Dr. Smith's ECG Blog

MAY 31, 2023

I received the following text message with these 3 EKGs (providers text me ECGs all day every day; most are false positives; many are subtle true positives): "Hi Steve, here are 3 EKGs for you (my colleague's case). Opiates are associated with worse outcomes in Myocardial Infarction. Cath attending is aware. Am Heart J.

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Dr. Smith's ECG Blog

MAY 30, 2023

His prehospital ECG was diagnostic of inferior posterior OMI. Here is his ED ECG: There is bradycardia with a junctional escape. We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. The patient was in clinical shock with a lactate of 8.

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Shock EKG/ECG Academics Stroke 97

Emergency Medicine Journal

APRIL 22, 2024

Methods This was a multicentre prospective observational study of adult ED patients presenting to five Australian hospitals between November 2020 and September 2021. Participants included those with symptoms of suspected AMI (without ST-segment elevation MI on presentation ECG).

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Emergency Department Outcomes EKG/ECG Hospitals 98

Don't Forget the Bubbles

JUNE 30, 2023

You request a 12 lead ECG and repeat a blood gas, asking for it to be run on the PICU analyser. Your trusted nurse hands you the ECG: Paediatric ECG interpretation has never been your strong suit. What is the likely cause of Elsa’s ECG changes? You look at her monitor, and an arterial blood gas performed moments ago.

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Dr. Smith's ECG Blog

AUGUST 2, 2024

His ECG is shown below. How does RCA occlusion fit with the ECG? The answer is that the ECG really shows right ventricular OMI. the investigators reviewed outcomes in 118 patients presenting with NSTEMI. Written by Willy Frick A 50 year old man with no medical history presented with acute onset substernal chest pain.

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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.

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EKG/ECG Ultrasounds EMS Documentation/Coding 52

Taming the SRU

JANUARY 10, 2024

Phenobarbital has been proven to be equivalent to benzodiazepines with regard to clinical, pharmacologic and utilization outcomes. Scrutinize but don’t overthink (interpret your EKGs with context) Know your splints Be comfortable with OMI EKGs Know your resources & know when to ask for help Be creative

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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.

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Dr. Smith's ECG Blog

AUGUST 19, 2023

Below is the 15 lead ECG. The ECG above was only done an hour after arrival, when the first high sensitivity troponin I returned at 300ng/L (normal <26 in males and <16 in females). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. RR18 sat 99% HR 90 BP 90/60, afebrile.

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EKG/ECG Wellness Outcomes Hospitals 98

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.

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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."

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Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

I was texted these ECGs by a recent residency graduate after they had all been recorded, along with the following clinical information: A 50-something with no cardiac history, but with h/o Diabetes, was doing physical work when he collapsed. Here is the initial ED ECG: This is pretty obviously and inferior posterior OMI, right?

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Dr. Smith's ECG Blog

JUNE 17, 2016

The medics recorded a prehospital ECG: The computerized QTc is 397 ms Jason writes: " What's your thoughts Steve?" Unfortunately, the R-wave is cut off on this ECG but it appears as if it would be at least 20 mm. But this measurement was at the J-point, which on this ECG is 4 mm. What was the outcome? What do you think?

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Dr. Smith's ECG Blog

FEBRUARY 10, 2022

The ECG was labeled ‘normal’ by the computer (Marqette 12SL), later confirmed by the cardiologist. Smith : this proves my impression that the inferior T-waves on the first ECG are hyperacute. Six hours later a repeat ECG was done, with a repeat troponin downtrending at 1,000 ng/L. What do you think?

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Dr. Smith's ECG Blog

FEBRUARY 4, 2023

The medics recorded a prehospital ECG: The computerized QTc is 397 ms Jason writes: " What's your thoughts Steve?" Unfortunately, the R-wave is cut off on this ECG but it appears as if it would be at least 20 mm. But this measurement was at the J-point, which on this ECG is 4 mm. What was the outcome? What do you think?

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ACEP Now

JULY 7, 2023

2,3 In general, patients who develop cardiac arrest with an initial rhythm of VT or VF tend to have favorable outcomes compared to patients who develop cardiac arrest from either asystole or pulseless electrical activity. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. Circulation. 2018;137(12). Kimblad H, et al.

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Dr. Smith's ECG Blog

APRIL 12, 2023

Prehospital Conventional algorithm interpretation: ANTERIOR INFARCT, STEMI Transformed ECG by PM Cardio: PM Cardio AI Bot interpretation: OMI with High Confidence What do you think? An ECG was recorded: ED ECG 1: The findings are still present but not nearly as profound now. Therefore, the cath lab was activated.

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EKG/ECG COPD Ultrasounds Outcomes 52

The Skeptics' Guide to EM

SEPTEMBER 19, 2020

Date: September 16th, 2020 Guest Skeptics: Dr. Robert Goulden and Dr. Audrey Marcotte are Chief Residents from the Royal College of Emergency Medicine Program at McGill University. The Lancet 2020 This was an SGEM Journal Club episode recorded live at McGill University Grand Rounds. The CRASH-2 trial showed a 1.5%

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RebelEM

MARCH 30, 2023

Background: Previous observational studies published in 2015 (Geri 2015)(Vyas 2015) indicated that early cardiac catheterization in patients with out-of-hospital cardiac arrest (OHCA) might improve mortality and result in more favorable neurological outcomes. Article: How-Berlemont C, Lamhaut L, Diehl J, et al.

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Hospitals Outcomes EKG/ECG Resuscitation 59

RebelEM

MARCH 13, 2023

Nevertheless, mortality of prehospital traumatic cardiac arrest (TCA), and survivability with good neurologic outcome, remain the gold standards of trauma care in and out of the hospital and are effectively the criterion by which we measure outcomes in the trauma literature. Discussion: Dead On Scene: The 96.2% mortality rate and 43.5%

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EMDocs

MAY 15, 2024

ECG: Evaluate for ischemia, right heart strain. Causes and outcomes of the acute chest syndrome in sickle cell disease. American Society of Hematology 2020 guidelines for sickle cell disease: transfusion support. Published 2020 Feb 12. Overestimates arterial oxygen saturation. Up to 3x less accurate in black patients.

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Dr. Smith's ECG Blog

FEBRUARY 23, 2023

It is unclear whether he had active pain at the time of the first ECG: What do you think? 0.20 (above which, the ECG likely represents OMI). The team was concerned about possibly ischemic ST elevations on the ECG above, so they took it to Dr. Nossen for consultation. Vitals were within normal limits.

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EKG/ECG Ultrasounds Outcomes Hospitals 52

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Here is his first ED ECG: What do you see? STD maximal in V1-V4 (in this case V3-V4) is in my opinion the single best way to identify posterior OMI on the anterior 12 lead ECG. Another ECG was recorded based on the elevated troponin and ongoing symptoms: The heart rate is slightly lower. Apparently he denied chest pain.

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EKG/ECG Hospitals Outcomes Wellness 52

EMDocs

MAY 28, 2024

ECG: Evaluate for ischemia, right heart strain. Causes and outcomes of the acute chest syndrome in sickle cell disease. American Society of Hematology 2020 guidelines for sickle cell disease: transfusion support. Published 2020 Feb 12. Overestimates arterial oxygen saturation. Up to 3x less accurate in black patients.

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Dr. Smith's ECG Blog

JANUARY 6, 2023

F Triage ECG: ECG Interpretation: Sinus rhythm with normal QRS. I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Cardiology interpretation of the initial ECG: “ST depressions laterally.”

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Dr. Smith's ECG Blog

JANUARY 3, 2022

This fantastic case and post was written by Jesse McLaren (@ECGcases), edited by Smith Case You’re shown an ECG from a patient in the waiting room with chest pain. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1]

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EKG/ECG EMS Outcomes 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. Yes * Was the outcome accurately measured to minimize bias? Annals of Emergency Medicine.

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Ken Grauer, MD

SEPTEMBER 21, 2024

The ECG in Figure-1 was obtained from a previously healthy man in his early 20s — who initially presented with GI symptoms, that then evolved into CP ( C hest P ain ). QUESTIONS: Given the above history — How would YOU interpret the initial ECG that is shown in Figure-1 ? Figure-1: The initial ECG in today's case. (

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Dr. Smith's ECG Blog

AUGUST 28, 2020

I was texted these ECGs. This insistence on calling it lateral is due to a paper by Bayes de Luna -- [link] ] Case Continued I could only see the ECGs, not the echo. By the ECG, it is not necessarily subacute, but could be. ECG from 2 days later: Atrial Fibrillation now. Then SOB and nausea the next day.

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Shock EKG/ECG Wellness Outcomes 40

Mind The Bleep

OCTOBER 29, 2024

Circulation Assess heart rate, blood pressure, peripheral and central CRT, pulses and 3 lead ECG. Proper stabilization and detailed communication with the burns centre are essential for optimal patient outcomes. Administer high-flow oxygen if indicated and consider arterial blood gas ( ABG ). Acute Crit Care. 2019 Nov;34(4):276-281.

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Dr. Smith's ECG Blog

DECEMBER 11, 2023

Willy is a cardiology fellow with a keen interest in the ECG in OMI. If an immediate EKG was obtained, it was not saved in the medical record. The first available EKG was recorded just after midnight, presumably around the time the result of the troponin came to clinical attention. The patient said, "I just don't feel good."

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Dr. Smith's ECG Blog

DECEMBER 13, 2023

This is the result for this ECG, from MDcalc.com : The most accurate cutpoint is 18.2. Outcome: 100% LAD Occlusion Here the Queen explains why: The dark blue tells us that she is looking especially at the QRS in V3 and the T-wave in V2 and V3. Here is a similar case from Pendell: This ECG was handed over at triage.

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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).

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Dr. Smith's ECG Blog

NOVEMBER 15, 2023

She has no previous cardiac history of which she is aware 911 was called and here is her Prehospital ECG: What do you think? link] Case continued She arrived in the ED and here is the first ED ECG. In comparison with the first ECG, I would guess that the artery is reperfusing. Figure-1: The initial ECG in today's case.

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Dr. Smith's ECG Blog

JUNE 27, 2024

Here was his initial ED ECG: Formal interpretation by interventional cardiologist: There is "Non-diagnostic" ST Elevation in V2-V4 and aVL. A reliable study would keep track of all patients with shockable arrest and analyze the ones who were not enrolled to see their outcomes. These studies did not address OMI ECG findings!!!

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Dr. Smith's ECG Blog

NOVEMBER 30, 2022

Our first 12 lead ECG was then recorded at 0926. Another ECG was recorded 5 minutes later just before arrival at the hospital: Similar The patient was transported to a nearby suburban hospital with PCI capabilities while my partner cared for her. Smith: this ECG and clinical presentation is diagnostic of LAD Occlusion.

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EKG/ECG Emergency Department Ultrasounds Hospitals 52

Dr. Smith's ECG Blog

JULY 14, 2023

Non-randomized trials show better outcomes (neurologic survival) using this device; see this article in Resuscitation: Head and Thorax Elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. A 12-lead ECG was obtained: What do you think? The patient had ROSC and maintained it.

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