tag:blogger.com,1999:blog-549949223388475481.post4608387358803862647..comments2024-03-18T03:32:48.613-05:00Comments on Dr. Smith's ECG Blog: How can you persuade your cardiologist to take a Non-STEMI patient to the cath lab emergently?Unknownnoreply@blogger.comBlogger16125tag:blogger.com,1999:blog-549949223388475481.post-61783342694404243302018-10-28T20:03:07.879-05:002018-10-28T20:03:07.879-05:00Wow, great post.Wow, great post.Anonymoushttps://www.blogger.com/profile/16977649527576522763noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-4259309729473348542018-05-04T01:46:55.822-05:002018-05-04T01:46:55.822-05:00Great informationGreat informationCardiologist in Jayanagarhttp://www.primadiagnostics.com/cardiologynoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-31338887702005454352018-04-02T09:14:37.463-05:002018-04-02T09:14:37.463-05:00Diffuse subendocardial ischemia due to LAD occlusi...Diffuse subendocardial ischemia due to LAD occlusion! Not Left Main.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3860378132791609322018-04-01T21:12:05.889-05:002018-04-01T21:12:05.889-05:00Based in these serial ECGs, (prior to cath)would i...Based in these serial ECGs, (prior to cath)would it be reasonable to say that this patient has diffuse subendocardial ischaemia that is probably secondary to left mainstem insuffiency ? Kenhttps://www.blogger.com/profile/17266588380020804028noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-25831583030917416302017-11-23T10:10:12.148-06:002017-11-23T10:10:12.148-06:00Yes, especially now the the ACC/AHA guidelines giv...Yes, especially now the the ACC/AHA guidelines give the go ahead for STE in aVR. See 2013 guidelines.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-5589510912403956402017-11-23T00:55:15.088-06:002017-11-23T00:55:15.088-06:00I'm an ED medical officer working in a hospita...I'm an ED medical officer working in a hospital where cath lab is not available around the clock. In this center in such instance (this patient, presenting off hours), he would've received IV thrombolytic therapy. Moreover he presented within 3 hours of onset. Would IV thrombolytics be an acceptable standard of care when facing recalcitrant cardiologist? (no question if cath lab is not available)Azmanhttps://www.blogger.com/profile/13571191995256771358noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-50499720380504453092017-11-12T04:42:33.364-06:002017-11-12T04:42:33.364-06:00Highly illustrative case by Dr. Smith. I believe t...Highly illustrative case by Dr. Smith. I believe the answer to the question, “How to persuade the Cardiologist to take this patient to cath?” — is that the ED physician has to INSIST that the cardiologist come in and evaluate the patient. Bruce Auerbach’s comment is on right on target. As per Bruce, the chart should document that the cardiology consultant REFUSED to see the patient … It should be obvious from the 1st ECG that a patient with new-onset severe chest pain is having an acute cardiac event — even though this 1st ECG is not yet diagnostic of acute coronary occlusion. The ECG 1 hour later shows dynamic ST-T wave change. This confirms acute evolution in a patient with unrelieved acute chest pain. A call in the middle of the night to the Chief-of-Staff might help “nudge” the on call cardiologist out of bed. This is not an easy situation for the ED physician — but patient care comes first. THANKS to Dr. Smith for his superb ongoing work in this area. By continuing to publish insightful cases such as this — the hope is that eventually this lesson will be learned by those who still refuse to see the light …ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-58135737742513855222017-11-10T13:46:08.119-06:002017-11-10T13:46:08.119-06:00Jackson,
what I'm trying to say is that, yes, ...Jackson,<br />what I'm trying to say is that, yes, activate the cath lab! But none of these meet "criteria."<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-77510803138078240022017-11-08T14:43:21.783-06:002017-11-08T14:43:21.783-06:00Dr. Smith
On EKG's 2 and 3, is there significa...Dr. Smith<br />On EKG's 2 and 3, is there significant enough ST elevation (regardless of the de Winter's) to activate the cath lab for a 1st diagonal or LAD lesion? <br /><br />ie<br />http://rebelem.com/five-ecg-patterns-you-must-know/<br />Jackson Girardeaunoreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-15496381583492552512017-11-07T21:06:08.700-06:002017-11-07T21:06:08.700-06:00Thank you for the clarification!Thank you for the clarification!Anonymoushttps://www.blogger.com/profile/17513846747982914434noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-7916045168918414602017-11-07T16:00:43.861-06:002017-11-07T16:00:43.861-06:00Allen, the typical ST depression vector in diffuse...Allen, the typical ST depression vector in diffuse subendocardial ischemia is towards the apex (II, V5). This makes for slight ST depression, or isoelectric ST segment, in aVL. That aVL is elevating shows that the ischemia in the high lateral wall is becoming transmural.<br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-38647111243305635902017-11-07T15:58:35.250-06:002017-11-07T15:58:35.250-06:00Bruce, This is not an isolated case. Of course, o...Bruce, This is not an isolated case. Of course, off hours is no excuse I'm sure you would agree. 121 of 168 hours in the week are off hours. I communicate every week with at least one emergency physician who can't get his cardiologist to take a patient like this to the cath lab and the cardiologist believes that it is not indicated. That is one reason that 25% of acute total coronary occlusions do not get immediate cath and indeed do not get one until 24 hours. See this meta-analysis published a couple months ago: https://academic.oup.com/eurheartj/article/38/41/3082/4075374<br /><br />What seems obvious to us is not obvious to everyone. Unfortunately.<br /><br />Steve Smith Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-66647298032191395862017-11-07T15:52:24.793-06:002017-11-07T15:52:24.793-06:00You mean de Winters, not de Wellens! de Winters w...You mean de Winters, not de Wellens! de Winters waves look very similar to this and one could say they are an atypical version. Wellens waves are post-ischemic T-wave inversions, totally different!Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-42953247958725594552017-11-07T00:03:50.058-06:002017-11-07T00:03:50.058-06:00Dr. Smith:
Diffuse subendocardial ischemia often p...Dr. Smith:<br />Diffuse subendocardial ischemia often presents as diffuse STD most obvious at lateral leads (I, aVL, V5, V6). Could isoelectric J point at the lead aVL in the first ECG imply that it is about to elevate (since there should be STD at aVL during typical presentation of diffuse subendocardial ischemia)? <br />Allen HsiaoAnonymoushttps://www.blogger.com/profile/17513846747982914434noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-75119613034426115632017-11-06T18:27:11.136-06:002017-11-06T18:27:11.136-06:00I am an interventional cardiologist. Not documente...I am an interventional cardiologist. Not documented, but I presume this was an off hour event. Any moron would look at the data and the ecg and know failure to cath would result in an adverse outcome. The only way to get the recalcitrant cardiologist out of bed, should she resist the call to do her duty, would be for the ER doc to tell her that he was going to document in the chart that she (the cardiologist)was practicing below the standard of care and would be held liable for any adverse event. This is a sleep deprived cardiologist case, not a difficult ECG/clinical case.Anonymoushttps://www.blogger.com/profile/09197943569340057398noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-68207161922034932692017-11-06T10:04:31.246-06:002017-11-06T10:04:31.246-06:00Hello.
Great post thanks
A question... Can we say ...Hello.<br />Great post thanks<br />A question... Can we say that the leads v3 v4 v5 have de wellens waves suggesting LAD occlusion? <br />Thanks. MGhttps://www.blogger.com/profile/06233522417024317416noreply@blogger.com