Dr. Smith's ECG Blog

JULY 7, 2024

Here’s the EMS ECG, digitized with PM cardio. They arrived in the ED 30 minutes later to meet the cardiology team, where an ECG was repeated: Again no STEMI criteria, and there has been improvement in the deWinter and swirl pattern. What do you think? There’s sinus arrhythmia with normal conduction, normal axis and normal voltages.

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Dr. Smith's ECG Blog

AUGUST 8, 2020

Here is her prior baseline ECG (first), and her ED ECG (second): Baseline: ED ECG: What do you think? Do you agree with the computer's interpretation of "Normal ECG"? The ECG shows sinus rhythm with normal QRS and R wave progression. This ECG clearly meets STEMI criteria by the way, regardless of age or gender.

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The Skeptics' Guide to EM

MAY 2, 2020

July 2019 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. July 2019 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. The EMS crew arrives and performs a 3 lead EKG that does not show an ST elevated myocardial infarction.

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Dr. Smith's ECG Blog

FEBRUARY 13, 2023

(photocopy of prehospital ECGs digitized by PMcardio) ECG #1 (top): there’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression, and normal voltages. ECG # 2 (bottom): there’s sinus rhythm with normal conduction, normal axis, loss of R wave in V2, normal voltages. Will be missed easily.”

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Dr. Smith's ECG Blog

APRIL 15, 2020

Here is her ED ECG: Here is the ED physician's interpretation: IMPRESSION UNCERTAIN REGULAR RHYTHM, wide complex tachycardia, likely p-waves. Here is the post-cardioversion ECG: There is sinus with RBBB There are inferior Q-waves suggesting old inferior MI. Figure-1: The 2 ECGs in this case ( See text ).

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Dr. Smith's ECG Blog

JULY 31, 2020

Meyers, Weingart and Smith published their OMI Manifesto — in which they extensively document the critically important concept that management of acute MI by separation into a “STEMI” vs “non-STEMI” classification is an irreversibly flawed approach.

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Dr. Smith's ECG Blog

NOVEMBER 13, 2022

His vitals were normal and his first ECG was as shown below: There is obvious ST segment elevation (STE) in anterior leads. Is this a subtle ECG ? This was a clearly diagnostic ECG that makes me think of a proximal left anterior descending artery (LAD) occlusion. A second ECG was taken at 15:16. Wait for the angiogram.

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Dr. Smith's ECG Blog

MARCH 31, 2023

Here is the result: Next, it interprets the digital data: A perfect interpretation Unfortunately, this ECG was not interpreted as OMI and the patient did not get another ECG recorded until 2 hours later. I tell them that it is not the ECG that is nonspecific, but the interpreter who is nonspecific.

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Dr. Smith's ECG Blog

MAY 16, 2023

Here is his triage ECG: What do you think? No prior ECG was available. Pretest probability is crucial in ECG diagnosis of OMI or ECG diagnosis of OMI mimic. As Ken says below, tachycardia is not common in OMI and distorts the ST segment, so managing the tachycardia and repeating the ECG is a good strategy.

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Dr. Smith's ECG Blog

JUNE 23, 2023

Here is the ED ECG: What do you think? For clarity in Figure-1 — I've reproduced and labeled the 2 ECGs in today's case. Figure-1: I've labeled the 2 ECGs in today's case ( See text ). MY Thoughts to Today's Initial ECG: In the BEST of hands — prediction of the etiology of a regular WCT rhythm is less than perfect.

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Mind The Bleep

OCTOBER 29, 2024

Circulation Assess heart rate, blood pressure, peripheral and central CRT, pulses and 3 lead ECG. Provide detailed documentation of the initial assessment, treatment provided, and the patient’s response to interventions. 2019 Nov;34(4):276-281. Epub 2019 Nov 29. J Med Toxicol. 2015 Jun;11(2):227-31. Murari A, Singh KN.

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Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. A near 60 year old male called 911 for increasingly severe fever and SOB.

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Ken Grauer, MD

JULY 29, 2023

The ECG in Figure-1 was obtained from an 18-year old woman — who moments before been resuscitated from out-of-hospital cardiac arrest. How would YOU interpret her post-resuscitation ECG? Does this ECG in Figure-1 provide clue(s) to the etiology of this patient's cardiac arrest? QUESTIONS: In light of the above clinical history.

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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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Dr. Smith's ECG Blog

JUNE 4, 2019

Here is the ED ECG (no previous ECG was available for comparison). Computer interpretation: Normal ECG Cardiology overread: Normal ECG QTc-Bazett by computer = 479 ms Computer algorithm name unavailable What do you think? T his is a systematic failure that has been documented in the following study: Garg A, Lehmann MH.

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Dr. Smith's ECG Blog

JANUARY 9, 2024

The ECG below was recorded. The ECG was interpreted as showing atrial flutter with 2:1 conduction. Answer : The ECG above shows a regular wide complex tachycardia. Said differently, the ECG shows a rather slow ventricular tachycardia with a 2:1 VA conduction. How do you interpret the below ECG?

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Dr. Smith's ECG Blog

JANUARY 30, 2019

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. What is the differential for this EKG? T wave inversion III, aVR, TWF in aVF. Is this an OMI?

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Dr. Smith's ECG Blog

MARCH 4, 2024

I have often written about how an ECG interpreted as "normal" by a conventional algorithm may well be manifesting OMI, or even long QT or hyperkalemia. Shifa Karim and Gabe Keller helped with a project to assess all these ECGs with the Queen of Hearts. The ECG told the story. I wanted to show some of the cases here.

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Dr. Smith's ECG Blog

JANUARY 5, 2020

Here is the ECG: What do you think? See below how this has been documented. IJC Heart and Vasculature 25(2019). Shah and Rubin studied the computer rhythm interpretation of 2160 12-lead ECGs, compared to 2 cardiologists [ 18 ]. noted computer over-interpretation (false positives) of AF in 9 to 19% of ECGs [ 19 ].

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Dr. Smith's ECG Blog

JUNE 8, 2023

Here’s the paramedic ECG (digitized by PMcardio). I sent the ECG to Dr. Meyers without any information, and he immediately replied, “inferior OMI.” Here’s the first and repeat paramedic ECG: According to some interpretations of the literature on “transient STEMI”, this patient doesn’t need the cath lab because ST segments improved.

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Dr. Smith's ECG Blog

JUNE 28, 2019

Terminal QRS distortion is definitely significant for anterior OMI in V2 and V3: An intoxicated, agitated, 20-something with chest pain Here is an ECG from one month ago: There is a definite change in the inferior leads, with new ST elevation. Another ECG was recorded at 58 minutes: Again, no big difference. Compare with an old ECG.

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Dr. Smith's ECG Blog

NOVEMBER 12, 2020

He had the following EKG recorded: Low voltage, suggests effusion. A Rising Troponin That afternoon, he complained of increased shortness of breath and was noted to have oxygen saturations in the 70s, prompting a mini code to be called. This is the ECG on V-V ECMO: Very little STE He had a lot of troponins measured.

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Dr. Smith's ECG Blog

JULY 19, 2019

Here is his triage ECG: What do you think? We'll simply never know without ECGs from that time period. The extremely high troponin and ECG evidence of LVA morphology are very worrisome long term features for resultant morbidity and mortality. His initial ECG in the ED ( = E CG # 1 ) is shown in Figure-1.

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Dr. Smith's ECG Blog

AUGUST 17, 2019

Here is his ECG: As you can see, the computer called it completely normal What do you think? Some patient's baseline ECG has zero STE. Bedside echo revealed anteroseptal wall motion abnormality at which point I activated a code STEMI. Figure-1: The initial ECG done in the ED ( See text ). Initial TnI was negative. "I

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Dr. Smith's ECG Blog

FEBRUARY 28, 2020

An ECG was texted to me (Smith) without any clinical information: What did I say? Some providers were worried about ACS because of this ECG. It turns out there was a previous ECG for comparison, which I did not see for weeks afterwards: Sinus rhythm with PACs, one is aberrantly conducted. This is NOT Wellens. The answer was yes.

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Dr. Smith's ECG Blog

DECEMBER 5, 2019

As part of the workup, she underwent an ECG. Thus, Brugada is the likely diagnosis _ A very nice explanation of this is given in the document quoted below on current ECG criteria for Brugada pattern. We repeated the ECG: Brugada pattern is mostly resolved. Is this Type 2 Brugada syndrome/ECG pattern?

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EB Medicine

JULY 8, 2019

I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30 th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS.

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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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ACEP Now

MAY 10, 2024

His vital signs are normal and the ECG does not demonstrate a myocardial infarction. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Your clinical gestalt has you suspecting an acute aortic dissection (AoD).

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EB Medicine

AUGUST 1, 2018

In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. An RCT is underway in Canada on the use of ondansetron versus haloperidol with an estimated completion of July 2019.

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Dr. Smith's ECG Blog

JANUARY 15, 2025

This was submitted by Hans Helseth, who is applying to med school and who is working as an EKG tech right now. He looked back in time in the patient's chart and saw these ECGs and immediately recognized that they manifested subtle OMI. He had an EKG recorded right away. EKG 1, 1646: What do you think?

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Dr. Smith's ECG Blog

FEBRUARY 16, 2025

Despite the noisy baseline, this ECG is easily diagnostic for OMI. The emergency medicine physician documented, "His initial EKG is riddled with artifact and difficult to interpret but does not look like a STEMI." One wonders why repeat ECG was not immediately performed, if artifact was felt to be a problem.

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Dr. Smith's ECG Blog

FEBRUARY 4, 2025

That today's patient may be predisposed to this disorder is suggested in Figure-1 by: i ) Obvious QRS widening on this single-lead ECG monitoring strip ( suggesting some form of bundle branch block ) ; and , ii ) 1st-Degree AV Block of conducted beats ( PR interval ~0.26 The baseline ECG before idiopathic PAVB tends to be normal.

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