Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation.

Cardiac Arrest 85

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 85

Dr. Smith's ECG Blog

JUNE 5, 2024

The ECG does not show any definite signs of ischemia. Uncontrolled coronary spasm may be associated with serious arrhythmias , including cardiac arrest ( Looi et al — Postgrad Med, 2012 ; Tan et al — Eur Heart J Case Rep, 2018 ; Chevalier et al — JACC, 1998 ; Rodriguez-Manero — EP Europace, 2018 ). The below ECG was recorded.

Chest Pain 106

Chest Pain Cardiac Arrest Blog Cardiomyopathy 106

Dr. Smith's ECG Blog

JUNE 21, 2023

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form This EMS ECG was transmitted to the nearby Emergency Department where it was remotely reviewed by a physician, who interpreted it as normal, or at least without any features of ischemia or STEMI.

Chest Pain 95

Chest Pain Cardiac Arrest STEMI Defibrillator 95

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

We periodically review this intriguing ECG finding that is best known for its association with hypothermia — but which may also be seen in association with a number of other entities, including acute infarction and cardiac arrest. My Comment addresses a few additional aspects of this phenomenon.

Cardiac Arrest 132

Cardiac Arrest Blog Atrial Fibrillation AFIB 132

Ken Grauer, MD

DECEMBER 29, 2023

The H ISTORY in T oday's C ASE: The patient in today's case is a teenager who presented to the ED ( E mergency D epartment ) in cardiac arrest after electrocution. Shark Fin" ST segment elevation is most often a sign of severe transmural ischemia that results from acute coronary occlusion.

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Blog Cardiac Arrest Ischemia Hospital 153

Dr. Smith's ECG Blog

JUNE 23, 2024

This was interpreted by the treating clinicians as not showing any evidence of ischemia. He was intubated in the field and sedated upon arrival at the hospital. Here is his presenting ECG: ECG 1, t = 0 What do you think? At first glance, it is easy to dismiss leads V1-V3 due to baseline wander.

Chest Pain 107

Chest Pain Cardiac Arrest Sudden Cardiac Death Stents 107

Ken Grauer, MD

OCTOBER 21, 2023

Subendocardial Ischemia from another Cause ( ie, sustained tachyarrhythmia; cardiac arrest; shock or profound hypotension; GI bleeding; anemia; "sick patient" , etc. ). To EMPHASIZE: This pattern of diffuse Subendocardial Ischemia does not suggest acute coronary occlusion ( ie, it is not the pattern of an acute MI ).

Blog 102

Blog Chest Pain Ischemia STEMI 102

Dr. Smith's ECG Blog

OCTOBER 4, 2010

There is profound LVH with anterolateral ST elevation and reciprocal ST depression in II, III, aVF, and ST depression in V5 and V6 that could all be secondary to LVH or could represent ischemia superimposed on the repolarization abnormalities of LVH: note that wherever there is ST depression, it is associated with a very high voltage R-wave.

Cardiac Arrest 52

Cardiac Arrest Ischemia Stenosis Echocardiogram 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

His response: “subendocardial ischemia. Smith : It should be noted that, in subendocardial ischemia, in contrast to OMI, absence of wall motion abnormality is common. With the history of Afib, CTA abdomen was ordered to r/o mesenteric ischemia vs ischemic colitis vs small bowel obstruction. Anything more on history?

Ischemia 52

Ischemia STEMI Stenosis Coronary Artery Disease 52

EMS 12-Lead

JULY 24, 2023

It should be known that each category can easily manifest the generic subendocardial ischemia pattern. In general, subendocardial ischemia is a consequence of global supply-demand mismatch that usually ameliorates upon addressing, and mitigating, the underlying cause. What’s interesting is that the ECG can only detect ischemia.

Angina 52

Angina Ischemia Coronary Angiogram Stenosis 52

Wellnest

DECEMBER 21, 2022

Cardiac arrest Cardiac arrest is a medical emergency in which the heart stops pumping blood to the body. Electrocardiogram, echocardiogram, and some other tests are done for patients with cardiac arrest. If the vital organs do not get their blood supply back quickly, it can lead to death.

Cardiac Arrest 52

Cardiac Arrest Heart Attack Heart attacks Atrial Fibrillation 52

Dr. Smith's ECG Blog

OCTOBER 23, 2023

Edited by Bracey, Meyers, Grauer, and Smith A 50-something-year-old female with a history of an unknown personality disorder and alcohol use disorder arrived via EMS following cardiac arrest with return of spontaneous circulation. The described rhythm was an irregular, wide complex rhythm.

Tachycardia 120

Tachycardia Cardiac Arrest ICU Blood Pressure 120

Dr. Smith's ECG Blog

DECEMBER 18, 2022

The differential is: Posterolateral OMI or subendocardial ischemia The distinction between posterior OMI and subendocardial ischemia can be important and sometimes difficult. Ischemic ST depression includes posterior OMI and subendocardial ischemia. Her prior ECG on file is shown below: What are your next steps?

Chest Pain 52

Chest Pain Ischemia Aortic Aortic valve 52

Dr. Smith's ECG Blog

JUNE 11, 2021

Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So there is now high pre-test probability + refractory ischemia + Modified Sgarbossa + dynamic ECG changes. VF arrest is of course "electrical instability"! Learning points 1.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

JULY 21, 2024

There is no definite evidence of acute ischemia. (ie, Simply stated — t he patient was having recurrent PMVT without Q Tc prolongation, and without evidence of ongoing transmural ischemia. ( Some residual ischemia in the infarct border might still be present. Both episodes are initiated by an "R-on-T" phenomenon.

Arrhythmia 112

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 112

Dr. Smith's ECG Blog

OCTOBER 8, 2023

Remember, in diffuse subendocardial ischemia with widespread ST-depression there may b e ST-E in lead s aVR and V1. There are well formed R-waves with good voltage/amplitude which is uncommon for ischemia. Smith: This bizarre ECG looks like a post cardiac arrest ECG with probable acidosis or hyperkalemia in addition to OMI.

Ischemia 108

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 108

Ken Grauer, MD

MAY 26, 2023

This ST depression appears to be maximal in leads V3-to-V5 — which could reflect acute posterior OMI ( O cclusion-based M yocardial I nfarction ) — most probably with multi -vessel disease ( ie, diffuse subendocardial ischemia suggested by the ST depression with ST elevation in aVR>V1 ). This patient has new CP — and — he is hypotensive.

Blog 78

Blog Ischemia STEMI Cardiac Arrest 78

Cardiology Update

APRIL 30, 2024

The highly impactful International Study of Comparative Health Effectiveness With Medical and Invasive Approaches ( ISCHEMIA ) trial investigated the effectiveness of invasive (INV) versus conservative (CON) strategies for managing stable coronary artery disease. EuroIntervention. 2024 Mar 5:EIJ-D-24-00011.

Coronary Artery Disease 119

Coronary Artery Disease Ischemia Outcomes Cardiac Arrest 119

DAIC

APRIL 8, 2024

Patients who suffered out-of-hospital cardiac arrest with coma and increased risk of brain damage were excluded from the trial. However, the results also showed significantly higher rates of complications among patients who received the heart pump, including bleeding, limb ischemia, renal replacement therapy and sepsis. “It

Heart Attack 52

Heart Attack Heart attacks Cardiogenic Shock Catheterization Laboratory 52

Dr. Smith's ECG Blog

DECEMBER 23, 2014

None of these findings are diagnostic of ischemia, but they should give you a high index of suspicion and prompt serial ECGs at a minimum. The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Ischemia comes and goes. He was defibrillated. Anterolateral STEMI.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 52

Dr. Smith's ECG Blog

APRIL 29, 2020

A 60-something woman presented after a witnessed cardiac arrest. This is commonly found after epinephrine for cardiac arrest, but could have been pre-existing and a possible contributing factor to cardiac arrest. Final Diagnosis: Cardiac Arrest due to Torsades from long QT of unknown etiology.

Cardiac Arrest 52

Cardiac Arrest Defibrillator Ischemia Tachycardia 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

In terms of ischemia, there is both a signal of subendocardial ischemia (STD max in V5-V6 with reciprocal STE in aVR) AND a signal of transmural infarction of the inferior wall with Q wave and STE in lead III with reciprocal STD in I and aVL. He had multiple cardiac arrests with ROSC regained each time.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

JANUARY 25, 2017

See this post and associated case reports: Cardiac arrest, severe acidosis, and a bizarre ECG The patient was admitted and ruled out for acute MI by serial troponins. Cocaine not only has effects on dopamine neurotransmission, but is also a sodium channel blocker, as are all "-caine" local anesthetics.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

The ECG is diagnostic of LAD occlusion (or even left main occlusion possibly), with the classic pattern of RBBB and LAFB with huge concordant STE in V1-V2, I, and aVL, with reciprocal depression in most other leads (and/or a component of subendocardial ischemia pattern). Plus recommendations from a 5-member panel on cardiac arrest.

Cardiogenic Shock 52

Cardiogenic Shock Chest Pain Tachycardia Ischemia 52

Dr. Smith's ECG Blog

JULY 27, 2023

hours ECG: Not much change hs troponin I peaks at 500 ng/L 8 hours Next morning Urine drug screen: Amphetamine, Methamphetamine, Fentanyl, Fentanyl metabolite Formal Bubble Contrast Echocardiogram: Indications for Study: Silent Ischemia. Conclusion: Type II MI probable due to hypoxia and tachycardia from resp arrest and amphetamine use.

Tachycardia 52

Tachycardia Ischemia Cardiac Arrest Echocardiogram 52

Dr. Smith's ECG Blog

AUGUST 1, 2020

He has done a lot of great work on cardiac arrest, including as co-author of our study on esmolol in refractory cardiac arrest, and much more with Keith Lurie. The Queen was not able to see this one: Of course we do not know for certain that the inferior findings represent ischemia. It was not.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

JANUARY 21, 2023

Occurrence of “J Waves” in 12-Lead ECG as a Marker of Acute Ischemia and Their Cellular Basis. Occurrence of "J waves" in 12-lead ECG as a marker of acute ischemia and their cellular basis. The final letter in the SLOWED mnemonic is " D " for "Dead" ( resulting from VT/VF or asystolic cardiac arrest ).

STEMI 52

STEMI Bradycardia Arrhythmia Cardiac Arrest 52

All About Cardiovascular System and Disorders

OCTOBER 26, 2023

They include myocardial ischemia, acute pericarditis, pulmonary embolism, external compression due to mass over the right ventricular outflow tract region, and metabolic disorders like hyper or hypokalemia and hypercalcemia. These are the conditions which have to be considered or excluded as they can sometimes manifest Brugada pattern on ECG.

Sudden Cardiac Death 52

Sudden Cardiac Death Atrial Fibrillation Electrophysiology Arrhythmia 52

Dr. Smith's ECG Blog

MAY 5, 2023

Common explanations for unusual rhythms such as this one include: i ) Hyperkalemia ( or other severe electrolyte disorder ); ii ) Recent infarction/ischemia; iii ) Sleep apnea; iv ) Severe hypothyroidism; v ) Acute neurologic catastrophe (ie, stroke, bleed, trauma, tumor ); vi ) Some other toxicity.

Bradycardia 52

Bradycardia Cardiac Arrest Arrhythmia Pacemaker 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

He had a previous MI with cardiac arrest 2 years prior. Down-up T-waves in inferior leads are almost always reciprocal to ischemia in the territory underlying aVL. This is not normal and is a tip off that there is posterior ischemia accompanying the ischemia in aVL. This ECG is diagnostic of ischemia.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

MAY 6, 2019

Followup ECG: No Change Absence of evolution is the best evidence against ischemia as the etiology. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada. Ischemia/infarction. Acute febrile illness. Hypothermia.

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

Is there likely to be fixed coronary stenosis that led to demand ischemia during pneumonia? --Was Was the ST elevation due to transient demand ischemia, or is it false positive? Here are three more dramatic cases that illustrate RBBB + LAFB Case 1 of cardiac arrest with unrecognized STEMI, died.

STEMI 52

STEMI Chest Pain Cardiac Arrest Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). In there ECG evidence of possible ongoing ischemia? (ie, IMPRESSION: I’d interpret this tracing as consistent with LVH and/or “strain” and/or ischemia. ie , Is it more than 50-60% likely? ).

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Journal of the American Heart Association

FEBRUARY 27, 2024

We evaluated the primary outcome (cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) and other end points, by sex, in 1168 (22.6%) women and 4011 (77.4%) men. of invasive‐assigned women revascularized versus 81.2% of invasive‐assigned men;P<0.001).

Ischemia 45

Ischemia Coronary Artery Disease Myocardial Infarction Outcomes 45

Dr. Smith's ECG Blog

OCTOBER 25, 2023

A prior ECG was available for comparison: Normal One might be tempted to interpret the ST depression as ischemia, but as Smith says, "when the QT is impossibly long, think of hypokalemia and a U-wave rather than T-wave." Polymorphic Ventricular Tachycardia Long QT Syndrome with Continuously Recurrent Polymorphic VT: Management Cardiac Arrest.

Ischemia 111

Ischemia Chest Pain Cardiac Arrest Blog 111

Dr. Smith's ECG Blog

DECEMBER 15, 2015

There is ST depression beyond the end of the wide QRS in I, II, aVF, and V4-V6, diagnostic of with subendocardial ischemia. First, what kind of arrest was this? It was a PEA or bradyasystolic arrest , not a shockable rhythm. There is either RBBB (see rSR' in V1) or there is a left sided escape rhythm that gives RBBB morphology.

STEMI 52

STEMI Embolism Pulmonary Ultrasound 52

Ken Grauer, MD

APRIL 9, 2023

As discussed in ECG Blog #108 — AIVR generally occurs in one of the following C linical S ettings : i ) As a rhythm during cardiac arrest; ii ) In the monitoring phase of acute MI ( especially with inferior MI ) ; or , iii ) As a reperfusion arrhythmia ( ie, following thrombolysis, acute angioplasty, or spontaneous reperfusion ).

Blog 78

Blog Chest Pain Arrhythmia Cardiac Arrest 78