STEMI Coronary OR 81

Dr. Smith's ECG Blog

JULY 30, 2023

The ED physician read this as "Normal sinus rhythm. It does not meet STEMI criteria. Obvious STEMI(+) OMI of inferior, posterior, and lateral walls, now with likely 2nd degree heart block type 1 (Wenckebach). In Figure-1 — The ST-T wave abnormality in lead V2 of ECG #1 is obvious. Easy for anyone.

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E-9-1-1 STEMI OR ED 52

Dr. Smith's ECG Blog

JULY 18, 2014

He had walked into the ED (did not use EMS). Thus, this is BOTH an anterior and inferior STEMI in the setting of RBBB. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. Lessons : 1. Exact pain history was difficult to ascertain.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2019

Then, 1 hour before arrival, it recurred, again lasting 5 minutes. There is STE that does not meet STEMI criteria in V1-V6. For clarity — I’ve put the 2 pieces of the 1st ECG together, and I’ve relabeled the tracings ( Figure-1 ). Figure-1: The first 2 ECGs in this case ( See text ). It lasted 5 minutes then resolved.

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E-9-1-1 STEMI OR ED 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

This is a 30-something healthy patient presented with COVID pneumonia who presented to the ED. Here they are: Learning Points: 1. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease. He was moderately hypoxic.

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E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 The patient arrived in the ED. The pain completely resolved after nitroglycerine Moments later, the this ECG was recorded in the ED when she had been pain free for moments only: Computer read: Normal ECG.

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E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

On review of systems the patient reported back pain for approximately 1 week which he was treating with NSAIDs with minimal relief. normal variant, not pericarditis) A Young Man with Sharp Chest pain (normal variant, not pericarditis) 24 yo woman with chest pain: Is this STEMI? 15-9/6/2017 ). Pericarditis?

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E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

AUGUST 9, 2018

Here it is: The computer reads STEMI What do you think? More from the medic: "LifePak 15 interpretation was STEMI. My response: "I think it is very worrisome for STEMI." It meets STEMI criteria even for a male under age 40, with STE 2.84 No history, meds, or risk factors. Pattern looked to be BER. mm in V2 and 4.08

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E-9-1-1 STEMI Coronary Ambulance 52

Dr. Smith's ECG Blog

JANUARY 10, 2020

He presented to the ED because he developed sudden severe, sharp, pleuritic (but not positional), substernal and left mid to lower chest pain. I was relieved to see this MRI result: MRI IMPRESSION 1) Mildly decreased LV function with no focal wall motion abnormalities. Learning Points: 1. Pericarditis?

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

Dr. Smith's ECG Blog

AUGUST 3, 2017

There are two main etiologies of ischemic ST-depression: 1) subendocardial ischemia 2) reciprocal to ST-elevation in an opposite wall Here there are distinct R-waves with marked ST-depression throughout most of the precordium. But if there is none - then you are looking at least at an Isolated Posterior STEMI until proven otherwise.

STEMI 52

STEMI E-9-1-1 Coronary ALS 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Therefore it is not a STEMI. But what we truly care about is coronary occlusion, for which STEMI is just a surrogate that is only about 75% sensitive for occlusion. Some are STEMI-equivalents.

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E-9-1-1 STEMI Coronary CAD 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. per year incidence of SCD in this cohort [1].

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Dr. Smith's ECG Blog

MAY 5, 2022

Submitted and written by Destiny Folk MD , peer reviewed by Meyers, Smith, Grauer, McLaren A man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. On arrival in the ED, he was hypotensive with a systolic blood pressure in the 70s. What is it?

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Dr. Smith's ECG Blog

APRIL 22, 2022

But these cases show the potential dangers of delayed recognition and treatment of inferior reperfusion Take away 1. Rather than using terms like “STEMI” and “Wellens”, it’s more helpful to describe the underlying pathology and ECG pattern pattern: Occlusion MI, and reperfusion T wave inversion 4. JAMA Intern Med 2019 9.

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Dr. Smith's ECG Blog

NOVEMBER 30, 2022

mm of ST segment elevation, V2 and V3 have 1 mm of elevation, v4 has 2 mm of elevation and v5 around 1.5 Note 1: Levels were significantly lower in takotsubo that presented with T-wave inversion. Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. Learning Points: 1. What do you think? V1 has 0.5

Emergency Department 52

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

Dr. Smith's ECG Blog

JANUARY 30, 2019

The pattern of STE and STD reminded us of Brugada Type 1 morphology. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. 2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. per year incidence of SCD in this cohort [1]. Bicarb 20, Lactate 4.2,

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Dr. Smith's ECG Blog

MAY 19, 2022

Written by Pendell Meyers, edits by Smith and Grauer A man in his late 20s with history of asthma presented to the ED with a transient episode of chest pain and shortness of breath after finishing a 4-mile run. At the time of evaluation in the ED, his symptoms were resolved. Anterior STEMI? What is it? Activate the Cath Lab?

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