The Skeptics' Guide to EM

APRIL 10, 2021

He is a GP by training but works in Emergency Department, Anaesthesia, Internal Medicine and Paediatrics. He has a wonderful #FOAMed blog and podcast called Broomedocs and also work […] The post SGEM#326: The SALSA Study: Hypertonic Saline to Treat Hyponatremia first appeared on The Skeptics Guide to Emergency Medicine.

Emergency Department 130

Emergency Department Coronary ED OR 130

Dr. Smith's ECG Blog

MARCH 10, 2025

But like many similar studies, the study was small (one year at one centre with no indication of the incidence of acute coronary occlusion), and it used as the gold standard the final cardiologist interpretation of the ECG - not the patient outcome! See > 50 cases on Dr. Smiths EGC Blog. Am J Emerg Med. Am J Emerg Med.

STEMI 98

STEMI OR Coronary Emergency Department 98

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. Regular readers of this ECG Blog will be well familiar with many of these points. No ECG was ordered on Day #1.

Coronary 127

Coronary STEMI Emergency Department OR 127

EMDocs

DECEMBER 11, 2023

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. In October 2022, the American College of Cardiology released an updated expert consensus decision regarding the evaluation of chest pain in the emergency department.

STEMI 109

STEMI Coronary Emergency Department OR 109

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. 2014 AHA/ACC guideline for the management of patients with non-ST elevation acute coronary syndromes.

STEMI 128

STEMI Coronary ALS CAD 128

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. Guagliumi, G.,

E-9-1-1 137

E-9-1-1 OR Coronary ACS 137

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? Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med.

STEMI 125

STEMI Emergency Department Coronary OR 125

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. They too have dense white masses consistent with coronary atherosclerosis. Annals of Emergency Medicine 2011; Suppl 58(4): S211.

CAD 132

CAD STEMI Coronary ACS 132

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 122

STEMI Coronary Emergency Department ACS 122

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). From there you can link to other great websites (including Dr. Smith's ECG Blog) that provide multiple case studies of both subtle and overt hyperkalemia. Western Journal of Emergency Medicine, 18 (4), 752-760. [2]

ACS 130

ACS Coronary Paramedic ALS 130

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

Angiogram: Severe two-vessel coronary artery disease with possible co-culprits (90% proximal circumflex, 70% mid/distal RCA) in the setting of non-ST elevation myocardial infarction. Marked ST depression from multi-vessel coronary disease serves to attentuate what would have been ST elevation in leads II and aVF ).

ED 125

ED Coronary CAD STEMI 125

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." Hospital Course The patient was taken emergently to the cath lab which did not reveal any significant coronary artery disease, but she was noted to have reduced EF consistent with Takotsubo cardiomyopathy.

Emergency Department 52

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

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. A recent angiogram report indicated a totally occluded left anterior descending artery (LAD) and right coronary artery (RCA), with 30-40% narrowings in the left circumflex artery (LCx).

Coronary 118

Coronary EMR STEMI Emergency Department 118

Dr. Smith's ECG Blog

JANUARY 9, 2024

She presented to the emergency department after a couple of days of chest discomfort. The patient is an older woman with known coronary disease and an ICD-Pacemaker implanted because of a history of VT ( V entricular T achycardia ). I have emphasized on many occasions in Dr. Smith's ECG Blog how AFlutter is by far (!)

Coronary 126

Coronary ACS ED OR 126

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. The Need for Immediate Transport?

OR 136

OR STEMI Coronary Emergency Department 136

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 123

STEMI Coronary ACS ED 123

Dr. Smith's ECG Blog

MAY 27, 2024

1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. But STEMI criteria is only 43% sensitive for OMI.[1] Int J Cardiol 2024 2.

STEMI 130

STEMI Coronary ALS Emergency Department 130

Dr. Smith's ECG Blog

MAY 23, 2023

Am J Emerg Med. I have here 38 cases of "Computer Normal" ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized by the physician. Of the Non-STEMI in our cohort, about 25% will actually have acute coronary occlusion. 2022 Jan;51:384-387.

STEMI 98

STEMI Coronary Paramedic ED 98

Dr. Smith's ECG Blog

JUNE 11, 2024

Many systems now refrain from showing computer "normal" ECGs to the busy emergency physicians at triage because of very poorly conceived articles that say that if the computer algorithm says "normal," the emergency physician should not be bothered. We have shown many examples of this on this blog.

STEMI 119

STEMI Coronary Emergency Department OR 119

Dr. Smith's ECG Blog

JUNE 21, 2023

Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). link] ] Outcome The patient emerged neurologically intact. Clinical Cardiology 2019.

STEMI 98

STEMI Defibrillator Coronary EMS 98

Dr. Smith's ECG Blog

MARCH 14, 2024

According to this data a triage ECG labeled ‘normal’ rules out the possibility of acute coronary occlusion. This is obviously unreliable data, as Dr. Smith’s Blog has published 51 cases of OMI with ECGs labeled ‘normal’ , 35 of which were identified by the Queen of Hearts – with 10 examples here. It should never have been published.

STEMI 126

STEMI ACS Coronary Emergency Department 126

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Hgb 11g/dL (110g/L) and leukocytosis, and a mildly elevated troponin (36 ng/L, with normal 1mm STE in aVR due to ACS will require coronary artery bypass surgery for revascularization, the infarct artery is often not the LM, but rather the LAD or severe 3-vessel disease. Incidence of an acute coronary occlusion. Left main?

Coronary 52

Coronary ACS STEMI ALS 52

Dr. Smith's ECG Blog

MAY 19, 2020

She was unable to be defibrillated but was cannulated and placed on ECMO in our Emergency Department (ECLS - extracorporeal life support). Angiography showed normal coronaries. MINOCA: Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease). 2) overlooked obstructive coronary disease (e.g.,

Defibrillator 52

Defibrillator CPR Coronary CAD 52

ECG Medical Training

SEPTEMBER 4, 2016

He is transported to the Emergency Department where care is transferred to a nurse. Assuming the patient has signs and symptoms of an acute coronary syndrome (you always want clinical correlation), you should consider the T-waves in example A. Further Reading Take a look at these blog posts from Dr. Smith’s ECG Blog.

STEMI 52

STEMI Paramedic Coronary Emergency Department 52

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. Also see this incredible case of the use of 12-lead ST Segment monitoring.

Coronary 52

Coronary STEMI ALS Emergency Department 52

Dr. Smith's ECG Blog

MARCH 17, 2023

Submitted by anonymous, written by Pendell Meyers A woman in her 50s presented to the Emergency Department with chest pain and shortness of breath that woke her from sleep, with diaphoresis. A very similar case to the one presented today appears in the January 17, 2023 post of Dr. Smith’s ECG Blog.

Coronary 52

Coronary Emergency Department ED OR 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

He arrived in the emergency department hemodynamically stable. The next day, and angiogram showed normal coronary arteries. He was resuscitated with chest compressions and defibrillation and 1 mg of epinephrine. On his bib it stated that he had a congenital heart disorder. His initial ECG is shown here. He awoke and did well.

ACS 52

ACS Defibrillator Epinephrine STEMI 52

Dr. Smith's ECG Blog

JULY 27, 2021

Earlier this morning, he developed severe chest pain that lasted about 6-7 hours along with shortness of breath at which point he called 911 and was brought to the emergency department. Cath Lab was activated and patient underwent left heart catheterization coronary angiogram. There is also 1-2 mm ST depression in leads V1-V3.

Coronary 52

Coronary Emergency Department EMS 52

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. An angiogram showed no acute coronary lesions. This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain.

ACS 52

ACS STEMI OR Critical Care 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. STEMI criteria is bad at differentiating between normal variant and acute coronary occlusion or reperfusion, and initial troponin levels don't differentiate between occlusive and non-occlusive MI 3. Am J Emerg Med 2023 2. What do you think?

STEMI 76

STEMI Coronary OR ALS 76

REBEL EM

FEBRUARY 22, 2023

difficult to see due to corneal edema) Emergency Department Management All patients should get emergency ophthalmologic consultation Start with eye drops (see table below) and add systemic medications if severe or refractory symptoms/IOP. Decreased visual acuity, Cup to disc ratio >0.6 Cup to disc ratio >0.6

Emergency Department 52

Emergency Department ALS ED Coronary 52

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. It is not a missed STEMI, but it is a missed coronary occlusion. Ann Emerg Med 1998;31(1):3-11.

STEMI 52

STEMI Coronary ALS CAD 52

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. Relationship between an in-farct related artery, acute total coronary occlusion, and mortality in patients with ST-segment and non-ST-segment myocardial infarction.

E-9-1-1 52

E-9-1-1 STEMI Coronary ALS 52

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 52

ACS Coronary Defibrillator STEMI 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

The pain resolved as he arrived to the emergency department. As has been emphasized on numerous blog posts on this site — more than a single tracing will usually be needed for optimal diagnosis whenever the slightest of doubt regarding acuity exists. He had 2 episodes over the past 2 days of similar chest tightness.

ED 52

ED STEMI Coronary Emergency Department 52

Dr. Smith's ECG Blog

APRIL 22, 2022

A prospective validation of the HEART score for chest pain patients at the emergency department. External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Am J Emerg Med 2020 3. Backus BE, Six AJ, Kelder JC, et al. Int J Cardiol 2013 2. Lancet 2015 6.

E-9-1-1 52

E-9-1-1 STEMI ALS ED 52

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 52

ACS STEMI Coronary CAD 52