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 113

Seizures EKG/ECG EMS Stroke 113

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 131

EKG/ECG Shock Hospitals Sepsis 131

ACEP Now

DECEMBER 6, 2024

During initial assessment, an ECG was obtained and revealed ST-segment elevation (STE) in the inferior leads with ST depression anteriorly. Initial ECG demonstrating inferolateral ST segment elevation and anteroseptal depression, just prior to cardiac arrest. The ECG showed ST-segment elevation without obstructive coronary disease.

Resuscitation 98

Resuscitation EKG/ECG Documentation/Coding COPD 98

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The following ECG was obtained. Note that the machine read is "normal sinus rhythm, normal ECG." ECG 1 What do you think? I sent this ECG to Dr. Smith and Dr. Meyers with no clinical context. Smith comment: this troponin alone should be enough data to activate the cath lab, regardless of the ECG. <0.049 ng/mL).

EKG/ECG 131

EKG/ECG Documentation/Coding Wellness Emergency Department 131

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Triage EKG: What do you think? A prior ECG was available for comparison. Prior EKG from 2 months ago was available: Let's put the precordial leads from the 2 ECGs side by side: Now you can really see the difference. Immediately after the second ECG was performed, the patient's pain resolved completely.

EKG/ECG 52

EKG/ECG Ultrasounds EMS 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 119

EKG/ECG Stroke Hospitals Documentation/Coding 119

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The baseline ECG is basically normal with no ischemia. Here is what the Queen of Hearts says about the Baseline ECG: Active chest pain triage ECG also read as not OMI: She says "not OMI", but she does not have access to the baseline ECG. In the future, we will be able to have her compare with previous and serial ECGs.

EKG/ECG 83

EKG/ECG Shock Documentation/Coding Academics 83

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

I was reading EKGs on the system and came across this one: What do you think? No followup EKG was recorded!! See many examples of Pseudo STEMI due to hyperkalemia at these two posts: Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.

EKG/ECG 52

EKG/ECG Documentation/Coding Administration 52

Dr. Smith's ECG Blog

MARCH 22, 2024

His ECG is shown: What do you think? The history thus far is highly suggestive of OMI, so we must study the ECG very closely to see if we can confirm this. The Queen of Hearts does not care about rhythm analysis, she simply looks at the ECG and decides whether it represents OMI or not.

EKG/ECG 114

EKG/ECG Wellness Documentation/Coding 114

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

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. Administer high-flow oxygen if indicated and consider arterial blood gas ( ABG ). Acute Crit Care. doi: 10.4266/acc.2019.00647.

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

Here is his initial ECG: What do you think? The patient's chest pain had resolved by the time of the ECG 2. Although this ECG does not demand immediate cath lab activation, it is very worrisome. For clarity — I’ve reproduced and labeled the ECG shown in this case ( Figure-1 ). There are well-formed Q-waves 3.

EKG/ECG 52

EKG/ECG Wellness Documentation/Coding Hospitals 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. P.S.: Our September 3, 2020 post features Dr. Meyers' 17-minute summary of the OMI Manifesto.

EKG/ECG 52

EKG/ECG Documentation/Coding 52

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

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

SEPTEMBER 10, 2023

Triage ECG (no prior for comparison): Computer algorithm read: "Sinus rhythm, low voltage QRS, inferior myocardial infarction, probably old." I texted this ECG with no information to Dr. Smith, who immediately said: "If CP, then anterior OMI until proven otherwise." Every note says "no ischemic changes on ECG." Deemed "NSTEMI."

EKG/ECG 78

EKG/ECG Outcomes Academics Documentation/Coding 78

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

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

The Skeptics' Guide to EM

MAY 2, 2020

Date: April 24th, 2020 Reference: Watanabe et al. Date: April 24th, 2020 Reference: Watanabe et al. The EMS crew arrives and performs a 3 lead EKG that does not show an ST elevated myocardial infarction. The crew then asks if you want them to transport your father Code 3 with full lights and sirens.

Documentation/Coding 40

Documentation/Coding EMS EKG/ECG Outcomes 40

Dr. Smith's ECG Blog

MARCH 19, 2023

This ECG was texted to me in real time, but I did not notice the message until about an hour after it came. "50 This was my response: "This looks like a worrisome EKG. But by now you must have a repeat ECG. But by now you must have a repeat ECG. Another ECG was recorded while waiting for the cath team (it was nighttime).

EKG/ECG 52

EKG/ECG Documentation/Coding Wellness 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

Here are his three EMS ECGs: EMS1 at 0735 This was sent to Dr. Smith with no other information. Meyers sent this ECG to Smith without any other info and this was the response: Smith interpretation: "A very rare anterior OMI w high S-wave voltage." ED ECGs: 0814 0830 These show continued reperfusion with no evidence of reocclusion.

EKG/ECG 52

EKG/ECG EMS Documentation/Coding Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

A 12 lead ECG was obtained by EMS and is shown below: What do you think? The ECG is diagnostic of LAD occlusion (or even left main occlusion possibly), with the classic pattern of RBBB and LAFB with huge concordant STE in V1-V2, I, and aVL, with reciprocal depression in most other leads (and/or a component of subendocardial ischemia pattern).

EKG/ECG 52

EKG/ECG Shock 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

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.

EKG/ECG 52

EKG/ECG Documentation/Coding Wellness 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

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

JANUARY 5, 2020

Here is the ECG: What do you think? See below how this has been documented. 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 ]. Among, 2447 ECGs, Mant et al.

EKG/ECG 52

EKG/ECG COPD Wellness Sepsis 52

PEMBlog

OCTOBER 18, 2024

Always consider the risk of arrhythmia, which can occur despite relatively normal ECG findings. These documents should be reviewed promptly upon presentation, as they often contain critical information about the patient’s DNR status, preferred ventilation strategies, and other key management instructions. 2020 Jun 5;15(1):141.

Emergency Department 52

Emergency Department Fractures Best Practices Documentation/Coding 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? This patient was reported to have distant heart sounds but was not hypotensive and did not have JVD according to documentation. For clarity in Figure-1 — I've reproduced her initial ECG.

EKG/ECG 40

EKG/ECG Ultrasounds Documentation/Coding COPD 40

Dr. Smith's ECG Blog

JULY 19, 2024

Here is his triage ECG at time = 0: What do you think? (No If you understand wide QRS complexes and appropriate discordance, you will understand that this ECG shows ischemic ST depression maximal in V1-V4 , which is the best and simplest available feature we have studied for identifying posterior OMI. Final diagnosis: NSTEMI.

EKG/ECG 115

EKG/ECG Documentation/Coding Outcomes Wellness 115

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?

EKG/ECG 68

EKG/ECG Wellness Documentation/Coding Emergency Department 68

Dr. Smith's ECG Blog

FEBRUARY 12, 2025

I came across this ECG: What do you think? Even before we have clinical context, this ECG simply does not appear concerning for OMI, notwithstanding the machine's interpretation ** ** ACUTE MI / STEMI ** **. I sent this ECG to Dr. Smith with no clinical context, and he immediately replied "Fake."

EKG/ECG 82

EKG/ECG Documentation/Coding EMS Outcomes 82

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.

EKG/ECG 72

EKG/ECG Documentation/Coding 72

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Here is his triage ECG: What do you think? The Queen of Hearts agrees, calling the ECG not specific for OMI. It is essential to compare with old ECGs. In the absence of old ECGs, one must record serial ECGs every 15 minutes. In the absence of old ECGs, one must record serial ECGs every 15 minutes.

EKG/ECG 86

EKG/ECG Documentation/Coding Outcomes 86

Dr. Smith's ECG Blog

NOVEMBER 3, 2024

The rhythm strip in Figure-1 shows four ECG leads. Returning to the mechanism in Figure-3 of today's case: Grauer: For clarity in Figure-5 — I've kept the same color coding, and illustrate Dr Nossen's above explanation of reciprocal beating in a Laddergram that concentrates on lead III from Figure-3. aVF, III, V1 and V5).

Documentation/Coding 65

Documentation/Coding EKG/ECG Operations Wellness 65

Taming the SRU

FEBRUARY 3, 2025

Initial work up when suspicious of this process should include ECG, chest x-ray, urinalysis, and the following labs: CBC, CMP, magnesium, phosphate, calcium, uric acid, VBG (for pH), and lactate dehydrogenase (10). Therefore, it should only be administered in life-threatening arrhythmia and not simply for peaked t waves on ECG (2,20).

Fluid Resuscitation 56

Fluid Resuscitation Seizures Dehydration Emergency Department 56