Cardiac Arrest at the airport, with an easy but important ECG for everyone to recognize

 Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR interval. Some learners might be worried about VT initially, if they do not recognize the QRS. Instead it is RBBB and LAFB. There is striking concordant STE in V2-V4 that is easy and unmistakable in this case, but often times is much harder to recognize when the J point is not quite as pronounced as it is in this case (see harder cases below).This pattern is one of the highest risk OMI patterns recordable on an ECG: it is large proximal LAD occlusion until proven otherwise. The LAD supplies the anterior septum where the right bundle branch and left anterior fascicle are located. Acute proximal LAD occlusion can cause ischemia of these fascicles causing the combination of RBBB and LAFB. See below for review and references.The cath lab was activated, and the patient fortunately suffered no further arrests. She was of course found to have an ostial LAD occlusion t...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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 Written by Pendell MeyersEvery once in a while we need to go back and cover some easy but important ECGs.This will be far too easy for most readers of this blog, so please go find a learner and show them this case. Make sure they understand this case well, so that they will be able to learn from the harder versions of this case.A middle aged female suffered sudden witnessed cardiac arrest at the airport, with quick bystander CPR.EMS arrived and found her in VF. She was successfully defibrillated.Her EMS ECG on the way to the ED was sent to us:What do you think?There is likely sinus tachycardia with a prolonged PR int...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This ECG was texted to me with no other information:Computer Diagnosis:SINUS TACHYCARDIAINCOMPLETE RIGHT BUNDLE BRANCH BLOCK [90+ ms QRS DURATION,TERMINAL R IN V1/V2, 40+ ms S IN I/aVL/V4/V5/V6]LEFT ANTERIOR FASCICULAR BLOCK [QRS AXIS
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
This is written by Brooks Walsh.https://twitter.com/BrooksWalshA 30 year-old woman was brought to the ED with chest pain.It had started just after nursing her newborn, about an hour prior, and she described it as a severe non-pleuritic “pressure” radiating to the back.She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying " I'm just an anxious person. "A CXR and a CTA for PE were normal.The ECGsAn initial ECG was obtained as the pain was rapidly resolving:Minimal upsloping ST Elevation in III, with a steeply biphasic...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Conclusions When high sensitivity cardiac troponin testing is performed widely or without previous clinical assessment, elevated troponin concentrations are common and predominantly reflect myocardial injury rather than myocardial infarction. These observations highlight how selection of patients for cardiac troponin testing varies across healthcare settings and markedly influences the positive predictive value for a diagnosis of myocardial infarction.-----------------------------------------------------------Comment by KEN GRAUER, MD (2/5/2019):-----------------------------------------------------------Exce...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A 60-something presented with hypotension, bradycardia, chest pain and back pain.She had a h/o aortic aneurysm, aortic insufficiency, peripheral vascular disease, and hypertension.  She had a mechanical aortic valve.  She was on anti-hypertensives including atenolol, and on coumadin, with an INR of 2.3. She was ill appearing.  BP was 70/49, pulse 60.A bedside echo showed good ejection fraction and normal right ventricle and no pericardial fluid. Here is the initial ECG:What do you think?This ECG actually looks like a left main occlusion (which rarely presents to the ED alive):  ST Elevation in...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
One of our graduates, Rochelle Zarzar, who is now an education fellow, sent me this from one of the hospitals she works at now:An elderly woman presented with chest pain.  She had been nauseous the night before and did not feel well, then awoke 2 hours prior with chest pain.She had had a completely normal angiogram 3 months prior.Here is that angiogram report:The left main coronary artery is normal.Left anterior descending is a type 3 vessel and is normal.Left circumflex is nondominant and normal.The right coronary artery is dominant and normal.The nurses immediately recorded an ECG.  This was 2 hours after the o...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Rationale: Left main shock syndrome (LMSS) induced by thrombosed coronary artery dissection is very rare and has a fatal prognosis. Optimal treatment strategy includes early reperfusion and hemodynamic support to prevent cardiogenic shock. However, it involves the extension of technical difficulties under different conditions. Patient concerns: A 49-year-old woman developed symptoms of left main shock syndrome. The main clinical manifestations were retrosternal pain radiating to his back and left shoulder, heavy sweating, palpitation and brachypnea. Diagnoses: Acute anterioseptal myocardial infarction (Killip Class...
Source: Medicine - Category: Internal Medicine Tags: Research Article: Clinical Case Report Source Type: research
Discussion, we all know why they performed this study, what they expected it to show, and how it will be cited for years to come. It demonstrates an association between morphine and worse outcomes in patients with ST-elevation acute myocardial infarction (STEMI). I don’t know why everyone has been ganging up on poor old morphine for acute coronary syndrome (ACS)—maybe because it’s been beloved by so many for so long—but while I may not be able to empathize with the hardships of being popular, I sympathize with the hate it’s been receiving and hope to offer some exculpation.   How did we g...
Source: EMS 12-Lead - Category: Cardiology Authors: Tags: Original Articles Vince DiGiulio Source Type: research
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