1 00:00:00,276 --> 00:00:04,420 T.R. Eckler (2): That was the deepest most heavy section we have ever done 2 00:00:04,420 --> 00:00:08,740 on the podcast And if you can just get that from this you're gonna be 3 00:00:08,740 --> 00:00:12,820 the greatest emergency doctor and you will really be carrying water in 4 00:00:12,820 --> 00:00:15,100 your pale for your cardiology folks 5 00:00:21,056 --> 00:00:23,816 Sam : Hi everyone, and welcome to another episode of EMPlify 6 00:00:23,816 --> 00:00:25,326 I'm your host, Sam Ashoo. 7 00:00:25,606 --> 00:00:29,556 Before we dive into this month's episode, I want to say thank you for joining us. 8 00:00:29,606 --> 00:00:33,146 I sincerely hope that you find it to be helpful and informative for your 9 00:00:33,146 --> 00:00:37,576 clinical practice, and I want to remind you that you can go to ebmedicine.net 10 00:00:37,646 --> 00:00:41,796 where you will find our three journals, Emergency Medicine Practice, Pediatric 11 00:00:41,806 --> 00:00:46,956 Emergency Medicine Practice, and Evidence Based Urgent Care, and a multitude of 12 00:00:46,976 --> 00:00:51,326 other resources, like the EKG course, the laceration course, interactive 13 00:00:51,326 --> 00:00:55,766 clinical pathways, just tons of information to support your practice 14 00:00:55,906 --> 00:00:57,516 and help you in your patient care. 15 00:00:57,786 --> 00:00:59,976 And now, let's jump into this month's episode. 16 00:01:00,636 --> 00:01:03,066 Sam (2): Welcome back, ladies and gentlemen to the podcast. 17 00:01:03,066 --> 00:01:07,686 I am one of your hosts, Sam Ashoo, and on the other side of the microphone, 18 00:01:08,564 --> 00:01:13,184 T.R. Eckler (2): Expert at Rural Medicine TN case administration Dr TR Eckler 19 00:01:13,686 --> 00:01:15,666 Sam (2): that is quite the niche. 20 00:01:16,650 --> 00:01:18,390 You are a TN case list. 21 00:01:20,633 --> 00:01:23,813 T.R. Eckler (2): we gotta work on that lytic-ologist is pretty good I'm a lot of 22 00:01:23,820 --> 00:01:26,265 Sam (2): that Oh, I do like, the sound of that. 23 00:01:26,762 --> 00:01:30,002 today we're talking about the emergency medicine practice article. 24 00:01:30,002 --> 00:01:35,912 This is the February 20, 26 issue on acute coronary occlusion. 25 00:01:36,212 --> 00:01:41,885 So things that will occlude your coronary artery, authored by Dr. Horning. 26 00:01:42,165 --> 00:01:46,525 And really a thorough review, I think of this topic. 27 00:01:46,525 --> 00:01:50,455 I thought it was very well written and today we're gonna try and summarize that 28 00:01:50,455 --> 00:01:53,045 all for you quickly in this podcast. 29 00:01:53,045 --> 00:01:56,075 But this is definitely one of those articles you just need to go read. 30 00:01:56,165 --> 00:02:02,295 Lots of figures, lots of EKGs, lots of examples which are very, very helpful. 31 00:02:03,520 --> 00:02:06,130 We'll do our best to convey over the microphone. 32 00:02:06,260 --> 00:02:09,770 But I strongly recommend you just go look at these diagrams and 33 00:02:09,770 --> 00:02:11,360 why are we talking about this? 34 00:02:11,360 --> 00:02:16,070 Well, because this is a pretty significant piece of our population in the emergency 35 00:02:16,070 --> 00:02:17,570 department, and I love the numbers. 36 00:02:17,570 --> 00:02:22,700 So the numbers say somewhere between 25 and 30% of high risk patients 37 00:02:22,700 --> 00:02:28,680 with acute coronary occlusion fail to meet the traditional STEMI criteria. 38 00:02:28,920 --> 00:02:32,370 And that's what we seem to be always talking about, STEMI or non STEMI. 39 00:02:32,610 --> 00:02:35,520 But it turns out somewhere like a third of those patients don't 40 00:02:35,520 --> 00:02:39,300 meet STEMI criteria, and yet they have an acute coronary occlusion. 41 00:02:39,540 --> 00:02:45,930 And conversely, somewhere between 15 and 35% of STEMI activations end up being 42 00:02:46,050 --> 00:02:48,480 false positives without a culprit lesion. 43 00:02:48,660 --> 00:02:53,190 So there's still a significant number of people who fall outside of the 44 00:02:53,460 --> 00:02:57,900 STEMI, non-STEMI categorization, and we're always looking for better 45 00:02:57,900 --> 00:03:00,330 ways to try and redefine them. 46 00:03:00,330 --> 00:03:05,670 And one of them is this scheme of acute coronary syndromes 47 00:03:05,670 --> 00:03:06,870 and acute coronary occlusions. 48 00:03:07,680 --> 00:03:14,430 And what kinds of things are more likely to be occlusions, not just STEMI on EKG. 49 00:03:15,080 --> 00:03:20,740 The American Heart Association and the American College of Cardiology in 2025 50 00:03:20,740 --> 00:03:24,520 published updated guidelines for the management of acute coronary syndromes. 51 00:03:24,520 --> 00:03:28,850 And so we'll talk about some of those today and let you know where we stand 52 00:03:28,850 --> 00:03:31,820 with things that are STEMI equivalents. 53 00:03:31,970 --> 00:03:35,870 And that's a, a very, very important topic that we'll touch on in a little bit. 54 00:03:35,870 --> 00:03:39,290 But first, some interesting nomenclature. 55 00:03:39,290 --> 00:03:44,840 So, ACO acute coronary occlusion is a term that encompasses all things 56 00:03:44,840 --> 00:03:46,940 that will occlude a coronary artery. 57 00:03:46,940 --> 00:03:48,470 So not just STEMI. 58 00:03:48,810 --> 00:03:52,740 And as I mentioned before, there is some newer data that suggests that 59 00:03:52,740 --> 00:03:57,150 the STEMI, non-STEMI categorization system is a little inadequate. 60 00:03:57,150 --> 00:04:03,180 There was a, a large study in 2024 was a meta-analysis of 23,000 patients and found 61 00:04:03,270 --> 00:04:09,303 that the pool sensitivity for STEMI for actually detecting coronary occlusion was 62 00:04:09,303 --> 00:04:12,813 only 43%, which I found shockingly low. 63 00:04:13,233 --> 00:04:17,703 There was another meta-analysis of 40,000 patients with non 64 00:04:17,703 --> 00:04:22,663 STEMIs and about a quarter of them had acute coronary occlusion. 65 00:04:22,693 --> 00:04:27,433 So that suggests that what we are doing, in forcing people into a 66 00:04:27,433 --> 00:04:31,453 categorization system of STEMI versus NSTEMI, is actually inadequate 67 00:04:31,453 --> 00:04:33,043 and there's room for improvement. 68 00:04:33,253 --> 00:04:36,223 So, glad to see the conversation is still ongoing. 69 00:04:36,553 --> 00:04:41,413 The, there is a new nomenclature that's kind of leaching its way into the 70 00:04:41,413 --> 00:04:46,103 literature and in the common practice of occlusion, myocardial infarction 71 00:04:46,103 --> 00:04:51,083 versus non occlusion myocardial infarction, or OMI versus NOMI. 72 00:04:51,363 --> 00:04:56,313 And the, the paradigm there is really more about the underlying physiology 73 00:04:56,313 --> 00:04:58,023 is the coronary artery occluded? 74 00:04:58,243 --> 00:05:03,013 And can we pick up on STEMI or any other EKG pattern that suggests that 75 00:05:03,013 --> 00:05:05,023 this is an occluded coronary artery? 76 00:05:05,323 --> 00:05:08,263 and interestingly enough, the authors suggest that maybe. 77 00:05:08,613 --> 00:05:13,363 As we look at things that are STEMI equivalents, as we look at some adjunct 78 00:05:13,363 --> 00:05:19,077 tools like AI interpreting EKGs or helping us interpret EKGs that maybe we could 79 00:05:19,077 --> 00:05:24,637 get better and improve on our diagnostic capability for acute coronary inclusion, 80 00:05:24,727 --> 00:05:27,157 which I thought is a worthwhile cause. 81 00:05:27,358 --> 00:05:30,563 T.R. Eckler (2): I thought this was a great summary of what I think is kind of 82 00:05:30,563 --> 00:05:33,653 like the big transition in the evidence and the data that we're staring at right 83 00:05:33,653 --> 00:05:39,653 now And I think it's a good thing for you as the emergency provider at the bedside 84 00:05:39,893 --> 00:05:44,183 to basically realize that if you think your patient is sick and if you think 85 00:05:44,183 --> 00:05:47,903 that this patient could be having a heart attack It doesn't just have to rely on 86 00:05:47,903 --> 00:05:52,493 them having elevation of their ST segment on their EKG We're gonna talk about a lot 87 00:05:52,493 --> 00:05:56,003 of other things today that can indicate that and I think this is gonna empower 88 00:05:56,003 --> 00:05:59,753 you to take the the patient in front of you that you're worried about and the 89 00:05:59,753 --> 00:06:04,163 EKGs that you're looking at and take them to your cardiologist and say Hey I know 90 00:06:04,163 --> 00:06:08,843 it's not a STEMI but I see this What do you think And it's gonna give you more 91 00:06:08,843 --> 00:06:13,223 tools to catch more of these patients that really do have an occlusion that isn't 92 00:06:13,223 --> 00:06:14,603 gonna show up by the classic guidelines 93 00:06:15,032 --> 00:06:15,212 Sam (2): Yeah. 94 00:06:15,212 --> 00:06:16,082 Well, well said. 95 00:06:16,155 --> 00:06:19,635 In our typical method, we start talking about a diagnosis, and 96 00:06:19,635 --> 00:06:22,125 the first thing we mentioned is the differential diagnosis for it. 97 00:06:22,125 --> 00:06:25,185 There's a great table, table one on page six, which goes through 98 00:06:25,185 --> 00:06:29,985 all of the diagnoses that should be on your differential for STEMI. 99 00:06:30,225 --> 00:06:34,335 This includes everything from a true MI to pericarditis and myocarditis 100 00:06:34,335 --> 00:06:38,395 and takatsubo cardiomyopathies as well as non coronary things like 101 00:06:38,395 --> 00:06:43,365 pulmonary embolism aortic dissection coronary vasospasm left ventricular 102 00:06:43,365 --> 00:06:44,655 hypertrophy, and on and on and on. 103 00:06:44,655 --> 00:06:49,005 This is a very long list, but it talks about the specific diagnoses 104 00:06:49,005 --> 00:06:54,485 and then what you might see on A EKG that might mimic something going on 105 00:06:54,585 --> 00:06:55,875 like an acute coronary occlusion. 106 00:06:55,875 --> 00:06:57,555 So I thought that was a helpful list. 107 00:06:57,555 --> 00:07:01,245 It's definitely a list of things you need to keep in mind when you are seeing these 108 00:07:01,245 --> 00:07:02,715 patients in the emergency department. 109 00:07:02,985 --> 00:07:07,105 And as I mentioned before somewhere around a quarter of the patients who make it 110 00:07:07,105 --> 00:07:12,055 to the cath lab have normal coronaries or are found not to have a culprit 111 00:07:12,055 --> 00:07:14,395 vessel that has led to the STEMI alert. 112 00:07:14,395 --> 00:07:17,465 So it's important that you keep the differential in mind. 113 00:07:17,715 --> 00:07:21,045 Your patient may end up having another one of these other diagnoses. 114 00:07:22,280 --> 00:07:26,180 For our pre-hospital personnel, the author did a great job of 115 00:07:26,180 --> 00:07:31,290 reinforcing the importance of EMS as a partner in this system. 116 00:07:31,470 --> 00:07:36,120 So if you live in an urban area, hopefully you guys already have a 117 00:07:36,120 --> 00:07:41,060 STEMI alert system that will get a hold of a hospital with PCI capabilities. 118 00:07:41,060 --> 00:07:43,980 Send field EKGs ahead of time. 119 00:07:44,010 --> 00:07:47,520 Maybe do multiple ones if the transport is any kinda lengthy transport. 120 00:07:47,800 --> 00:07:48,490 The goal. 121 00:07:48,765 --> 00:07:52,455 Is an EKG within 10 minutes of first medical contact. 122 00:07:52,455 --> 00:07:53,655 And that includes EMS. 123 00:07:53,685 --> 00:07:56,985 So if you're gonna be on scene for a while, or if it's gonna take you longer 124 00:07:56,985 --> 00:08:00,465 than 10 minutes to get this patient to the hospital, that first EKG is 125 00:08:00,465 --> 00:08:03,165 yours and is very, very important. 126 00:08:03,255 --> 00:08:07,815 And if it's non-diagnostic, a repeat, EKG is equally as important. 127 00:08:08,035 --> 00:08:12,265 Especially if it's starting to show some transient or developing changes. 128 00:08:12,475 --> 00:08:16,735 Those are all very, very important and things you want to be able to transmit 129 00:08:16,735 --> 00:08:22,235 ahead of time or print or transmit and print and provide to the physician when 130 00:08:22,235 --> 00:08:26,315 you arrive at the hospital so that they can look and see that, oh yes, this EKG 131 00:08:26,315 --> 00:08:28,265 is evolving in front of our own eyes. 132 00:08:28,398 --> 00:08:34,793 A second or third field, EKG by EMS was found to identify up to 15% of 133 00:08:34,793 --> 00:08:38,093 additional STEMI cases that were not present on the initial ECG. 134 00:08:38,093 --> 00:08:40,373 So it definitely makes a difference. 135 00:08:40,743 --> 00:08:44,223 And the author corroborated that your typical STEMI protocol 136 00:08:44,223 --> 00:08:47,043 for pre-hospital treatment is exactly what you should be doing. 137 00:08:47,043 --> 00:08:49,533 You're gonna administer that aspirin . You're gonna give the 138 00:08:49,533 --> 00:08:53,133 sublingual nitroglycerin 0.4 milligrams every five minutes for 139 00:08:53,133 --> 00:08:56,023 three doses as needed for the symptoms. 140 00:08:56,203 --> 00:09:00,583 And then you're only going to give oxygen if they're hypoxic 141 00:09:00,673 --> 00:09:02,533 less than or equal to 90%. 142 00:09:02,533 --> 00:09:05,653 So not everybody needs oxygen. 143 00:09:05,833 --> 00:09:09,013 It's only those who are hypoxic that really need the oxygen. 144 00:09:09,293 --> 00:09:11,753 We'll get into this a little later, but there is evidence showing 145 00:09:11,753 --> 00:09:13,343 that it's completely useless. 146 00:09:13,343 --> 00:09:16,443 If they're not hypoxic, it doesn't add anything clinically 147 00:09:16,443 --> 00:09:17,463 relevant for the patient. 148 00:09:17,493 --> 00:09:21,073 So, aspirin, sublingual nitro oxygen. 149 00:09:21,373 --> 00:09:25,333 Get an EKG, get a repeat EKG if there's gonna be any kind of delay. 150 00:09:25,513 --> 00:09:31,903 And most importantly, if you can get them to a PCI capable hospital, if they have 151 00:09:32,263 --> 00:09:35,783 suspected or confirmed STEMI on their ECG. 152 00:09:35,783 --> 00:09:38,113 A very, very important step. 153 00:09:38,363 --> 00:09:44,033 If you're in a rural area your hospital choices are very limited 154 00:09:44,313 --> 00:09:50,073 then 90 minutes is about the cutoff time for first contact, to balloon 155 00:09:50,073 --> 00:09:53,383 time for a PCI capable hospital. 156 00:09:53,593 --> 00:09:58,819 If your first contact as an EMS person to, whenever they can inflate that balloon 157 00:09:58,819 --> 00:10:02,739 in the coronary artery is gonna take longer than two hours, 120 minutes then 158 00:10:02,739 --> 00:10:05,829 they want you to take 'em to a close hospital where they can get thrombolytics. 159 00:10:06,279 --> 00:10:10,029 And hopefully that's all already protocolized for you in 160 00:10:10,029 --> 00:10:12,459 whatever county you are working. 161 00:10:12,769 --> 00:10:14,689 Especially if it's a rural place. 162 00:10:14,959 --> 00:10:18,949 I know for us in our hospital, we have agreements with rural hospitals for 163 00:10:18,949 --> 00:10:20,869 rapid acceptance and rapid transfer. 164 00:10:20,869 --> 00:10:24,319 And so if you're in one of those outlying places and you're brought a patient, you 165 00:10:24,319 --> 00:10:29,509 are expected to give TN K or whatever your thrombolytic is, and then rapidly get them 166 00:10:29,509 --> 00:10:33,589 to our facility because we know they're just not getting here within 120 minutes. 167 00:10:33,899 --> 00:10:36,859 And so, hopefully those hospitals have those agreements and if 168 00:10:36,859 --> 00:10:40,513 you're in the EMS field, already have those protocols established. 169 00:10:40,513 --> 00:10:43,633 They're very, very important, critically important. 170 00:10:43,633 --> 00:10:48,143 So can't overstate the role of EMS in this particular scenario. 171 00:10:48,419 --> 00:10:51,694 T.R. Eckler (2): I think one thing I would add to that is I think there's 172 00:10:51,694 --> 00:10:58,234 such a challenge of rural EMS access and and only having like you know one or two 173 00:10:58,234 --> 00:11:03,694 ambulances for a county in rural places I think there's a role for having these 174 00:11:03,694 --> 00:11:08,074 discussions with your flight teams to see if someone clearly has a STEMI and you 175 00:11:08,074 --> 00:11:12,884 can identify that In the field or identify that on first medical contact then looking 176 00:11:12,884 --> 00:11:16,514 at whether or not you can get them there by flight or whether you can basically 177 00:11:16,514 --> 00:11:20,234 move them to a hospital and bring the helicopter to the hospital and kind of 178 00:11:20,234 --> 00:11:24,044 meet in the middle and then basically they can get lytics and get going I found in 179 00:11:24,044 --> 00:11:27,824 practice that patients get better with lytics but then can sometimes become 180 00:11:27,824 --> 00:11:31,664 unstable and need to still get quickly to a PCI center So I think there's a role 181 00:11:31,664 --> 00:11:35,804 for like you know facilitating as two stage transport as soon as you can to get 182 00:11:35,804 --> 00:11:36,989 these people to where they need to end up 183 00:11:37,526 --> 00:11:38,096 Sam (2): Great points. 184 00:11:38,273 --> 00:11:42,323 . And when they do get to where they need to end up, so hopefully in 185 00:11:42,323 --> 00:11:46,763 our ED and we're trying to obtain a history, it's your typical history. 186 00:11:46,763 --> 00:11:47,933 Not much has changed there. 187 00:11:47,933 --> 00:11:51,683 So acute chest discomfort or dyspnea is usually the presenting symptom, but 188 00:11:51,893 --> 00:11:56,243 they may complain of chest pressure, chest tightness, chest heaviness, 189 00:11:56,243 --> 00:11:58,043 chest burning, whatever it is. 190 00:11:58,043 --> 00:12:00,473 It's all under the blanket of some kind of discomfort. 191 00:12:00,753 --> 00:12:02,583 There's gonna be some kind of radiation. 192 00:12:02,583 --> 00:12:04,773 It might involve the arms or the neck or the jaw. 193 00:12:04,953 --> 00:12:06,483 There might be associated symptoms. 194 00:12:06,483 --> 00:12:06,933 There might. 195 00:12:07,253 --> 00:12:10,223 Only be associated symptoms and no chest pain. 196 00:12:10,283 --> 00:12:14,243 Things like nausea, vomiting, upper abdominal pain shortness of 197 00:12:14,243 --> 00:12:17,903 breath, diaphoresis unexplained fatigue or even syncope. 198 00:12:17,903 --> 00:12:19,613 So it's a wide net. 199 00:12:19,613 --> 00:12:23,243 We cast in a bunch of symptoms that can present under the blanket 200 00:12:23,243 --> 00:12:24,413 of acute coronary syndrome. 201 00:12:24,663 --> 00:12:25,953 But just keep that in mind. 202 00:12:26,073 --> 00:12:28,563 None of that has really changed, but it's important to remember. 203 00:12:28,701 --> 00:12:32,241 T.R. Eckler (2): I think especially having a higher threshold for people that are 204 00:12:32,501 --> 00:12:36,471 minimizers people that are very tough people that are trying to play down their 205 00:12:36,471 --> 00:12:40,311 symptoms cause they need to go take care of family or pets or something else I 206 00:12:40,311 --> 00:12:43,551 don't think I've ever regretted an EKG in my career and there's some tests where 207 00:12:43,551 --> 00:12:46,311 I've been sad that I ordered them cause I wasn't sure the patient really needed 208 00:12:46,311 --> 00:12:51,801 it But an EKG is a harmless test that you know other than driving my my poor EKG 209 00:12:51,801 --> 00:12:55,611 techs crazy sometimes for all the EKGs that I want I would tell you that it's 210 00:12:55,611 --> 00:12:58,821 never something that you're gonna regret getting on a patient And there are times 211 00:12:58,821 --> 00:13:02,751 when they surprise you And I think if you got one and it makes you nervous then 212 00:13:02,751 --> 00:13:07,401 I think you need to consider getting a second for those kind of people because 213 00:13:07,401 --> 00:13:10,011 that's one of those things as you're taking the history and they come in and 214 00:13:10,011 --> 00:13:14,156 they say Hey do you want an EKG on this patient You say yeah And can I get one 215 00:13:14,156 --> 00:13:17,816 again in 15 minutes while you're having that conversation with the patient If 216 00:13:17,816 --> 00:13:21,656 you offload that cognitive task in a busy time and you make it so that somebody 217 00:13:21,656 --> 00:13:24,926 else is gonna make sure and get a follow up on that I've had a lot of luck where 218 00:13:24,926 --> 00:13:27,866 I've caught things that I I don't think I would've caught from that second EKG 219 00:13:28,774 --> 00:13:32,194 Sam (2): and, a prebuilt order set for that could also help. 220 00:13:32,284 --> 00:13:34,504 Like, Hey, why, why do I have to place two orders? 221 00:13:34,504 --> 00:13:35,614 I can just click one button. 222 00:13:35,704 --> 00:13:38,164 The patient's 75 years old here with chest pain, they're 223 00:13:38,164 --> 00:13:39,544 obviously gonna get more than one. 224 00:13:39,724 --> 00:13:41,614 So here, I'm just gonna click the set. 225 00:13:41,674 --> 00:13:42,484 That's gonna get me three. 226 00:13:43,334 --> 00:13:45,964 So, definitely make it easier for yourselves and 227 00:13:45,964 --> 00:13:47,494 definitely get the repeat EKGs. 228 00:13:48,184 --> 00:13:53,744 when it comes to physical exam again, there isn't any single physical exam 229 00:13:53,744 --> 00:13:56,684 finding that's gonna tell you somebody has an acute coronary occlusion. 230 00:13:57,304 --> 00:13:58,354 That's the crux of it. 231 00:13:58,734 --> 00:14:02,624 But you do have to remember that somewhere between seven and 10% of 232 00:14:02,624 --> 00:14:06,404 patients who have mi are gonna be complicated by cardiogenic shock. 233 00:14:06,584 --> 00:14:10,014 So, if they're hypotensive, if they're bradycardic, if they're 234 00:14:10,159 --> 00:14:13,984 hypotensive and tachycardic if they look like they're in shock, just 235 00:14:13,984 --> 00:14:18,574 keep mi in the back of your mind as a possible cause for that presentation. 236 00:14:18,874 --> 00:14:21,904 'cause that definitely complicates matters very quickly. 237 00:14:22,277 --> 00:14:24,582 T.R. Eckler (2): I still think you're looking to consider some of the other 238 00:14:24,582 --> 00:14:28,272 diagnostic things here So like do they have a clot Do they have a recent surgery 239 00:14:28,272 --> 00:14:32,502 Is their leg really swollen Do can you already hear the fluid in their lungs Can 240 00:14:32,502 --> 00:14:36,172 you already notice some jugular venous distension patients like these often 241 00:14:36,172 --> 00:14:40,192 are really easy to put ejs into because they're already backed up So I think 242 00:14:40,192 --> 00:14:43,162 that that's always something that at a glance I'm looking at the patient and 243 00:14:43,162 --> 00:14:46,642 going huh we're already backing up We're already starting to have trouble getting 244 00:14:46,642 --> 00:14:49,652 blood through our heart there's something there I need to figure out whether that's 245 00:14:49,782 --> 00:14:53,722 an occlusion in their their coronary arteries or it's a blood clot or it's new 246 00:14:53,722 --> 00:14:55,282 onset heart failure from something else 247 00:14:55,904 --> 00:14:56,194 Sam (2): Yeah. 248 00:14:57,384 --> 00:14:58,824 And then of course there's the EKG. 249 00:14:58,824 --> 00:15:02,304 So we're gonna spend a little time running through all of the 250 00:15:02,304 --> 00:15:07,674 different methods of identifying acute coronary occlusion on EKG. 251 00:15:07,984 --> 00:15:09,034 And why do we talk about it? 252 00:15:09,034 --> 00:15:11,494 'cause it's one of the most frequently ordered tests that we 253 00:15:11,494 --> 00:15:12,904 have in the emergency department. 254 00:15:13,114 --> 00:15:13,984 There is data. 255 00:15:14,054 --> 00:15:18,914 From a national cardiovascular registry that has over 40,000 patients 256 00:15:19,094 --> 00:15:23,904 diagnosed with STEMI that found that 11% had an initial non-diagnostic 257 00:15:23,904 --> 00:15:27,474 EKG, that's like one in 10 are gonna have a non-diagnostic one. 258 00:15:27,814 --> 00:15:32,494 72% of those had a repeat ECG, where the STEMI was found, and that was 259 00:15:32,494 --> 00:15:34,204 within 90 minutes of the initial one. 260 00:15:34,204 --> 00:15:40,184 So it, there's definitely strong evidence that ECG will change and until we get to 261 00:15:40,184 --> 00:15:45,524 the point where every ED has continuous 12 lead telemetry and you're catching 262 00:15:45,524 --> 00:15:50,834 this live and watching it evolve, your only choice is to do intermittent EKGs 263 00:15:50,834 --> 00:15:54,824 and get them repeated so one begets another, and that's totally okay. 264 00:15:55,957 --> 00:16:00,037 T.R. Eckler (2): Can I make a brief plug to the fine people that are generating 265 00:16:00,037 --> 00:16:05,377 all these electronic medical records I think that this is one of those places 266 00:16:05,377 --> 00:16:11,587 where you could make medicine awesome If when I open an EKG on my computer it 267 00:16:11,587 --> 00:16:17,347 automatically pulls up any old EKGs or any future EKGs Like let's say I pull one up 268 00:16:17,347 --> 00:16:21,157 and there was one already done that was more recent And the last one I honestly 269 00:16:21,157 --> 00:16:24,667 want to grid of four Like show me the four EKGs in this patient that are the 270 00:16:24,667 --> 00:16:28,237 most recent If I pull one up like if it's a one in the future or three in the past 271 00:16:28,237 --> 00:16:31,897 whatever But if you can pull up all four of those EKGs and let me quickly compare 272 00:16:31,897 --> 00:16:36,347 them or just overlay them and let my brain do awesome things by looking at the four 273 00:16:36,347 --> 00:16:40,187 and going oh geez look everyone else look pretty good But now this is up and this is 274 00:16:40,187 --> 00:16:45,407 down huh There we are So I think there's room for not necessarily AI to do this 275 00:16:45,647 --> 00:16:49,547 Just let me do it Show show me the data better and I'll do the the awesomeness 276 00:16:50,124 --> 00:16:52,734 Sam (2): You could click on a lab and trend it with the 277 00:16:52,854 --> 00:16:55,344 most recent past, six months. 278 00:16:55,344 --> 00:16:58,164 Why can't I just click on an EKG and trend it in the same way? 279 00:16:58,164 --> 00:17:01,494 Yeah, there's images involved, but hey, come on, AI can do it. 280 00:17:02,397 --> 00:17:04,977 T.R. Eckler (2): One other piece And now now that I'm getting old I'm starting to 281 00:17:04,977 --> 00:17:10,347 tell like what I was in residency stories but my my program director and just the 282 00:17:10,347 --> 00:17:15,297 people that ran my hospitals in New York every EKG you were handed came with the 283 00:17:15,297 --> 00:17:21,537 patient's most recent prior EKG So you got two EKGs every time you got handed an EKG 284 00:17:21,807 --> 00:17:27,177 which was a heck of a pain in the butt for EKG techs But boy did it do a better job 285 00:17:27,177 --> 00:17:32,277 of making you go wow this is way different And then you you had a clear idea that 286 00:17:32,277 --> 00:17:35,487 you were dealing with something different And that's that doesn't need any smartness 287 00:17:35,487 --> 00:17:40,287 to it other than just your EKG machines have to be enable you to pull up and print 288 00:17:40,287 --> 00:17:43,497 the one that's today and whatever was prior And I would tell you that I think 289 00:17:43,497 --> 00:17:46,797 that's probably a better standard of care than what a lot of places are doing now 290 00:17:48,294 --> 00:17:51,644 Sam (2): Okay, well since we're on this topic, here's what I want epic and Oracle. 291 00:17:51,644 --> 00:17:54,704 Since you're listening in all the technology companies, I want my EKG 292 00:17:54,704 --> 00:17:58,394 Tech to walk into a room, do a 12 lead EKG, and then come to me with an iPad. 293 00:17:58,859 --> 00:17:59,639 I don't want paper. 294 00:17:59,819 --> 00:18:00,869 I want the iPad there. 295 00:18:00,959 --> 00:18:04,139 I wanna be able to scroll to the left to see the previous EKG 296 00:18:04,139 --> 00:18:05,549 from whatever year it was done. 297 00:18:05,759 --> 00:18:10,229 I wanna be able to scroll to the right to see automatic grid lines appear. 298 00:18:10,409 --> 00:18:12,719 I want my St baseline marked. 299 00:18:12,779 --> 00:18:15,239 I want any st elevations in red. 300 00:18:15,479 --> 00:18:18,719 I want the computer AI interpretation to bring my eyes 301 00:18:18,719 --> 00:18:21,749 to any, any of the syndromes. 302 00:18:21,749 --> 00:18:23,729 We're about to discuss any one of these. 303 00:18:24,009 --> 00:18:27,849 And I want all my indices, all my intervals, all of this stuff in 304 00:18:27,849 --> 00:18:29,889 the, in a little column on the left. 305 00:18:30,199 --> 00:18:31,609 And I don't think that's too much to ask. 306 00:18:31,609 --> 00:18:32,989 You know that That's it. 307 00:18:32,989 --> 00:18:36,689 And then I just wanted to say, Hey, sign your name here, or, or it's an iPad. 308 00:18:36,689 --> 00:18:37,499 Read my fingerprint. 309 00:18:37,499 --> 00:18:38,249 I'm just gonna sign it. 310 00:18:38,249 --> 00:18:38,489 Yeah. 311 00:18:38,519 --> 00:18:39,539 Clock it for right now. 312 00:18:39,539 --> 00:18:42,739 I saw it, and if it's a STEMI, I'm gonna push a little button and 313 00:18:42,739 --> 00:18:45,109 that's gonna activate the order set and bring the patient to a room. 314 00:18:45,379 --> 00:18:47,029 That's not too much to ask really. 315 00:18:47,029 --> 00:18:47,629 Now it is. 316 00:18:47,701 --> 00:18:49,981 T.R. Eckler (2): Could not be more jazzed about that idea 317 00:18:50,221 --> 00:18:52,141 Give us what we want Computers 318 00:18:52,918 --> 00:18:54,928 Sam (2): There's a technology company somewhere out there listening. 319 00:18:55,828 --> 00:18:58,528 But back to the topic at hand, let's first talk about STEMI. 320 00:18:58,543 --> 00:19:03,598 So, STEMI definition by EKG criteria has not changed a millimeter of ST segment 321 00:19:03,598 --> 00:19:05,818 elevation in any two consecutive leads. 322 00:19:05,948 --> 00:19:09,998 Starting at the J point, not including V two and V three, right? 323 00:19:09,998 --> 00:19:13,538 So a millimeter in at least two consecutive leads, not 324 00:19:13,538 --> 00:19:14,798 including V two and V three. 325 00:19:15,158 --> 00:19:17,978 If the ST elevation is in V two and V three, it gets a little bit 326 00:19:17,978 --> 00:19:21,008 more complicated because there are age and gender-based criteria. 327 00:19:21,218 --> 00:19:26,538 So, for V two and V three, in the absence of left ventricular hypertrophy or a 328 00:19:26,538 --> 00:19:31,278 bundle branch block, it's greater than two millimeters in men aged 40 years 329 00:19:31,668 --> 00:19:36,363 greater than two and a half millimeters in men under 40 years old and greater 330 00:19:36,363 --> 00:19:39,333 than 1.5 millimeters in women of any age. 331 00:19:39,723 --> 00:19:44,455 Those have been around for a while and those are not changing the 332 00:19:44,455 --> 00:19:47,035 magnitude of st segment elevation. 333 00:19:47,215 --> 00:19:49,585 It starts being measured at the J point. 334 00:19:49,585 --> 00:19:54,845 That's that transition from the, the s the qr s into the the section between the 335 00:19:54,845 --> 00:20:00,415 S and the T. And the ST segment should be measured against some kind of isoelectric. 336 00:20:01,030 --> 00:20:02,020 Baseline. 337 00:20:02,020 --> 00:20:05,080 And that baseline is between the end of the T wave and the 338 00:20:05,080 --> 00:20:06,700 beginning of the next P wave. 339 00:20:06,700 --> 00:20:10,000 And so anything compared to that would be ST elevation or depression. 340 00:20:10,660 --> 00:20:13,000 And then we talk about our STEMI equivalents. 341 00:20:13,000 --> 00:20:15,670 So again, a great table, page eight. 342 00:20:15,850 --> 00:20:17,740 Table number two, STEMI equivalents. 343 00:20:17,930 --> 00:20:22,330 You've got things like left bundle branch blocks or ventricular paced 344 00:20:22,350 --> 00:20:27,780 rhythms with SCARBOSA You've got the Smith modified SCARBOSA criteria. 345 00:20:28,020 --> 00:20:32,430 You've got Hyperacute T waves, posterior STEMI, and the de Winter sign. 346 00:20:32,460 --> 00:20:36,150 So that's five different STEMI equivalents we're gonna touch on real 347 00:20:36,150 --> 00:20:40,420 quick . If there is the presence of a left bundle branch block or some 348 00:20:40,420 --> 00:20:41,950 kind of ventricular paced rhythm. 349 00:20:42,070 --> 00:20:43,990 You can still identify STEMI. 350 00:20:44,430 --> 00:20:48,620 Scarbosa criteria were first published in like 1996, and you have to get a 351 00:20:48,620 --> 00:20:50,480 total score of three or more points. 352 00:20:50,480 --> 00:20:53,810 And those points are awarded based on the presence of three things. 353 00:20:54,020 --> 00:20:57,740 One is concordant ST elevation greater than a millimeter. 354 00:20:58,400 --> 00:21:00,750 In a lead with a positive QRS. 355 00:21:00,750 --> 00:21:04,740 So a positive ST elevation with a positive QRS and the ST elevation 356 00:21:04,740 --> 00:21:06,120 is more than a millimeter. 357 00:21:06,270 --> 00:21:07,170 That's five points. 358 00:21:07,170 --> 00:21:08,550 That's automatic your in. 359 00:21:09,180 --> 00:21:14,430 Concordant ST depression greater than a millimeter in the anterior leads, so V 360 00:21:14,430 --> 00:21:16,680 one through V three, that's three points. 361 00:21:16,740 --> 00:21:18,390 Again, automatically you're in. 362 00:21:18,750 --> 00:21:19,800 The discordance. 363 00:21:19,800 --> 00:21:22,830 So that's the QRS is heading in one direction and the st 364 00:21:22,830 --> 00:21:23,820 segment's heading in another. 365 00:21:24,000 --> 00:21:27,120 This is the most frequent finding we're gonna see in the left bundle branch block. 366 00:21:27,370 --> 00:21:32,190 But if that discordance is bigger than five millimeters, that's worth two points. 367 00:21:32,190 --> 00:21:33,840 Now, alone, that's not enough. 368 00:21:33,870 --> 00:21:35,190 'cause you gotta have three or more. 369 00:21:35,380 --> 00:21:38,230 So you've gotta have it in conjunction with one of the other two. 370 00:21:38,480 --> 00:21:42,290 And that is the traditional scarbosa criteria. 371 00:21:42,480 --> 00:21:47,880 Those were modified that was published by Smith et al. And lovingly titled 372 00:21:47,880 --> 00:21:51,960 the Smith Modified Scarbosa Criteria, which kind of tried to simplify matters. 373 00:21:52,190 --> 00:21:53,990 The first two criteria stayed the same. 374 00:21:54,170 --> 00:21:59,755 The biggest influence was on the third criteria where ST elevation at the J 375 00:21:59,755 --> 00:22:05,202 point relative to the QRS had to be at least 25% 25 of the preceding S wave. 376 00:22:05,452 --> 00:22:08,692 And again, this is way easier to show you on a figure. 377 00:22:08,692 --> 00:22:12,382 Figure six demonstrates that very nicely, and all you're looking at is 378 00:22:12,382 --> 00:22:16,672 the discordance between the ST elevation or depression and the QRS, which is 379 00:22:16,672 --> 00:22:18,022 heading in the opposite direction. 380 00:22:18,312 --> 00:22:23,212 It's the amplitude of the S wave or the R wave, depending on if it's a positive 381 00:22:23,212 --> 00:22:27,482 or negative QRS and the depression or elevation of the ST segment. 382 00:22:27,672 --> 00:22:35,322 And if that discordance is 25% or more, that's highly suggestive of mi. And it 383 00:22:35,322 --> 00:22:40,002 improved upon the original scar bosa criteria by improving on the sensitivity. 384 00:22:40,082 --> 00:22:43,982 T.R. Eckler (2): Okay So I think when we talk about the scar criteria I think 385 00:22:43,982 --> 00:22:47,102 it's something that I've always really struggled with because to really take the 386 00:22:47,102 --> 00:22:50,582 time and look at the EKG and figure it out I found that oftentimes cardiology 387 00:22:50,582 --> 00:22:53,942 was not that impressed with most of the EKGs that I was concerned might meet 388 00:22:53,952 --> 00:22:58,382 scarbosa because you had such a low sensitivity in a lot of those studies But 389 00:22:58,412 --> 00:23:02,972 now with the Smith modified criteria that they give you you're basically taking the 390 00:23:02,972 --> 00:23:09,172 sensitivity up from say 49-52% In some of the the the trials they have now with the 391 00:23:09,172 --> 00:23:15,022 Smith modified criteria you get 80 to 91% sensitive And I think that gives you more 392 00:23:15,022 --> 00:23:19,492 of a leg to stand on when you show these EKGs to cardiology to say Hey I'm looking 393 00:23:19,492 --> 00:23:23,902 at the Smith Modified Scarbosa criteria and this really fits the criteria I really 394 00:23:23,902 --> 00:23:25,702 think this should be considered a STEMI 395 00:23:25,822 --> 00:23:30,236 Sam (2): Yeah, and I cannot overstate how important these figures are. 396 00:23:30,296 --> 00:23:31,436 Please go look at them. 397 00:23:31,746 --> 00:23:34,806 Figure five shows you the traditional scarbosa criteria, and figure 398 00:23:34,806 --> 00:23:36,516 six shows you the modified Smith. 399 00:23:36,826 --> 00:23:41,086 And again, Smith's objective was just to make the, the math simpler. 400 00:23:41,086 --> 00:23:45,816 So we're just looking at a discordance of 25% or more measured in millimeters. 401 00:23:45,976 --> 00:23:49,276 And that's sufficient to, to make the diagnosis. 402 00:23:49,526 --> 00:23:52,766 And that's a, a handy little table to keep in your back pocket. 403 00:23:53,659 --> 00:23:56,719 T.R. Eckler (2): I really like this too Just the the Smith approach to this 404 00:23:56,959 --> 00:24:00,349 cause he went backward from the real pathology into like combing through 405 00:24:00,349 --> 00:24:04,099 their EKGs and things and developed this that way And I think that's why 406 00:24:04,099 --> 00:24:07,939 the numbers got so much better is he started from the the the patients with 407 00:24:07,939 --> 00:24:09,409 disease and built backwards from there 408 00:24:10,926 --> 00:24:13,716 Sam (2): The next STEMI mimic was Hyperacute T Waves. 409 00:24:13,716 --> 00:24:17,286 So again, if you're not new to emergency medicine, you've heard this a bunch of 410 00:24:17,286 --> 00:24:23,896 times already, but this is just saying that hyperacute or markedly tall and wide 411 00:24:23,956 --> 00:24:27,926 T waves be port pretenders of badness. 412 00:24:27,926 --> 00:24:31,556 So this is the the early STEMI sign, and if you sit around and 413 00:24:31,556 --> 00:24:34,916 just watch this long enough, the ST segment's gonna follow soon enough. 414 00:24:35,166 --> 00:24:37,356 But this is a STEMI equivalent. 415 00:24:37,794 --> 00:24:39,384 T.R. Eckler (2): Don't sit around and watch this 416 00:24:39,546 --> 00:24:39,606 Sam (2): Yeah. 417 00:24:39,654 --> 00:24:43,434 T.R. Eckler (2): Take more pictures if the cardiologist isn't convinced but you don't 418 00:24:43,434 --> 00:24:46,734 need to sit around and watch this You can just keep saying hyperacute T waves 419 00:24:46,944 --> 00:24:48,744 until someone takes them to the cath lab 420 00:24:49,386 --> 00:24:52,626 Sam (2): There was a, an interesting point the author made, and that's that it's 421 00:24:52,626 --> 00:24:59,186 not about the height of the T-wave, it's about the area encompassed by the T-wave. 422 00:24:59,196 --> 00:25:04,716 So width and height, the total area under that curve is what you're looking at. 423 00:25:04,866 --> 00:25:09,646 It's not just how tall the T-wave is in, because, you can see peak T waves and 424 00:25:09,646 --> 00:25:11,056 hyperkalemia or something of that sort. 425 00:25:11,056 --> 00:25:12,886 It's gonna look remarkably different. 426 00:25:13,096 --> 00:25:16,556 There's a great figure, figure seven there that shows you the big fat 427 00:25:16,556 --> 00:25:18,596 T wave compared to a QRS complex. 428 00:25:18,756 --> 00:25:20,316 And that's helpful to keep in mind. 429 00:25:21,248 --> 00:25:26,738 Myocardial infarction or posterior STEMI has ST. Depression in 430 00:25:26,738 --> 00:25:28,358 the anterior septal lead. 431 00:25:28,358 --> 00:25:33,600 So V one, V two and V three are gonna show this deep ST depression with the 432 00:25:33,600 --> 00:25:38,290 QRS complex being positive in V two and V three and that should really start 433 00:25:38,290 --> 00:25:40,790 signaling some alarm bells in your brain. 434 00:25:40,970 --> 00:25:44,570 My old attendings in medical school used to love flipping the EKG upside 435 00:25:44,570 --> 00:25:47,420 down and looking at those anterior leads to kind of make it look like 436 00:25:47,420 --> 00:25:49,530 there's st elevation which I still do. 437 00:25:49,530 --> 00:25:54,330 Honestly, it helps me but the presence of those deep st depressions, V one through 438 00:25:54,330 --> 00:26:00,000 V three especially if there's reciprocal ST segment elevation in other leads is, is 439 00:26:00,000 --> 00:26:02,550 diagnostic and that's a STEMI equivalent. 440 00:26:02,800 --> 00:26:05,440 There's usually a big dominant R wave in V two. 441 00:26:05,690 --> 00:26:08,270 You might see some upright T waves in the anterior leads. 442 00:26:08,450 --> 00:26:12,990 All of that adds to it and is incorporated in that, making that diagnosis. 443 00:26:13,290 --> 00:26:16,320 You can do posterior lead placement. 444 00:26:16,320 --> 00:26:19,410 So you can take V seven, V eight and V nine and stick 'em on the 445 00:26:19,410 --> 00:26:21,390 back and get that posterior EKG. 446 00:26:21,700 --> 00:26:25,510 Just know that if you do the posterior leads and you don't see 447 00:26:25,630 --> 00:26:27,670 st elevation, it doesn't matter. 448 00:26:27,790 --> 00:26:31,210 That is not an exclusion for acute coronary occlusion. 449 00:26:31,430 --> 00:26:34,280 You still need to get your cardiologist on the phone and 450 00:26:34,280 --> 00:26:35,600 treat this person like a STEMI. 451 00:26:35,630 --> 00:26:35,960 So, 452 00:26:36,093 --> 00:26:39,963 T.R. Eckler (2): they're always impressed Sam when you have the posterior EKG to 453 00:26:39,963 --> 00:26:45,093 show em and I would tell you that of all the like how To do a diagnostic test 454 00:26:45,093 --> 00:26:50,133 Stuff that lives in my brain nothing lives in my brain like V eight goes right 455 00:26:50,133 --> 00:26:54,363 underneath the bottom of their scapula and then you just put V nine a little 456 00:26:54,363 --> 00:26:59,403 next to their spine and V seven a little bit over laterally to that I've taught 457 00:26:59,403 --> 00:27:05,283 so many EKG teachs that and then I'd love I love writing posterior and slashing 4 458 00:27:05,283 --> 00:27:09,873 5 6 V 4 5 6 and turn it into V seven V eight V nine I feel like I really know 459 00:27:09,873 --> 00:27:13,263 what I'm doing and most of those look pretty normal but I really thought that 460 00:27:13,263 --> 00:27:16,323 this article did a great job of saying Hey if you're still worried about the 461 00:27:16,323 --> 00:27:21,993 patient if the posterior EKG is negative this can still be an occlusion mi Take 462 00:27:21,993 --> 00:27:25,593 those pictures to your cardiologist and say Hey I'm worried about this sweaty 463 00:27:25,593 --> 00:27:27,993 diaphoretic dyspneic patient that looks like they're having a heart attack 464 00:27:28,425 --> 00:27:28,755 Sam (2): Yeah. 465 00:27:29,025 --> 00:27:32,175 And interestingly, you do those posterior leads and your 466 00:27:32,205 --> 00:27:34,335 definition for STEMI is changing. 467 00:27:34,335 --> 00:27:38,205 You only need a half a millimeter of elevation in any of those leads. 468 00:27:38,475 --> 00:27:42,375 But please don't forget that if they don't have those st elevations 469 00:27:42,375 --> 00:27:44,325 posteriorly, that's not an exclusion. 470 00:27:44,325 --> 00:27:46,275 That doesn't tell you that their coronaries are okay. 471 00:27:46,455 --> 00:27:49,845 But if they have the elevation that just really tightens up that diagnosis 472 00:27:49,845 --> 00:27:52,875 for you and get you some bonus brownie points with your cardiologist. 473 00:27:53,230 --> 00:27:55,540 T.R. Eckler (2): I think the the take I had from this article there's so many 474 00:27:55,540 --> 00:27:59,800 diagnostic criteria It it's one of those things where like I think you have to 475 00:27:59,980 --> 00:28:03,490 have a little paradigm shift in your head which is I'm worried about this patient 476 00:28:03,640 --> 00:28:07,030 I think they're having a heart attack I'm gonna go through and test every single 477 00:28:07,030 --> 00:28:10,600 one of these things to make sure there's not an easy way for me to say yes this is. 478 00:28:10,810 --> 00:28:15,550 Cause it's not just about STEMI anymore It's about can I find a picture for 479 00:28:15,550 --> 00:28:17,410 occlusion mi that fits this patient. 480 00:28:17,530 --> 00:28:20,470 And if you're worried about em just keep pushing until you feel like 481 00:28:20,470 --> 00:28:23,556 you've exhausted all routes and all cardiologists that'll listen to you 482 00:28:24,038 --> 00:28:24,338 Sam (2): Yeah. 483 00:28:24,518 --> 00:28:25,568 Yeah, that's a great point. 484 00:28:25,568 --> 00:28:28,538 Really, this should be a checklist that you go through for somebody 485 00:28:28,538 --> 00:28:29,948 who has a positive troponin. 486 00:28:30,078 --> 00:28:34,198 Before you write the words non STEMI you need to make sure there's no 487 00:28:34,198 --> 00:28:36,808 STEMI equivalent, and you should be going through this checklist. 488 00:28:37,098 --> 00:28:39,078 The last one is the de winter sign. 489 00:28:39,078 --> 00:28:42,988 So again, figure 10 is an excellent way to visualize it. 490 00:28:43,048 --> 00:28:47,678 If you have access to the article the diagnostic criteria are one to three 491 00:28:47,678 --> 00:28:53,338 millimeters of ST depression that's up sloping, starting at the J point in leads 492 00:28:53,338 --> 00:28:58,198 V one through V six and associated with a big, tall, upright symmetrical T-wave. 493 00:28:58,448 --> 00:29:03,668 And so it's a very distinct looking pattern and lots of case reports describe 494 00:29:03,668 --> 00:29:08,728 it sometimes as a persistent pattern in patients with acute proximal left anterior 495 00:29:08,728 --> 00:29:10,858 descending coronary artery occlusion. 496 00:29:11,048 --> 00:29:13,988 And so those patients don't tend to do very well at all. 497 00:29:14,188 --> 00:29:18,928 And if you see it on your EKG, you should be talking to a cardiologist very quickly. 498 00:29:20,195 --> 00:29:23,975 So that's five STEMI equivalents, right? 499 00:29:23,975 --> 00:29:28,055 So we haven't started talking about the non STEMI or the, the changes 500 00:29:28,055 --> 00:29:29,975 that are harbinger of ischemia. 501 00:29:30,005 --> 00:29:31,505 We're just talking about occlusion. 502 00:29:31,655 --> 00:29:36,615 If you see any one of those, the ST elevation, the standard ST elevation 503 00:29:36,865 --> 00:29:41,215 the Scarbosa or the Smith Scarbosa criteria, the Hyperacute T waves, the 504 00:29:41,215 --> 00:29:43,135 posterior STEMI or the de Winter sign. 505 00:29:43,315 --> 00:29:47,065 You need to treat all of those like acute occlusion, like an acute STEMI 506 00:29:47,285 --> 00:29:49,325 and set off the alerts and off you go. 507 00:29:49,835 --> 00:29:55,445 Then we move on to the non STEMIs, or these are ECG or EKG findings 508 00:29:55,445 --> 00:29:58,875 that are consistent with some kind of acute or subacute ischemia that 509 00:29:58,875 --> 00:30:03,375 you should still be concerned about, but cath lab activation becomes 510 00:30:03,535 --> 00:30:07,397 more at the cardiologist discretion 'cause there are less clear criteria. 511 00:30:07,587 --> 00:30:11,137 And there's again several of these that we're gonna talk about today. 512 00:30:11,137 --> 00:30:12,697 Let's start with a VR. 513 00:30:12,907 --> 00:30:16,807 So if you don't know what a VR is, it's that lead in the second 514 00:30:16,807 --> 00:30:18,937 column on your EKG at the very top. 515 00:30:19,067 --> 00:30:23,157 And we don't frequently look at it, but just know that if you have ST segment 516 00:30:23,157 --> 00:30:27,447 elevation in that lead combined with depression anywhere else, that that 517 00:30:27,447 --> 00:30:31,417 patient's at high risk for associated morbidity and mortality, usually 518 00:30:31,597 --> 00:30:35,377 represents some kind of diffuse ischemia because of significant 519 00:30:35,377 --> 00:30:37,747 stenosis involving the left main. 520 00:30:38,537 --> 00:30:42,257 So the left main or the proximal LAD, neither one of those is a 521 00:30:42,257 --> 00:30:46,407 place you want to have an occlusion or a narrowing a stenosis. 522 00:30:47,097 --> 00:30:50,457 if you've got significant disease there, usually those patients end 523 00:30:50,457 --> 00:30:54,787 up having to go and get bypass or have multi-vessel involvement. 524 00:30:55,007 --> 00:30:57,707 And so it's important to identify them early. 525 00:30:57,707 --> 00:31:01,327 The medical management for them might be different and your cardiologist looking 526 00:31:01,327 --> 00:31:05,327 at that EKG might suggest a completely different approach to that patient. 527 00:31:05,547 --> 00:31:08,247 And if you're not at a center that can do bypass grafting, 528 00:31:08,457 --> 00:31:09,747 that patient may get sent out. 529 00:31:09,807 --> 00:31:17,027 So just just be aware that ST elevation in a VR is a significant disease harbinger. 530 00:31:17,287 --> 00:31:20,327 And the ST segment elevation can be less than a millimeter. 531 00:31:20,687 --> 00:31:24,747 So it doesn't have to be very significant in order for this to be the case. 532 00:31:24,747 --> 00:31:28,157 It, it is usually associated with ST depression in other leads and 533 00:31:28,157 --> 00:31:29,297 something you need to keep in mind. 534 00:31:30,123 --> 00:31:33,753 T.R. Eckler (2): As we get into these though I think it was important for me to 535 00:31:34,053 --> 00:31:38,163 set my expectations that this is not like if you find this a hundred percent of the 536 00:31:38,163 --> 00:31:42,663 time they have an acute coronary occlusion Like when we're talking about aVR ST 537 00:31:42,663 --> 00:31:48,783 segment elevation Even if you have it with multi lead ST depression only 10% of these 538 00:31:48,783 --> 00:31:52,833 are gonna be in acute coronary occlusion So that's worth it's still worth saying 539 00:31:52,833 --> 00:31:55,923 Hey I'm worried about this patient I don't like the way they look I think this 540 00:31:55,923 --> 00:31:59,253 is what I see This is what I'm thinking But just know that if your cardiologist 541 00:31:59,253 --> 00:32:02,913 says Hey okay I think it's more likely that it's not Let's watch em Let's kind 542 00:32:02,913 --> 00:32:06,123 of see how this develops That's not an unreasonable thing and I think there's 543 00:32:06,123 --> 00:32:09,213 a few of these that are like that It's about having the conversation and alerting 544 00:32:09,213 --> 00:32:10,713 them early and then seeing where it goes 545 00:32:11,875 --> 00:32:12,085 Sam (2): All right. 546 00:32:12,085 --> 00:32:13,495 Let's talk about Wellen syndrome. 547 00:32:13,495 --> 00:32:18,700 So, Wellen Syndrome is a specific EKG pattern that you will see in 548 00:32:18,700 --> 00:32:20,620 a patient when they're pain free. 549 00:32:20,810 --> 00:32:23,540 So the classic board question is that they come in with pain and 550 00:32:23,540 --> 00:32:26,390 they have a normal EKG, and then you give 'em some nitroglycerin 551 00:32:26,390 --> 00:32:27,590 and then you go to repeat it. 552 00:32:27,590 --> 00:32:28,610 And now they're pain free. 553 00:32:28,760 --> 00:32:33,290 And they have this abnormality with a biphasic T wave in V two through V 554 00:32:33,290 --> 00:32:37,380 three, meaning it goes up and down or a deeply inverted T-wave in V two and 555 00:32:37,380 --> 00:32:42,710 V three that when they're pain free, can be a harbinger of disease as well. 556 00:32:42,870 --> 00:32:47,080 And is something you want to bring to the attention of your cardiologist. 557 00:32:47,150 --> 00:32:50,544 . And much like the previous things that we mentioned, you should be concerned 558 00:32:50,544 --> 00:32:54,774 about disease at the proximal left anterior descending, or the proximal LAD. 559 00:32:54,804 --> 00:32:59,644 Again, not a place that you want to have stenosis or disease because 560 00:32:59,794 --> 00:33:03,724 if it occludes, you're looking at some pretty remarkable symptoms 561 00:33:03,724 --> 00:33:05,224 and dysrhythmias and death. 562 00:33:05,324 --> 00:33:08,534 So finding this on EKG is very, very important. 563 00:33:08,534 --> 00:33:11,114 Detecting it early, and especially if there's someone who has 564 00:33:11,114 --> 00:33:14,354 presented with chest pain, now they're already symptomatic. 565 00:33:14,534 --> 00:33:16,784 That person is not somebody you want to send home. 566 00:33:17,084 --> 00:33:19,604 That person is also not somebody you wanna put in like your obs 567 00:33:19,604 --> 00:33:21,284 unit and give a stress test to. 568 00:33:21,494 --> 00:33:23,774 You need to get cardiology involved in that case. 569 00:33:23,904 --> 00:33:25,224 And they need to go get a cath. 570 00:33:26,067 --> 00:33:26,427 All right. 571 00:33:26,517 --> 00:33:29,067 Reciprocal ST segment depression. 572 00:33:29,187 --> 00:33:35,437 So, there are oftentimes where you might see something concerning on your ECG or 573 00:33:35,437 --> 00:33:39,187 your EKG, and it's an ST elevation, and your cardiologist is gonna say, great, 574 00:33:39,187 --> 00:33:40,717 you've got all these ST elevations. 575 00:33:40,717 --> 00:33:41,647 Are there depressions? 576 00:33:41,647 --> 00:33:42,937 Are there some reciprocal changes? 577 00:33:42,937 --> 00:33:45,947 I get that question all the time especially from our interventionalists. 578 00:33:45,947 --> 00:33:53,307 And so table four outlines the reciprocal portions of the EKG anatomically 579 00:33:53,457 --> 00:33:57,057 so that when you have elevations in one section, you should expect 580 00:33:57,057 --> 00:33:59,127 depressions in the reciprocal section. 581 00:33:59,337 --> 00:34:03,687 That's just more proof that what you're seeing in ST elevation is not due to 582 00:34:03,687 --> 00:34:08,617 some kind of electrical conduction disorder, but is due to actual ischemia. 583 00:34:09,167 --> 00:34:14,057 So if they have posterior ST elevation, you're gonna see anterior ST depression. 584 00:34:14,057 --> 00:34:15,377 That's how you're gonna diagnose that. 585 00:34:15,527 --> 00:34:19,757 If they have anterior ST elevation, you're gonna see the ST depression inferiorly. 586 00:34:19,757 --> 00:34:21,167 That's the reciprocal changes. 587 00:34:21,477 --> 00:34:25,287 If they're having an inferior mi, you're gonna see reciprocal changes laterally. 588 00:34:25,617 --> 00:34:28,227 If they're having a lateral mi, you're gonna see the reciprocal 589 00:34:28,227 --> 00:34:29,739 changes in the septal leads. 590 00:34:30,439 --> 00:34:34,379 And if they're having a septal mi you're gonna see posterior ST depression with 591 00:34:34,379 --> 00:34:35,879 posterior leads if you're using that. 592 00:34:35,879 --> 00:34:39,919 So, there's a nice little mnemonic, the PAILS mnemonic which helps remind you 593 00:34:39,919 --> 00:34:44,959 about the posterior, anterior, inferior lateral and septal areas on the EKG and 594 00:34:44,959 --> 00:34:46,909 where those reciprocal changes will occur. 595 00:34:47,009 --> 00:34:49,649 That's a helpful mnemonic to keep in mind, and it's probably a question 596 00:34:49,649 --> 00:34:52,379 you're gonna get from your cardiologist when you call about the STEMI. 597 00:34:52,649 --> 00:34:55,254 T.R. Eckler (2): I think worth looking at these basically like once you've 598 00:34:55,254 --> 00:34:59,634 looked at this table now you go pull up a posterior MI and you see the anterior 599 00:34:59,634 --> 00:35:03,264 depressions You pull up an anterior mi you see the inferior depressions as 600 00:35:03,264 --> 00:35:07,464 you said for the lateral mi Then you're looking for septal or inferior depressions 601 00:35:07,464 --> 00:35:11,364 I think once you see it this is one of those being a more visual human that 602 00:35:11,364 --> 00:35:15,534 that figured this out gradually in his education I think if you show me the 603 00:35:15,534 --> 00:35:19,614 positive and negative changes on the EKG I'm much more likely to recognize 604 00:35:19,614 --> 00:35:21,324 it when I see that pattern in the future 605 00:35:22,181 --> 00:35:22,401 Sam (2): Yep. 606 00:35:22,736 --> 00:35:26,466 And then the last one is inferior mi. So inferior MI is defined 607 00:35:26,476 --> 00:35:32,206 as ST elevation of any degree in two contiguous inferior leads. 608 00:35:32,206 --> 00:35:35,896 So it doesn't matter how much elevation, but if you see ST elevation of any degree 609 00:35:35,896 --> 00:35:41,266 in two contiguous inferior leads with any amount of depression in a VL that's 610 00:35:41,416 --> 00:35:48,426 highly suspicious for inferior mi and a VL in that scenario is the only lead that's 611 00:35:48,426 --> 00:35:50,676 truly reciprocal for the inferior wall. 612 00:35:50,836 --> 00:35:52,696 And that's something that's that's concerning. 613 00:35:52,726 --> 00:35:54,166 You need to bring that up to your cardiologist. 614 00:35:54,196 --> 00:35:57,826 There was a retrospective review, like 150 patients confirmed with inferior 615 00:35:57,916 --> 00:36:03,236 STEMI found that all of them had these st changes and had the ST depression in a VL. 616 00:36:03,589 --> 00:36:06,079 these patients are at higher risk as well for arrhythmias. 617 00:36:06,079 --> 00:36:08,129 They're at higher risk for hypotension. 618 00:36:08,319 --> 00:36:10,359 If you see these changes, you gotta be careful with the 619 00:36:10,359 --> 00:36:11,649 nitroglycerin you're giving them. 620 00:36:11,649 --> 00:36:15,179 So, lots of things you gotta keep in mind when you see these changes. 621 00:36:15,577 --> 00:36:18,822 T.R. Eckler (2): I think the thing that I took away from this too was like now we're 622 00:36:18,822 --> 00:36:22,962 starting to really get down Now we're talking about a quarter of a millimeter 623 00:36:23,192 --> 00:36:27,902 of depression is what they're trying to describe here And I think that you 624 00:36:27,902 --> 00:36:32,132 need to remember when you're doing EKGs if you have a low QRS voltage That was 625 00:36:32,132 --> 00:36:35,072 one of the things they talked about the limiting factor in diagnosing these You 626 00:36:35,072 --> 00:36:40,562 can change the sizes of the waves if you ask your EKG texts nicely So if you think 627 00:36:40,562 --> 00:36:44,762 there's something there but the waves are too small repeat EKG Increase the size 628 00:36:44,792 --> 00:36:48,182 increase the amount that you have the ability to see and it's gonna draw out 629 00:36:48,182 --> 00:36:49,952 more of these things more clearly for you 630 00:36:51,059 --> 00:36:53,819 Sam (2): Yeah, one more plug for whatever tech companies listening 631 00:36:53,819 --> 00:36:57,029 to try and develop that iPad with the EKG readings on it for me. 632 00:36:57,309 --> 00:37:00,849 It'd be nice to be able to change the settings live on the EKG I'm looking at, 633 00:37:00,849 --> 00:37:04,149 instead of having to send the tech back to do another one so we can make this 634 00:37:04,149 --> 00:37:06,709 diagnosis immediately for future tech. 635 00:37:07,369 --> 00:37:07,469 you go. 636 00:37:09,454 --> 00:37:13,054 So that's all of the conditions that are harbinger of ischemia. 637 00:37:13,054 --> 00:37:16,354 So that's not necessarily STEMI equivalents, but these are things 638 00:37:16,354 --> 00:37:17,914 that will tell you something is wrong. 639 00:37:17,914 --> 00:37:21,064 And that's aVR ST elevation. 640 00:37:21,364 --> 00:37:23,584 That's our Wellen syndrome. 641 00:37:23,734 --> 00:37:28,224 That's our reciprocal changes, and that's our inferior mi. Those st 642 00:37:28,224 --> 00:37:31,704 elevations in the inferior leads with ST depression and a VL, all 643 00:37:31,704 --> 00:37:33,864 of those are harbinger of ischemia. 644 00:37:34,789 --> 00:37:36,559 T.R. Eckler (2): Just a brief pause for applause for the 645 00:37:36,559 --> 00:37:38,359 crowd for listening to that 646 00:37:38,852 --> 00:37:39,392 Sam (2): a hundred percent. 647 00:37:40,097 --> 00:37:41,512 . Go look at this issue. 648 00:37:41,612 --> 00:37:46,482 If you have access to it@ebmedicine.net copy these images and stick it in your 649 00:37:46,692 --> 00:37:49,042 favorite image section on your phone. 650 00:37:49,232 --> 00:37:50,222 And just keep this handy. 651 00:37:50,222 --> 00:37:52,657 This is such a powerful issue if. 652 00:37:53,282 --> 00:37:54,902 Laboratory testing is pretty easy. 653 00:37:54,902 --> 00:37:57,692 Everybody's gonna get a troponin, a high sensitivity troponin, they'll 654 00:37:57,692 --> 00:37:59,462 elevate in as little as an hour. 655 00:37:59,652 --> 00:38:02,652 And nothing new in that realm. 656 00:38:02,652 --> 00:38:04,392 So, you're gonna get your labs. 657 00:38:04,452 --> 00:38:05,202 Not a big deal. 658 00:38:05,442 --> 00:38:08,172 When it comes to imaging, again, there's not a whole bunch 659 00:38:08,172 --> 00:38:09,672 of imaging we're relying on. 660 00:38:09,672 --> 00:38:11,596 Everybody gets a screening, chest xray 661 00:38:11,980 --> 00:38:14,494 . Interesting actually, that there's not great evidence to indicate 662 00:38:14,614 --> 00:38:18,154 that there's really much value added within a chest x-ray. 663 00:38:18,404 --> 00:38:22,094 But as they get their chest x-ray, it's not usually taking up a whole 664 00:38:22,094 --> 00:38:23,834 bunch of resources in the department. 665 00:38:23,834 --> 00:38:27,184 And so we still do it, we're looking at the aortic knob, we're looking for 666 00:38:27,394 --> 00:38:30,754 anything else pneumothoraces or anything else that might cause chest pain. 667 00:38:31,004 --> 00:38:33,314 Maybe looking to see that they're not in florid failure, although you've 668 00:38:33,314 --> 00:38:34,664 probably already diagnosed that. 669 00:38:34,664 --> 00:38:38,624 So again, it's not adding a whole bunch, but it's, it gets done all the time. 670 00:38:39,837 --> 00:38:42,592 T.R. Eckler (2): I thought there was a case to be made though when they talk 671 00:38:42,592 --> 00:38:47,322 about transthoracic echo cause these patients STEMI patients NOMI patients 672 00:38:47,322 --> 00:38:51,132 OMI patients these are quick patients you're trying to figure this out quickly 673 00:38:51,312 --> 00:38:55,452 You're looking at that EKG I think if they're unstable especially you should 674 00:38:55,452 --> 00:38:58,062 take the time that you would've used your stethoscope or you would've used 675 00:38:58,062 --> 00:39:01,032 the chest x-ray and put it into an ultrasound because I think you're gonna 676 00:39:01,032 --> 00:39:03,252 get much better data much more quickly. 677 00:39:03,382 --> 00:39:06,022 You're gonna confirm your diagnosis or you're gonna notice other things 678 00:39:06,022 --> 00:39:10,492 developing like a pericardial effusion like fluid in their lungs like pleural 679 00:39:10,492 --> 00:39:13,912 effusions You're gonna just know more about this human as you're trying to 680 00:39:13,912 --> 00:39:17,818 resuscitate them and stabilize them enough to get them to the cath lab And I think 681 00:39:17,818 --> 00:39:21,808 that's the case here is you can get a lot of an echo pretty quickly that's gonna 682 00:39:21,808 --> 00:39:23,878 help you do more to save these patients 683 00:39:24,432 --> 00:39:27,552 Sam (2): Yeah, so the, the echo isn't visualizing coronary anatomy 684 00:39:27,552 --> 00:39:28,992 or diagnosing coronary disease. 685 00:39:28,992 --> 00:39:32,682 The echo is looking for regional wall motion abnormalities. 686 00:39:32,952 --> 00:39:37,142 There is data that suggests that the ventricular movement, the wall motion 687 00:39:37,142 --> 00:39:41,432 of the ventricle, is going to look different before any EKG changes occur. 688 00:39:41,582 --> 00:39:44,282 So this could be your earliest tool for detection. 689 00:39:44,522 --> 00:39:49,362 And there is good data that says that in the hands of emergency medicine 690 00:39:49,362 --> 00:39:54,772 trainees, even that identification of regional wall motion abnormalities 691 00:39:54,992 --> 00:39:59,742 is possible with a sensitivity of 88% and a specificity of 92%. 692 00:39:59,742 --> 00:40:03,102 So we do a pretty decent job with training. 693 00:40:03,102 --> 00:40:06,822 If you've never had that training, go take a course, look at a bunch of echoes. 694 00:40:06,942 --> 00:40:07,752 It's important. 695 00:40:07,752 --> 00:40:09,312 It's a good skill to have. 696 00:40:09,702 --> 00:40:15,412 Also equally important to keep in mind that if they don't have regional wall 697 00:40:15,412 --> 00:40:19,612 motion abnormalities that does not rule out acute coronary occlusion. 698 00:40:19,642 --> 00:40:22,042 So it's one of those things that can help you rule it in, 699 00:40:22,222 --> 00:40:23,362 but it isn't gonna rule it out. 700 00:40:23,672 --> 00:40:28,112 And like you said, if they're unstable or have shock, it's it's definitely your 701 00:40:28,112 --> 00:40:30,402 first go-to for evaluating the ventricle. 702 00:40:31,300 --> 00:40:34,290 T.R. Eckler (2): The caveat to that being and and I liked how the authors 703 00:40:34,290 --> 00:40:39,540 got to this was If the regional wall motion abnormality fits in the area where 704 00:40:39,540 --> 00:40:45,840 you think they have an occlusion that increases the likelihood that they have 705 00:40:46,050 --> 00:40:50,430 an occlusion mi there And that should hopefully push your cardiologist more to 706 00:40:50,430 --> 00:40:53,760 take them for reperfusion And I've seen some of our cardiologists do this where 707 00:40:53,760 --> 00:40:57,720 it's kind of not clear they're taking that echo and looking and seeing what 708 00:40:57,720 --> 00:41:00,510 like that certain region of the heart looks like And if it doesn't look like 709 00:41:00,510 --> 00:41:03,930 it's it's moving normally to them it pushes them to the cath lab And I think 710 00:41:03,930 --> 00:41:04,795 that's something to have in your mind 711 00:41:06,097 --> 00:41:06,912 Sam (2): Yeah, great point. 712 00:41:07,155 --> 00:41:11,605 So that's transthoracic, echocardiography supplemental oxygen. 713 00:41:11,605 --> 00:41:14,375 We touched on this earlier in the EMS section but there 714 00:41:14,375 --> 00:41:15,725 have been several trials. 715 00:41:15,935 --> 00:41:20,015 The air versus oxygen in ST segment Elevation, myocardial 716 00:41:20,015 --> 00:41:21,785 infarction or AVOID trial. 717 00:41:21,785 --> 00:41:22,055 Great. 718 00:41:22,055 --> 00:41:23,065 Name the, 719 00:41:23,133 --> 00:41:27,208 T.R. Eckler (2): With air versus oxygen in an ischemic disease But what a great 720 00:41:27,208 --> 00:41:32,518 team of people making up the names for these trials because then the D two 721 00:41:32,608 --> 00:41:38,848 OX a MI trial I love how they combine detox and oxygen into one word Just 722 00:41:39,778 --> 00:41:40,658 really creative work by these folks 723 00:41:40,845 --> 00:41:41,035 Sam (2): Yeah. 724 00:41:41,425 --> 00:41:41,605 Yeah. 725 00:41:41,605 --> 00:41:45,025 Both of these the first trial had 441 STEMI patients in it. 726 00:41:45,085 --> 00:41:49,105 The second trial had over 6,000 patients with myocardial infarction in it. 727 00:41:49,415 --> 00:41:54,125 And both of them found really no benefit whatsoever to just routinely 728 00:41:54,125 --> 00:41:57,215 applying oxygen to people who have normal oxygen saturation. 729 00:41:57,425 --> 00:42:00,155 So if they're hypoxic, if their saturation's less than 730 00:42:00,155 --> 00:42:02,235 90% then there's a benefit. 731 00:42:02,385 --> 00:42:05,235 Otherwise, there is no benefit to it whatsoever. 732 00:42:05,687 --> 00:42:10,062 T.R. Eckler (2): In some of the patients on oxygen had larger sized infarcts 733 00:42:10,242 --> 00:42:15,072 when they went back and looked at them later and oxygen did not reduce all 734 00:42:15,072 --> 00:42:19,602 cause mortality and did not reduce hospitalization with myocardial infarction 735 00:42:19,602 --> 00:42:25,422 So really like lots of things that didn't help and things that may make it worse 736 00:42:25,482 --> 00:42:28,722 So I'm now more inclined to pull oxygen off my patients if they're coming in 737 00:42:28,722 --> 00:42:30,162 with chest pain and they're over 90% 738 00:42:30,550 --> 00:42:30,730 Sam (2): Yeah. 739 00:42:30,730 --> 00:42:33,880 Very few conditions in medicine benefit from Hyperoxia. 740 00:42:33,940 --> 00:42:37,397 Really, it, it's just, it's not, it's not a great thing for us as human beings. 741 00:42:38,100 --> 00:42:38,340 All right. 742 00:42:38,340 --> 00:42:40,770 Analgesia, you're gonna give them nitroglycerin. 743 00:42:40,770 --> 00:42:43,860 You can give them morphine, you can give them fentanyl. 744 00:42:43,990 --> 00:42:48,800 There is data that your first go-to agent should be some kind of nitrate. 745 00:42:49,030 --> 00:42:53,290 The nitrates themselves really don't have evidence to improve 746 00:42:53,290 --> 00:42:54,970 or reduce myocardial injury. 747 00:42:54,970 --> 00:42:59,000 In patients with STEMI, they can help in vasospasm and they might 748 00:42:59,000 --> 00:43:00,650 clinically relieve some of the pain. 749 00:43:00,740 --> 00:43:04,400 But as far as like reperfusion goes, giving 'em a sublingual nitroglycerin 750 00:43:04,400 --> 00:43:05,630 is not gonna reperfuse them. 751 00:43:06,110 --> 00:43:10,930 And the analgesics there is some mild observational data that says yes, you 752 00:43:10,930 --> 00:43:12,980 can give them medications for pain. 753 00:43:13,160 --> 00:43:17,990 Just remember that their response to pain medication does not become diagnostic. 754 00:43:18,050 --> 00:43:20,420 So if you give them morphine and they get better, it doesn't mean they don't 755 00:43:20,420 --> 00:43:21,740 have an acute coronary occlusion. 756 00:43:21,920 --> 00:43:23,270 It just means their pain got better. 757 00:43:23,390 --> 00:43:26,060 'cause now you're covering it up with morphine and there's nothing wrong 758 00:43:26,060 --> 00:43:28,640 with making the patient comfortable while they're waiting for your 759 00:43:28,640 --> 00:43:30,260 cardiology colleague to make a decision. 760 00:43:30,350 --> 00:43:31,460 That's okay. 761 00:43:32,268 --> 00:43:36,108 T.R. Eckler (2): My takeaway from this was I was gonna make sure if I'm transferring 762 00:43:36,108 --> 00:43:40,368 a patient that if I can control their pain with Nitro I put em on a Nitro drip 763 00:43:40,608 --> 00:43:44,883 and send them that way But I wouldn't be opposed to basically giving my EMS 764 00:43:44,883 --> 00:43:48,933 crews orders to use Nitro and fentanyl and give them kind of short acting things 765 00:43:48,933 --> 00:43:53,103 to address this But I think that was my thought was a nitro drip can be a pain 766 00:43:53,103 --> 00:43:57,553 control adjunct for transporting these patients especially if they responded 767 00:43:57,553 --> 00:44:00,458 to it in the ER while they're moving for an hour or two to another hospital 768 00:44:01,675 --> 00:44:01,915 Sam (2): Yeah. 769 00:44:01,920 --> 00:44:03,835 Or if they're critically hypertensive and you wanna give 770 00:44:03,835 --> 00:44:05,095 it for blood pressure management. 771 00:44:05,095 --> 00:44:06,625 There are other reasons why you might start it. 772 00:44:06,875 --> 00:44:08,735 But just remember it's not diagnostic. 773 00:44:09,705 --> 00:44:11,235 And then there is pharmacotherapy. 774 00:44:11,235 --> 00:44:13,275 So this is an extensive section. 775 00:44:13,365 --> 00:44:15,615 You, your hospital's going to have a protocol. 776 00:44:15,615 --> 00:44:17,685 Your cardiologists are gonna have their preferences. 777 00:44:17,815 --> 00:44:21,625 The greatest benefit ever from anything has been aspirin. 778 00:44:21,715 --> 00:44:24,955 So as far as medication goes, so everybody's getting their aspirin, 779 00:44:24,955 --> 00:44:31,225 either 162 or 325 milligrams as soon as possible, chew this aspirin and you 780 00:44:31,225 --> 00:44:34,955 have given 'em the greatest benefit you can if you're not the cardiologist. 781 00:44:35,255 --> 00:44:38,120 T.R. Eckler (2): I disagree Just for one second I would like to speak on 782 00:44:38,120 --> 00:44:43,700 behalf of my fellow rural providers or lytic-ologists as we like to be called 783 00:44:43,880 --> 00:44:47,660 the NNT for aspirin in STEMI is what Sam 784 00:44:48,752 --> 00:44:49,502 Sam (2): I dunno, what is it? 785 00:44:49,915 --> 00:44:50,545 T.R. Eckler (2): 42 786 00:44:51,932 --> 00:44:52,202 Sam (2): Hey, 787 00:44:52,220 --> 00:44:54,200 T.R. Eckler (2): you know what comes one place behind it 788 00:44:55,142 --> 00:44:55,502 Sam (2): what's that? 789 00:44:55,610 --> 00:44:57,710 T.R. Eckler (2): At 43 TNK 790 00:44:58,562 --> 00:44:59,042 Sam (2): Wow. 791 00:44:59,162 --> 00:44:59,912 Hey, that's pretty good. 792 00:45:00,620 --> 00:45:03,200 T.R. Eckler (2): So I would tell you aspirin is incredible I think every heart 793 00:45:03,200 --> 00:45:06,560 attack should get it But I also think that if they're not close enough to get 794 00:45:06,560 --> 00:45:11,580 PCI you should also be making sure they don't meet any of the exclusion criteria 795 00:45:11,580 --> 00:45:14,790 and they're not gonna explode blood into their brain or from their recent surgery 796 00:45:14,795 --> 00:45:20,490 or arterial catheter site I think that TNK is also going to now and and at 797 00:45:20,490 --> 00:45:23,970 the same time setting expectations for yourself cause you know you wanna be 798 00:45:23,970 --> 00:45:28,290 that ER doctor on TV that saves every life You're not going to win every 799 00:45:28,290 --> 00:45:33,510 one of these acute mis but aspirin and lytics are your best tools in that kit 800 00:45:33,600 --> 00:45:36,660 And when they work they're gonna work and you're gonna make a difference with 801 00:45:36,660 --> 00:45:38,460 them And NNT of 42 and 43 is pretty good 802 00:45:39,005 --> 00:45:39,725 Sam (2): That is very good. 803 00:45:40,485 --> 00:45:42,165 There are other categories. 804 00:45:42,165 --> 00:45:44,655 So you've got P2Y12 inhibitors. 805 00:45:44,655 --> 00:45:49,965 That's your things like clopidogrel and prasugrel and ticagrelor and cangrelor 806 00:45:50,915 --> 00:45:52,385 which is the only one that's iv. 807 00:45:52,575 --> 00:45:56,895 And then you've got your GP2B3A receptor antagonists. 808 00:45:57,045 --> 00:46:00,485 You've got traditional anticoagulation like heparin and then you've 809 00:46:00,485 --> 00:46:01,955 got your fibrinolytic therapies. 810 00:46:01,955 --> 00:46:06,215 So all of these fall under the blanket of pharmacotherapy, starting with 811 00:46:06,215 --> 00:46:11,135 aspirin, which everybody's gonna get when it comes to the P2Y12 inhibitors. 812 00:46:11,135 --> 00:46:12,845 These are anti-platelet agents. 813 00:46:12,845 --> 00:46:16,645 They keep the platelets from aggregating three outta the four are oral. 814 00:46:16,765 --> 00:46:19,895 If the patient's not already taking it your cardiologist or your 815 00:46:19,895 --> 00:46:23,585 hospital protocol may include a loading dose of these for STEMI. 816 00:46:23,895 --> 00:46:30,080 The only time your cardiologist might hesitate is if the EKG suggests something 817 00:46:30,080 --> 00:46:33,640 like a main artery or a large artery occlusion and they're concerned there 818 00:46:33,640 --> 00:46:36,850 might be multi-vessel disease and this person might end up having to go get 819 00:46:36,850 --> 00:46:42,070 shipped off for a bypass graft, then some of these agents are not reversible. 820 00:46:42,070 --> 00:46:43,780 Actually, all of these agents are not reversible. 821 00:46:43,780 --> 00:46:47,260 So once you've given it, you have to wait for it to wash out and that delays 822 00:46:47,260 --> 00:46:49,180 their bypass graft, surgical time. 823 00:46:49,390 --> 00:46:53,104 So ask your cardiologist or give whatever the protocol says. 824 00:46:53,294 --> 00:46:54,044 I do both. 825 00:46:54,094 --> 00:46:56,104 Hey, per protocol I'm supposed to give yada, yada. 826 00:46:56,104 --> 00:46:56,764 Are you good with that? 827 00:46:56,764 --> 00:46:57,064 Yes. 828 00:46:57,094 --> 00:46:58,084 Okay, I'm giving it now. 829 00:46:58,274 --> 00:47:02,214 That kind of thing, it's okay to have that conversation but just know that there's 830 00:47:02,214 --> 00:47:04,614 good evidence that those will help. 831 00:47:04,854 --> 00:47:08,629 The decision for which one to give is purely up to your 832 00:47:08,629 --> 00:47:10,069 hospital and your cardiologist. 833 00:47:10,349 --> 00:47:15,152 Clopidogrel has the best evidence behind it as far as bleeding 834 00:47:15,152 --> 00:47:16,892 goes, and the side effects. 835 00:47:17,042 --> 00:47:21,692 While things like ticagrelor and prasugrel have the best response 836 00:47:21,782 --> 00:47:26,042 as far as anti-platelet aggregation goes, but with higher bleeding risks. 837 00:47:26,042 --> 00:47:28,932 So, I leave that decision up to my cardiology colleagues. 838 00:47:29,022 --> 00:47:30,822 I don't have a preference between all of those. 839 00:47:31,550 --> 00:47:35,140 T.R. Eckler (2): Some of those medications are very expensive though and a lot of 840 00:47:35,170 --> 00:47:39,580 your patients that come in are gonna be quote unquote prescribed these medicines 841 00:47:39,700 --> 00:47:44,320 and it's important to ask them Hey are you really taking it Or did your prescription 842 00:47:44,320 --> 00:47:47,770 run out Or did you not have the money to fill it Because I find that a lot of 843 00:47:47,770 --> 00:47:53,080 patients that come in with occluded stents with mis if you really ask em they're like 844 00:47:53,080 --> 00:47:58,110 yeah I came off my my Brilinta ticagrelor same drug I came off that Month or so 845 00:47:58,110 --> 00:47:59,460 ago cause I couldn't afford it anymore 846 00:47:59,702 --> 00:47:59,942 Sam (2): Yeah. 847 00:48:00,602 --> 00:48:00,812 And 848 00:48:00,900 --> 00:48:01,410 T.R. Eckler (2): So it's 849 00:48:01,412 --> 00:48:01,982 Sam (2): is higher. 850 00:48:02,102 --> 00:48:04,962 So, even if they did take it, you're gonna have to give 'em another dose. 851 00:48:04,962 --> 00:48:09,222 If they're do, if they took 75 milligrams this morning, the loading dose is 600, 852 00:48:09,222 --> 00:48:10,392 you gotta give them the rest of it. 853 00:48:10,392 --> 00:48:12,832 So, so yes, absolutely ask that question. 854 00:48:13,742 --> 00:48:17,762 The glycoprotein or two B three A receptor inhibitors, that's something 855 00:48:17,762 --> 00:48:19,322 we're just not giving in the ed. 856 00:48:19,352 --> 00:48:21,002 That's something they're gonna give in the cath lab. 857 00:48:21,192 --> 00:48:25,392 There are specific times where they might want that extra platelet 858 00:48:25,392 --> 00:48:28,882 aggregation blocking, and that's up to your cardiology colleagues. 859 00:48:28,882 --> 00:48:31,642 This is an adjunct at the time of PCI. 860 00:48:31,862 --> 00:48:34,562 And so there was a brief period of time where we were giving those in the 861 00:48:34,567 --> 00:48:36,482 ed, or at least had them available. 862 00:48:36,612 --> 00:48:42,112 Now it's universally given in the cath lab, When it comes to standard 863 00:48:42,112 --> 00:48:47,102 anticoagulation like heparin versus low molecular weight heparin this again is 864 00:48:47,102 --> 00:48:50,282 very cardiology and hospital specific. 865 00:48:50,282 --> 00:48:55,672 So, unfractionated heparin was established at the standard of care long time ago, 866 00:48:55,702 --> 00:49:00,052 and there is good data that says that low molecular weight heparin can work. 867 00:49:00,272 --> 00:49:05,372 But there are, again, regional and physician specific preferences and 868 00:49:05,372 --> 00:49:06,812 there's no need to get into any of that. 869 00:49:07,062 --> 00:49:10,722 Some of the cardiology colleagues like that, you can turn off IV heparin 870 00:49:10,722 --> 00:49:14,282 and rapid reverse and if there's other issues or complications or 871 00:49:14,282 --> 00:49:15,632 bleeding complications that come up. 872 00:49:15,632 --> 00:49:18,842 So just have that conversation with your cardiology colleague. 873 00:49:18,842 --> 00:49:21,422 Make sure it's in whatever your hospital protocol says. 874 00:49:21,842 --> 00:49:25,112 And then lastly, let's talk about those reperfusion therapies. 875 00:49:25,302 --> 00:49:31,282 So there are fibrinolytics that can be given the American Heart Association 876 00:49:31,282 --> 00:49:35,272 and American College of Cardiology recommendations are that if your 877 00:49:35,272 --> 00:49:40,312 patient with the STEMI can't make it to a PCI center within 120 minutes, 878 00:49:40,792 --> 00:49:44,932 that they should go to somewhere where fibrinolytics can be given, if they 879 00:49:44,992 --> 00:49:48,562 can make it to a PCI Ready Hospital. 880 00:49:48,772 --> 00:49:53,372 The first contact to balloon time in the artery should be 90 minutes. 881 00:49:53,372 --> 00:49:56,192 So that's two different numbers, but don't get them confused. 882 00:49:56,192 --> 00:49:58,382 One is a goal time for PCI centers. 883 00:49:58,382 --> 00:49:59,372 That's 90 minutes. 884 00:49:59,682 --> 00:50:04,572 The other is the overall timeframe for how you decide, okay, should we 885 00:50:04,572 --> 00:50:08,992 get this person all the way to the PCI center that's three hours away, 886 00:50:09,232 --> 00:50:11,962 or should we take 'em to the local hospital where they're gonna get lytics? 887 00:50:12,152 --> 00:50:14,582 And the answer is, 120 minutes is the cutoff. 888 00:50:14,582 --> 00:50:17,222 So if they can't make it to the PCI center in 120 minutes or 889 00:50:17,222 --> 00:50:20,312 two hours, then they need to go somewhere where they can get lytics. 890 00:50:20,915 --> 00:50:22,715 You've given lytics before TR? 891 00:50:23,352 --> 00:50:26,592 T.R. Eckler (2): I would say probably honestly like pretty getting close to like 892 00:50:26,592 --> 00:50:30,312 a hundred times now And I would tell you that I think that I've watched patients 893 00:50:30,312 --> 00:50:33,942 get better in front of me Not every time Sometimes you give it and you're sure 894 00:50:33,942 --> 00:50:37,332 it's a STEMI and the cardiologist's sure it's a STEMI and it doesn't break the clot 895 00:50:37,332 --> 00:50:42,202 down but I've seen patients diaphoretic dyspneic all of a sudden the color returns 896 00:50:42,202 --> 00:50:46,878 to their face and they're like Ah I feel great And then my understanding of sign 897 00:50:46,878 --> 00:50:51,198 language is limited but I I know the sign for helicopter because I love to signal 898 00:50:51,198 --> 00:50:56,958 that to my rural emergency secretary to call the helicopter because now I feel 899 00:50:56,958 --> 00:50:59,808 like you've got a brief window of time where they're open again and you gotta 900 00:50:59,808 --> 00:51:04,248 get em somewhere before they they try to close up on you again So I think that 901 00:51:04,362 --> 00:51:09,065 the other part of this which I think this article assumes aliveness throughout but 902 00:51:09,065 --> 00:51:13,205 I've had patients with N STEMIs that then progressed in rural places while waiting 903 00:51:13,205 --> 00:51:16,685 for their transfer And I had one that walked to the bathroom came back and I 904 00:51:16,685 --> 00:51:20,885 heard him hit the ground in his room while he walked his heparin pipe back And we 905 00:51:20,885 --> 00:51:25,655 came down and he was pulseless apnic he got intubated And I asked for TNK within 906 00:51:25,655 --> 00:51:29,945 the first minute or two cause I figured he had a STEMI And he got the TNK and was 907 00:51:29,945 --> 00:51:34,355 back in four minutes We had to sedate him to to keep him intubated But he did great 908 00:51:34,355 --> 00:51:38,195 He came back like a week later and it said he quit smoking and he was so glad 909 00:51:38,195 --> 00:51:41,315 that that he had come in and and gotten checked out for his chest pain that day 910 00:51:41,867 --> 00:51:42,137 Sam (2): Wow. 911 00:51:42,137 --> 00:51:44,207 That's, that's an incredible story. 912 00:51:44,755 --> 00:51:47,520 T.R. Eckler (2): if they have a STEMI and they got worse you don't have if if you're 913 00:51:47,520 --> 00:51:52,020 at a PCI center this was my big point If there's a STEMI and you're waiting for em 914 00:51:52,020 --> 00:51:55,180 to go to the cath lab and they code you can give them lytics if you can get em 915 00:51:55,180 --> 00:51:58,300 back and they can go to the cath lab great But if you can't get em back you can give 916 00:51:58,300 --> 00:52:01,270 these people lytics and you can make them better there on the spot And especially 917 00:52:01,270 --> 00:52:05,290 if they're young and healthy and you think it's worth the risk like it's another tool 918 00:52:05,290 --> 00:52:06,370 I think you should put in your toolkit 919 00:52:07,286 --> 00:52:09,386 Sam (2): And just for your own personal knowledge, once you've 920 00:52:09,386 --> 00:52:13,856 given the lytics, those people still go on to get coronary angiography. 921 00:52:14,016 --> 00:52:17,826 Typically they'll wait a few hours, so, not within the first two or three 922 00:52:17,826 --> 00:52:21,216 hours, but, but somewhere in the first 24 hours they'll go and get 923 00:52:21,216 --> 00:52:23,116 a cath assuming that they improved. 924 00:52:23,266 --> 00:52:26,926 If they have persistent chest pain, persistent EKG changes, those are 925 00:52:26,926 --> 00:52:29,626 all indications to just treat 'em like they're still having a STEMI and 926 00:52:29,626 --> 00:52:31,526 take 'em to the cath lab immediately. 927 00:52:31,776 --> 00:52:35,196 but the cardiologist definitely, if the person has improved and they're 928 00:52:35,196 --> 00:52:38,706 resolving their EKG changes, they'll let them cool off a little bit. 929 00:52:38,856 --> 00:52:42,066 And then the evidence suggests they'll do better if they cath them sometime in 930 00:52:42,066 --> 00:52:44,196 the first 24 hours instead of emergently. 931 00:52:45,814 --> 00:52:46,024 All right. 932 00:52:46,024 --> 00:52:49,264 Lastly, let's talk about as you just mentioned with that case example, 933 00:52:49,264 --> 00:52:51,094 the patients who have cardiac arrest. 934 00:52:51,094 --> 00:52:55,514 So somewhere around 10% of STEMIs that are transferred by EMS have 935 00:52:55,514 --> 00:52:57,524 an out-of-hospital cardiac arrest. 936 00:52:57,554 --> 00:53:00,714 That's a pretty significant number of STEMIs having arrests. 937 00:53:00,714 --> 00:53:03,594 So one in 10 of those STEMIs that are presenting by EMS 938 00:53:03,654 --> 00:53:04,824 will have a cardiac arrest. 939 00:53:05,014 --> 00:53:09,084 And they're mostly observational data in this population. 940 00:53:09,244 --> 00:53:14,554 Just know that if you get return of spontaneous circulation and the EKG shows 941 00:53:14,554 --> 00:53:17,914 STEMI that you're gonna progress down the STEMI pathway in those patients. 942 00:53:18,224 --> 00:53:21,914 And that there is guidelines from the American College of Cardiology 943 00:53:21,914 --> 00:53:25,834 and the American Heart Association stating just that so you get 944 00:53:25,864 --> 00:53:27,394 spontaneous return of circulation. 945 00:53:27,674 --> 00:53:31,364 The EKG shows STEMI, that patient is still a candidate for a primary PCI. 946 00:53:32,359 --> 00:53:33,079 And that's it. 947 00:53:33,199 --> 00:53:36,409 So that brings us to the end of this article. 948 00:53:36,619 --> 00:53:40,999 There are a lot of things that we covered, so please go take a look, look 949 00:53:40,999 --> 00:53:45,229 at the STEMI equivalents, look at the ischemic changes that you might see 950 00:53:45,229 --> 00:53:51,689 on ECG and try and shift your mental model away from just STEMI or non STEMI 951 00:53:51,869 --> 00:53:55,379 to occlusion versus non occlusion. 952 00:53:55,539 --> 00:53:59,049 And I think you'll find this categorization system much more helpful. 953 00:53:59,239 --> 00:54:04,949 I wanna say thanks to Dr. Horning for being the author for this February, 2026 954 00:54:04,949 --> 00:54:06,839 article on acute coronary occlusion. 955 00:54:06,839 --> 00:54:08,129 It was fantastic. 956 00:54:08,219 --> 00:54:10,619 Just jam packed full of information. 957 00:54:10,809 --> 00:54:14,919 And if you're listening, don't forget to go and claim your CME. 958 00:54:14,979 --> 00:54:16,659 Click the link in the show notes. 959 00:54:16,789 --> 00:54:18,229 Fill out the CME questions. 960 00:54:18,359 --> 00:54:21,429 Hopefully ace them because we did such a fantastic job 961 00:54:21,459 --> 00:54:22,779 walking you through the article. 962 00:54:22,939 --> 00:54:24,419 And don't forget , as always. 963 00:54:24,804 --> 00:54:28,314 clinical pathway in the back of the issue that will walk you through, step 964 00:54:28,314 --> 00:54:32,554 by step, each one of those decisions for this critical patient population. 965 00:54:33,064 --> 00:54:33,814 And that's a wrap. 966 00:54:33,874 --> 00:54:37,874 So until next time, everyone, I'm one of your hosts, Sam Ashoo. 967 00:54:38,519 --> 00:54:42,149 T.R. Eckler (2): TR Eckler wishing you the best of luck and keep your TNK ready 968 00:54:43,316 --> 00:54:45,136 Sam : And that's a wrap for this month's episode. 969 00:54:45,176 --> 00:54:47,756 I hope you found it educational and informative. 970 00:54:47,956 --> 00:54:52,816 Don't forget to go to ebmedicine.net to read the article and claim your CME. 971 00:54:52,986 --> 00:54:56,176 And of course, check out all three of the journals and the multitude of 972 00:54:56,176 --> 00:55:00,536 resources available to you, both for emergency medicine, pediatric emergency 973 00:55:00,536 --> 00:55:02,806 medicine, and evidence based urgent care. 974 00:55:03,116 --> 00:55:05,086 Until next time, everyone be safe.