Dr. Smith's ECG Blog

DECEMBER 18, 2022

Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, Smith A woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. Bedside ultrasound is another very important piece. Do you activate the Cath Lab?

Chest Pain 40

Chest Pain Ischemia Aortic Aortic valve 40

Dr. Smith's ECG Blog

JANUARY 9, 2023

No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of breath. He denied headache or neck pain associated with exertion. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. 24 yo woman with chest pain: Is this STEMI?

Chest Pain 52

Chest Pain Aneurysm STEMI Thrombosis 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. At this time he reported ongoing chest pain and was given aspirin and nitroglycerin. J Am Heart Assoc.

Chest Pain 52

Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

MARCH 26, 2024

There is also STE in lead III with reciprocal depression in aVL and I, as well as some subendocardial ischemia pattern with STD in V5-V6 and STE in aVR. Aslanger's is a combination of acute inferior OMI plus subendocardial ischemia, and due to the ischemia vectors , it has STE only in lead III. Now another, with ultrasound.

Chest Pain 69

Chest Pain Embolism Pulmonary Ischemia 69

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Submitted by Benjamin Garbus, MD with edits by Bracey, Meyers, and Smith A man in his early 30s presented to the ED with chest pain described as an “explosion" of left chest pressure. Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Triage EKG: What do you think?

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 24, 2013

There is no way to tell the difference between GI etiology of chest pain and MI. Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia. Could this have been avoided? Lesson : 1.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

AUGUST 3, 2018

In the evening, a middle-aged man complained of chest pain at the nursing home. His chest pain was vague. He mentioned "cancer" and "chest". Here was his prehospital ECG, which I viewed immediately while the resident performed cardiac ultrasound: What do you think? Fluids were started. Is is sinus?

Chest Pain 40

Chest Pain Tachycardia Atrial Flutter Ultrasound 40

Dr. Smith's ECG Blog

JANUARY 4, 2021

An ECG was recorded during pain: What do you think? This suggests diffuse subendocardial ischemia. However, along with that subendocardial ischemia, there is also STE in lead III with reciprocal ST depression in aVL, and some STE in V1. These suggest inferior OMI with possible RV involvement. with ADDED STE in III?

Ischemia 40

Ischemia Pulmonary STEMI Chest Pain 40

Dr. Smith's ECG Blog

MAY 13, 2020

A 60-something man presented by EMS with 5 hours of fairly typical sounding substernal chest pain. Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS.

Echocardiogram 52

Echocardiogram Ischemia Chest Pain Blog 52

Dr. Smith's ECG Blog

JUNE 11, 2021

Jesse McLaren (@ECGcases), of Emergency Medicine Cases Reviewed by Pendell Meyers and Steve Smith An 85yo with a history of hypertension developed chest pain and collapsed, and had bystander CPR. On arrival, GCS was 13 and the patient complained of ongoing chest pain. Vitals were HR 58 BP 167/70 R20 sat 96%.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. Smith comment: This patient did not have a bedside ultrasound. The paramedic’s initial impression of the patient was that he was critically ill.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Written by Pendell Meyers and Peter Brooks MD A man in his 30s with no known past medical history was reported to suddenly experience chest pain and shortness of breath at home in front of his family. Thus, this apparently is Aslanger's Pattern (inferior OMI with single lead STE in lead III, with simultaneous subendocardial ischemia).

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

APRIL 26, 2017

There was no chest pain or SOB at the tim of the ECG: Computerized QTc is 464 ms A previous ECG from 8 years prior was normal. My opinion was that it was not a cath lab case, but I did suggest they do a bedside ultrasound to look for an anterior wall motion abnormality. I had not seen the cardiac ultrasounds at this time.

Chest Pain 52

Chest Pain STEMI Ultrasound Pulmonary 52

Dr. Smith's ECG Blog

APRIL 24, 2020

A middle aged man had off and on chest pain for 2 weeks, then 2 hours of more severe and constant pain. Contrary to what Ken stated, the ST vector remains mostly posterior __ What about subendocardial ischemia? Similarly, STD in aVL is usually reciprocal to inferior ST elevation, not "lateral ischemia."

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

DECEMBER 6, 2010

He had no previous history of CAD, and presented with very typical waxing and waning chest pain, much worse with exertion but also present at rest and on presentation, though his pain was minimal at the time of the ECG. I saw this 59 year old male 3 weeks ago. Blood pressure was 150/80.

STEMI 52

STEMI Chest Pain Ultrasound Blood Pressure 52

Dr. Smith's ECG Blog

JUNE 27, 2021

A 50-something man with history only of alcohol abuse and hypertension (not on meds) presented with sudden left chest pain, sharp, radiating down left arm, cramping, that waxes and wanes but never goes completely away. A bedside ultrasound was done, with dozens of clips, and was even done with Speckle Tracking.

Myocardial Infarction 40

Myocardial Infarction Ischemia STEMI Pulmonary 40

Dr. Smith's ECG Blog

OCTOBER 26, 2010

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. He presented to the Emergency Department with a blood pressure of 111/66 and a pulse of 117. He had this ECG recorded.

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 52

Dr. Smith's ECG Blog

JUNE 28, 2023

He arrived in the ED and had an immediate bedside cardiac ultrasound while this ECG was being recorded. The bedside ultrasound (video not available) reportedly showed only a slightly reduced LV function. The patient was given 6mg, then 12 mg, of adenosine, without a change in the rhythm. Here is the ECG: What do you think?

Tachycardia 98

Tachycardia Ultrasound Heart Disease Atrial Fibrillation 98

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. There is no definite evidence of acute ischemia. (ie, The below ECG was recorded.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

DAIC

FEBRUARY 29, 2024

ET Main Tent (Hall B1) This session offers more insights from key clinical trials presented at ACC.24 24 and find out what it all means for your patients.

Aortic valve 103

Aortic valve Myocardial Infarction Aortic Blood Pressure 103

Dr. Smith's ECG Blog

JUNE 18, 2011

3 hours prior to calling 911 he developed typical chest pain. 1.196 x STE60 in V3 in mm) + (0.059 x computerized QTc) - (0.326 x RA in V4 in mm) Third, one can do an immediate cardiac ultrasound. Medics gave him nitroglycerine sublingual and his pain resolved. greater than 23.4 is likely anterior STEMI).

STEMI 52

STEMI Pericarditis Hospital Aneurysm 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. His response: “subendocardial ischemia. Anything more on history? J Electrocardiol 2013;46:240-8 2.

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

A 70-something female with no previous cardiac history presented with acute chest pain. She awoke from sleep last night around 4:45 AM (3 hours prior to arrival) with pain that originated in her mid back. She stated the pain was achy/crampy. Over the course of the next hour, this pain turned into a pressure in her chest.

Coronary Angiogram 109

Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Case A 47 year old male called 911 for severe chest pain. 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 40

Ischemia Chest Pain STEMI Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. Normally, concavity in ST segments suggests absence of anterior ischemia (though concavity by itself is not reassuring - see this study ). Later on during the night of his admission he had a short episode of chest pain that resolved with sublingual nitroglycerin. His vitals were initially normal.

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

This is the initial ED ECG of a 46 year old male with chest pain: The QTc was 420 ST Elevation at 60 ms after the J-point in lead V3 = 2.5 ng/ml) A 45 year old male called 911 for chest pain: The QTc was 400 ST Elevation at 60 ms after the J-point in lead V3 = 3.5 100% LAD occlusion. He underwent CABG. QRS V2 = 15.5

Chest Pain 52

Chest Pain STEMI Bradycardia Stenosis 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. On medic arrival, she walked out of the house in no distress, but was diaphoretic.

Plaque 52

Plaque Chest Pain Thrombosis Stenosis 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

Case 3 : Male in 30's with chest pain, cough, and fever. A bedside ultrasound was done by the emergency physician, using Speckle Tracking. 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?

STEMI 40

STEMI Chest Pain Cardiac Arrest Stents 40

Dr. Smith's ECG Blog

JUNE 20, 2018

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. She was reportedly "pacing in her room while holding her chest". The source of this case is anonymous. TnI peaked at 67.10

Pericarditis 52

Pericarditis Chest Pain Blog Ultrasound 52

Dr. Smith's ECG Blog

FEBRUARY 6, 2020

male with a history of HTN and ETOH developed squeezing epigastric abdominal pain with associated vomiting and diaphoresis, followed by a syncopal episode which lasted about 10 seconds. When medics arrived, he denied any chest pain, shortness of breath, or palpitations prior to the syncopal episode.

Chest Pain 40

Chest Pain Ischemia Angina Electrocardiogram 40

Dr. Smith's ECG Blog

APRIL 3, 2019

History : An extremely elderly patient who lived independently presented with acute "oppressive" chest pain 7/10 in severity that was not positional, pleuritic, or reproducible. These ultrasounds confirm LAD occlusion. Pain will resolve with completed infarct or with resolution of ischemia. What's the story?"

STEMI 40

STEMI Chest Pain Ischemia Aneurysm 40

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

Dr. Nossen performed a bedside ultrasound which was interpreted as normal. Learning Points: Ectopic atrial rhythm can produce atrial repolarization findings that can be confused for acute ischemia, STEMI, or OMI.

Blog 52

Blog Bradycardia Ischemia Exercise 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? A bedside cardiac ultrasound was performed with a parasternal long axis view demonstrated below: There is a large pericardial effusion with collapse of the right ventricle during systole. She has already had syncope.

Tachycardia 40

Tachycardia Pericarditis Ultrasound Blood Pressure 40

Dr. Smith's ECG Blog

OCTOBER 24, 2018

This was diagnosed by IVUS (intravascular ultrasound) as a ruptured plaque. This was clearly severe subepicardial ischemia causing ST Elevation, but it was not of a long enough duration to result in measurable infarct. Values: STE60V3 = 2.0, QRS V2 = 10, RAV4 = 15.5, QTc = 377 by computer 4-variable formula value = 16.2, But maybe not.

STEMI 40

STEMI Angina Myocardial Infarction Plaque 40

Dr. Smith's ECG Blog

MARCH 15, 2023

She did notice something slightly wrong subjectively, but had no palpitations, chest pain, or SOB, or any other symptom. Her bedside cardiac ultrasound was normal We decided to cardiovert her since the time of onset was very recent. Her Apple Watch suddenly told her that she is in atrial fibrillation. She was on no medications.

Atrial Fibrillation 52

Atrial Fibrillation AFIB Arrhythmia Exercise 52

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. I have read articles that say that patients without ischemia are at low risk of complications from hypokalemia, But it is not entirely without risk.

STEMI 52

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia 52

Dr. Smith's ECG Blog

JANUARY 28, 2012

A middle aged patient who was 3 weeks s/p STEMI came from cardiac rehab where he developed some chest pain, dyspnea and weakness on the treadmill. In the ED he had some continued chest pain and hypotension. 5 of 6 presented with chest pain and an ECG indicating reperfusion therapy, but were detected by bedside ultrasound.

Chest Pain 40

Chest Pain STEMI Pericarditis Ultrasound 40