Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mass delusion (and Opiate pain relief).
I received the following text message with these 3 EKGs (providers text me ECGs all day every day; most are false positives; many are subtle true positives):" Hi Steve, here are 3 EKGs for you (my colleague ' s case). A 67 yo f developed chest pain this morning. "EKG #1Followed 15 minutes by this #2 EKG:Then the patient received aspirin andDilaudid (hydromorphone, same effect as morphine) and the pain went away and there was this 3rd ECG:Smith comment: hydromorphone will make any pain go away (or improve) without any improvement in the underlying pathology. Do NOT give it unless you are committed to t...
Source: Dr. Smith's ECG Blog - May 31, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his early 40s with chest pain a " normal ECG " by computer algorithm. Should we avoid interrupting a physician to interpret his ECG?
This study looked at less than 1000 cases, which is not nearly enough (see below for analysis) and they used cardiologists as the gold standard (a very poor gold standard), NOT presence or absence of Occlusion MI (which we have done in all of our ECG studies, and must be ascertained by 1) TIMI 0/2 flow on angiogram or 2) culprit + TIMI 3 flow and very high troponin. So this study is worthless and must be ignored. I have here 38 cases of " Computer Normal " ECGs which were critically abnormal and the vast majority are missed acute coronary occlusions (Missed Acute OMI) and most were recognized ...
Source: Dr. Smith's ECG Blog - May 23, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Can Radial Artery be Used as Conduit for CABG After Transradial Coronary Angiography?
Radial artery is being increasingly used as a conduit for coronary artery bypass grafting in multi-vessel coronary artery disease as it provides superior long term patency rates compared to saphenous vein grafts [1]. Radial artery is also increasingly being used as access point for coronary angiography and percutaneous coronary interventions. Concerns have been raised regarding the use of radial artery as conduit after transradial procedures as there is likelihood of vascular trauma during the procedures.
Some authors even mention that prior transradial catheterization is a contraindication for the use of radial artery fo...
Source: Cardiophile MD - May 8, 2023 Category: Cardiology Authors: Johnson Francis Tags: Angiography and Interventions Cardiac Surgery Coronary Interventions General Cardiology Source Type: blogs
A 20-something with intermittent then acute chest pain
This was sent to me by a partner:" Curious what you think of this one we had overnight. Healthy male under 25 years old with a pretty good story for acute onset crushing chest pain relieved with nitro. He had another episode the day before after exerting himself. No pericardial effusion on ultrasound. "What do you think?First, many on Twitter said " Pericarditis " . This is NOT pericarditis, which virtually NEVER has ST depression any where except aVR. When there is ST depression (as in aVL, V2, V3), then top on the differential is OMI or myocarditis.See our publication: ST depression in ...
Source: Dr. Smith's ECG Blog - April 25, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Off and on chest pain for 24 hours in a 50s year old man
Submitted by Ali Khan MD and James Mantas MD, MS, written by Pendell MeyersA man in his 50s with history of diabetes, hypertension, and tobacco use presented to the ED with 24 hours of worsening left sided chest pain radiating to the back, characterized as squeezing and pinching, associated with shortness of breath. His pain was initially mild, then became severely worse several hours prior to presentation, but then eased off again and was minimal on arrival. There was no associated diaphoresis, nausea, vomiting, arm pain, jaw pain, syncope, lightheadedness or other acute symptoms.Initial vitals: Temp 36.7 C, BP 161/79, RR...
Source: Dr. Smith's ECG Blog - April 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
70-year-old with acute chest pain, STEMI negative: just an old infarct?
Submitted by Dr. Dennis Cho (@DennisCho),
written by Jesse McLaren A 70-year-old with no cardiac history
presented with 2 hours of chest pain radiating to the neck, associated with
shortness of breath. What do you think?There ’s normal sinus rhythm, first-degree
AV block, normal axis and voltages. R wave progression is abnormal: there are Q
waves in aVL/V2-3 and loss of R wave in V2. This is accompanied by minimal ST
elevation in aVL/V1-V2 and more pronounced inferior reciprocal ST depression, and minimal ST depression V5-6.
This is diagnostic of OMI, either proximal LAD or first diagonal. Q wave, old
infarct?B...
Source: Dr. Smith's ECG Blog - April 4, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 40s with epigastric pain and ST Elevation
Case submitted by Magnus Nossen MD, written by Pendell MeyersA previously healthy man in his 40s presented to the ED with epigastric abdominal pain off and on for several days. Vitals were within normal limits.It is unclear whether he had active pain at the time of the first ECG:What do you think?Here is PM Cardio ' s Queen of Hearts interpretation (AI ECG interpretation trained by Meyers, Smith, and PM Cardio team using thousands of cases and their outcomes):The output number ranges from 0 to 1, with numbers closer to zero meaning likely NOT OMI, and numbers closer to 1 meaning OMI. This result of 0.0002 is obviousl...
Source: Dr. Smith's ECG Blog - February 23, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Dueling OMI: does this 30 year old with chest pain have any signs of occlusion or reperfusion?
Written by Jesse McLaren, with edits from Smith A 30 year old with a history of diabetes presented with two days of intermittent chest pain and diaphoresis, which recurred two hours prior to presentation. Below is ECG #1 at triage. Are there any signs of occlusion or reperfusion?There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression and normal voltages. There’s mild inferior ST elevation in III that doesn’t meet STEMI criteria, but it’s associated with ST depression in aVL and V2 that makes itdiagnostic of infero-posterior Occlusion MI (from either RCA or circumflex) – accomp...
Source: Dr. Smith's ECG Blog - January 29, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Chest pain, and Cardiology didn't take the hint from the ICD
Submitted and written by Megan Lieb, DO with edits by Bracey, Smith, Meyers, and GrauerA 50-ish year old man with ICD presented to the emergency department with substernal chest pain for 3 hours prior to arrival. The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG:What do you think?Triage physician interpretation: -sinus bradycardia-lateral ST depressionsWhile there are lateral ST depressions (V5, V6) the deepest ST depressions are in V4. Additionally, lead V3 has ST depressions, which are always abnormal (recall that lead V3 will haveST elevation under nor...
Source: Dr. Smith's ECG Blog - January 23, 2023 Category: Cardiology Authors: Bracey Source Type: blogs
A teenager with chest pain, a troponin below the limit of detection, and " benign early repolarization "
Sent by anonymous, written by Pendell MeyersA male in his teens presented with complaints of chest discomfort and dyspnea beginning while exercising but without obvious injury. He immediately stopped exercising and symptoms started to improve. Later that evening he felt recurrent central chest discomfort, shortness of breath, and vomited. Symptoms have been constant since this second episode, and are still present on arrival, which seems to have been less than 1 to 2 hours from onset of symptoms. No similar symptoms in the past. No prior exertional complaints of chest pain, dizziness, lightheadedness, or undue shortness of...
Source: Dr. Smith's ECG Blog - January 9, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A woman in her 50s with acute chest pain
Submitted and written by Anonymous, edits by Meyers and SmithA 50s-year-old patient with no known cardiac history presented at 0045 with three hours of unrelenting central chest pain. The pain was heavy, radiated to her jaw with an associated headache.Triage VS: 135/65 mmHg, 95 bpm, 94% on room air, 16/min, 98.6 FTriage ECG:ECG Interpretation:Sinus rhythm with normal QRS. There is slight STE in V1, V2, and aVR, with STD in V3-V6, I, aVL, and II. There are T waves in lead III which are suspicious for hyperacute T waves, with reciprocal negative large T wave inversions in aVL. I do not think this ECG is by itself diagnostico...
Source: Dr. Smith's ECG Blog - January 6, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Syncope, hypotension, vomiting and diaphoresis in a 60-something male with Diabetes and Hypertension
I was texted this ECG by one of my partners, with the following history: A 60-something male with diabetes and HTN presented with syncope. Per EMS report, the patient had a syncopal episode at work. On medics arrival, patient noted to be pale and diaphoretic, SBPs 60-80s, complaining of nausea and had one episode of emesis en route, possible hematemesis. There was no chest discomfort, though the patient was non-English speaking and reportedly " stoic " .What do you think?This was my response, in quotes: " I have a sneaking suspicion that this is a mimic. Tough one! &n...
Source: Dr. Smith's ECG Blog - December 6, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
65 year old with syncope and a'normal' ECG: discharge home?
A 65 year old with diabetes presented with a syncopal episode while sitting, associated with weakness but no chest pain or shortness of breath. Vital signs were normal and first ECG was labeled as normal by the computer and confirmed by the treating emergency physician and cardiology over-read. What do you think? There ’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression, and normal voltages with J waves from early repolarization. There ' s inferior down-up ST segments and hyperacute T waves, with reciprocal up-down T wave in aVL. I sent this " normal " ECG without any informa...
Source: Dr. Smith's ECG Blog - December 6, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
December 2022: Which is Best? Manual or Drill for IO Access in Neonates
Intraosseous (IO) vascular access use in children began in the 1940s, but the practice was abandoned when intravenous catheters were invented. A resurgence of interest in IO access began decades later, and the procedure was first added to the Pediatric Advanced Life Support guidelines in 1986. Intraosseous access has now become the preferred access method over central line placement and for peripheral IV access that takes longer than 30 seconds.Initially, manual intraosseous needles were used for neonatal resuscitations because they were the only tools available. Once we learned the skill, manual IO needles served their pu...
Source: M2E Too! Mellick's Multimedia EduBlog - November 30, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Upon arrival to the emergency department, a senior emergency physician looked at the ECG and said " Nothing too exciting. "
This article fails to specify whether it was troponin I or T, but I contacted the institution and they used exclusively troponin I during that time period.Reference on Troponins: Xenogiannis I, Vemmou E, Nikolakopoulos I, et al. The impact of ST-segment elevation on the prognosis of patients with Takotsubo cardiomyopathy. J Electrocardiol [Internet] 2022;Available from: http://dx.doi.org/10.1016/j.jelectrocard.2022.09.009Cardiology opinion: Takotsubo Cardiomyopathy (EF 30-35%)V Fib Cardiac arrestProlonged QTCNSTEMI (Smith comment: is it NSTEMI or is it Takotsubo? -- these are entirely different)Moderate sin...
Source: Dr. Smith's ECG Blog - November 30, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
