Emergency Department, Events and STEMI

Does the literature support medications for stable, monomorphic ventricular tachycardia?

EMDocs

DECEMBER 23, 2024

Major adverse cardiac events 40 minutes after giving the antiarrhythmic. The following table shows their results, take a look: Note that procainamide leads with less adverse cardiac events. Procainamide therapy was associated with less major cardiac adverse events and a higher proportion of tachycardia termination within 40 min.

ALS

ALS OR STEMI EMS

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

Dr. Smith's ECG Blog

JANUARY 27, 2024

, tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal: Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage Patients I reviewed this article for a different journal and recommended rejection and it was rejected.

STEMI

STEMI Coronary ACS ED

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Dr. Smith's ECG Blog

MAY 20, 2024

The cardiologist recognized that there were EKG changes, but did not take the patient for emergent catheterization because the EKG was “not meeting criteria for STEMI”. Diagnosis of Type I vs. Type II Myocardial Infarction in Emergency Department patients with Ischemic Symptoms (abstract 102). Murakami MM.

CAD

CAD STEMI Coronary ACS

Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

Quiz : What percent of full blown STEMI have an open artery with normal flow at angiogram? It too is "normal" and you decide that this is not OMI or STEMI and you just decide to get troponins. So despite the artifact — and even without any history — this initial ECG has to be interpreted as an acute event until proven otherwise.

STEMI

STEMI Emergency Department OR ALS

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

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." Takotsubo is a sudden event, not one with crescendo angina. Even in patients whose moderate stenosis undergoes thrombosis, most angiograms show greater than 50% stenosis after the event.

Emergency Department

Emergency Department E-9-1-1 Coronary STEMI

What does this ECG show?

Dr. Smith's ECG Blog

AUGUST 4, 2024

QOH versions 1 and 2 both say Not OMI, with high confidence, without any clinical context, despite the abnormal STE meeting STEMI criteria. Context: a man in his 40s presented to the emergency department with 1 day of sudden onset chest pain. I sent this to our group without information and Dr. Smith responded: "Not OMI.

STEMI

STEMI OR Emergency Department

The Computer and Overreading Cardiologist call this completely normal. Is it?

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

Coronary STEMI Emergency Department OR

A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!

Dr. Smith's ECG Blog

DECEMBER 26, 2020

Is this inferor STEMI? Atrial Flutter with Inferior STEMI? Inferolateral ST elevation, vomiting, and elevated troponin The treating team did not identify the flutter waves and they became worried about possible "STEMI" (despite the unusual clinical scenario). The EM provider asked if the cardiologist thought it was a "STEMI."

STEMI

STEMI ACS Coronary Emergency Department

Case Report: The Not So Normal, Normal EKG

ACEP Now

AUGUST 12, 2024

A 35-year-old male presented to the emergency department complaining of chest pain that started 1.5 5 Studies looking at this phenomenon in the emergency department setting for patients presenting with chest pain are lacking. Dr. Young is an emergency physician at Saint Francis Hospital and Medical Center, Hartford, Conn.

Emergency Department

Emergency Department STEMI ACS ED

50-year old with chest pain, “no ischemic changes”

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

STEMI Coronary OR ALS

A man in his 50s with chest pain

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

E-9-1-1 STEMI Coronary ALS

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

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. As per Drs.

E-9-1-1

E-9-1-1 STEMI ALS ED

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

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. New ST elevation diagnostic of STEMI [equation value = 25.3

Coronary

Coronary STEMI ALS Emergency Department

Compare these two ECGs. Do either, neither, or both show anything important?

Dr. Smith's ECG Blog

APRIL 17, 2023

The remainder of his Emergency Department stay was uneventful. The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)? Physician interpretation: "No STEMI." Physician: "No STEMI." He had no symptoms of ACS.

OR

OR STEMI ACS ALS

Watch what happens when you teach others how to find OMI

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. mm in lead I, thus not STEMI criteria) and was finally understood by the cardiologist.

STEMI

STEMI ACS CAD ED

Watch what happens when "pericarditis" and morphine cloud your judgment

Dr. Smith's ECG Blog

JULY 3, 2018

While in the emergency department, he undergoes an additional ECG: 00:49 - Not much change Second ECG with measurements and calculations Magnified view of second ECGs measurements and calculation It is still "negative" for LAD occlusion (less than 23.4) Despite having acute coronary occlusion by cath, his ECGs never met STEMI criteria.

ACS

ACS STEMI Coronary CAD

2021 Wrap-Up

EM Literature of Note

JANUARY 9, 2022

[link] Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation An RCT showing no advantage to routine immediate angiography in non-STEMI OHCA. link] Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media Afebrile infants ≤ 90 days diagnosed with AOM do not seem to be at risk for IBI.

Emergency Department

Emergency Department STEMI OR

An ECG sent to me with concern for hyperacute T-waves

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

STEMI Coronary OR ED

Chest pain, and Cardiology didn't take the hint from the ICD

Dr. Smith's ECG Blog

JANUARY 23, 2023

Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and Grauer A 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The most recent event had occurred just before being triaged. Triage EKG: What do you think?

ACS

ACS Coronary Defibrillator STEMI

A man in his 70s with chest pain during a bike ride

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

The patient’s ECG on arrival at the emergency department is shown below. Add in the fact that symptoms began at least 24 hours ago — and these subtle-but-real ECG findings suggest a recent event until we can prove otherwise. He was expected to arrive at the tertiary care center within 60 minutes of the call.

E-9-1-1

E-9-1-1 Coronary STEMI Emergency Department

Profound ST Elevation in V1-V3. What do you think?

Dr. Smith's ECG Blog

DECEMBER 27, 2018

A Deep Neural Network learning algorithm outperforms a conventional algorithm for emergency department electrocardiogram interpretation. But lead V2 has a worrisome amount of ST elevation, and in a chest pain patient, I would be worried about STEMI. I do research on Cardiologs' algorithm: Smith SW et al. What an honor.

E-9-1-1

E-9-1-1 STEMI ALS OR

75 year old with 24 hours of chest pain, STEMI negative

Dr. Smith's ECG Blog

JUNE 8, 2023

STEMI negative : the EMS automated interpretation read, “STEMI negative. According to the STEMI paradigm, the patient doesn’t have an acute coronary occlusion and doesn't need emergent reperfusion, so the paramedics can bring them to the ED for assessment, without involving cardiologists. Sinus bradycardia.”

STEMI

STEMI Coronary Paramedic ALS

Chest pain and T wave inversion, NSTEMI?

Dr. Smith's ECG Blog

AUGUST 10, 2023

Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLaren A 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. This doesn’t meet STEMI criteria so in the current paradigm there’s no urgency to getting an angiogram.

STEMI

STEMI ACS Emergency Department ED

A 50-something with chest pain.

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

Defibrillator Coronary STEMI CPR

85 year old with chest pain, STEMI negative, then normal troponin but with relatively large delta: discharge?

Dr. Smith's ECG Blog

MARCH 24, 2023

There’s minimal concave ST elevation in III which does not meet STEMI criteria, so this ECG is "STEMI negative". Use STEMI criteria to identify acute coronary occlusion: the ECG was STEMI negative 2. A repeat ECG was done on way to cath lab: "STEMI negative" again. The cath lab was activated. Take home 1.

STEMI

STEMI Coronary CAD OR

Management of STEMI (ST-Elevation Acute Myocardial Infarction)

ECG & Echo Learning

JANUARY 18, 2023

STEMI , ST-segment elevation acute myocardial infarction ). 1 Initial diagnosis of STEMI ECG Management Recommendation Level of evidence A 12-lead ECG should be interpreted immediately (within 10 minutes) at first medical contact. I B Designated PCI centres should provide angiography and reperfusion 24/7 without delay.

STEMI

STEMI Coronary OR Defibrillator

A man in his 60s with syncope and ST depression. What does the ECG mean?

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

Overdose OR ACS ICU

Extreme shock and cardiac arrest in COVID patient

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Clin Chem [Internet] 2020;Available from: [link] Smith mini-review: Troponin in Emergency Department COVID patients Cardiac Troponin (cTn) is a nonspecific marker of myocardial injury. 12 All STEMI patients had very high cTn typical of STEMI (cTnT > 1.0

E-9-1-1

E-9-1-1 STEMI Coronary ALS

This ECG was texted to me after the fact with no information. What do you think?

Dr. Smith's ECG Blog

OCTOBER 13, 2023

There is worrisome T-wave inversion in inferior leads as well, which is another clue to LAD Occlusion In fact, this ECG meets STEMI criteria!! Why does the conventional algorithm not diagnose STEMI? Transient STEMI, serial ECGs prehospital to hospital, all troponins negative (less than 0.04

STEMI

STEMI OR Coronary Emergency Department

What does a final diagnosis of STEMI vs. NSTEMI depend upon?

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

The is very small STE in III and aVF which do not meet STEMI criteria, hyperacute T waves, reciprocal TWI in aVL, and maximal STD in V2-V3 showing posterior OMI. The ECG was transmitted to the Emergency Medicine physician who recognized inferior and posterior OMI findings, and confirmed that the patient has potential ACS symptoms.

STEMI

STEMI OR ED EMS

A 34 yo Man with chest pain and Zero ST Elevation

Dr. Smith's ECG Blog

JANUARY 28, 2025

His first EKG is shown below, with a lead II rhythm strip: EKG 1, 1645 A provisder who is looking for STEMI would not see much in this EKG. It is possible that the T waves in this EKG are of an intermediate morphology between full-blown STEMI and inferior reperfusion. This is the classic morphology of hyperacute T waves.

STEMI

STEMI ED ACS Emergency Department

Potassium 6.2 with narrow QRS: any indication for calcium?

Dr. Smith's ECG Blog

FEBRUARY 10, 2025

1] In a review of hyperkalemia in the ED, all adverse events occurred prior to calcium and usually with multiple signs of hyperkalemia (like the first ECG) with the biggest predictors not only wide QRS, but also bradycardia and/or junctional rhythm.[2] Eur J Emerg Med 2020. West J Emerg Med 2017. References 1. Lindner et al.

ALS

ALS ED OR ICU

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Dr. Smith's ECG Blog

MARCH 3, 2025

A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. Truly, the Marquette 12 SL algorithm correctly identifies this STEMI.

E-9-1-1

E-9-1-1 Coronary STEMI Emergency Department

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

He presented to the emergency department for evaluation. 50% of LAD STEMI have Q-waves by one hour. Smith : In limb leads, the ST vector is towards lead II (STE lead II STE lead III, which is more likely with pericarditis than with STEMI). How extensive was this patient's heart disease prior to this recent event?

STEMI

STEMI ALS OR Coronary

Paramedicine Now

Does the literature support medications for stable, monomorphic ventricular tachycardia?

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.

Trending Sources

An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?

Computer: "Normal ECG," TIMI-3 flow at angiography: Does this ECG manifest Occlusion MI?

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

What does this ECG show?

The Computer and Overreading Cardiologist call this completely normal. Is it?

A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!

Case Report: The Not So Normal, Normal EKG

50-year old with chest pain, “no ischemic changes”

A man in his 50s with chest pain

Chest pain, a ‘normal’ ECG, a 'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.

Why we need continuous 12-lead ST segment monitoring in Wellens' syndrome

Compare these two ECGs. Do either, neither, or both show anything important?

Watch what happens when you teach others how to find OMI

Watch what happens when "pericarditis" and morphine cloud your judgment

2021 Wrap-Up

An ECG sent to me with concern for hyperacute T-waves

Chest pain, and Cardiology didn't take the hint from the ICD

A man in his 70s with chest pain during a bike ride

Profound ST Elevation in V1-V3. What do you think?

75 year old with 24 hours of chest pain, STEMI negative

Chest pain and T wave inversion, NSTEMI?

A 50-something with chest pain.

85 year old with chest pain, STEMI negative, then normal troponin but with relatively large delta: discharge?

Management of STEMI (ST-Elevation Acute Myocardial Infarction)

A man in his 60s with syncope and ST depression. What does the ECG mean?

Extreme shock and cardiac arrest in COVID patient

This ECG was texted to me after the fact with no information. What do you think?

What does a final diagnosis of STEMI vs. NSTEMI depend upon?

A 34 yo Man with chest pain and Zero ST Elevation

Potassium 6.2 with narrow QRS: any indication for calcium?

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Chest pain followed by 6 days of increasing dyspnea -- what happened?

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