Emergency Department, OR and STEMI

Better Watch Your Back… Finding the Needle in the Haystack.

Core EM

JULY 23, 2024

The Case A 71-year-old male with a history of chronic obstructive pulmonary disease, hyperlipidemia, and peptic ulcer disease presents to the emergency department with substernal chest pain radiating down the right arm and dyspnea that began acutely while “running” up the stairs from the subway.

STEMI

STEMI Coronary Emergency Department OR

ECG Cases 49 – ECG and POCUS for Dyspnea and Chest Pain

Emergency Medicine Cases

APRIL 2, 2024

In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chest pain. The post ECG Cases 49 – ECG and POCUS for Dyspnea and Chest Pain appeared first on Emergency Medicine Cases.

Emergency Department

Emergency Department OR STEMI EMS

ECG Pointers: STEMI Equivalents from the American College of Cardiology

EMDocs

DECEMBER 11, 2023

Traditionally, emergency providers looked for signs of ST-segment elevation myocardial infarction (STEMI) to indicate the need for intervention. Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG.

STEMI

STEMI Coronary Emergency Department OR

Early repol or anterior OMI?

Dr. Smith's ECG Blog

MAY 13, 2024

Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain. Chest Pain – Benign Early Repol or OMI? which is concerning for LAD occlusion.

OR

OR STEMI Heart Attack Coronary

Better Watch Your Back… Finding the Needle in the Haystack.

Core EM

FEBRUARY 23, 2024

The Case A 71-year-old male with a history of chronic obstructive pulmonary disease, hyperlipidemia, and peptic ulcer disease presents to the emergency department with substernal chest pain radiating down the right arm and dyspnea that began acutely while “running” up the stairs from the subway.

STEMI

STEMI Coronary Emergency Department OR

Chest pain and computer ‘normal’ ECG. Wait for troponin? And what is the reference standard for ECG diagnosis? Cardiologist or outcome?

Dr. Smith's ECG Blog

MARCH 10, 2025

If we took this as the gold standard, we would conclude that the computer interpretation was safe and accurate at least accurate enough to not miss STEMI, and that physicians should not be interrupted to interpret it, because there would be no change in patient management. What is the gold standard for ECG interpretation: patient outcome!!!

STEMI

STEMI OR Coronary Emergency Department

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

Dr. Smith's ECG Blog

OCTOBER 18, 2023

If you were working in a busy emergency department, would you like to be interrupted to interpret these ECGs or can these patients safely wait to be seen because of the normal computer interpretation? Written by Jesse McLaren Four patients presented with chest pain.

STEMI

STEMI Emergency Department Coronary OR

Journal Feed Weekly Wrap-Up

EMDocs

MAY 4, 2024

1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation. . #1:

STEMI

STEMI Emergency Department OR

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]

STEMI

STEMI Coronary ALS Emergency Department

Something Winter This Way Comes

EMS 12-Lead

AUGUST 14, 2022

The specific ST/T pattern was not fully appreciated by the attending EMS personnel, yet alarming enough to convince the patient to be seen in the Emergency Department despite his intentions of seeking evaluation on his own accord through his respective family physician. it has been subsequently deemed a STEMI-equivalent.

MICU

MICU STEMI CAD Coronary

Is OMI an ECG Diagnosis?

Dr. Smith's ECG Blog

APRIL 18, 2024

Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency department with 2 weeks of increasing exertional chest pain radiating to the left arm, associated with nausea. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion.

STEMI

STEMI Coronary ALS CAD

Journal Feed Weekly Wrap-Up

EMDocs

SEPTEMBER 14, 2024

Source Use of Glucagon-Like Peptide-1-Agonists and Increased Risk of Procedural Sedation and Endotracheal Intubation in the Emergency Department. Ann Emerg Med. Ann Emerg Med. We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 2024 Aug;84(2):226-227. 2024.03.007.

Defibrillator

Defibrillator STEMI Emergency Department OR

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

Dr. Smith's ECG Blog

OCTOBER 26, 2010

He presented to the Emergency Department with a blood pressure of 111/66 and a pulse of 117. He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. He had this ECG recorded. The HCO3 was 8.

ACS

ACS STEMI OR Critical Care

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

Journal Feed Weekly Wrap-Up

EMDocs

OCTOBER 28, 2023

2: STREAM-2 RCT | Half-Dose Tenecteplase for STEMI Spoon Feed The STREAM-2 trial found half-dose tenecteplase was effective in treating STEMI patients ≥60, though with increased risk of intracranial hemorrhage. We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 2023.04.023.

STEMI

STEMI Emergency Department Coronary OR

emDOCs Podcast – Episode 86 Tricky Cases Part 2

EMDocs

SEPTEMBER 19, 2023

Reference: emDOCs – NCSE Journal of Emergency Medicine – Review Case 4: 52-year-0ld male brought in by EMS with “code STEMI” ECG demonstrates ST depressions with rocket like T waves in V2-V4. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

STEMI

STEMI Coronary Emergency Department ICU

Case Study: Arkansas EMS Dept. Enhances Pediatric Behavioral Health Services

Pulsara

JANUARY 25, 2024

In 2020, MEMS adopted Pulsara to improve communication with area hospitals for time-sensitive emergencies such as stroke, STEMI, and trauma. The organization’s service area covers approximately 1,800 square miles and nearly half a million Arkansans. MEMS transports around 77,000 patients each year.

Emergency Medical Services

Emergency Medical Services EMS STEMI Emergency Department

Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?

Dr. Smith's ECG Blog

MARCH 14, 2024

We also studied 7 years of Code STEMI patients requiring emergent reperfusion, and found that 4% presented with an ECG labeled ‘normal’, often confirmed by the final blinded interpretation. This was just published in print in this month's Academic Emergency Medicine: McLaren, Meyers, Smith and Chartier.

STEMI

STEMI ACS Coronary Emergency Department

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

In SCAPE (sympathetic crashing acute pulmonary edema), Emergency providers seem now to regularly give high dose NTG, but when the BP is 170/105 in a patient who is not crashing, we often fail to give something to lower afterload. __ Here are some Images: The red circle shows the LAD coursing down the anterior interventricular sulcus.

CAD

CAD STEMI Coronary ACS

SGEM#344: We Will…We Will Cath You – But should We After An OHCA Without ST Elevations?

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

She arrives in the emergency department (ED) with decreased level of consciousness and shock. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes.

EMR

EMR Coronary Defibrillator Life Support

An elderly male with acute altered mental status and huge ST Elevation

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

STEMI Coronary Emergency Department ACS

When Acute Anterior STEMI Does Not Meet Guidelines

ECG Medical Training

SEPTEMBER 4, 2016

He is transported to the Emergency Department where care is transferred to a nurse. At the hospital a 12-lead ECG is recorded within 10 minutes and read by the attending physician, who activates the “Code STEMI” protocol. Is this a STEMI? So technically it is a STEMI equivalent. The answer is yes!

STEMI

STEMI Paramedic Coronary Emergency Department

SGEM#243: Enough is Enough (O2 Saturation of 94-96%)

The Skeptics' Guide to EM

FEBRUARY 2, 2019

Case: You’re working a shift in a rural emergency department when a 68-year-old man presents with a two-day course of worsening cough, shortness of breath, and fever. This is Bob’s ninth visit to the SGEM. DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE.

Life Support

Life Support ALS STEMI Emergency Department

A man in his 50s with acute chest pain who is lucky to still be alive.

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

STEMI Coronary Defibrillator EMS

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

EMDocs

DECEMBER 23, 2024

Its narrow indication for stable VT means many emergency departments may not routinely stock the medication. His initial EKG is the following: What do you think? Naturally you would assume that this was a large, multicenter trial, right? This was based on 11, thats not a typo, ELEVEN patients. Ok, so what did the PROCAMIO trial find?

ALS

ALS OR STEMI EMS

A man in his 30s with chest pain. How was he managed? What if they had used the Queen of Hearts?

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

STEMI CAD ED ALS

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

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

E-9-1-1 ACS Emergency Department Coronary

Case Report: Pancreatitis Mimics STEMI

ACEP Now

DECEMBER 11, 2023

Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. The Case FIGURE 1: Initial EKG were notable for a leukocytosis of 23.19 Click to enlarge.)

STEMI

STEMI Coronary ACS Critical Care

Large Transmural STEMI with Myocardial "Rupture" of Ventricular Septum

Dr. Smith's ECG Blog

JULY 7, 2013

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. Armstrong et al.)], the presence of such well developed anterior Q-wave suggests completed transmural STEMI. Ann Emerg Med 1994;23(6):1333-42.

STEMI

STEMI E-9-1-1 ALS Coronary

What if your system adopted the recommendation that a computer "normal" ECG need not be shown to the doctor?

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

STEMI Coronary Emergency Department OR

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

Hypertrophic Cardiomyopathy

EMS 12-Lead

MAY 20, 2022

This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI. New insights into the use of the 12-lead electrocardiogram for diagnosing acute myocardial infarction in the emergency department.

Coronary

Coronary STEMI Firefighter ED

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

Dr. Smith's ECG Blog

JULY 18, 2014

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. the presence of such well developed, wide, anterior Q-wave suggests completed transmural STEMI. Could it be acute (vs.

STEMI

STEMI E-9-1-1 ALS Coronary

50 year-old in remote rural community with chest pain and ‘normal’ ECG

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.

OR

OR STEMI Coronary Emergency Department

A man with chest pain off and on for two days, and "No STEMI" at triage.

Dr. Smith's ECG Blog

JUNE 19, 2023

Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen Smith A 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. It is true this ECG does not meet STEMI criteria (there is 1.0

STEMI

STEMI ACS Coronary Defibrillator

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

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

STEMI Coronary Paramedic OR

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. Queen: The Queen got this one wrong, but we are teaching her reperfusion too. What would I expect the angiogram to show? Jesse McLaren et al.

STEMI

STEMI Emergency Department OR ALS

46 year old with chest pain develops a wide complex rhythm -- see many examples

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The receiving emergency physician consulted with interventional cardiology who stated there was no STEMI. Is there STEMI?

STEMI

STEMI Coronary Heart Attack ACS

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." Many paramedics are far better than any physician (Emergency or Cardiology) at diagnosing OM 3. V1 has 0.5 mm of elevation. More notably there are hyperacute T waves in V3 through V5.

Emergency Department

Emergency Department E-9-1-1 Coronary STEMI

50 Shades of T

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] ECG's are difficult. link] [1] Zachary et al.

ACS

ACS Paramedic Coronary ALS

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 Emergency Department

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 C Pain Titrated i.v. IIa C Anxiety Tranquillizer (e.g benzodiazepine) is considered.

STEMI

STEMI Coronary OR Defibrillator

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?

STEMI

STEMI Coronary OR ALS

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

Better Watch Your Back… Finding the Needle in the Haystack.

ECG Cases 49 – ECG and POCUS for Dyspnea and Chest Pain

Trending Sources

ECG Pointers: STEMI Equivalents from the American College of Cardiology

Early repol or anterior OMI?

Better Watch Your Back… Finding the Needle in the Haystack.

Chest pain and computer ‘normal’ ECG. Wait for troponin? And what is the reference standard for ECG diagnosis? Cardiologist or outcome?

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

Journal Feed Weekly Wrap-Up

Chest pain: Are these really "Nonspecific ST-T wave abnormalities", as the cardiologist interpretation states?

Something Winter This Way Comes

Is OMI an ECG Diagnosis?

Journal Feed Weekly Wrap-Up

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

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

Journal Feed Weekly Wrap-Up

emDOCs Podcast – Episode 86 Tricky Cases Part 2

Case Study: Arkansas EMS Dept. Enhances Pediatric Behavioral Health Services

Three patients with chest pain and “normal” ECGs: which had OMI? Which were normal? And how did the Queen of Hearts perform?

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

SGEM#344: We Will…We Will Cath You – But should We After An OHCA Without ST Elevations?

An elderly male with acute altered mental status and huge ST Elevation

When Acute Anterior STEMI Does Not Meet Guidelines

SGEM#243: Enough is Enough (O2 Saturation of 94-96%)

A man in his 50s with acute chest pain who is lucky to still be alive.

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

A man in his 30s with chest pain. How was he managed? What if they had used the Queen of Hearts?

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Case Report: Pancreatitis Mimics STEMI

Large Transmural STEMI with Myocardial "Rupture" of Ventricular Septum

What if your system adopted the recommendation that a computer "normal" ECG need not be shown to the doctor?

A 50-something with chest pain.

Hypertrophic Cardiomyopathy

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

50 year-old in remote rural community with chest pain and ‘normal’ ECG

A man with chest pain off and on for two days, and "No STEMI" at triage.

A man in his early 40s with chest pain a "normal ECG" by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?

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

46 year old with chest pain develops a wide complex rhythm -- see many examples

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

50 Shades of T

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

Management of STEMI (ST-Elevation Acute Myocardial Infarction)

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

What does this ECG show?

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