Dr. Smith's ECG Blog

OCTOBER 23, 2023

An Initial ECG was performed: Initial ECG: Sinus tachycardia with prolonged QT interval (QTc of 534 ms by Bazett). A repeat ECG was performed 2 hours after arrival: QTc prolongation ato 722 ms now with alternating T wave pattern (T wave alternans) I texted this to Smith who responded: “T wave alternans and long QT. 2005.08.066.

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EKG/ECG Documentation/Coding Psychiatric EMS 131

Dr. Smith's ECG Blog

JULY 21, 2024

The below ECG was recorded. The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. This ECG does not have the typical ST-vector of an LAD occlusion. See below for Ken Grauer Comment on the initial ECG: == On arrival, another ECG was recorded: There appears to have been quite a bit of spontaneous reperfusion!

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EKG/ECG Shock Hospitals Sepsis 131

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

The following ECG was recorded. The presenting ECG shows SR with narrow QRS complexes. There is some upwards concave ST segment elevation in the inferior leads with what seems to be well formed J-waves. First troponin I returned 3174 ng/l, at which point a repeat ECG was ordered. Not much difference from 1st ECG.

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EKG/ECG COPD Shock Wellness 116

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

The ECG below was recorded by EMS. ECG #1 Interpretation: ECG #1 shows sinus rhythm at a heart rate of 77 bpm. At first glance, the ECG does not look too abnormal. In my experience, the pathologic finding in the above ECG is the easiest one to overlook — especially if you are in a rush and do not do a systematic review.

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Seizures EKG/ECG EMS Stroke 113

Dr. Smith's ECG Blog

JANUARY 30, 2019

I remember Allie well from her days in the Research volunteer program at Hennepin. An initial EKG was obtained: Computer read: sinus tachycardia, early acute anterior infarct. Here is her prior EKG: When compared to the old EKG – Q waves present before, TWI in aVR present before, but all other changes are new.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia EKG/ECG Wellness Documentation/Coding 52

Northwestern EM Blog

MARCH 1, 2025

In this study, they found that prone positioning resulted in significant improvement in oxygenation, as well as a 50% decrease in mortality at 28 days (Guerin et. Remove ECG leads and patches. Reattach EKG leads to back. The PROSEVA study is the most recent and famous randomized control trial. Leave most of the sheet hanging.

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Emergency Department Fractures EKG/ECG Wellness 52

Dr. Smith's ECG Blog

AUGUST 14, 2024

Written by Willy Frick I was reading through ECGs in the queue when I saw the following. At first glance there seems to be a lot of variation happening, but by focusing on one part of the ECG at a time we can make sense of it. So why does the sinus node apparently stop pacing for a few seconds in the middle of the ECG?

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EKG/ECG Outcomes Wellness 110

EMDocs

JANUARY 4, 2024

3 Bupropion blocks the reuptake of dopamine and norepinephrine, as well as antagonizes acetylcholine at nicotinic receptors. 3 Always get an EKG to assess for cardiotoxicity, including widened QRS and prolonged QTc, although this may not be evident right away. 3 Cardiotoxicity 3 All patients need an EKG and cardiac monitoring.

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Seizures EKG/ECG Poisoning Shock 92

Dr. Smith's ECG Blog

OCTOBER 23, 2022

The ECG told the story. EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 Time = 24 min S-wave depth is diminishing These prehospital ECGs were lost and not seen. This patient has a non-diagnostic ECG by most rules. She called 911. STE 60 V3 = 1.5

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EKG/ECG Hospitals EMS Ultrasounds 40

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Recently diagnosed with intermittent paroxysmal atrial fibrillation but no EKGs available to confirm. Find a QRS complex that begins on a heavy ECG grid line. The actual rate for the rhythm in ECG #1 is therefore ~70 X 4 ~280/minute. The answer to this question is fascinating — albeit extending beyond the scope of this ECG Blog.

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EKG/ECG Wellness Hospitals 64

Dr. Smith's ECG Blog

JUNE 2, 2023

She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? She was awake, alert, well perfused, with normal mental status and overall unremarkable physical exam except for a regular tachycardia, possible rales at both bases, some mild RUQ abdominal tenderness. And another example.

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EKG/ECG Wellness Ultrasounds EMS 96

Dr. Smith's ECG Blog

MARCH 10, 2017

Here is his ED ECG: The computer interpretation was " normal " What do you think? This ECG is NOT normal. Years later, I sent this to the Queen of Hearts: The Queen can see Hyperacute T-waves incredibly well. Acad Emerg Med 2017; 24(1): 120 – 24. Recording serial ECGs would be useful. There is low QRS amplitude.

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EKG/ECG Outcomes EMS Wellness 52

The Skeptics' Guide to EM

OCTOBER 22, 2017

[display_podcast] Date: October 19th, 2017 Reference: Hofmann et al. NEJM Sept 2017. display_podcast] Date: October 19th, 2017 Reference: Hofmann et al. NEJM Sept 2017. The ECG shows an inferior ST-Elevated Myocardial Infarction (STEMI). Oxygen Therapy in Suspected Acute Myocardial Infarction.

Hospitals 52

Hospitals EKG/ECG Wellness 52

Don't Forget the Bubbles

OCTOBER 7, 2024

Suspected low voltage injuries (<1000v) should still be approached with an A-E assessment, but if 12 lead ECG and urinalysis are normal, it’s reasonable to discharge the patient. If the ECG is abnormal, the patient should be managed as if exposed to a high voltage (>1000v). Pittman O, Toner H. Narayanan, K., 531-537.

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Burns Fluid Resuscitation Shock Resuscitation 80

ACEP Now

JULY 7, 2023

1 Ventricular tachycardia (VT) and ventricular fibrillation (VF) represent the most common initial rhythms for patients presenting to the ED in out-of-hospital cardiac arrest, as well as for patients who develop cardiac arrest while in the ED. Heart disease and stroke statistics-2017 update: A report from the American Heart Association.

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Resuscitation Shock Stroke Hospitals 98

Dr. Smith's ECG Blog

FEBRUARY 5, 2019

He had a triage ECG at time 0 (ECG-1): Computer read, with Physician overread: Sinus rhythm. If you see this, you must very closely question the patient about any chest symptoms, and even if no relevant symptoms, to be certain to look for old ECG, and to do serial ECGs and troponins. A 3rd ECG was recorded at 3.5

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EKG/ECG Emergency Department Wellness Shock 52

Dr. Smith's ECG Blog

DECEMBER 13, 2019

On exam the patient was well appearing, with normal vitals signs other than BP 155/82, no murmurs or rubs, normal pulses, no reproducible chest pain. Here is his triage ECG: What do you think? A repeat ECG was performed and cardiology was re-consulted: Roughly unchanged. 15-9/6/2017 ).

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EKG/ECG Operations Ultrasounds Wellness 52

Dr. Smith's ECG Blog

JULY 27, 2023

He had a prehospital ECG that was worrisome to the medics, so they called me to see him at the door. His prehospital ECG showed "inferior" ST depression and high voltage, with tachycardia. His prehospital ECG showed "inferior" ST depression and high voltage, with tachycardia. and had dilated pupils. He was alert and oriented.

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EKG/ECG Documentation/Coding Wellness 52

EMDocs

APRIL 22, 2024

If RV pressure is extreme, it can exceed LV pressure causing paradoxical septal wall motion toward the LV as well. When RV pressures elevate, RA pressures increase as well given forward blood flow is obstructed. During a short period of ROSC an ECG was performed. EKG RV strain. DVT Left Saphenofemoral Junction.

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Ultrasounds Advances Cardiac Life Support (ACLS) EKG/ECG Resuscitation 98

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The ECGs An initial ECG was obtained as the pain was rapidly resolving: Minimal upsloping ST Elevation in III, with a steeply biphasic T wave, and with reciprocal ST depression in leads I and aVL. On the other hand , high-risk lesions appear to do well with aggressive treatment. Figure-1: The 2 ECGs in this case ( See text ).

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EKG/ECG Shock Ultrasounds Wellness 52

Dr. Smith's ECG Blog

MAY 11, 2019

The pain was 7 out of 10 when this ECG was recorded: The QTc = 375 What do you think? Computer interpretation: SINUS RHYTHM NON-DIAGNOSTIC ANTEROLATERAL ST ELEVATION BORDERLINE ECG The overreading cardiologist confirmed the computer interpretation (did not diagnose OMI or STEMI). But many do not recognize ECGs like this!

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EKG/ECG Wellness 52

EMDocs

SEPTEMBER 25, 2023

They increase the risks of hypoxia and acidosis during the apneic period as well as hypotension and hypoperfusion caused by the abrupt transition from negative-pressure to positive-pressure ventilation (10). 2017 Dec;10(1):1. Epub 2017 Jan 25. 2017, 43:226-8. Int J Emerg Med. doi: 10.1186/s12245-017-0129-8.

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Emergency Department Soft Tissue Injuries Airway Management Operations 92

Dr. Smith's ECG Blog

OCTOBER 3, 2018

The medics recorded the following initial ECG at time 0: The computer read (see below) gives no further comment beyond ventricular pacemaker. The medic was very worried about the concordant STE and T-wave in aVR, and the downsloping concordant ST depression in II, III, aVF, as well as V5 and V6. What do you think? What happened?"

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EKG/ECG Emergency Department Research Outcomes 52

Dr. Smith's ECG Blog

DECEMBER 27, 2018

This ECG comes from Pierre Taboulet ( [link] /)( [link] ) an ECG whiz who codes a lot of ECGs for Cardiologs' Artificial Intelligence Deep Neural Network algorithm ( [link] ). This ECG is displayed on the Cardiologs platform. My immediate impression of the ECG was LVH. JACC 69(23):1694-1703; April 4, 2017.

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EKG/ECG Documentation/Coding Emergency Department Wellness 40

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Beware of using it to reverse your prior opinion that the ECG represents LAD occlusion. I recommend using it when you are worried that an ECG with apparent normal ST Elevation might be LAD occlusion. J Electrocardiology 50(5):561-569; September/October 2017. WARNING: the formula is not perfect. Sensitivity is not perfect.

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EKG/ECG Outcomes Emergency Department Ultrasounds 52

Dr. Smith's ECG Blog

JULY 12, 2020

I found a well appearing young lady in the room with her parents who witnessed the event. She had presented initially with 6 days of recurrent chest, back, and shoulder pain and was worked up with a reportedly normal ECG, CXR, and d-dimer. Here is her ECG at that first visit: There is the slightest STE in lead II and III.

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EKG/ECG Hospitals Ultrasounds Wellness 40

Dr. Smith's ECG Blog

NOVEMBER 24, 2017

However, none of the formulas have proven to be definitively better than another and none are well correlated with outcomes or events! Example ECG: The heart rate is 167; the RR interval is 0.36 Answer : you must treat the patient's underlying condition causing sinus tachycardia, and repeat the ECG at the lower heart rate.

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EKG/ECG Outcomes Wellness Hospitals 52

ACEP Now

MARCH 14, 2024

1,4-5 Thus, an electrocardiogram (ECG) and cardiac monitoring should be performed for unstable, electrical injury patients. 7 Thus, an ECG is recommended for all electrical injuries. His ECG was unremarkable. Syncope can also occur due to disruption of central nervous tissue. McGraw Hill; 2016. Accessed October 21, 2023.

Burns 52

Burns Fluid Resuscitation EKG/ECG EMS 52

Northwestern EM Blog

JANUARY 24, 2022

Due to its extremely high morbidity and mortality as well as high healthcare costs, the prompt recognition, diagnosis and resuscitation of shock is key. To reverse these effects as well as refractory hypotension, hydrocortisone is the preferred agent due to both its glucocorticoid and mineralocorticoid properties. 2010; 36: 2019-2029.

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Anaphylaxis Shock Sepsis Resuscitation 52

Pediatric Emergency Playbook

JUNE 1, 2017

This child is at risk for expected complications, as well as overdiagnosis and iatrogenia. These children depend on their preload to run blood passively into the pulmonary circuit; afterload reduction is also important to compensate for a poor left ejection fraction, as well as to avoid the development of pulmonary hypertension.

Pediatrics 52

Pediatrics EKG/ECG Wellness Seizures 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? 2017 Nov;35(4):525-537. The beat-to-beat variation in the QRS complexes (electrical alternans) is a classic ECG finding of a large pericardial effusion or pericardial tamponade. . Cardiac Tamponade. Cardiol Clin.

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EKG/ECG Ultrasounds Documentation/Coding COPD 40

EB Medicine

JULY 8, 2019

Jeff: Well that’s kind worrisome. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. In 2017, these were performed 60%, 18%, and 3% of the time.

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Emergency Department Sepsis Operations Dehydration 40

EB Medicine

JUNE 6, 2019

For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. An EKG and troponin should be considered.

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Ultrasounds Radiology Radiology Sepsis 40

ACEP Now

MARCH 11, 2025

I recommend an order set that includes ECG, glucose, creatinine, liver enzymes, lipase, amylase, electrolytes including calcium, magnesium, and phosphate ketones, and urinalysis. 16 An elevated amylase suggests repetitive vomiting as well. 16 An elevated amylase suggests repetitive vomiting as well. Dermatoendocrinol.

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Emergency Department Psychiatric Dehydration Pediatrics 83

Dr. Smith's ECG Blog

JANUARY 17, 2024

Patient 1 (ECG on the left) was a 45 year-old male, and patient 2 (ECG is on the right) was a 70 year-old male. Using T wave amplitude, can you tell which ECG has hyperacute T waves? What other parts of the ECG would you like to see, and how will you use this to refine your interpretation?

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EKG/ECG Documentation/Coding Emergency Department Wellness 118

Dr. Smith's ECG Blog

AUGUST 10, 2023

ECG interpretation: sinus rhythm, normal conduction (PR, QRS, and QTc), normal axis, delayed R-wave progression, and normal voltages. 1) This ECG represents reperfused inferoposterior occlusion MI (likely from the RCA) but could also be seen in subacute and ongoing occlusion. What do you think? He was moved to a monitored bed.

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EKG/ECG Emergency Department Wellness 98

Dr. Smith's ECG Blog

APRIL 8, 2015

True Syncope: If, on the other hand, the patient is well, had no other serious symptoms , has a normal sinus rhythm, and normal physical exam , then you need to be certain the syncope was not due to a dangerous brady- or tachydysrhythmia that could recur. Abnormal ECG – looks for cardiac syncope. Vasovagal syncope is generally benign.

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Emergency Department EKG/ECG Outcomes Seizures 52