Dr. Smith's ECG Blog

MAY 20, 2024

This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Diagnosis of Type I vs. Type II Myocardial Infarction in Emergency Department patients with Ischemic Symptoms (abstract 102).

CAD 126

CAD STEMI Coronary ACS 126

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. She arrives in the emergency department (ED) with decreased level of consciousness and shock. She has a history of hypertension and non-insulin dependent diabetes mellitus.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

JANUARY 20, 2024

Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity.

STEMI 121

STEMI CAD ED ALS 121

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

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. Below is the initial ED ECG. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. Manual of Cardiovascular Medicine (5th ed.). Smith comment : V5 and V6 are excessively discordant!!!!

Coronary 130

Coronary STEMI Firefighter ED 130

Dr. Smith's ECG Blog

JULY 7, 2013

He had walked into the ED (did not use EMS). Thus, this is both an anterior and inferior STEMI. How old is this antero-inferior STEMI? Although acute anterior STEMI frequently has narrow QR-waves within one hour of onset (1. Ann Emerg Med 1994;23(6):1333-42. Exact pain history was difficult to ascertain.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? A man in his 90s with a history of HTN, CKD, COPD, and OSA presented to the emergency department after being found unresponsive at home. Vital signs were within normal limits on arrival to the Emergency Department. Blood glucose was not low at 162 mg/dL.

STEMI 116

STEMI Coronary Emergency Department ACS 116

Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. What do you think?

E-9-1-1 139

E-9-1-1 ACS Emergency Department Coronary 139

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. Ann Emerg Med 1994; 23(6):1333-42. There was some SOB. Brunette D.

STEMI 52

STEMI E-9-1-1 ALS Coronary 52

Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Learning Points: You cannot trust conventional algorithms even to find STEMI(+) OMI, even when they say "normal ECG." At this point — a STEMI was diagnosed, and cardiac cath with PCI was performed.

STEMI 113

STEMI Coronary Emergency Department OR 113

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chest pain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.

Defibrillator 135

Defibrillator Coronary STEMI CPR 135

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." 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. From Gue at al.

Emergency Department 52

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

EMS 12-Lead

APRIL 14, 2022

There is mixed overlap of ST-segment elevation (STE), ST-segment depression (STD), Hyperacute T waves (HATW), and deWinter pattern (which the ACC regards as a STEMI-equivalent but is better suited under the blanket of OMI). Western Journal of Emergency Medicine, 18 (4), 752-760. [2] link] [1] Zachary et al. 2] Costanzo, L. Physiology.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. Figure-1: The first 2 tracings in today's case.

OR 130

OR STEMI Coronary Emergency Department 130

ACEP Now

AUGUST 12, 2024

A 35-year-old male presented to the emergency department complaining of chest pain that started 1.5 FIGURE 1: First ED EKG. FIGURE 2: Baseline ED from 2 months prior. FIGURE 3: Second ED EKG. Dr. Young is an emergency physician at Saint Francis Hospital and Medical Center, Hartford, Conn. Click to enlarge.)

Emergency Department 52

Emergency Department STEMI ACS ED 52

EMS 12-Lead

APRIL 21, 2022

The ECG’s were sent to the PCI center, and the providers in the respective ED identified the T wave characteristics mentioned above. STEMI was activated and the patient went to Cath on arrival. New insights into the use of the 12 Lead Electrocardiogram for diagnosing Acute Myocardial Infarction in the emergency department.

Coronary 130

Coronary ALS OR ACS 130

Dr. Smith's ECG Blog

OCTOBER 20, 2013

She was hypotensive in the ED and her bedside echo showed a normal RV and LV. Two prehospital 12-lead ECGs looked similar to this ED ECG: This shows diffuse ST depression (I, II, III, aVL, aVF, V3-V6) with reciprocal ST elevation in lead aVR. Also note that they allow ST depression c/w posterior MI to be a STEMI equivalent.

STEMI 52

STEMI Coronary ACS Emergency Department 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. The emergency physician was called to see the patient 90 minutes later after the troponin I returned at 1100 ng/L. What do you think? Take home 1.

STEMI 70

STEMI Coronary OR ALS 70

Dr. Smith's ECG Blog

JUNE 18, 2013

This was my thought: if this patient presented to the ED with chest pain, then this is an LAD occlusion. His ECG was repeated at this point: This shows a well developed anterior STEMI. To not see these findings is very common, and this patient would be given the diagnosis of NonSTEMI, with subsequent development of STEMI.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. These elevations meet STEMI criteria ( ≥ 1mm in 2 contiguous leads). In STEMI, they are generally upright and large in proportion to the QRS. So this argues against acute STEMI.

STEMI 52

STEMI ACS Emergency Department OR 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

An ECG was recorded quickly on return to the ED: (sorry for poor quality, cannot get originals) What do you think? Is this inferor STEMI? Atrial Flutter with Inferior STEMI? The EM provider asked if the cardiologist thought it was a "STEMI." There is a narrow complex regular rhythm at a rate of approximately 120 bpm.

STEMI 52

STEMI ACS Coronary Emergency Department 52

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. This 65-year old male patient with severe underlying coronary disease presented to the ED after receiving several ICD shocks. That was also my initial concern.

Coronary 112

Coronary EMR STEMI Emergency Department 112

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

This was a male in his 50's with a history of hypertension and possible diabetes mellitus who presented to the emergency department with a history of squeezing chest pain, lasting 5 minutes at a time, with several episodes over the past couple of months. Here is the first ED ECG, with no pain: Sinus rhythm.

Coronary 52

Coronary STEMI ALS Emergency Department 52

ACEP Now

JULY 6, 2023

Emergency physicians have earned the right to “re-brand” ourselves as indispensable, money-saving change agents in the health care enterprise. 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.

ALS 52

ALS Emergency Department STEMI ED 52

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

A 56 year old male with a history of diabetes, dyslipidemia, hypertension, and coronary artery disease presented to the emergency department with sudden onset weakness, fatigue, lethargy, and confusion. At 2111, the troponin I peaked at 12.252 ng/mL (this is in the range of STEMI patients, quite high).

Coronary 120

Coronary STEMI Emergency Department OR 120

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

AUGUST 9, 2019

Smith and Meyers answer: First , LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded. All are, however, clearly massive STEMI. Chris Mondie of the Newark Beth Israel Emergency Medicine Residency sent case 1 below of a 100% LM occlusion.

Coronary 52

Coronary STEMI ACS ALS 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

A man in his 60s with a history of severe alcohol use disorder and epidural abscess on long-term ciprofloxacin presented to the emergency department after an episode of syncope while standing in line at a grocery store. Is it STEMI? Written by Sean Trostel MD, peer reviewed by Meyers, Smith, Grauer, etc. What is going on here?

Overdose 124

Overdose ACS OR ICU 124

Dr. Smith's ECG Blog

MARCH 20, 2023

I finished my residency of Emergency Medicine and I’m working at a great Emergency Department here in Brazil. Since then, I started looking for OMI EKG findings and not just STEMI. Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Risk Factors: High Cholesterol.

STEMI 52

STEMI ACS CAD ED 52

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. The remainder of his Emergency Department stay was uneventful. Physician interpretation: "No STEMI."

OR 52

OR STEMI ACS Emergency Department 52

Dr. Smith's ECG Blog

MARCH 9, 2023

Sent by anonymous, written by Pendell Meyers A man in his 50s with no prior known medical history presented to the Emergency Department with severe intermittent chest pain. 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

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

APRIL 22, 2022

The HEART and EDACS scores are helpful to risk stratify patients with chest pain, but they hinge on accurate ECG interpretation: a low score doesn’t apply if the ECG shows STEMI(+)OMI, and shouldn’t be used for STEMI(-)OMI or OMI reperfusion either 2. Am J Emerg Med 2020 3. Backus BE, Six AJ, Kelder JC, et al.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

His symptoms were reportedly resolved upon arrival to the ED. ED ECGs: 0814 0830 These show continued reperfusion with no evidence of reocclusion. I am going to code this as an acute STEMI as he had transient ST elevation which started to evolve in the emergency department but I think this is most appropriately termed STEMI."

EMS 52

EMS STEMI ED Emergency Department 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

AUGUST 26, 2019

She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? This one likely does meet STEMI criteria in II, III, and aVF. Criteria for a STEMI are definitely not met in ECG #1. What happened?

STEMI 52

STEMI Coronary OR ED 52