Dr. Smith's ECG Blog

JULY 9, 2024

He arrived to the ED with severe hypotension, heart rate in the 70s, unable to follow commands but moving all extremities requiring restraint and sedation, respiratory rate around 24/min being supported with bag valve mask, with significant hypoxemia. His family started CPR and called EMS, who arrived to find him in ventricular fibrillation.

Defibrillator 101

Defibrillator STEMI CPR EMS 101

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 27, 2024

So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. The patient was admitted as ‘NSTEMI’ which is supposed to represent a non-occlusive MI, but the underlying pathophysiology is analogous to a transient STEMI. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab?

STEMI 101

STEMI Coronary ACS ED 101

REBEL EM

JULY 5, 2023

If it looks and feels like a STEMI clinically, get serial ECGs and consult Cardiology immediately. If it looks and feels like a STEMI clinically, get serial ECGs and consult Cardiology immediately. Take Home Points Provider assessment of how the patient looks is extremely important.

Coronary 119

Coronary STEMI EMS ED 119

Dr. Smith's ECG Blog

MARCH 31, 2024

The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI"). Despite the ACC guidelines for posterior STEMI, the cardiologist again refused to take the patient to the cath lab. mm STE in the posterior leads.

STEMI 91

STEMI ACS ED 91

Core EM

NOVEMBER 15, 2023

He arrived initially with diaphoresis and pallor which have self-resolved following arrival to the ED. Serial ECG's should be obtained to assess for evolution to acute STEMI. As demonstrated by this case, serial EKG’s may show complete resolution of these findings without progressing into a STEMI pattern.

Coronary 130

Coronary STEMI ED 130

EMS 12-Lead

AUGUST 14, 2022

The ST changes went overlooked by both the ED physician and the on-call cardiologist, and the patient was subsequently admitted to telemetry. it has been subsequently deemed a STEMI-equivalent. These sunken J-points make a rapid, crescendo rise into large, fat, and bulky T waves. However, when the Troponin I returned 8.4

STEMI 130

STEMI MICU CAD Coronary 130

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

The biggest problem with STEMI criteria are false negatives – because this costs patient’s myocardium, with greater mortality and morbidity. The essential "immediate" decision to be made in "zero time" in the ED, is whether or not prompt cath and reperfusion is needed. Could this false positive cath lab activation been prevented?

STEMI 88

STEMI Coronary OR ED 88

Pulsara

JANUARY 25, 2024

With a new protocol and Pulsara, Metropolitan Emergency Medical Services can now transport eligible pediatric behavioral health patients directly to behavioral health facilities—resulting in a 44% decrease of pediatric behavioral health patients transported to the ED. MEMS transports around 77,000 patients each year.

Emergency Medical Services 104

Emergency Medical Services EMS STEMI Emergency Department 104

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. The patient re-presented to the ED a few days after his discharge with syncope. Edited by Smith He also sent me this great case.

CAD 124

CAD STEMI Coronary ACS 124

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. The young ED tech immediately suspected LAD OMI.

ED 113

ED STEMI Coronary Paramedic 113

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 90

Defibrillator STEMI EMT EMT 90

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

STEMI 119

STEMI Emergency Department Coronary OR 119

ACEP Now

NOVEMBER 27, 2023

The third annual Stanford Emergency Medicine Innovation Symposium (STEMI X) was held on June 22nd, 2023.This Topics covered included doctor-driven disruption, innovation through entrepreneurship, and the revolutionary power of AI in the ED. The post Stanford’s Innovation Exchange appeared first on ACEP Now.

STEMI 52

STEMI ED 52

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. Having severe pain drives people to the ED for faster treatment! We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7

STEMI 107

STEMI Emergency Medical Services Coronary OR 107

Dr. Smith's ECG Blog

MARCH 4, 2024

Unknown algorithm The Queen gets it right Case 4 How unreliable are computer algorithms in the Diagnosis of STEMI? The patient's prehospital ECG showed that there was massive STEMI and these are hyperacute T-waves "on the way down" as they normalize. The Queen gets it right First ED ECG: Hyperacute T-waves persist.

STEMI 109

STEMI OR ED ALS 109

EMDocs

SEPTEMBER 19, 2023

On ED arrival GCS is 3, there are rapid eye movements to the right but no other apparent seizure activity. Official diagnosis requires EEG, which is not something we can typically obtain in the ED. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

STEMI 72

STEMI Coronary Emergency Department EMS 72

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." What do you think?

OR 115

OR STEMI EMS ED 115

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. There is pericardial tamponade.

STEMI 62

STEMI Coronary CAD ED 62

Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. COACT: The COACT trial was fatally flawed, and because of it, many cardiologists are convinced that if there are no STEMI criteria, the patient does not need to go to the cath lab.

Defibrillator 91

Defibrillator STEMI Coronary ALS 91

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

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

Dr. Smith's ECG Blog

JUNE 17, 2023

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 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

APRIL 22, 2024

It was present on arrival at triage but then resolved before bed placement in the ED. Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). It is a ssociated with mild dyspnea on exertion. Aspirin given.

Coronary 118

Coronary STEMI ED OR 118

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 95

STEMI Coronary Defibrillator EMS 95

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. 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. I don't know if her pain was getting better or not. From Gue at al.

Coronary 100

Coronary E-9-1-1 STEMI ACS 100

Dr. Smith's ECG Blog

FEBRUARY 22, 2024

It is unclear what changes happened to the rhythm based on the EMS interventions, but the patient arrived to the ED remaining critically ill and with a very wide complex reported (no ECGs from ED available sadly). Hyperkalemia was diagnosed and more treatment was given including more calcium, bicarb, insulin/dextrose, and albuterol.

EMS 135

EMS STEMI ED OR 135

EMS 12-Lead

MARCH 19, 2023

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. Is this OMI?

Coronary 130

Coronary STEMI Paramedic Defibrillator 130

EMS 12-Lead

MAY 8, 2022

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 Then, three minutes later… Crews activated STEMI as she deteriorated into PEA arrest.

STEMI 130

STEMI ED EMS Firefighter 130

EMDocs

FEBRUARY 24, 2024

1: How to Treat Infected Kidney Stones Spoon Feed All patients with infected ureteral stones necessitate a urine culture, antibiotics, and urology consultation in the ED, with the majority requiring admission for surgical intervention. Clay Smith at @spoonfedEM , and sign up for email updates here. #1: J Thromb Haemost. doi: 10.1016/j.jtha.2023.09.025.

Coronary 76

Coronary STEMI ED OR 76

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 86

STEMI Coronary Paramedic OR 86

Dr. Smith's ECG Blog

AUGUST 10, 2023

This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram. The initial ECG suggested either subacute or reperfused inferoposterior occlusion and clearly does not meet traditional STEMI criteria. Discharge diagnosis was ‘STEMI’, even though no ECG ever met STEMI criteria.

STEMI 86

STEMI ACS Emergency Department ED 86

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Post Cath ECG: Obviously completing MI with LVA morphology, and STE that meets STEMI criteria (but pt is still diagnosed as "NSTEMI"). Day 12 ECG: FINAL DIAGNOSIS: "NSTEMI" Despite the fact that his day 4 ECG easily meets STEMI criteria, the patient is diagnosed as NSTEMI. Setting – large, academic, suburban ED.

E-9-1-1 81

E-9-1-1 ACS STEMI Coronary 81

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

STEMI 73

STEMI Coronary OR ALS 73

Dr. Smith's ECG Blog

MAY 8, 2023

Edits by Meyers and Smith A man in his 70s with PMH of hypertension, hyperlipidemia, type 2 diabetes, CVA, dual-chamber Medtronic pacemaker, presented to the ED for evaluation of acute chest pain. Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Limkakeng AT.

STEMI 52

STEMI Coronary ED ACS 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal disease was sent to the ED after dialysis for three days of nausea, vomiting, loose stool, lightheadedness and fatigue. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. RR18 sat 99% HR 90 BP 90/60, afebrile.

STEMI 83

STEMI ACS OR ALS 83

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteria in V4 and V5. Triage ECG: What do you think?

STEMI 118

STEMI ED OR Coronary 118