Blog, Dysrhythmia and STEMI - Cardiovascular Update

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

Dr. Smith's ECG Blog

APRIL 8, 2016

Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? Comments: STEMI with hypokalemia, especially with a long QT, puts the patient at very high risk of Torsades or Ventricular fibrillation (see many references, with abstracts, below). There is atrial fibrillation.

STEMI

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia

A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!

Dr. Smith's ECG Blog

DECEMBER 26, 2020

Is this inferor STEMI? Atrial Flutter with Inferior STEMI? Inferolateral ST elevation, vomiting, and elevated troponin The treating team did not identify the flutter waves and they became worried about possible "STEMI" (despite the unusual clinical scenario). The EM provider asked if the cardiologist thought it was a "STEMI."

Atrial Flutter

Atrial Flutter Ischemia STEMI Tachycardia

A man in his 70s with weakness and syncope

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. There were no dysrhythmias on cardiac monitor during observation. So maybe she is better than I am. He was found to be influenza positive. Is there fever again?

Chest Pain

Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia

What is the rhythm? And is there new left bundle branch block (LBBB)?

Dr. Smith's ECG Blog

MAY 27, 2012

In other words, after reperfusion therapy for STEMI, the appearance of AIVR is usually a good sign, meaning that the artery is reperfused. The second explanation (AIVR), whether as a reperfusion dysrhythmia or not, seems most likely. In fact, there may be less than 1 mm of concordant ST depression in lead V3. But it is not conclusive.

Chest Pain

Chest Pain Ischemia Dysrhythmia STEMI

An adolescent with trauma, chest pain, and a wide complex rhythm

Dr. Smith's ECG Blog

JUNE 14, 2017

He has a great blog too: ECG Interpretation He is also well known on the Facebook EKG Club page , where you can learn tons about ECGs: Here is his response, with the first ECG labelled: Hello Steve & Avinash. Is there STEMI? It is commonly seen in the reperfusion setting. Most physicians, at first glance, get this wrong.

Chest Pain

Chest Pain Congenital Heart Disease Article Congenital

Syncope and ST Elevation on the Prehospital ECG

Dr. Smith's ECG Blog

JUNE 20, 2020

The medics were worried about STEMI, as it meets STEMI criteria. He was admitted for monitoring, as his risk of a ventricular dysrhythmia as cause of the syncope is high ( very high due to HFrEF and ischemic cardiomyopathy ). The troponins are NOT consistent with STEMI (OMI), which typically has a troponin I of at least 5 ng/mL.

STEMI

STEMI Hospital Coronary Angiogram Dysrhythmia

Patient with severe DKA, look at the ECG

Dr. Smith's ECG Blog

FEBRUARY 2, 2017

So the real QT is shorter, but the computer does not mention the U-wave, and the U-wave is as important as the T-wave in predicting cardiac dysrhythmias. There is a very prominent U-wave and some of what may appear to be a QT interval is a QU interval. This is an extremely dangerous ECG. The K returned at 1.9 This is extremely low for DKA.

Cardiac Arrest

Cardiac Arrest Dysrhythmia Arrhythmia Nursing

Hyperthermia and ST Elevation

Dr. Smith's ECG Blog

JANUARY 30, 2019

2) The STE in V1 and V2 has an R'-wave and downsloping ST segments, very atypical for STEMI. Cardiology was consulted and they agreed that the EKG had an atypical morphology for STEMI and did not activate the cath lab. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. Bicarb 20, Lactate 4.2,

Heart Rhythm

Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI

Diffuse ST depression, and ST elevation in aVR. Left main, right?

Dr. Smith's ECG Blog

MARCH 2, 2019

Opinions vary widely on the K level at which a patient must be admitted on a monitor because of the risk of ventricular dysrhythmias. My rationale is that if the K is affecting the ECG, then it is affecting the electrical milieu and can result in serious dysrhythmias. Until some real data is available, my opinion is this: 1.

Sickle Cell Disease

Sickle Cell Disease Ischemia Dysrhythmia Chest Pain

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Then there is loss of pulses with continued narrow complex on the monitor ("PEA arrest") Learning Points: Sudden witnessed Cardiac Arrest due to ACS is almost always due to dysrhythmia. He had multiple cardiac arrests with ROSC regained each time.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

An athletic 30-something woman with acute substernal chest pressure

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Now you have ECG and troponin evidence of ischemia, AND ventricular dysrhythmia, which means this is NOT a stable ACS. If you would not have activated the cath lab based on the first ECG, you really should strongly think about it now. Again, cath lab was not activated.

SCAD

SCAD Chest Pain Myocardial Infarction Ischemia

Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5 I could find very little literature on the treatment of severe life-threatening hypokalemia. There is particularly little on how to treat when the K is less than 2, and/or in the presence of acute MI. If the patient is at 1.8, that will raise it to 5.1

Cardiac Arrest

Cardiac Arrest Tachycardia Nursing Ultrasound

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

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.

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

Syncope, chest pain, and inferior ST Elevation with Reciprocal ST depression in aVL

Dr. Smith's ECG Blog

JANUARY 9, 2025

Smith : I recognize this as a STEMI mimic. He was admitted for monitoring and had no dysrhythmias. Although this is not a common phenomenon You will see it on occasion ( See the June 30, 2023 post the November 27, 2023 post and the July 24, 2013 post in Dr. Smith's ECG Blog ). I was not alarmed. She is very good.

Chest Pain

Chest Pain Ischemia Dysrhythmia Arrhythmia

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!

A man in his 70s with weakness and syncope

What is the rhythm? And is there new left bundle branch block (LBBB)?

An adolescent with trauma, chest pain, and a wide complex rhythm

Syncope and ST Elevation on the Prehospital ECG

Patient with severe DKA, look at the ECG

Hyperthermia and ST Elevation

Diffuse ST depression, and ST elevation in aVR. Left main, right?

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

An athletic 30-something woman with acute substernal chest pressure

Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Syncope, chest pain, and inferior ST Elevation with Reciprocal ST depression in aVL

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