Dr. Smith's ECG Blog

NOVEMBER 14, 2023

In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). Here is his first prehospital ECG: 1st Prehospital ECG What do you think?

EKG/ECG 110

EKG/ECG EMS Stroke Outcomes 110

Dr. Smith's ECG Blog

MAY 23, 2023

EMS arrived and recorded this ECG: What do you think? See same ECG below with computer automated interpretation, using the Glasgow ECG algorithm which apparently is used by many different providers and devices Amazing that the computer calls this normal. Next day ECG. And yet it still says "normal". Learning Points: 1.

EKG/ECG 88

EKG/ECG Wellness Emergency Department EMS 88

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Serial ECGs remained unchanged. What do you think?

EKG/ECG 119

EKG/ECG EMS Outcomes Wellness 119

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). And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!!

EKG/ECG 79

EKG/ECG Outcomes Academics Wellness 79

Dr. Smith's ECG Blog

JUNE 15, 2023

Here was his triage ECG: What do you think? I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2.

EKG/ECG 92

EKG/ECG Documentation/Coding Outcomes Hospitals 92

Dr. Smith's ECG Blog

JULY 14, 2024

Here is his ECG at triage: What do you think? See this post if you dont know that pattern yet: Precordial Swirl -- 20 cases of Swirl or Look-Alikes Here was a repeat ECG done within 20 minutes (still with ongoing pain): It still looks like active OMI to me, but perhaps slightly improved from the first one. Outcome of case 2?

EKG/ECG 76

EKG/ECG Outcomes Wellness 76

Dr. Smith's ECG Blog

OCTOBER 6, 2023

This is one case where it made a difference: Right Ventricular MI seen on ECG helps Angiographer to find Culprit Lesion Nevertheless, it is sometimes a fun academic exercise to try to predict the infarct artery: An elderly patient had onset of chest pain one hour prior. Here is the prehospital ECG. He called 911. What do you think?

EKG/ECG 70

EKG/ECG Academics Shock Outcomes 70

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.

Shock 81

Shock EKG/ECG Academics Stroke 81

RebelEM

SEPTEMBER 21, 2023

ECG shows a regular, narrow-complex, tachycardia at 190 bpm consistent with SVT. Up to 80% of patients will have at least one troponin sent ( Gabrielli 2022 ). The available literature shows that SVT is not associated with ACO, Type I MI or serious outcomes either in the short term or after prolonged follow up ( Gabrielli 2022 ).

EKG/ECG 143

EKG/ECG Sepsis EMS Outcomes 143

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 70

EKG/ECG Documentation/Coding EMS Wellness 70

Dr. Smith's ECG Blog

DECEMBER 6, 2022

Vital signs were normal and first ECG was labeled as normal by the computer and confirmed by the treating emergency physician and cardiology over-read. Repeat troponin declined to 2,500 and repeat ECG ECG was done after another 2 hours, also interpreted as normal. C ircumflex occlusions can have subtle to no ECG changes 3.

EKG/ECG 52

EKG/ECG Outcomes 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

He had a triage ECG at time zero: Here is the computer interpretation (Normal) This was the Veritas algorithm. This ECG is DIAGNOSTIC of acute LAD Occlusion. He came to me with the ECG and I said, "Yup, this is an LAD Occlusion." But even this ECG by itself is quite suspicious. 2022 Jan;51:384-387. Am J Emerg Med.

EKG/ECG 52

EKG/ECG Wellness Emergency Department Outcomes 52

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.

EKG/ECG 112

EKG/ECG Fluid Resuscitation Academics Resuscitation 112

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 87

EKG/ECG Shock Documentation/Coding Academics 87

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. Full case details and outcomes are below. His triage at 0127 is the ECG above. Repeat ECG at 0221: Basically unchanged. Physician: "No STEMI."

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Psychiatric 52

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.

EKG/ECG 85

EKG/ECG Wellness Outcomes Hospitals 85

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. No labs were performed.

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Shock 52

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?

EKG/ECG 40

EKG/ECG Emergency Department Outcomes 40

EMDocs

NOVEMBER 29, 2023

Double-blind, placebo-controlled multicenter RCT Included 795 patients > 18 years admitted to the ICU with severe PNA Intervention: Hydrocortisone as a continuous infusion of 200 mg/day IV with a planned taper for 8 or 14 days compared to placebo Primary Outcome: All-cause mortality at 28 days Hydrocortisone 6.2% 2022 Aug;48(8):1009-1023.

Outcomes 80

Outcomes Resuscitation EKG/ECG 80

Dr. Smith's ECG Blog

JANUARY 23, 2023

The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG: What do you think? Close up of V3 with baseline in red Close up of V4 with baseline in red This ECG alone is highly suspicious for posterior OMI! This is a very specific marker of posterior OMI. ng/mL (ULN 0.04).

EKG/ECG 52

EKG/ECG Shock Emergency Department Ultrasounds 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.

Resuscitation 87

Resuscitation EKG/ECG CPR Outcomes 87

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. A post-arrest ECG doesn’t show any signs of STEMI. Date: February 1, 2023 Reference: Wolfrum et al. Circulation. Circulation.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Hospitals Outcomes Documentation/Coding 52

Dr. Smith's ECG Blog

APRIL 8, 2022

Initial ECG on presentation at 1554 (no prior for comparison): What do you think is happening to his 30s woman? The ECG shows NSR with a normal QRS except for poor R wave progression and pathologic QS-waves in V2-3. mm of STE - thus, technically this ECG does not meet STEMI criteria, although it is a quite obvious OMI.

EKG/ECG 52

EKG/ECG Outcomes Wellness Shock 52

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.

EKG/ECG 52

EKG/ECG Ultrasounds Outcomes Hospitals 52

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.

EKG/ECG 103

EKG/ECG Ultrasounds Wellness Stroke 103

Dr. Smith's ECG Blog

JANUARY 12, 2023

Here are their ECGs: Patient 1: Patient 2: See below for "answers", and below that for both cases. Patient 2 has a normal variant ECG which mimics high lateral OMI, and ruled out for MI, see case below. Patient 2 has a normal variant ECG which mimics high lateral OMI, and ruled out for MI, see case below. All very very subtle.

EKG/ECG 52

EKG/ECG Outcomes 52

Dr. Smith's ECG Blog

MAY 14, 2022

Here is his ED ECG: Regular Wide Complex Tachycardia at a rate of 229 First : What do you want to do? Next : What do you think is the ECG diagnosis? ECG analysis: T his is a regular wide complex tachycardia. Here is the post cardioversion ECG (texted to me): This what I texted back: "Could be WPW. Antidromic WPW).

EKG/ECG 52

EKG/ECG Shock Operations EMS 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

What is your ECG interpretation and what would you do next? This ECG shows a normal sinus rhythm with a normal conduction pattern (normal PR, normal QRS, and normal QTc), normal axis, late R wave progression (and misplaced V2), normal voltages, ST-elevation in aVR and global ST-depressions. BP was 110 and oxygen saturation was normal.

EKG/ECG 52

EKG/ECG Shock Sepsis Emergency Department 52

Dr. Smith's ECG Blog

MARCH 30, 2023

= My Comment by K EN G RAUER, MD ( 3/30 /2023 ): = The ECG in Figure-1 was sent to me without the benefit of any history. Figure-1: The initial ECG in today's case. To improve visualization — I've digitized the original ECG using PMcardio ). Unfortunately — we are not privilege to the clinical outcome in today's case.

EKG/ECG 52

EKG/ECG Outcomes Wellness 52

EMDocs

MAY 11, 2024

Endovascular and Clinical Outcomes of Vertebrobasilar Intracranial Atherosclerosis-Related Large Vessel Occlusion. June 26, 2022. Salim Rezaie, “Thrombolysis in Acute Ischemic Stroke: Now We Have No Positive RCTs”, REBEL EM blog, July 27, 2020. Available at: [link]. Baek JH, Kim BM, Heo JH, et al. Front Neurol. 2019.00215.

Stroke 89

Stroke EMS EKG/ECG Radiology 89

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]

EKG/ECG 52

EKG/ECG EMS Outcomes 52

EMDocs

MAY 15, 2024

ECG: Evaluate for ischemia, right heart strain. 2022 Aug;58:235-244. Epub 2022 Jun 11. Causes and outcomes of the acute chest syndrome in sickle cell disease. Overestimates arterial oxygen saturation. Up to 3x less accurate in black patients. When the clinical picture does not match the SpO 2 , get an ABG. Am J Emerg Med.

Blood Transfusions 78

Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 78

The Skeptics' Guide to EM

JANUARY 7, 2023

AJEM 2022 Guest Skeptics: Dr. Timlin Glaser currently a fourth-year resident in emergency medicine at Lehigh Valley Health Network and future medical toxicology fellow at the University of Arizona College of Medicine – Phoenix. You order an ECG and confirm the patient has atrial fibrillation (AF) with rapid ventricular response (RVR).

Emergency Department 40

Emergency Department Research Shock EKG/ECG 40

EMDocs

MAY 28, 2024

ECG: Evaluate for ischemia, right heart strain. 2022 Aug;58:235-244. Epub 2022 Jun 11. Causes and outcomes of the acute chest syndrome in sickle cell disease. Overestimates arterial oxygen saturation. Up to 3x less accurate in black patients. When the clinical picture does not match the SpO 2 , get an ABG. Am J Emerg Med.

Blood Transfusions 75

Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 75

Dr. Smith's ECG Blog

AUGUST 6, 2024

Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( Chest Pain ). All ECGs were recorded by EMS, and transferred to a PCI capable center for evaluation. For 2 of the 3 patients — the cath lab was activated based on the ECG.

EKG/ECG 86

EKG/ECG Wellness Hospitals EMS 86

Taming the SRU

APRIL 13, 2023

stent, percutaneous nephrostomy) by urology or IR Hypokalemia evaluate for EKG changes assess for underlying cause and factors that may influence ability to replete (i.e. stent, percutaneous nephrostomy) by urology or IR Hypokalemia evaluate for EKG changes assess for underlying cause and factors that may influence ability to replete (i.e.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Poisoning EKG/ECG Seizures 52

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 119

EKG/ECG Documentation/Coding Wellness Emergency Department 119