Tag Archive for: STEMI

Cardiac Arrest, Return of Spontaneous Circulation (ROSC) With No ST-Segment Elevation on ECG. Now What?

15 Dec
December 15, 2016

cardiac-arrestBackground: The American Heart Association/American College of Cardiology (AHA/ACC) give a Class I recommendation for activation of the cardiac catheterization lab in patients with out-of-hospital cardiac arrest (OHCA) whom ST-segment elevation myocardial infarction (STEMI) is present.  The evidence for early cardiac catheterization in patients after cardiac arrest, with ROSC and no STEMI is a bit more controversial.  The most recent 2015 AHA/ACC guidelines recommend, “it may be reasonable,” to perform an emergent cardiac catheterization in select patients without STEMI. Read more →

December 2015 All Cardiology REBELCast

10 Dec
December 10, 2015

REBELCastWelcome to the December 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Cardiology and Critical Care. First of all, we all know that the optimal treatment for STEMI is getting the patient to the cardiac catheterization lab, and time is muscle, but does it help to get patients to the catheterization lab even faster than 90 minutes? Or does speeding up the time have bad outcomes? Secondly, it has been drilled into our heads that high-quality CPR with minimal to no interruptions is key in OHCA.  This gives our patients the best chance of neurologically intact survival.  But a new study just published might beg to differ. So with that introduction today we are going to specifically tackle:

Topic #1: Reducing Door to Balloon (D2B) Times to <90 Minutes in STEMI
Topic #2: Continuous vs Interrupted CPR in OHCA Read more →

R.E.B.E.L. ECG of the Week: Wellens’ Syndrome or STEMI

14 Aug
August 14, 2014

Wellens' Syndrome or STEMI

A 52 year old female with a past medical history of type II diabetes mellitus and tobacco abuse presents with a chief complaint of chest pain.

According to the patient she had about 2 – 3 months of stuttering, substernal chest pain without any radiation.  She described the pain as pressure-like, with activity, but that it would typically resolve after a few minutes of rest.  Today she awoke with substernal chest pain that never resolved and continued in the emergency department.  She quantifies her pain as 7/10 and not relieved with 2L nasal cannula of oxygen, 325mg PO aspirin, and SL NTG x3.

BP 127/89     HR 76     RR 20      O2 sat 100% on 2L NC     Temp 99.3

Awake, A&Ox3, appears uncomfortable
Mild JVD on examination
RRR w/o m/r/g
CTA B
2+ pulses in her extremities, no edema

ECG is shown (No prior ECG for comparison)…..

Read more →

R.E.B.E.L. ECG of the Week: LBBB and STEMI

09 Jun
June 9, 2014

R.E.B.E.L. ECG of the Week

89 year old male with PMH of hypertension, stage 3 chronic kidney disease with chief complaint of shortness of breath. Several days ago patient had a laminectomy for radicular pain. He was doing fine post-operatively and began to develop gradual shortness of breath.  He had no complaints of chest pain, nausea/vomiting, fevers, diaphoresis, but did have some weakness.  There were no prior ECGs for comparison.

BP: 98/48 HR: 103 RR: 18 O2 on RA: 94% Temp: 38.6

JVD to the angle of the mandible
Bibasilar Crackles
Sinus Tachycardia
Bilateral lower extremity pitting edema

Labs: Na 125, K+ 4.2, Creatinine 2, BNP > 2500

ECG from triage is shown… Read more →

R.E.B.E.L. ECG of the Week #6

12 Dec
December 12, 2013

R.E.B.E.L. EM ECG of the Week #6The case from this week is from one of the PGY-1 residents at University of Texas Health Science Center at San Antonio (UTHSCSA).  Several of the details of the case have been changed to keep patient information confidential.

53 year old female with a past medical history of hypertension, hyperlipidemia, coronary artery disease, and 3 anterior myocardial infarctions s/p 4-vessel CABG (LIMA-LAD, RIMA-RCA, SVG-D1-OM1 sequentially) 9 months ago who presents with intermittent 10/10 chest pain that radiates to his left arm for the past 6 months. The chest pain is associated with nausea and shortness of breath but denies diaphoresis or syncope. Patient reports that the pain is the same as his index chest pain and is both exertional and non-exertional and will often wake him up from sleep. The pain can last 5-10 minutes and is always relieved by rest. The patient reports good medication compliance (on metoprolol, atorvastatin, enalapril, amlodipine, aspirin). He presented with similar symptoms 3 months ago but left against medical advice before a work-up could be performed. Now he presents with increasing frequency of chest pain.

BP 152/105  HR 86 RR 16 O2 sat 99% on RA   Temp 98.0

ECG from triage is shown… Read more →

Modified Sgarbossa Criteria: Ready for Primetime?

03 Dec
December 3, 2013

Modified Sgarbossa CriteriaThe recognition of ST-segment elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult and frustrating to both emergency medicine physicians and cardiologists.  According to the 2004 STEMI guidelines, emergent reperfusion therapy was recommended to patients with suspected ischemia and new LBBB however, the new 2013 STEMI guidelines made a drastic change by removing this recommendation.  Several papers have recently been published discussing a modified Sgarbossa’s criteria and a new algorithm to help decrease false cath lab activation and/or fibrinolytic therapy but, are they ready for primetime? Read more →

R.E.B.E.L. ECG of the Week #2

11 Nov
November 11, 2013

R.E.B.E.L. EM ECG of the Week #258 year old female with chief complaint of chest pain x2hours with PMH of type 2 diabetes mellitus, Hyperlipidemia, and hypertension.    She is brought in via EMS still having active chest pain.

BP: 102/88  HR: 82  RR: 24  O2 Sat on 2L: 99%  Temp 99.0

ECG obtained at arrival is shown…

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The Importance of Reciprocal Changes in aVL

01 Nov
November 1, 2013

Reciprocal Change in aVLECG interpretation is one of the most important skills to master as an emergency  physician, and its interpretation can be very complex and frustrating. ECG manifestations can be very subtle, and sometimes the earliest and only ECG change seen will be reciprocal changes alone. To further complicate this, many patients have the atypical symptoms of nausea/vomiting, weakness, or shortness of breath and not chest pain.

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