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.

Seizures 108

Seizures EKG/ECG EMS Stroke 108

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!

EKG/ECG 118

EKG/ECG Shock Hospitals Sepsis 118

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.

EKG/ECG 66

EKG/ECG Documentation/Coding EMS Wellness 66

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

EKG/ECG 52

EKG/ECG Documentation/Coding 52

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?

EKG/ECG 103

EKG/ECG Stroke Hospitals Documentation/Coding 103

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.”

EKG/ECG 52

EKG/ECG Documentation/Coding EMS Wellness 52

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?

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia EKG/ECG Wellness Documentation/Coding 52

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.

Documentation/Coding 40

Documentation/Coding EMS EKG/ECG Outcomes 40

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.

EKG/ECG 52

EKG/ECG Documentation/Coding Wellness 52

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.

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52

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.

Shock 52

Shock EKG/ECG Outcomes Hospitals 52

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.

EKG/ECG 52

EKG/ECG Academics Wellness Documentation/Coding 52

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.

EKG/ECG 52

EKG/ECG Documentation/Coding 52

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.

EKG/ECG 52

EKG/ECG Stroke Documentation/Coding Outcomes 52

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.

EKG/ECG 52

EKG/ECG Burns Documentation/Coding Hospitals 52

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 ).

EKG/ECG 52

EKG/ECG EMS Documentation/Coding 52

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.

EKG/ECG 52

EKG/ECG Academics Documentation/Coding Wellness 52

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.

EKG/ECG 52

EKG/ECG Documentation/Coding 52

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.

EKG/ECG 52

EKG/ECG COPD Documentation/Coding Shock 52

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.

EKG/ECG 52

EKG/ECG Burns Documentation/Coding Hospitals 52

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 ].

EKG/ECG 52

EKG/ECG COPD Wellness Sepsis 52

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.

EKG/ECG 52

EKG/ECG Sepsis Documentation/Coding Shock 52

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?

EKG/ECG 104

EKG/ECG Documentation/Coding Wellness Emergency Department 104

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.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

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.

EKG/ECG 66

EKG/ECG Documentation/Coding EMS Emergency Department 66

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).

Ultrasounds 52

Ultrasounds Outcomes Academics Documentation/Coding 52

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?

EKG/ECG 52

EKG/ECG Hyperthermia / Hypothermia Seizures Documentation/Coding 52

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.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40