Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. It’s unclear if the paramedic ECGs were seen or missed in the ED. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. At this point the emergency physician asked for a stat cardiology consult.

STEMI 100

STEMI Paramedic Coronary EMS 100

ESO

APRIL 19, 2024

From April 2-5, the top fire services and EMS industry thought leaders and data analysts gathered at Wave 2024 to share what trends they’re forecasting for both fields and how they’re enacting change within their own organizations through the power of data-driven insights. Data impacts every aspect of duties, from shifts start to end.

MIH 105

MIH EMS Paramedic Firefighter 105

Dr. Smith's ECG Blog

JULY 7, 2024

Written by Jesse McLaren A previously healthy 60 year old developed exertional chest pain with diaphoresis, and called EMS. Here’s the EMS ECG, digitized with PM cardio. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.

STEMI 66

STEMI Coronary ALS OR 66

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. The TOMAHAWK Investigators.

EMR 130

EMR Coronary Defibrillator Life Support 130

Dr. Smith's ECG Blog

OCTOBER 1, 2023

He called EMS who brought him to the ED. She knows the baseline is normal, and she knows the STEMI(-) OMI one is diagnostic of OMI, with the highest possible confidence. Here is the EM decision making: "The patient's EKG revealed some repolarization abnormalities but no clear signs of a STEMI. ED Diagnoses: 1.

OR 127

OR STEMI Coronary CAD 127

EMDocs

SEPTEMBER 19, 2023

Episode 86: Tricky Cases Part 2 Case 3: 56-year-old female with history of seizures, actively seizing, EMS called. Patient seized for approximately 20 minutes prior to EMS arrival. On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Every airway requires a plan and backups.

STEMI 98

STEMI Coronary Emergency Department ICU 98

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. He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic.

CAD 125

CAD STEMI Coronary ACS 125

Dr. Smith's ECG Blog

JUNE 21, 2023

EMS was called, and they recorded the following ECG on scene at 13:16: What do you think? In this medical system, the EMS provider can then be routed to the ED or to a type of urgent care facility that is open 24 hrs/day and staffed by a primary care provider. No troponins were measured!

STEMI 98

STEMI Coronary Defibrillator EMS 98

EMS 12-Lead

MARCH 19, 2023

Fire/EMS crews found him clammy and uncomfortable. It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. But until its magic is available at bedside the clinician must train his/her eyes to spot the subtle features of OMI, and equally allow the bias of STEMI to fossilize.

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

EMS 12-Lead

MAY 20, 2022

Fire/EMS personnel find her laying supine on the kitchen floor, awake and verbal, although acutely ill. 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.

Coronary 130

Coronary STEMI Firefighter ED 130

Emergency Medicine Cases

SEPTEMBER 23, 2019

In EM Cases' first ECG Cases blog we review 7 examples of ECGs of patients presenting to the ED with chest pain, who's ECG were read as normal by the computer. And guess what.they all show acute ischemia!

EMS 130

EMS ED STEMI 130

EMS 12-Lead

JUNE 20, 2022

According to the EMS narrative, this patient initially refused hospital transport and advised that he would seek evaluation at a later time with his personal physician. A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. Here is the final ECG just prior to ED transfer.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

JUNE 17, 2016

Jason was very skeptical of STEMI. This also argues against STEMI. Turns out that the patient regularly called EMS for complaints of chest pain that frequently led to cath lab activation.) He complained of 3 days of diarrhea and abdominal pain. What do you think? Jason, I agree. V4 especially looks like early repolarization.

STEMI 52

STEMI OR Coronary EMS 52

Dr. Smith's ECG Blog

MAY 2, 2019

Written by Pendell Meyers I received this prehospital ECG (we receive prehospital ECGs by telemetry from EMS in a large area around our hospital) and was told that there was a patient in her 50s with chest pain who was headed to an outside hospital (which happens to be a catheterization center). Here is the ECG: What do you think?

STEMI 52

STEMI ALS ED OR 52

Dr. Smith's ECG Blog

APRIL 12, 2013

A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. The patient was transported to the ED. Here is his ED ECG: There is sinus tachycardia. Is this acute STEMI? Is this an acute STEMI? -- Unlikely!

STEMI 52

STEMI ED Coronary OR 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

A 60-something woman called EMS for chest pain. Waiting to cath a transient STEMI can be hazardous. In the only ED study of its kind, sensitivity increased from 46% to 62%. This case comes from Jason Winter, of The Facebook Clinical Electrocardiology ECG Page. Here is her first prehospital ECG: What do you think?

STEMI 121

STEMI EMS ED OR 121

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

There’s inferior ST depression which is reciprocal to subtle lateral convex ST elevation, and the precordial T waves are subtly hyperacute – all concerning for STEMI(-)OMI of proximal LAD. There’s ST elevation I/aVL/V2 that meet STEMI criteria. This is obvious STEMI(+)OMI of proximal LAD. Non-STEMI or STEMI(-)OMI?

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain and RBBB. The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. Do either, both, or neither have occlusion MI? Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

Dr. Smith's ECG Blog

OCTOBER 12, 2024

Written by Bobby Nicholson What do you think of this “STEMI”? With EMS, patient had a GCS of 3 and was saturating 60% on room air. He improved to 100% with the addition of non-rebreather, however remained altered and was intubated by EMS with ketamine and succinylcholine. or basilar ischemia. There is high QRS voltage.

STEMI 115

STEMI Coronary Emergency Department ACS 115

Dr. Smith's ECG Blog

DECEMBER 9, 2023

He has a history of STEMI and heart failure. link] Case continued The conventional algorithm diagnosed STEMI and so did the paramedics. On arrival in the ED, the patient denied any symptoms at all. Figure-1: The initial ECG in today's case — obtained by the EMS team. ( A 50-something had syncope while driving.

STEMI 115

STEMI Coronary ED Paramedic 115

Dr. Smith's ECG Blog

MAY 23, 2023

EMS arrived and recorded this ECG: What do you think? 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.

STEMI 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

JULY 25, 2024

EMS arrived and found him in Ventricular Fibrillation (VF). The patient was brought to the ED and had this ECG recorded: What do you think? Cardiac arrest #3: ST depression, Is it STEMI? They started CPR. He was defibrillated into VT. He then underwent dual sequential defibrillation into asystole. sodium bicarbonate.

Defibrillator 124

Defibrillator Coronary Epinephrine ACS 124

Dr. Smith's ECG Blog

APRIL 20, 2019

EMS showed us their ECG on arrival at her house: What do you think? There is sinus rhythm with minimal STE in V1-V3, not meeting STEMI criteria. The cardiologist arrived quickly and was skeptical about these findings on EMS ECG. The delay between OMI and STEMI sometimes causes unacceptable loss of myocardium or worse.

STEMI 52

STEMI EMS Coronary OR 52

EMS 12-Lead

APRIL 14, 2022

He presented to EMS with extreme pallor, Levine sign, diaphoresis, bilateral arm pain, and an apprehensive sense of doom. Chou's Electrocardiography in Clinical Practice, 6th ed. David Didlake, NRP, APRN, ACNP-BC This case is provided by C. Madden, Paramedic. Many thanks for sharing! Hyperkalemia revisited. 4] Surawicz, B. McCance, K.

ACS 130

ACS Paramedic Coronary ALS 130

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

When EMS found her, she was dyspneic and diaphoretic. The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. She was out walking her dog when she developed sudden dizziness and light-headedness. As per Dr.

E-9-1-1 127

E-9-1-1 Coronary STEMI ALS 127

Dr. Smith's ECG Blog

MARCH 9, 2013

He awoke from sleep with crushing central chest pain and called ems. EMS recorded a 12-lead, then gave 2 sublingual nitros with complete relief of pain. This male in his 40's had been having intermittent chest pain for one week. Type B waves are deeper and symmetric. A stent was placed.

ED 52

ED Coronary ALS STEMI 52

Dr. Smith's ECG Blog

JUNE 17, 2023

Written by Pendell Meyers A middle aged man called EMS for acute chest pain. EMS recorded this ECG during active symptoms and transmitted it to the ED: I had no information when I was shown the ECG. I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 I said "Not OMI.

OR 52

OR STEMI ALS EMS 52

Dr. Smith's ECG Blog

JANUARY 20, 2017

The case below was contributed by Pendell Meyers, an EM G1 at Mt. Validation of the Modified Sgarbossa Rule for Diagnosis of STEMI in the Presence of Left Bundle Branch Block. His ED ECG showed his baseline LBBB, with no evidence of MI. Sinai (the case did not come from Mt. Sinai though!) Limkakeng AT. Theiling BJ.

STEMI 52

STEMI Coronary OR ALS 52

Dr. Smith's ECG Blog

JUNE 1, 2012

This was a middle aged female with a h/o CAD who presented to the ED by EMS sudden onset of central chest pressure 45 min prior to ED arrival with associated diaphoresis and SOB.  There is LVH and there are ST-T abnormalities (large inferior T-waves and ST elevation, with reciprocal findings in aVL).

STEMI 52

STEMI CAD ED EMS 52

ESO

JANUARY 19, 2024

One of these areas is assessing patients with ED-diagnosed strokes. Working towards better detection Another area ESO has identified as an opportunity to improve is how EMS services detect a possible STEMI or NSTEMI with a 12-lead EKG. Improving the numbers So how can EMS services work together to improve these numbers?

CPR 52

CPR Advanced Life Support Life Support STEMI 52

EMergucate

MARCH 5, 2019

The following ECG is from a 55 year old male who presented to the ED after experiencing on-going left sided … Continue reading →

ED 130

ED STEMI EMS 130

Dr. Smith's ECG Blog

JANUARY 19, 2020

Her family called EMS and EMS recorded hypotension and this ECG: What do you think? 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. This is an obvious inferoposterior OMI.

E-9-1-1 52

E-9-1-1 STEMI ED EMS 52

Dr. Smith's ECG Blog

SEPTEMBER 3, 2010

EMS found him with an irregular heart rate at 200-250 beats per minute. Upon arrival to the ED, he had the following 12-lead ECG: There is striking ST segment elevation in V1 and V2, with ST depression in V3-V6 as well as I, II, and aVF. He subsequently had a syncopal event and was down for 1-2 minutes. His wife called 911.

STEMI 52

STEMI Coronary EMS ED 52

EMS 12-Lead

APRIL 2, 2022

Figure 1-1 My colleague, a faithful student of ECG interpretation, handed me the tracing and said that it warranted STEMI activation because of apparent terminal QRS distortion (TQRSD) in V2. ASA 324mg was administered while a STEMI activation was simultaneously transmitted to the nearest PCI center. Attached is the first ECG.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

DECEMBER 14, 2022

EMS arrived and administered aspirin and nitroglycerin. Here are his three EMS ECGs: EMS1 at 0735 This was sent to Dr. Smith with no other information. His symptoms were reportedly resolved upon arrival to the ED. ED ECGs: 0814 0830 These show continued reperfusion with no evidence of reocclusion. Do not miss them!

EMS 52

EMS STEMI ED Emergency Department 52

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below).

STEMI 52

STEMI Coronary ALS ACS 52

Dr. Smith's ECG Blog

JUNE 24, 2016

This case was contributed by Brooks Walsh, an ECG enthusiast who has contributed frequently , and edited by Smith Case An elderly male called EMS after he developed “indigestion.” He was almost asymptomatic when he arrived in the ED. The paramedic interpreted this as a STEMI. Can you employ the Subtle Anterior STEMI calculator

STEMI 40

STEMI Coronary Paramedic ED 40