Emergency Medicine Cases

JANUARY 28, 2020

And for STEMI too. The post JJ 16 Heparin for ACS and STEMI appeared first on Emergency Medicine Cases. Does heparin - LMWH or unfractionated heparin - benefit the patient with a pretty good story for angina with a bump in their troponin and some ST depression in the lateral leads? But should we? But should we?

ACS 130

ACS STEMI OR EMS 130

University of Maryland Department of Emergency Med

JUNE 10, 2023

Is this a STEMI or Pericarditis? a 37 year old patient comes in with chest pain, you obtain the following ECG. Click to view the rest

STEMI 76

STEMI OR 76

Core EM

JULY 23, 2024

EKG Show Details EKG Characteristics Rate 54 Rhythm Sinus Bradycardia Intervals Normal PR, QRS, QT Intervals Axis Normal ST Segments ST Depression in Leads V2-V6 Diagnosis Diagnosis: Posterior STEMI Questions What is the next test that should be obtained in the management of this patient?

STEMI 173

STEMI Coronary Emergency Department OR 173

Emergency Medicine Cases

FEBRUARY 13, 2024

The post ECG Cases 48 – ECG Interpretation in Cardiac Arrest appeared first on Emergency Medicine Cases.

STEMI 273

STEMI OR EMS 273

Dr. Smith's ECG Blog

MAY 29, 2024

Triage ECG: It was interpreted as lateral STEMI, and he was sent to the cath lab, where the angiogram showed unchanged CAD from known prior, with no acute culprit. Written by Pendell Meyers Two patients with acute chest pain. Do either, neither, or both have OMI and need reperfusion? Described as a dull ache, 6/10 in severity.

OR 100

OR CAD STEMI 100

The Skeptics' Guide to EM

NOVEMBER 25, 2023

Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. We looked at 101 STEMI patients from two rural EDs. Date: November 22, 2023 Reference: Stopyra et al. AEM November 2023.

Heart Attack 279

Heart Attack STEMI Emergency Medical Services Coronary 279

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 52

STEMI Coronary ACS Critical Care 52

Dr. Smith's ECG Blog

JANUARY 3, 2024

Interpretation : diagnostic of acute anterior OMI with STE less than STEMI criteria in V1-V4, hyperacute T waves in V2-V4, and suspiciously flat isoelectric ST segments in III and aVF suspicious for reciprocal findings. Now it even meets STEMI criteria, and HATWs continue to inflate. So the cath lab was not activated. Ongoing OMI.

STEMI 88

STEMI EMS ED OR 88

ECG & Echo Learning

JUNE 28, 2023

Posterior (posterolateral) acute myocardial infarction (STEMI) The heart is rotated 30° to the left in the thorax. The answer is rather simple: the probability that the patient has NSTE-ACS/NSTEMI is small and the vast majority has STE-ACS/STEMI. Leads V7–V9 must be placed to reveal the ST-segment elevations.

STEMI 52

STEMI ACS OR 52

International Journal of Paramedicine

JULY 8, 2024

Objective: ST-elevation myocardial infarction (STEMI) is a leading cause of mortality in Australia. Paramedics treating adults with STEMI in the out-of-hospital environment can use fentanyl or morphine to manage the patient’s pain, although there is little research comparing the efficacy and safety of these drugs.

STEMI 52

STEMI Paramedic Ambulance OR 52

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. Inferior infarct, age undetermined.

STEMI 61

STEMI Coronary Paramedic ALS 61

Core EM

FEBRUARY 23, 2024

EKG Show Details EKG Characteristics Rate 54 Rhythm Sinus Bradycardia Intervals Normal PR, QRS, QT Intervals Axis Normal ST Segments ST Depression in Leads V2-V6 Diagnosis Diagnosis: Posterior STEMI Questions What is the next test that should be obtained in the management of this patient?

STEMI 130

STEMI Coronary Emergency Department OR 130

Dr. Smith's ECG Blog

AUGUST 6, 2023

link] == MY Comment, by K EN G RAUER, MD ( 8/6 /2023 ): == Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI”. The current STEMI paradigm that continues to be followed by all-too-many clinicians ( including all-too-many cardiologists ) is fallacious.

OR 93

OR STEMI Coronary 93

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

It does, in fact, the STE meets STEMI criteria since there is 1 mm of in V4 and V5. This ECG was texted to me with no other information. I assumed the presentation was consistent with acute MI. What did I say? Activate the cath lab." The T-waves in V2-V6 are diagnostic. There is also some non-diagnostic STE in inferior leads.

OR 123

OR STEMI Coronary 123

Dr. Smith's ECG Blog

JUNE 17, 2023

I believe there is not quite enough STE for formal STEMI criteria, but some might measure 1.0 mm of STE in II and III, or III and aVF, or V4 and V5, so some might say it fulfills STEMI criteria (remember, the interrater reliability of STEMI criteria is poor as shown in references below): McCabe et al.

OR 52

OR STEMI ALS EMS 52

Emergency Medicine Cases

AUGUST 8, 2023

We consider electrolyte disturbances and look for ECG signs of hyperkalemia or hypokalemia/hypomagnesemia, and we consider the differential of diffuse ST depression with reciprocal ST elevation in aVR, and false positive STEMI.

STEMI 204

STEMI OR EMS 204

Dr. Smith's ECG Blog

OCTOBER 1, 2023

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. Back to the case: Unfortunately, the ECG was not understood by the provider.

OR 127

OR STEMI Coronary CAD 127

Dr. Smith's ECG Blog

JANUARY 21, 2023

ECG met STEMI criteria and was labeled STEMI by computer interpretation. J waves can also be induced by Occlusion MI (5), STEMI mimics including takotsubo and myocarditis complicated by ventricular arrhythmias (6, 7), and subarachnoid hemorrhage with VF (8). There were no signs of trauma on scene or on the patient.

STEMI 52

STEMI ALS EMS OR 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

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." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

OR 115

OR STEMI EMS ED 115

Dr. Smith's ECG Blog

APRIL 4, 2023

This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion. OMI or STEMI? As cardiology documented, “possible STEMI.

STEMI 52

STEMI Coronary OR ACS 52

Dr. Smith's ECG Blog

JUNE 7, 2024

Obvious infero-postero-lateral STEMI(+)OMI, regardless of context Now let’s put them in order: what was the sequence? With serial ECGs that are ‘STEMI negative’ the physician could have waited for serial troponin levels or referred the patient as “non-STEMI”. 2 Normal ECG #3. What was the outcome and final diagnosis?

STEMI 95

STEMI Coronary OR EMS 95

Dr. Smith's ECG Blog

MAY 31, 2023

Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. It is a mass delusion.

STEMI 77

STEMI Coronary ACS OR 77

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. If this patient was managed according to the STEMI/NSTEMI paradigm (although he would be a candidate for early invasive treatment), he would probably be taken to the cath lab hours later. He has 40 packs-year of smoking history. He denies taking any medication.

STEMI 52

STEMI EMR Coronary OR 52

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. Do you think we discussed this patient's 2-3 hour delay to reperfusion in our quarterly "STEMI meeting"?

STEMI 52

STEMI ACS Coronary Defibrillator 52

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 40

STEMI Coronary OR Defibrillator 40

ECG & Echo Learning

MARCH 8, 2023

TIMI Risk Scores for NSTE-ACS (NSTEMI, UA) and STE-ACS ( STEMI ) can be calculated below. All patients with NSTE-ACS ( NSTEMI or unstable angina) are treated similarly with respect to anti-ischemic and anti-thrombotic drugs. Management must, however, be individualized with respect to the delay to coronary angiography (PCI).

STEMI 40

STEMI E-9-1-1 ACS Coronary 40

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 119

STEMI Coronary ALS Emergency Department 119

Dr. Smith's ECG Blog

JULY 9, 2024

Despite anticipation by many that the initial post-resuscitation ECG will show an obvious acute infarction — this expected "STEMI picture" is often not seen. As per My Comment in the above-cited Oct. 15, 2022 post — I like to focus on the ST-T wave appearance in leads V1 and V6 to facilitate recognition of Precordial Swirl.

Defibrillator 101

Defibrillator STEMI CPR EMS 101

Dr. Smith's ECG Blog

OCTOBER 15, 2022

As always, LAD OMI need not meet STEMI criteria and usually does NOT! Septal STEMI with ST elevation in V1 and V4R, and reciprocal ST depression in V5, V6 Case 8. Missed LAD Occlusion with Swirl, peak trop 80 ng/mL (equivalent to 80,000 ng/L), diagnosed as "Non-STEMI" Case 9. A 49 year old man with chest pain.

OR 52

OR E-9-1-1 STEMI 52

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Posterior leads are unnecessary if anterior leads are diagnostic According to the STEMI paradigm an ECG has to have ST elevation to diagnose acute coronary occlusion, and if there’s no ST elevation on anterior leads you can look for it on posterior leads. Do you need posterior leads? If so, how will they change management?

STEMI 112

STEMI ACS Coronary OR 112

Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1]

STEMI 118

STEMI Coronary ALS CAD 118

Dr. Smith's ECG Blog

AUGUST 11, 2024

While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. This case is an example of the steps we can all take in daily practice as the paradigm shifts from STEMI to OMI.

STEMI 74

STEMI Paramedic Coronary EMS 74

Dr. Smith's ECG Blog

JULY 31, 2020

Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.

STEMI 52

STEMI Coronary EMR ALS 52

Dr. Smith's ECG Blog

APRIL 17, 2023

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." Cardiologist interpretation: "Technically does not meet STEMI criteria but concerning for ischemia."

OR 52

OR STEMI ACS Emergency Department 52

The Bottom Line

APRIL 26, 2024

DOI: 10.1056/NEJMoa2312572 Clinical Question In adults presenting with STEMI and cardiogenic shock does the use of a microaxial flow pump (Impella CP) compared to standard care reduce death from any cause at day 180? Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock Møller JE et al.

STEMI 79

STEMI ALS OR 79

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. For this reason, ECGs need first to be interpreted in isolation, and then applied to the patient. Could this false positive cath lab activation been prevented?

STEMI 88

STEMI Coronary OR ED 88

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