Is OMI an ECG Diagnosis?
Written by Jesse McLaren A 70 year old with prior MIs and stents to LAD and RCA presented to the emergency
department with 2 weeks of increasing exertional chest pain radiating to the
left arm, associated with nausea. The pain recurred at rest 90 minutes prior to
presentation, felt like the patient ’s prior MIs, and was not relieved by 6
sprays of nitro. Paramedics provided another 3 sprays of nitro, and 6mg of
morphine, which reduced but did not resolve the pain. What do you think of the ECG, and does it
matter?There ’s normal sinus rhythm, LAFB, old anterior Q waves,
and no diagnostic sign of OMI. I sent th...
Source: Dr. Smith's ECG Blog - April 18, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 40s with 3 days of stuttering chest pain
Written byWilly FrickA man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chest pain. It started while he was at rest after finishing a workout. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It woke him the next day and radiated into his back. He was only able to sleep while sitting in a chair. He went to urgent care and had an ECG (not available) which was interpreted as normal, and was sent home. His pain returned, and he went back to the urgent care but was sent to the ER. His ECG is shown:What do you...
Source: Dr. Smith's ECG Blog - March 13, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
A man in his 30s with chest pain. How was he managed? What if they had used the Queen of Hearts?
Written by Pendell MeyersA man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity. He stated it did not feel like his prior episodes of reflux. Vitals were within normal limits except some hypertension. Triage ECG:And here she explains her assessment:The ECG was read as simply " No ST elevation. " Which is true.The initial high sensitivity troponin I returned at around 3300 ng/L. No repeat E...
Source: Dr. Smith's ECG Blog - January 20, 2024 Category: Cardiology Authors: Pendell Source Type: blogs
A heartfelt plea: the power of emotions in health care
I leaned over the bed’s railing, straining to hear the morphine-slurred words spilling out of his chapped lips. “Make them stop laughing,” he said, referring to the cohort of young nurses giggling around the code cart in the hallway. “I’m in here suffering, in pain, and I shouldn’t have to hear laughter. Tell them to
Read more…
A heartfelt plea: the power of emotions in health care originally appeared in KevinMD.com. (Source: Kevin, M.D. - Medical Weblog)
Source: Kevin, M.D. - Medical Weblog - January 19, 2024 Category: General Medicine Authors: Victoria Goodheart, DO Tags: Physician Emergency Medicine Source Type: blogs
Three normal high sensitivity troponins over 4 hours with a " normal ECG "
Written byWilly FrickA 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of " chest burning. " The documentation does not describe any additional details of the history. The following ECG was obtained.ECG 1What do you think?The ECG shows sinus bradycardia but is otherwise normal. There is TWI in lead III, but this can be seen in normal ECGs. No labs were obtained. The patient was given a prescription for albuterol and a referral to cardiology.Smith comment:No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matt...
Source: Dr. Smith's ECG Blog - January 5, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs
Acute OMI or " Benign " Early Repolarization?
Written by Willy FrickA man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. He described it as severe, sharp, and substernal with associated nausea, vomiting, chills, and diaphoresis. The following ECG was obtained. Note that the machine read is" normal sinus rhythm, normal ECG. " Cardiology over read the tracing and signed the interpretation without modification.ECG 1What do you think?The Queen of Hear...
Source: Dr. Smith's ECG Blog - December 27, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs
Is there OMI on this ECG?
This is a case I had quite a while back. The patient with no prior cardiac history presented in the middle of the night with acute chest pain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. It does not look entirely normal, since there are some nonspecific STT abnormalities, such as flattening of the T waves in aVL. There is a normal amount of ST elevation in the precordial leads. There are no hyperacute T waves. There is no inappropriate ST depression. But it certainly shows no sign of OMI.Or does it?Here is the Queen ' s interpretat...
Source: Dr. Smith's ECG Blog - December 22, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
What are nitazenes? Benzimidazole opioids
Benzimidazole opioids, also commonly known as nitazenes, were first synthesised by CIBA Pharmaceuticals in the 1950s as putative alternatives to morphine and heroin for use as strong painkillers. They have never made it into use in clinical medicine because the risk of addiction, respiratory depression, and death in use is too high.
Etonitazene has hundreds of times the potency of morphine
The compounds are classified as opioid New Psychoactive Substances (opioid NPS). Their mode of action is to bind to the brain’s mu-opioid receptors, but their unique structure means that some examples are several hundred times more...
Source: David Bradley Sciencebase - Songs, Snaps, Science - December 11, 2023 Category: Science Authors: David Bradley Tags: Chemistry Health and Medicine Pharma Source Type: blogs
Occlusion myocardial infarction is a clinical diagnosis
Written by Willy Frick (@Willyhfrick). Willy is a cardiology fellow with a keen interest in the ECG in OMI.A woman in her late 70s presented with left arm pain. The arm pain started the day prior when she was at the dentist ' s office for a root canal. Her systolic blood pressure at the dentist was over 200 mm Hg. She was given nitroglycerin which improved her blood pressure, and she completed the procedure. Her arm pain abated. The pain returned that evening and woke her from sleep. She eventually fell back asleep, and woke up feeling normal the next day (the day of presentation). After dinner the day of presentatio...
Source: Dr. Smith's ECG Blog - December 11, 2023 Category: Cardiology Authors: Willy Frick Source Type: blogs
What is SCAPE in Cardiovascular Medicine?
SCAPE is an acronym for sympathetic crash acute pulmonary edema, which can typcially occur in Pickering syndrome with renal artery stenosis [1]. Another term for transient acute pulmonary edema which occurs in renal artery stenosis is flash pulmonary edema. SCAPE is the extreme end of the spectrum of acute pulmonary edema and needs urgent management in the emergency room [2]. Excessive release of catecholamines may increase the permeability of pulmonary capillaries and facilitate flash pulmonary edema [3]. Endothelial dysfunction secondary to excessive activity of renin-angiotenisn-aldosterone axis, impaired synthesis of ...
Source: Cardiophile MD - November 12, 2023 Category: Cardiology Authors: Johnson Francis Tags: General Cardiology Source Type: blogs
See this " NSTEMI " go unrecognized for what it really is, how it progresses, and what happens
Written by Nathanael Franks MD, reviewed by Meyers, Smith, Grauer, etc.A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. This episode of chest pain began 3 hours ago and was persistent even at rest.Triage ECG at Time = 0: Smith: I am suspicious for posterior OMI due to ST depression in V2 and V3Baseline EKG (several months prior):Smith: Now I am even more suspicious of posterior OMI, as the baseline ECG has normal ST elevation in V2 and V3ECG Interpretation:The tri...
Source: Dr. Smith's ECG Blog - November 3, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall
This is a re-post of an excellent case from 2021. See it again now, along with our new Queen of Hearts functionality. We ' ve come a long way in 2 years! And the pace only quickens.A man in his mid 60s with history of CAD and stents experienced sudden onset epigastric abdominal pain radiating up into his chest at home, waking him from sleep. He called EMS who brought him to the ED. He had active chest pain at the time of triage at 0137 at night, with this triage ECG:What do you think?I sent this ECG, without any text at all, to Dr. Smith, and he replied: " LAD OMI with low certainty. V3 is the one that is convincing. "&nbs...
Source: Dr. Smith's ECG Blog - October 1, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Which patient has the more severe chest pain?
ConclusionOnly a weak association between pre-hospital chest pain severity and markers of myocardial injury was identified, supporting more judicious use of opioid analgesia with a focus on patient comfort.___________This article shows that pain intensity is associated with shorter door to balloon times and thus smaller infarcts. Having severe pain drives people to the ED for faster treatment! It is good to have terrible pain! And as we have shown before, morphine leads to slower times to treatment and worse outcomes.Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Seg...
Source: Dr. Smith's ECG Blog - September 26, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Morphine + OMI is a bad combination
This is written by Magnus Nossen, with some edits by SmithThis ECG diagnosis will be obvious to the majority of the readers of this blog. It is not obvious for the majority of doctors or even cardiologists. A 50 something male was seen in the emergency room due to typical chest pain. The pain had started the same day about two hours prior to medical contact. Previous medical hx notable for type II DM. The first ECG is shown below.The medical care providers ascribed the patient ' s chest pain to new onset atrial fibrillation with rapid ventricular response after having viewed the ECG. Do you agree?The presentation ECG ...
Source: Dr. Smith's ECG Blog - September 24, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Judge for yourself the management of this patient with " NSTEMI, multivessel disease "
DISCUSSION:The administration of
opioid analgesia prior to cath in patients with concern for ACS is associated
with longer door-to-balloon times, and greater peak troponin levels. The rate
of Occlusion MI in those who received pre-cath opioids was double the rate of
those without pre-cath opioids, and STEMI(-) OMI patients who received pre-cath
opioids waited 10 hours on average longer to get cath than those who did not
received opioids. These results add support to our hypothesis that a major
mechanism of harm caused by opioid medications in ACS patients involves delays
to the cath lab for patients with STEMI(-) OMI.=====...
Source: Dr. Smith's ECG Blog - September 10, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
