The Skeptics' Guide to EM

JULY 2, 2022

Case: You are working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain. Background: Chest pain is one of the most common presentations to the ED. In prior decades nearly all patients presenting to EDs with chest pain were admitted to hospital. AEM June 2022.

Coronary 100

Coronary Heart Attack ACS CAD 100

Dr. Smith's ECG Blog

JANUARY 6, 2016

consult: In summary, this is a 47 year old male with past medical history of CAD s/p STEMI in 2010 s/p PCI to LAD with BMS, HTN, tobacco, alcohol and substance abuse that presented with chest pain and found to have ST elevation with T wave inversion in his ECG. Patient had a negative head CT and was admitted to the ICU for further work-up.

CAD 52

CAD ACS ICU STEMI 52

Dr. Smith's ECG Blog

OCTOBER 1, 2023

A man in his mid 60s with history of CAD and stents experienced sudden onset epigastric abdominal pain radiating up into his chest at home, waking him from sleep. He called EMS who brought him to the ED. ED Diagnoses: 1. We've come a long way in 2 years! And the pace only quickens. I ordered morphine but he refused.

OR 134

OR STEMI CAD Coronary 134

EMS 12-Lead

JULY 24, 2023

David Didlake Acute Care Nurse Practitioner Firefighter / Paramedic (ret) @DidlakeDW Expert commentary and peer review by Dr. Steve Smith [link] @smithECGBlog A 57 y/o Female with PMHx HTN, HLD, DM, and current use of tobacco products, presented to the ED with chest discomfort. A 12 Lead ECG was captured on her arrival. Coronary Angiogram 1.

Coronary 130

Coronary ACS CAD ED 130

EMS 12-Lead

JUNE 20, 2022

Moreover, he had no pertinent medical history to report in terms of CAD, HTN, HLD, or DM, for example. Here is the final ECG just prior to ED transfer. Attached below is the initial ED tracing upon hospital arrival, approximately 25 minutes after the prehospital ECG. A 12 Lead ECG was recorded. No serial ECG’s were recorded.

ACS 130

ACS Coronary STEMI CAD 130

ESO

SEPTEMBER 5, 2024

Their feedback represent ed over 957 incidents overall and provided a ton of information to help iron out some of the initial wrinkles. With API , participating CAD and RMS vendors will be able to automatically send data back and forth to NERIS.

CAD 59

CAD PSAP Mobile Integrated Health Community Paramedicine 59

Dr. Smith's ECG Blog

JANUARY 16, 2025

Was transferred to our ED for emergent PCI, clean cath. Outside ED (no cath lab) 66 yo female with past ho polysubstance use and htn c/o dhest tightness lasting for seconds. Sounds like based on ECGs, cardiologist recommended heparin, no lytics, and transfer to Bend ED. This was sent to me by Susy DeMeester. hs trop 37 ng/L.

CAD 52

CAD ACS STEMI ED 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

A middle-aged man complained of 15 minutes of classic angina that resolved upon arrival to the ED. So I made an ED diagnosis of Non-Occlusion Myocardial Infarction (NOMI), and his next day angiogram confirmed NOMI. Figure-1: The initial ECG that was done in the ED ( See text ). Here is his initial ECG: What do you think?

ED 52

ED Coronary ACS CAD 52

Dr. Smith's ECG Blog

JUNE 1, 2012

This was a middle aged female with a h/o CAD who presented to the ED by EMS sudden onset of central chest pressure 45 min prior to ED arrival with associated diaphoresis and SOB.  There is LVH and there are ST-T abnormalities (large inferior T-waves and ST elevation, with reciprocal findings in aVL).

STEMI 52

STEMI CAD ED EMS 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Pre-intervention.

CAD 52

CAD ACS STEMI Coronary 52

Dr. Smith's ECG Blog

OCTOBER 24, 2019

link] A 30 year-old woman was brought to the ED with chest pain. However, a smooth tapering of the mid-RCA was seen, highlighted in red below: How do we explain the MI if no sign of CAD was found? This MI wasn’t caused by a ruptured plaque of CAD - it was a coronary artery dissection of the RCA. This is written by Brooks Walsh.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

APRIL 24, 2015

He had a history of CAD with CABG. Here was his initial ED ECG: There is atrial fibrillation with a rapid ventricular response. A middle-aged male had a V Fib arrest. He had not complained of any premonitory symptoms (which is very common). There is profound ST depression especially in I, II, V2-V6.

Defibrillator 52

Defibrillator ACS CAD STEMI 52

Dr. Smith's ECG Blog

MAY 28, 2024

ED echo: The left ventricular ejection fraction appears: Severely reduced No pericardial effusion identified. Multivessel CAD 2. Underlying right basilar atelectasis and or infiltrate cannot be excluded. A line predominance, no B lines E-point septal separation 2.24 cm (normal = 0.7 The calculated post stress ejection fraction is 44%.

Coronary 52

Coronary CAD ACS STEMI 52

Dr. Smith's ECG Blog

JUNE 19, 2024

Case An 82 year old man with a history of hypertension presented to the ED with chest pain at 1211. The ED provider ordered a coronary CT scan to assess the patient for CAD. His pain suddenly became much worse in the ED and he became acutely diaphoretic, dizzy, and hypotensive. Another blood pressure was checked.

STEMI 64

STEMI Coronary CAD ED 64

Dr. Smith's ECG Blog

MAY 19, 2020

Diagnosis of MINOCA should be made according to the Fourth Universal Definition of MI, in the absence of obstructive coronary artery disease (CAD) (no lesion ≥50%). The authors recommend using optical coherence tomography or intravascular ultrasound imaging in patients with evidence of nonobstructive CAD by angiogram. myocarditis).

Defibrillator 52

Defibrillator CPR Coronary CAD 52

Dr. Smith's ECG Blog

JANUARY 28, 2018

A man is his late 50’s presents to the ED with 1 hour of post exertional chest pressure associated with diaphoresis and nausea. He has a history of known CAD, diabetes, and dyslipidemia. The ED ECG in the context of the prehospital ECGs was indeed diagnostic of acute coronary occlusion. Leads II, III, aVF show about 0.5

Coronary 52

Coronary STEMI CAD ED 52

Dr. Smith's ECG Blog

JUNE 12, 2017

He had a family history of early CAD and occasional drug and tobacco use. The ECG was alarming to the ED physician who did indeed review it. It is not yet available, but this is your way to get on the list. link] Here is the history: A 30 yo man presented complaining of severe chest pain.

STEMI 52

STEMI CAD Coronary ALS 52

Dr. Smith's ECG Blog

MARCH 20, 2023

Case "Male, 43yo, come to ED with Epigastric Pain started 3 hours ago. Remember: these findings above are included as STEMI equivalent findings in the 2022 ACC Expert Consensus Decision Pathway on ACS Patients in the ED. Since then, I started looking for OMI EKG findings and not just STEMI. Risk Factors: High Cholesterol.

STEMI 52

STEMI ACS CAD ED 52

ACEP Now

APRIL 4, 2024

A 59-year-old male with a past medical history of a repaired ventricular septal defect (VSD), dextrocardia, hypertension, hyperlipidemia, and current smoker presented to the emergency department (ED). This patient had known coronary artery disease (CAD), and previously required drug eluting stents to the obtuse marginal and diagonal arteries.

Coronary 40

Coronary STEMI CAD Emergency Department 40

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. Written by Nathanael Franks MD, reviewed by Meyers, Smith, Grauer, etc.

ACS 89

ACS Coronary ALS CAD 89

Dr. Smith's ECG Blog

MARCH 19, 2023

Concerning history, known CAD" Recorded 2 hours after pain onset: What do you think? To realize — Assessment of ECG #1 is complicated by knowing: i ) That today’s patient has a history of documented CAD ; and , ii ) The lack o f a prior tracing for comparison at the time the initial ECG was interpreted.

STEMI 52

STEMI Coronary CAD OR 52

Dr. Smith's ECG Blog

JANUARY 1, 2013

A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG: Here is the patient's previous ECG: Here is the patient's presenting ED ECG: There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6. There is no ST elevation.

STEMI 52

STEMI ACS CAD Coronary 52

Dr. Smith's ECG Blog

JUNE 18, 2013

This was my thought: if this patient presented to the ED with chest pain, then this is an LAD occlusion. See image below: Slow upstroke, fast downstroke. Asymmetric.

STEMI 52

STEMI Coronary ALS CAD 52

Dr. Smith's ECG Blog

DECEMBER 16, 2018

The case An older woman presented to the ED with dyspnea, diaphoresis, and chest pressure. She had a normal EF, and no significant CAD, and was taking flecainide to suppress the AF. Figure-1: TOP — ECG #1 ( = the initial ECG performed in the ED). The initial ECG: The rhythm is regular at 150, and the QRS is markedly wide.

OR 52

OR ED CAD Overdose 52

Dr. Smith's ECG Blog

JULY 11, 2019

Cardiology was called and the patient was taken for urgent catheterization with the time from ED arrival to cath about 1 hour and 45 minutes. He also had non-acute CAD of the RCA (50%) and LCX (50%). I focus my att ention on the interpretation of the initial ED tracing ( = E CG # 1 in Figure-1 ).

STEMI 52

STEMI ACS CAD ED 52

Dr. Smith's ECG Blog

MAY 10, 2023

CAD-RADS category 1. --No That said — I did not feel the history we were given pointed to any particular diagnosis ( ie, 3 episodes of CP and dyspnea of uncertain duration over the past day — with pain on deep breathing — but with symptoms apparently resolved by the time the patient arrived in the ED ).

Coronary 52

Coronary STEMI CAD ED 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

They found non-obstructive CAD, with only a 20% stenosis of OM2 and 10% RCA. The reason for this is clear — Statistically ( if you take all comers who present to the ED ) — acute coronary syndromes are much more common than acute pericarditis as a cause of new-onset chest pain with ST elevation on ECG. No acute culprit.

E-9-1-1 52

E-9-1-1 ACS Coronary CAD 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

A woman in her 60s with no prior history of CAD presented with 3 hours of sharp, centrally located chest pain with radiation to the anterior neck, with associated nausea. Medics recorded 2 ECGs, one before and one after sublingual NTG, and both are similar to the first ED ECG. Use ED Echo if available 4. Look at aVF.

E-9-1-1 40

E-9-1-1 STEMI Coronary CAD 40

Dr. Smith's ECG Blog

JUNE 20, 2020

A 75 yo with h/o CAD, CABG, and HFrEF presented after a syncopal episode. Of interest Lead I on the initial ECG from the ED = ECG #2 ( which was done a bit after the prehospital ECG #1 was done ) no longer shows this unusual 4-phase QRS deflection in lead I. There was no prodrome and no associated symptoms such as SOB or CP.

STEMI 52

STEMI CAD OR Coronary 52

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. Around 19 hours later, he experienced the same pain, which prompted his presentation to the ED.

ACS 52

ACS STEMI Coronary CAD 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

J Electrocardiol [Internet] 2022;Available from: [link] Cardiology opinion: Takotsubo Cardiomyopathy (EF 30-35%) V Fib Cardiac arrest Prolonged QTC NSTEMI (Smith comment: is it NSTEMI or is it Takotsubo? -- these are entirely different) Moderate single-vessel CAD. I could have told you this (and did tell you this) without an MRI.

Emergency Department 52

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

Dr. Smith's ECG Blog

JULY 31, 2018

She had zero CAD risk factors. The 1st “lesson” is, “All bets are off” — when an adult of any age presents to the ED with new-onset chest discomfort. hours of substernal chest pressure. It was non-radiating and without other associated symptoms except for nausea. Here was her ECG at time zero: What do you think?

Coronary 52

Coronary ACS STEMI OR 52

Dr. Smith's ECG Blog

DECEMBER 29, 2015

Case history A middle-aged woman with a history of HTN, but no prior CAD, presented to the ED with chest pain. There is ST elevation, but also high voltage (though the high voltage is NOT in the leads with worrisome STE, rather, it is in aVL). Is the ST elevation due to LVH? Her vitals signs were remarkable for marked hypertension.

STEMI 40

STEMI Coronary ALS CAD 40

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

The patient was brought directly to the cardiac catheterization lab for PCI, bypassing the ED. As I met the paramedics and cath team in the lab, I was ready to see severe coronary disease (CAD), but the vessels were non-obstructive. Folland ED, et al. In the cath lab, the patient’s blood pressure remained low. De Backer D et al.

Coronary 40

Coronary ACS ALS STEMI 40

Dr. Smith's ECG Blog

JUNE 2, 2023

Despite otherwise normal vital signs, she was appropriately triaged to the critical care area of the ED. They are rare and hard to find in normal practice in the ED. She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? There is mild-moderate tricuspid valve regurgitation.

ED 96

ED OR ALS CAD 96

EMS 12-Lead

APRIL 8, 2022

Furthermore, there was no family history of early CAD, MI, or sudden cardiac death. 1] Here is the admitting ED ECG after cancellation of Code STEMI. The patient continued to verbalize cessation of symptoms while in the ED. He reported to EMS a medical history of GERD only. However, in this context (i.e.

STEMI 130

STEMI ALS Coronary CAD 130

EMS 12-Lead

AUGUST 14, 2022

Otherwise, no admission of CAD, HLD, or family history of sudden cardiac death. The ST changes went overlooked by both the ED physician and the on-call cardiologist, and the patient was subsequently admitted to telemetry. He described the pain as “nagging,” and equally not exacerbated by any kind of movement.

MICU 130

MICU STEMI CAD Coronary 130