Dr. Smith's ECG Blog

APRIL 18, 2024

Paramedics provided another 3 sprays of nitro, and 6mg of morphine, which reduced but did not resolve the pain. I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. of such ‘high risk Non-STEMI’ patients get angiography within 2 hours.[2] But only 6.4%

STEMI 121

STEMI Coronary ALS CAD 121

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

FEBRUARY 13, 2023

Written by Jesse McLaren Two 70 year olds had acute chest pain with nausea and shortness of breath, and called paramedics. 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. Who needs the cath lab?

STEMI 52

STEMI Paramedic Coronary ALS 52

Dr. Smith's ECG Blog

MAY 5, 2024

He was a paramedic at the time. Such proficient interpreters include health care assistants and EKG technicians. Pendell Meyers had not started medical school by summer of 2012, but he had read every one of my blog posts over the preceding 4 years. By the summer of 2012, he could read an ECG for OMI better than any doctor I knew.

ED 124

ED STEMI Coronary Paramedic 124

Dr. Smith's ECG Blog

JUNE 17, 2016

Jason was very skeptical of STEMI. This also argues against STEMI. Outcome "I later found out that this is a patient who regularly calls paramedics to c/o chest pains and he had fooled many of them. He complained of 3 days of diarrhea and abdominal pain. What do you think? Jason, I agree. There is high R-wave voltage.

STEMI 52

STEMI OR Coronary EMS 52

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 98

STEMI Coronary Paramedic OR 98

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. 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. Vitals were normal.

STEMI 73

STEMI Paramedic Coronary ED 73

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

The paramedics achieve return of spontaneous circulation (ROSC) after CPR, advanced cardiac life support (ALCS), and Intubation. 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 130

EMR Coronary Defibrillator Life Support 130

EMS 12-Lead

APRIL 14, 2022

Madden, Paramedic. 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). Let's revisit the deWinter occlusion provided by Paramedic Madden.

ACS 130

ACS Paramedic Coronary ALS 130

EMS 12-Lead

MAY 20, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review and commentary by Dr. Steve Smith [link] @SmithECGblog It is early-summer, approximately 1330 hours, no cloud cover overhead, and 86 degrees with high humidity. As it currently stands, an ST/S ratio >15% should raise awareness for new anterior STEMI.

Coronary 130

Coronary STEMI Firefighter ED 130

ESO

APRIL 19, 2024

Prehospital – hospital interoperability As previously mentioned, the EMS industry is evolving and with it, so is the job of the paramedic. For Eagle County Paramedic Services, turning to MIH was integral to helping them provide services for their underserved population while also saving millions in costs.

MIH 105

MIH EMS Paramedic Firefighter 105

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. A Coronary angiogram from 8 years prior revealed that he had had an inferior posterior STEMI at the time due to 100% occlusion of the proximal RCA. He was belted and it was low speed.

STEMI 115

STEMI Coronary ED Paramedic 115

EMS 12-Lead

JUNE 20, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith @SmithECGblog I was conducting QA/QI on two very recent cases and was struck by the uniqueness of both. A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered.

ACS 130

ACS Coronary STEMI CAD 130

Dr. Smith's ECG Blog

AUGUST 26, 2009

He called 911 and paramedics recorded a prehospital 12 lead ECG which showed a clear inferior STEMI (not shown, tracing could not be found). The cath lab was activated by the paramedics. Objectives : To find the incidence of any rSTD or T-wave inversion (TWI) in angiographically proven inferior STEMI. There is 0.5

STEMI 52

STEMI Paramedic OR 52

ECG Medical Training

AUGUST 21, 2016

Acute anterior STEMI tends to be a more difficult ECG diagnosis than acute inferior STEMI. That’s because with acute inferior STEMI there’s almost always a downsloping ST-segment in lead aVL to help shore up the diagnosis. Once again, this acute anterior STEMI “crosses over” to the high lateral leads.

STEMI 52

STEMI ACS Ambulance Paramedic 52

EMS 12-Lead

APRIL 2, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Expert commentary provided by Dr. Ken Grauer CASE 1 An 82 y/o Male called 911 for sudden onset dizziness while at rest. ASA 324mg was administered while a STEMI activation was simultaneously transmitted to the nearest PCI center. Attached is the first ECG.

ALS 130

ALS STEMI Coronary OR 130

Dr. Smith's ECG Blog

JANUARY 8, 2024

She was diagnosed with a Non-STEMI and kept overnight for a next day angiogram. Paramedics found her semi-conscious, pale, cool, diaphoretic, tachypneic, very hypotensive. Medics recorded the above ECG and called a STEMI alert. Her troponin I returned at 900 ng/L. Patient was given aspirin, sublingual nitro as well as heparin.

Coronary 71

Coronary STEMI EMS OR 71

Dr. Smith's ECG Blog

AUGUST 9, 2018

This case was sent by Lou B, a paramedic and RN. Here it is: The computer reads STEMI What do you think? More from the medic: "LifePak 15 interpretation was STEMI. My response: "I think it is very worrisome for STEMI." It meets STEMI criteria even for a male under age 40, with STE 2.84 Pattern looked to be BER.

E-9-1-1 52

E-9-1-1 STEMI Coronary Ambulance 52

Dr. Smith's ECG Blog

JUNE 24, 2016

The paramedic recorded a series of ECGs; the initial ECG is representative here: Computer read: “ Normal ECG ” What do you think? The paramedic interpreted this as a STEMI. Can you employ the Subtle Anterior STEMI calculator ? It is not yet available, but this is your way to get on the list. or LAD occlusion?

STEMI 40

STEMI Coronary Paramedic ED 40

Dr. Smith's ECG Blog

SEPTEMBER 17, 2020

Her initial 12-lead ECG that was obtained by paramedics in the field is shown in Figure-1. Figure-1: The initial ECG in todays case, obtained by paramedics in the field. ( On seeing both of the tracings in Figure-2 the paramedic team and the ED physician activated the after-hours cath lab. Should you activate the cath lab?

STEMI 52

STEMI Paramedic OR ED 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2023

Jason was very skeptical of STEMI. This also argues against STEMI. Outcome "I later found out that this is a patient who regularly calls paramedics to c/o chest pains and he had fooled many of them. Look for old ECGs Do serial ECGs Do echocardiography June 17, 2016 Anterior STEMI? What do you think? Jason, I agree.

STEMI 52

STEMI Coronary EMS ED 52

Dr. Smith's ECG Blog

MARCH 30, 2014

My most talented blog readers are paramedics because they have to put themselves on the line every time they activate the cath lab. Trop T now very high, well into the range one sees with a STEMI; very unusual in type II MI. The minute this medical student saw the first ECG, he knew the diagnosis without any further information.

STEMI 52

STEMI Coronary Paramedic OR 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Learning Points: 1. Learn to Recognize Hyperacute T-waves 2. From Gue at al.

Emergency Department 52

Emergency Department E-9-1-1 Coronary STEMI 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The paramedics found the patient with ROSC and a GCS 7, and an ECG showing LBBB with possible lateral ST elevation. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. On arrival, GCS was 13 and the patient complained of ongoing chest pain.

EMR 52

EMR STEMI CPR ED 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. 2 The astute paramedic recognized this possibility and announced a CODE STEMI. Look at the aortic outflow tract. What do you see? Answer below in the still shot.

Coronary 40

Coronary ACS ALS STEMI 40

AmboFOAM

MAY 7, 2017

We have a large number of graduate paramedics starting with Ambulance Victoria this year, so it’s probably a good time to revisit a topic that seems to receive surprisingly little attention in an industry that relies so heavily upon it. Sometimes I just have to scratch the itch and have a rant. Learn it, use it. Listen more.

Ambulance 40

Ambulance CPR Paramedicine Paramedicine 40

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated. Long term outcome is unavailable.

STEMI 121

STEMI EMS ACS ED 121

Dr. Smith's ECG Blog

JUNE 8, 2023

Here’s the paramedic ECG (digitized by PMcardio). STEMI negative : the EMS automated interpretation read, “STEMI negative. But the latest ACC consensus on the evaluation of chest pain in the ED warns that “STEMI criteria will miss a significant minority of patients with acute coronary occlusion.”[1] What do you think?

STEMI 85

STEMI Coronary Paramedic ALS 85

Dr. Smith's ECG Blog

NOVEMBER 2, 2015

Serial ECGs demonstrated dynamic changes diagnostic of ACS (transient STEMI) 4. Finally, Transient STEMI should be taken emergently to the cath lab. Normalization of Diagnostic For STEMI Prehospital ECG with Nitroglycerin Therapy. If the initial ECG was diagnostic for STEMI the paramedic called to mobilize the reperfusion team.

Paramedic 52

Paramedic STEMI ACS Ambulance 52

EMS 12-Lead

APRIL 8, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review by Dr. Stephen Smith @smithECGblog I was reviewing ECG’s in our LifeNet database and happened upon this one without any knowledge of clinical circumstances. 1] Here is the admitting ED ECG after cancellation of Code STEMI. 1] Driver, B.

STEMI 130

STEMI ALS Coronary CAD 130

EMS 12-Lead

AUGUST 14, 2022

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic @DidlakeDW A 50 y/o Male was taking his dog for a leisurely stroll through the park when he suddenly experienced new onset chest discomfort. it has been subsequently deemed a STEMI-equivalent.

MICU 130

MICU STEMI CAD Coronary 130

ESO

APRIL 19, 2024

For Eagle County Paramedic Services, turning to mobile integrated healthcare was integral to helping them provide services for their underserved while also saving millions in costs. Supporting and advocating for mental health Mental health calls are increasing.

EMS 105

EMS Paramedic Critical Care STEMI 105

EMS 12-Lead

MAY 8, 2022

David Didlake Firefighter / Paramedic Acute Care Nurse Practitioner @DidlakeDW Peer review provided by Dr. Steve Smith [link] @SmithECGBlog An adult female called 911 for chest discomfort and difficulty breathing. Then, three minutes later… Crews activated STEMI as she deteriorated into PEA arrest.

STEMI 130

STEMI ED EMS Firefighter 130

Dr. Smith's ECG Blog

OCTOBER 7, 2019

When the paramedics arrived, they obtained a 12 lead ECG and confirmed the unstable vital signs. There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI).

STEMI 40

STEMI EMS Coronary ALS 40

Dr. Smith's ECG Blog

FEBRUARY 25, 2009

RBBB in acute STEMI has a very high mortality. The paramedics activated the cath lab from the field. Thus, there is right bundle branch block, which should never (unlike Left BBB) have any ST elevation. But here there is a large degree of ST elevation in V2-V6, I, and aVL.

Defibrillator 52

Defibrillator STEMI Paramedic EMS 52

Dr. Smith's ECG Blog

OCTOBER 3, 2018

This was shown to me by a very astute Hennepin paramedic. Although this comes from a Hennepin paramedic, the patient was not brought to Hennepin County Medical Center. It is important for cardiologists to realize that a paramedic may see something they do not. of this post. This is my reponse. This is not tribalism.

Coronary 52

Coronary STEMI Paramedic ALS 52

Dr. Smith's ECG Blog

MARCH 19, 2025

Case submitted by Andrew Grimes, Advanced Care paramedic, with additions from Jesse McLaren and Smith An 84-year-old male with a notable cardiac history (CABG, multiple stents) woke at 0500hrs with pressure in his chest, diaphoresis, and light-headedness. STEMI criteria are only 43% sensitive for OMI.

STEMI 116

STEMI Coronary ED Paramedic 116