Dr. Smith's ECG Blog

MARCH 9, 2023

He had episodes of chest pain off and on all night, until about 1 hour prior to arrival when the pain became constant, crushing, 10/10 chest pain that radiated to both arms. Barely any STE, and thus not meeting STEMI criteria. Only now that the patient has STEMI criteria is he allowed to go to the cath lab, at around 0530.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. First — Some thoughts on the post -resuscitation ECG.

E-9-1-1 87

E-9-1-1 Defibrillator CPR STEMI 87

Dr. Smith's ECG Blog

MARCH 1, 2023

A "STEMI alert" was called and soon cancelled. Comment by K EN G RAUER, MD ( 3/1 /2023 ): = Today's case by Dr. Meyers serves as a reminder of the important clinical entity known as diffuse subendocardial ischemia. ST depression will not always be present in 9/12 leads — as is seen in Figure-1.

Allergic Reaction 52

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

Dr. Smith's ECG Blog

MAY 30, 2023

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. 1 mg of Atropine was given and the heart rate increased transiently to 60. What is the atrial activity? How would one tell? What to do?

E-9-1-1 81

E-9-1-1 STEMI Coronary OR 81

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. The interventionalists insisted that the ECGs did not meet STEMI criteria and cancelled the activation, stating that they would consider urgent cath after further stabilization. This is an obvious inferoposterior OMI. mm STE with 9.5

E-9-1-1 52

E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

JULY 30, 2023

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). Learning Points: We can find OMI on ECG much sooner than STEMI criteria in many cases, and of course many OMIs never meet STEMI criteria at all.

E-9-1-1 52

E-9-1-1 STEMI OR ED 52

Dr. Smith's ECG Blog

OCTOBER 24, 2018

A 40-something male presented with dyspnea and left arm numbness, and perhaps some chest tightness, for 1 1/2 hours. This is all but diagnostic of STEMI, probably due to wraparound LAD The cath lab was activated. Here is his triage ECG: There is massive STE in V3-V6, and also STE in II, III, aVF. Why is this important?

E-9-1-1 52

E-9-1-1 STEMI ACS Coronary 52

Dr. Smith's ECG Blog

JULY 18, 2014

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. the presence of such well developed, wide, anterior Q-wave suggests completed transmural STEMI. Lessons : 1.

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.

E-9-1-1 52

E-9-1-1 STEMI OR ED 52

Dr. Smith's ECG Blog

OCTOBER 17, 2022

If you were thinking that this is not anterior OMI because there is no reciprocal ST depression , it is important to remember that half of anterior STEMI do NOT have any reciprocal ST depression. There are some unusual ECG findings in today's tracing ( that I labeled in Figure-1 ). This ECG has ST Elevation in multiple leads.

E-9-1-1 52

E-9-1-1 OR STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Here they are: Learning Points: 1. 7 These 3 studies, as well as 1 smaller meta-analysis, 6 and another small study, 8 make it clear that troponin is associated with increased severity and mortality in COVID when adjusted for multiple other variables. He remained supported on an intraaortic balloon pump. 3–8 Shi et al.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 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 Ambulated to ambulance for eval. Denied headache, chest pain, nausea / vomiting.

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 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?

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 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

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 If you use something like the HEART score: 1. E EKG: a negative ECG (score = 0) 3. She was having a transient STEMI, briefly. Learning Points : 1. The ECG told the story. She called 911.

E-9-1-1 52

E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

JANUARY 10, 2020

I was relieved to see this MRI result: MRI IMPRESSION 1) Mildly decreased LV function with no focal wall motion abnormalities. Learning Points: 1. Cases of acute MI that were initially misdiagnosed as myo- or peri-carditis: 24 yo woman with chest pain: Is this STEMI? Other thoughts: There is no abnormal PR depression.

E-9-1-1 52

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

EMDocs

JANUARY 11, 2024

The neurologic section was divided into (1) brain oxygenation, perfusion, edema, and intracranial pressure (ICP); (2) seizures and the ictal-interictal continuum (IIC); and (3) sedation and analgesia. Each small group identified topics, and then the topics were voted on by the entire panel. Instead, target 92-98%.

Critical Care 75

Critical Care E-9-1-1 OR ICU 75

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.

E-9-1-1 52

E-9-1-1 STEMI Coronary CAD 52

Dr. Smith's ECG Blog

DECEMBER 27, 2018

S-wave is in V2 = 17 mm S-wave V4 = 9 mm Total = 26 (not greater than 28), so not LVH by the new rule! But lead V2 has a worrisome amount of ST elevation, and in a chest pain patient, I would be worried about STEMI. For clarity — I’ve reproduced this ECG, to which I’ve made a few additions ( Figure-1 ). Peguero JG et al.

E-9-1-1 52

E-9-1-1 STEMI ALS OR 52

Dr. Smith's ECG Blog

JULY 22, 2023

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. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% He denied chest pain or shortness of breath.

E-9-1-1 69

E-9-1-1 CAD OR STEMI 69

Dr. Smith's ECG Blog

MAY 5, 2022

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". Hyperkalemia mimics STEMI and OMI in many distributions, but probably the most common is the Brugada morphology in V1-V2 which mimics anterior OMI for those who cannot recognize the Brugada pattern. Fluid resuscitation was initiated. What is it?

E-9-1-1 52

E-9-1-1 OR STEMI ED 52

Dr. Smith's ECG Blog

JULY 24, 2024

Easy LINK — [link] — My New E CG P odcasts ( 5/28/2024 ): These podcasts are part of the Mayo Clinic Cardiovascular CME Podcasts Series ( "Making Waves" ) — hosted by Dr. Anthony Kashou. 2:25 — Dr. Grauer: The 1st Error : Too many clinicians in 2024 are still stuck in the outdated millimeter-based STEMI Paradigm”.

E-9-1-1 52

E-9-1-1 Coronary STEMI OR 52

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. V1 has 0.5 mm of elevation.

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. Schick is a PGY3 at the Brown Emergency Medicine Residency in Rhode Island.

E-9-1-1 52

E-9-1-1 CAD STEMI OR 52

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.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

MAY 19, 2022

Anterior STEMI? Regarding the History: It sounds from the History as if this patient has at least a significant component of EIA ( E xercise- I nduced A sthma ). The ECG was read as concerning for Wellens (meaning anterior reperfusion pattern). Initial high sensitivity troponin I = 27 ng/L (URL for men 20 ng/L for this assay).

E-9-1-1 52

E-9-1-1 Coronary OR ED 52

Dr. Smith's ECG Blog

APRIL 3, 2019

Not quite a STEMI, but same effect.) There is ST elevation in V2-V4 that does not quite meet "STEMI criteria." That is a reasonable thought, but we have shown that if there is one lead of V1-V4 with a T/QRS ratio greater than 0.36, then it is STEMI, not LV aneurysm. Is this a transient STEMI? Learning Points: 1.

E-9-1-1 52

E-9-1-1 STEMI OR Coronary 52