EMDocs

SEPTEMBER 26, 2024

EKG, labs, and a CXR are interpreted by the EP as normal. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. It wasn’t, so you weren’t called, nor did the doc need to document anything. This patient’s history was either poorly taken or poorly documented.

Radiology 87

Radiology Radiology EKG/ECG Documentation/Coding 87

Dr. Smith's ECG Blog

JUNE 27, 2024

This is her first ECG in the ED: What do you see? This ECG shows both a right bundle branch block and a posterior fascicular block. Another ECG is taken about twenty minutes later and shows this: The rhythm is complex and variable, but overall shows various degrees of AV block. By the end of the ECG, there is 1:1 conduction.

EKG/ECG 123

EKG/ECG Documentation/Coding Emergency Department Wellness 123

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 134

EKG/ECG Shock Hospitals Sepsis 134

EMDocs

SEPTEMBER 19, 2023

Reference: emDOCs – NCSE Journal of Emergency Medicine – Review Case 4: 52-year-0ld male brought in by EMS with “code STEMI” ECG demonstrates ST depressions with rocket like T waves in V2-V4. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

Seizures 83

Seizures Documentation/Coding EKG/ECG Emergency Department 83

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 86

EKG/ECG Shock Documentation/Coding Academics 86

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 69

EKG/ECG Documentation/Coding EMS Wellness 69

Cook County EM Blog

MAY 15, 2023

Figure 1: Initial EKG The Case: 45-year-old Spanish speaking male with no known past medical history presented to the ED with 2-3 hours of severe back pain and throat pain. What does this EKG suggest? His EKG suggested a posterior MI as well as other signs of ischemia. Unfortunately, this EKG was not recorded in the EMR.

EKG/ECG 52

EKG/ECG Documentation/Coding Wellness 52

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

APRIL 17, 2023

Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)?

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Psychiatric 52

Dr. Smith's ECG Blog

JUNE 30, 2023

Queen: #1: NOT OMI, HIGH CONFIDENCE Queen: #2: NOT OMI, HIGH CONFIDENCE ECG 1 Interpretation: there is terminal T-wave in V3-V6. See 2 dozen examples here: Understanding this pathognomonic ECG would have greatly benefitted the patient. And ECGs can change and evolve even when there is no ischemia. Is this Wellens' pattern A?

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Wellness 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

This ECG was recorded: The computer called it "Normal" except for "Possible right ventricular conduction delay" What do you think? The team was there and I showed them the ECG and said "I am 80% certain this is OMI. While waiting for the cath team, a 3rd ECG was recorded: Now there is STE in V6, with large T-waves in V4-V6.

EKG/ECG 52

EKG/ECG Documentation/Coding 52

Dr. Smith's ECG Blog

JANUARY 13, 2025

An ECG was recorded quickly before any further history or physical exam: What do you think? When I saw this (presented at a conference), I immediately thought it looked like Thype 1 Brugada phenocopy (in other words, Type 1 Brugada ECG pattern ). Unexplained cardiac arrest or documented VF/polymorphic VT: +3 3. Family History 3.a.

Hyperthermia / Hypothermia 74

Hyperthermia / Hypothermia EKG/ECG Wellness Documentation/Coding 74

Dr. Smith's ECG Blog

DECEMBER 29, 2023

Below is the old ECG (on top) and then new ECG (on bottom). The old ECG has proportional ST elevation and T waves. But the new ECG has new Q waves in aVL and V2 (the distribution of the first diagonal artery) – and in the next context of Q waves, the T wave in V2 is upright and relative large. What do you think?

EKG/ECG 73

EKG/ECG Documentation/Coding Emergency Department 73

Dr. Smith's ECG Blog

MAY 8, 2023

Triage ECG: What do you think? Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Queen of Hearts interpretation: The cardiologist initially was not convinced, stating the ECG was not diagnostic or could not be diagnostic because it was paced.

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Shock 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 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

The Skeptics' Guide to EM

FEBRUARY 3, 2023

September 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are working an overnight shift at a small rural hospital. You are tidying your things in anticipation of the arrival of the dayshift when a code blue is called. Circulation.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Hospitals Documentation/Coding Outcomes 52

RebelEM

MARCH 9, 2023

Keyes 2022) Auditory and Visual Hallucinations (AH/VH) : The differential diagnosis for hallucinations is broad and includes medical pathology, psychiatry pathology, and transient causes such as acute drug intoxication. As always, document clinical sobriety before discharge. 2022 Jul;46(7):1306-1312. Alcohol Clin Exp Res.

Psychiatric 52

Psychiatric Emergency Department Fractures 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. 2022 Mar 2;83(3):1-12. Epub 2022 Mar 4. Kirkpatrick JJ, Enion DS, Burd DA. Br J Hosp Med (Lond).

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52

Mind The Bleep

JUNE 18, 2023

ICD-10 codes: F00-03 are the ICD codes for dementia and its subtypes F02. It is important to complete an ECG prior to initiating pharmacological therapy as drugs, such as antipsychotics can prolong the QT interval, increasing the risk of arrhythmias. If there is no benefit this should be stopped.

Psychiatric 52

Psychiatric Documentation/Coding Stroke Fractures 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

ACEP Now

JULY 6, 2023

Now, for selected patients, emergency physicians can leverage low and non-rising high sensitivity troponin values and a low HEART score (composed of history, ECG, age, risk factors, and troponin level) to implement outpatient follow-up plans safely, within a few hours. Updated September 21, 2022. February 22, 2022.

Head Injuries 52

Head Injuries Emergency Department Research Pediatrics 52

ACEP Now

FEBRUARY 11, 2024

This patient’s syncope is most likely due to metabolic disruptions and fluid-status physiology; nevertheless, assessment of cardiogenic etiologies through an EKG, troponin, and cardiac risk factors should be considered as appropriate. There have been documented cases of overdose, and of note, there is no known antidote.

Seizures 52

Seizures Fluid Resuscitation Poisoning EKG/ECG 52

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.

EKG/ECG 370

EKG/ECG Resuscitation Documentation/Coding Hospitals 370

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 134

EKG/ECG Documentation/Coding Wellness Emergency Department 134

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Willy is a cardiology fellow with a keen interest in the ECG in OMI. Triage documented a complaint of left shoulder pain. If an immediate EKG was obtained, it was not saved in the medical record. A patient with OMI can have a totally normal ECG!" Cardiology was consulted, and repeat EKG was obtained at around 2:30 AM.

EKG/ECG 126

EKG/ECG Outcomes Documentation/Coding Academics 126

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Initial ED ECG: What do you think? Then we must consider clinical data other than the ECG, for a pretest probability : Of all wide complex tachydysrhythmias, the majority are VT. Pretest probability: Even before the ECG, a patient with a history of coronary stent has a 90% chance that his wide complex tachycardia is VT.

EKG/ECG 141

EKG/ECG Shock Documentation/Coding Academics 141

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 117

EKG/ECG Wellness Documentation/Coding 117

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 115

Seizures EKG/ECG EMS Stroke 115

Dr. Smith's ECG Blog

JULY 22, 2023

An ECG was performed in the ED at 1554: Original image unavailable, this is the only recorded scanned ECG available. In a patient with syncope and fever, this ECG looks more like Brugada. Smith comment: the ECG in question could be due to Brugada, even though there is a change from baseline. PM Cardio digitized version.

EKG/ECG 92

EKG/ECG Hyperthermia / Hypothermia Documentation/Coding Wellness 92

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

Her presenting ECG is shown below: ECG 1 What do you think? I had previously run this ECG through QOH in the PMcardio app environment and she reported mid confidence, shown below. You can see that version 2 has a higher number than version 1, hence she sees the ECG as more OMI-like than version 1. I sent this to Drs.

EKG/ECG 69

EKG/ECG Operations Wellness Ultrasounds 69

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 122

EKG/ECG Stroke Hospitals Documentation/Coding 122

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.

EKG/ECG 130

EKG/ECG Documentation/Coding Wellness Resuscitation 130

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 86

EKG/ECG Documentation/Coding EMS Emergency Department 86

Dr. Smith's ECG Blog

MAY 23, 2022

Written by Jesse McLaren, with comments by Smith and Grauer Four patients presented with cardiorespiratory symptoms, with inferior ST elevation and reciprocal change on their ECG. Note: according to the STEMI paradigm these ECGs are easy, but in reality they are difficult. First lets start with each ECG without clinical context.

EKG/ECG 52

EKG/ECG Documentation/Coding Hyperthermia / Hypothermia Research 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. Documentation with coronary arteriography within 12 1/2 hours of the onset of symptoms in two cases (three episodes).

Burns 52

Burns Fluid Resuscitation EKG/ECG EMS 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 121

EKG/ECG Documentation/Coding Wellness Emergency Department 121