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

REBEL EM

JULY 5, 2023

If it looks and feels like a STEMI clinically, get serial ECGs and consult Cardiology immediately. Post Created By: William Caputo MD Post Peer Reviewed By: Anand Swaminathan MD, MPH (Twitter @EMSwami ) The post REBEL Core Cast 104.0 – Subtle ECGs in Acute Coronary Occlusion appeared first on REBEL EM - Emergency Medicine Blog.

Coronary 144

Coronary STEMI EMS ED 144

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 74

STEMI Paramedic Coronary EMS 74

Dr. Smith's ECG Blog

JANUARY 21, 2023

Case submitted and written by Dr. Mazen El-Baba and Dr. Evelyn Dell, with edits from Jesse McLaren EMS brought a John Doe, in his 30s, who was found in an urban forest near a homeless encampment on a cool fall day. EMS reported an initial GCS of 8 with pupils equal and reactive. Take home : Not all STEs are STEMIs or OMIs.

STEMI 52

STEMI ALS EMS OR 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

EMS 12-Lead

AUGUST 14, 2022

EMS personnel found him seated on a bench, uncomfortable, but without gross distress. A third, and final, EMS 12 Lead ECG was recorded: The precordial ST segments (even Leads I/aVL, as well) have reverted to a dramatically depressed state. it has been subsequently deemed a STEMI-equivalent.

MICU 130

MICU STEMI CAD Coronary 130

Dr. Smith's ECG Blog

JULY 9, 2024

His family started CPR and called EMS, who arrived to find him in ventricular fibrillation. 15 minutes after EMS arrival, after at least 6 defibrillations, the patient achieved sustained ROSC. Written by Pendell Meyers A man in his 50s was found by his family in cardiac arrest of unknown duration.

Defibrillator 102

Defibrillator STEMI CPR EMS 102

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

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

NOVEMBER 29, 2023

Written by Pendell Meyers Two adult patients in their 50s called EMS for acute chest pain that started within the last hour. Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" He diagnosed anterior "STEMI" and activated the cath lab. What do you think?

OR 116

OR STEMI EMS ED 116

Dr. Smith's ECG Blog

JUNE 13, 2024

Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chest pain that started 2-3 hours earlier while sitting on a porch swing. Here is her ED EKG: What do you think? See this post: Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6.

Defibrillator 89

Defibrillator STEMI EMT EMT 89

Dr. Smith's ECG Blog

FEBRUARY 22, 2024

Written by Pendell Meyers A woman in her 30s called EMS for acute symptoms including near-syncope, nausea, diaphoresis, and abdominal pain. EMS arrived and found her to appear altered, critically ill, and hypotensive. EMS reportedly gave 4 grams of calcium (unknown whether CaCl or gluconate) and 50 mEq of sodium bicarbonate.

EMS 136

EMS STEMI ED OR 136

Dr. Smith's ECG Blog

NOVEMBER 19, 2024

These ECGs were texted to me by one of our previous ultrasound fellows, Will Smoot An elderly male arrived via EMS for acute substernal chest pain with radiation to left shoulder and arm that awakened him from sleep at 0030. He took two full strength aspirin prior to EMS arrival. The pain was relieved by one prehospital NTG spray.

OR 64

OR STEMI Coronary CAD 64

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 97

STEMI Coronary Defibrillator EMS 97

EMS 12-Lead

MAY 8, 2022

EMS found her acutely ill, mottled, dry mucous membranes, modestly hypotensive, and lethargic. The attending crews were concerned for SVT with corresponding ischemic hyperacute T waves (HATW) and subsequently activated STEMI pre-hospital. The following ECG was captured upon arrival at the receiving ED. The ED resulted an 8.7

STEMI 130

STEMI ED EMS Firefighter 130

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 72

STEMI Coronary Emergency Department ICU 72

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 125

OR STEMI Coronary CAD 125

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 122

CAD STEMI Coronary ACS 122

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 STEMI Life Support 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

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

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

APRIL 8, 2022

He reported to EMS a medical history of GERD only. BP 142/100 HR 90 RR 16 (BBS CTA) SpO2 99 (RA) Dstick 110 My colleagues noted the ST-depression in the respective leads, as well, and STEMI activated to the nearest PCI center. 1] Here is the admitting ED ECG after cancellation of Code STEMI. However, in this context (i.e.

STEMI 130

STEMI ALS Coronary CAD 130

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 97

STEMI Coronary Emergency Department OR 97

Dr. Smith's ECG Blog

MARCH 10, 2017

A 61 year-old with chest pain arrived to the ED by ambulance with resolving chest pain. Here is his ED ECG: The computer interpretation was " normal " What do you think? The cath lab was activated, as it should be with transient STEMI. This ECG is NOT normal. The T-waves in V2-V4 are very large in proportion to the QRS.

STEMI 52

STEMI Ambulance ED ALS 52

EMDocs

OCTOBER 29, 2024

Authors: Rachel Bridwell, MD (EM Attending Physician; Tacoma, WA), Katey DG Osborne, MD (EM Attending Physician; Tacoma, WA) // Reviewed by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) Welcome to emDOCs revamp!

E-9-1-1 87

E-9-1-1 ICU Epinephrine EMS 87

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

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 OR ED 121

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

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

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 OR Coronary 52

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 90

STEMI Coronary Paramedic OR 90

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 107

STEMI Coronary ED Paramedic 107

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 110

Defibrillator Coronary Epinephrine ACS 110

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

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. Exact pain history was difficult to ascertain. There was some SOB.

STEMI 52

STEMI E-9-1-1 ALS Coronary 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