Dr. Smith's ECG Blog

NOVEMBER 4, 2022

This has been termed a “STEMI equivalent” and included in STEMI guidelines, suggesting this patient should receive dual anti-platelets, heparin and immediate cath lab activation–or thrombolysis in centres where cath lab is not available. aVR ST segment elevation: acute STEMI or not? aVR ST Segment Elevation: Acute STEMI or Not?

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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. On arrival, GCS was 13 and the patient complained of ongoing chest pain.

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Dr. Smith's ECG Blog

JUNE 14, 2017

This case was sent by Dr Avinash Krishnamurthy, a fine emergency medicine resident from Australia Cairns base hospital Case : An adolescent male had a mechanical fall and injured his left shoulder and arm. A bedside cardiac ultrasound was normal. Is there STEMI? His chest was tender. What is it? What is the rhythm?

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Dr. Smith's ECG Blog

APRIL 20, 2018

This is her pre-hospital ECG: This is her first ECG in the ED: What do you think? Given her risk factors (HTN, HLD, ESRD from diabetes) I decided to obtain a broad cardiac workup for the patient: serial ECGs, labs, serial troponins, CXR and bedside cardiac ultrasound. Case A 30 something y.o.

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Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

Important Learning Point: "STEMI" is defined by millimeter criteria (1 mm in limb leads), which this does not meet. Therefore it is not a STEMI. But what we truly care about is coronary occlusion, for which STEMI is just a surrogate that is only about 75% sensitive for occlusion. Some are STEMI-equivalents.

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Ischemia Chest Pain STEMI Stenosis 40

Dr. Smith's ECG Blog

OCTOBER 23, 2022

EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 To, me these look like anterior wall motion abnormality, but I showed them to one of our ultrasound fellows who is very interested in this. She was having a transient STEMI, briefly. She called 911.

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STEMI Chest Pain Hospital Risk Factors 40

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

These kinds of cases were excluded from the study as obvious anterior STEMI. --QTc Case 1 Acute anterior STEMI from LAD occlusion, or Benign Early Repolarization (BER)? Appropriately, the physicians repeated the ECG 20 minutes later and it was diagnostic of anterior STEMI. QTc is the computer measurement. 100% LAD occlusion.

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Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Smith comment: This patient did not have a bedside ultrasound. Had one been done, it would have shown a feature that is apparent on this ultrasound (however, this patient's LV function would not be as good as in this clip): This is recorded with the LV on the right. In fact, bedside ultrasound might even find severe aortic stenosis.

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Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

On arrival, the patient was in shock, was intubated, and had an immediate cardiac ultrasound. What does a heart look like on ultrasound when the EKG looks like that? Here you go: It's not the world's greatest cardiac ultrasound video, but it does appear to show poor function and low volume. They transported to the ED.

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Dr. Smith's ECG Blog

JULY 12, 2020

They informed me that she had just been hospitalized 10 days ago for "some fluid around the heart" and was discharged after one day without incident. So I immediately left the room to get an ultrasound machine. We performed a pericardiocentesis using a triple lumen central line kit under ultrasound guidance in a transthoracic position.

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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. The patient was worked up for abdominal pain with unclear diagnosis, and he was able to be discharged.

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Dr. Smith's ECG Blog

JANUARY 23, 2023

PMID: 34775811; PMCID: PMC9075358 A bedside ultrasound was performed, shown here: Parasternal short axis view demonstrating inferior LV wall motion akinesis Apical 2 chamber view again demonstrating inferior LV wall akinesis The cath lab was not activated based on the ECG and bedside echo. J Am Heart Assoc. 2021 Dec 7;10(23):e022866.

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Chest Pain Blog Stenosis Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 8, 2016

Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. Here is his ED ECG: There is obvious infero-posterior STEMI. What are you worried about in addition to his STEMI? to greatly decrease risk (although in STEMI, the optimal level is about 4.0-4.5 Learning Points: 1.

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Dr. Smith's ECG Blog

JULY 21, 2024

The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. The patient was extubated on Day-3 of the hospital stay. The patient improved, and on Day-11 of the hospital stay — he was off inotropes and on a small dose of a ß-blocker. The below ECG was recorded.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 130

Dr. Smith's ECG Blog

OCTOBER 7, 2019

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. EKG is pictured below: What do you think?

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Bradycardia STEMI Cardiogenic Shock Ischemia 40

Dr. Smith's ECG Blog

OCTOBER 2, 2021

He had been seen several weeks ago at an outside hospital for a similar issue and had been discharged home, presumably after unremarkable workup. After rethinking the case, he remained concerned about ACS and subsequently performed a point-of-care ultrasound in order to evaluate for regional wall motion abnormality. 1] Wereski, R.,

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Dr. Smith's ECG Blog

NOVEMBER 12, 2020

A bedside cardiac ultrasound was normal, with no effusion. 3 studied 416 patients hospitalized with COVID in China, of whom 82 had an initial cTn(I) above the upper reference limit. In a series of 18 patients with COVID and ST elevation, 8 were diagnosed with STEMI, 6 of whom had an angiogram and it showed obstructive coronary disease.

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Dr. Smith's ECG Blog

JUNE 17, 2024

for those of you who do not do Emergency Medicine, ECGs are handed to us without any clinical context) The ECG was read simply as "No STEMI." Given his exertional chest pain and elevated troponin, the patient was admitted to the hospital for "NSTEMI" with a plan for left heart catheterization the next day. Now another, with ultrasound.

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Dr. Smith's ECG Blog

OCTOBER 10, 2022

He spent almost 2 months in the hospital, and reportedly made a full neurologic recovery. Cardiac Ultrasound may be a surprisingly easy way to help make the diagnosis Answer: pulmonary embolism. Now another, with ultrasound. This patient arrested shortly after hospital arrival. He was prescribed apixaban. This is a quiz.

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Dr. Smith's ECG Blog

JANUARY 9, 2023

50% of LAD STEMIs do not have reciprocal findings in inferior leads, and many LAD OMIs instead have STE and/or HATWs in inferior leads instead. The ECG easily meets STEMI criteria in all leads V2-V6, as well. He was then transferred to quaternary care childrens hospital. 24 yo woman with chest pain: Is this STEMI?

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Dr. Smith's ECG Blog

MARCH 17, 2025

Nevertheless, the operator performed intravascular ultrasound and saw erupted calcium nodule consistent with plaque erosion. Limitations of registry data: This patient presented with STEMI (-) OMI and developed STEMI the following day. In the world of STEMI, we are incapable of recognizing the first ECG as a false negative.

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Dr. Smith's ECG Blog

NOVEMBER 19, 2024

These ECGs were texted to me by one of our previous ultrasound fellows, Will Smoot An elderly male arrived via EMS for acute substernal chest pain with radiation to left shoulder and arm that awakened him from sleep at 0030. He took two full strength aspirin prior to EMS arrival. The pain was relieved by one prehospital NTG spray.

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Dr. Smith's ECG Blog

APRIL 13, 2025

They recorded this ECG: Obvious inferior STEMI/OMI What else? Provocative testing is very helpful for this Coronary Thrombus with lysis (one must do optical coherence tomography or at least intravascular ultrasound to find thes non-obstructive plaques that ruptured. He called 911. Medics recorded a BP of 79/52 with pulse of 47.

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Dr. Smith's ECG Blog

MARCH 3, 2025

I suspect pulmonary edema, but we are not given information on presence of B-lines on bedside ultrasound, or CXR findings. Supply-demand mismatch can cause ST Elevation (Type 2 STEMI). Also see these posts of Type II STEMI. Truly, the Marquette 12 SL algorithm correctly identifies this STEMI. Management?

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Tachycardia Pulmonary Chest Pain Stenosis 73

Dr. Smith's ECG Blog

APRIL 9, 2025

The paramedics diagnosis was "Possible Anterolateral STEMI." On arrival in the ED, a bedside ultrasound showed poor LV function (as predicted by the Queen of Hearts) with diffuse B-lines. More proof that a huge STEMI may have normal or near normal initial troponin. I don't know what the device algorithm interpretation stated.

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Defibrillator Cardiac Arrest Myocardial Infarction STEMI 62

Dr. Smith's ECG Blog

DECEMBER 3, 2024

Case continued A bedside cardiac ultrasound revealed grossly preserved left ventricular function, no appreciable wall motion abnormality, pericardial effusion, or obvious valvular abnormality. The terminal part of the T-wave is inverted in lead III, and reciprocally terminally upright in lead aVL.

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