EMS 12-Lead

APRIL 14, 2022

It should be emphasized here that this is a presentation of high-pretest probability for Acute Coronary Syndrome (ACS). ACS and hyperkalemia both have lethal downstream consequences, so it is imperative for the clinician to acclimate to the presentation, or developing, features of each. ECG's are difficult. link] [1] Zachary et al.

ACS

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. Back to the case.

E-9-1-1

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. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. Then ACS (STEMI) might be primary; this might be cardiogenic shock. One must clearly rule out these processes before jumping on the ACS diagnosis.

ACS

Dr. Smith's ECG Blog

OCTOBER 4, 2010

He arrived in the emergency department hemodynamically stable. ACS would be highly unusual in a young athlete, and given the information on his race bib, one must first suspect that the abnormal ST elevation is due to demand ischemia, not ACS. On his bib it stated that he had a congenital heart disorder.

ACS

REBEL EM

FEBRUARY 2, 2023

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). Amiodarone versus digoxin for acute rate control of atrial fibrillation in the emergency department. Am J Emerg Med. Am J Emerg Med. 2022 Sep 7.

Emergency Department

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. Smith comment : Is the ACS (rupture plaque) with occlusion that is now reperfusing? The ST depressions in I and aVL have resolved.

CAD

Dr. Smith's ECG Blog

OCTOBER 12, 2024

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. Written by Bobby Nicholson What do you think of this “STEMI”? Blood glucose was not low at 162 mg/dL.

STEMI

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

The fire department, who operate at an EMT level in this municipality, arrived before us and administered 324 mg of baby aspirin to the patient due to concern for ACS. Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said "Nothing too exciting." References: 1.

Emergency Department

Dr. Smith's ECG Blog

JANUARY 9, 2024

She presented to the emergency department after a couple of days of chest discomfort. Ischemia from ACS causing the chest discomfort, with VT another consequence (or coincidence)? I have emphasized on many occasions in Dr. Smith's ECG Blog how AFlutter is by far (!) The last echocardiography 12 months ago showed HFmrEF.

Coronary

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

Dr. Smith's ECG Blog

FEBRUARY 14, 2024

A 41-year-old male who presents to the emergency department with chest pain. The faculty physician thought this is highly likely to be ACS. Patient reports approximately 2 hours prior to arrival he developed a sharp chest pain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling.

ACS

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. 1] European guidelines add "regardless of biomarkers". But only 6.4%

STEMI

REBEL EM

SEPTEMBER 11, 2023

1 It is a quickly deployable and easily interpreted study that can be done in real time to guide decisions in the Emergency Department. Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions. and specificity of 88.0% Trauma Surg Acute Care Open.

ED

REBEL EM

FEBRUARY 12, 2024

There are greater than 2 million annual emergency department visits for suspected renal colic in the US, and Ct scanning is performed for more than 90% of patients who receive a diagnosis of kidney stone. PMID: 25229916 DOI: 10.1056/NEJMoa1404446 Westphalen AC, Hsia RY, Maselli JH, Wang R, Gonzales R. N Engl J Med.

Emergency Department

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Smith: If this is ACS (a big if), t his is just the time when one should NOT use "upstream" dual anti-platelet therapy ("upstream" means in the ED before angiography). History sounds concerning for ACS (could be critical stenosis, triple vessel), but differential also includes dissection, GI bleed, etc. Anything more on history?

Coronary

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) Use caution when prescribing opioids to patients concerning for ACS.

ACS

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. So, I'm a follower of your blog, and I think I have a interesting case that I attended yesterday." Aguiar last week: "Last year I had a couple of lessons with you while on my internship.

STEMI

Dr. Smith's ECG Blog

DECEMBER 26, 2020

On arrival to the PCI center's Emergency Department, the receiving team recorded an ECG on arrival: Persistent atrial flutter, however this time the QRS occurs on a slightly different portion of the flutter wave. The cardiologist also did not see atrial flutter, and advised giving thrombolytics for perceived "inferior STEMI."

STEMI

Dr. Smith's ECG Blog

APRIL 17, 2023

He had no symptoms of ACS. The remainder of his Emergency Department stay was uneventful. Here is the clinical informaton on ECG 2: A man in his 50s presented to the Emergency Department with acute chest pain that started within the past few hours. QOH: "OMI High confidence". Physician interpretation: "No STEMI."

OR

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 screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG: What do you think?

ACS

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. Beware of ACS presenting with atypical symptoms, including absence of chest pain. This was written by Sam Ghali ( @ EM_RESUS ), with a few edits by me. She is somewhat hypertensive, but her vital signs are otherwise normal.

STEMI

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? I wouldn't activate the lab for this EKG alone, but if the patient is clinically compatible with ACS you could call a heart alert.

STEMI

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

consistent with LAD occlusion) This was not recognized, repeat ECG at 69 minutes showed new Q-waves in V2-V4 that were not appreciated, and patient waited for a prolonged period in the emergency department before STEMI was diagnosed. The QTc was 455 ST Elevation at 60 ms after the J-point in lead V3 = 3.0 100% LAD occlusion.

STEMI

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ST segment changes are compatible with severe subendocardial ischemia which can be caused by type I MI from ACS or potentially from type II MI (non-obstructive coronary artery disease with supply/demand mismatch). The patient was rushed to the nearest emergency department (non-PCI facility) for stabilization.

Coronary

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. This has been discussed many times before on this blog. In-depth discussion is beyond the scope of this blog. link] Fesmire, F.

STEMI

EMS 12-Lead

APRIL 21, 2022

Dedicated followers of the Smith ECG Blog know that the STD of true subendocardial ischemia does not localize, yet some of the examples listed below demonstrate the opposite, and were subsequently labeled “diffuse ischemia” or “generic subendocardial changes” as a diagnosis of convenience. However, the maximal STD in this case is V3.

Coronary

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. looked at consecutive patients with PE, ACS, or neither. What do you think? ng/mL, BNP 2790, and lactate 3.7.

E-9-1-1

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. The pain improved (6/10) but is persisting, which prompted him to visit the Emergency Department. Shroff, G.

STEMI

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. Moreover, the Queen is only supposed to be used with a high pretest probability of ACS/OMI.

Overdose

AAEM RSA

DECEMBER 3, 2020

Wysoki MG, Santora TA, Shah RM, Friedman AC. West J Emerg Med. Inadequate Sensitivity of Laboratory Risk Indicator to Rule Out Necrotizing Fasciitis in the Emergency Department. West J Emerg Med. Image credit: Pixabay This post was peer reviewed. Click to learn more. Fournier gangrene. 2010;87(4):218-223.

Emergency Department

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

FOAMfrat

OCTOBER 20, 2023

Previously, I wrote a blog on pre-oxygenation, referencing my personal “weapon of choice” as chosen from the 7 Ps of RSI. But, putting them both into one blog would make for a read far too long to maintain even my attention span (which honestly is pretty short). Heffner AC, Swords DS, Neale MN, Jones AE. Crit Care Med.

E-9-1-1

Dr. Smith's ECG Blog

AUGUST 9, 2019

But if they do present: The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion , though it might be due to sub total LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. TIMI 0/1 flow).(61,62) Knotts et al.

Coronary

Dr. Smith's ECG Blog

JUNE 8, 2023

As recurrent ischaemia is the principle event reduced by early intervention in NSTE-ACS, these are important endpoint events occurring with delayed angiography and there is a consistent signal for harm now from two data sources.”[5] 5] This patient had ongoing chest pain, bradycardia, and no signs of reperfusion T wave inversion. Welsh et al.

STEMI

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Because the patient's pain had resolved completely and cardiology had declined immediate intervention, the patient was admitted but continued to board in the emergency department. Approximately 4 hours after arrival, the patient was re-examined by the emergency physician. There is no age cut-off for ACS. 1] Wereski, R.,

OR

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. of Cardiology AC, Others. Cardiac Troponin Testing in Patients with COVID-19: A Strategy for Testing and Reporting Results.

E-9-1-1

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. What do you think? Stay tuned for upcoming studies showing this.

STEMI