Dr. Smith's ECG Blog

DECEMBER 3, 2024

Given his history, an EKG, labs including high sensitivity troponin, and chest radiograph were ordered. Here is the first ECG at Time zero: Here is his initial EKG: What do you think? I put this through the Queen of Hearts and was shocked that she did not see it. Another EKG was also obtained.

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EKG/ECG Burns Wellness Shock 92

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. Shocked x 2 without effect. Warning: if this is VT, a calcium channel blocker can result in shock and death. Why did I say that? What to do now?

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EKG/ECG Shock Documentation/Coding Academics 133

Dr. Smith's ECG Blog

JUNE 23, 2024

They shocked him twice before return of spontaneous circulation. Here is his presenting ECG: ECG 1, t = 0 What do you think? His transfer packet included notes, labs, cath report, and ECG reports, but no actual ECG images. Smith's ECG Blog. He did not have access to ECG 1.

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EKG/ECG CPR EMS Hospitals 104

Pediatric EM Morsels

MARCH 17, 2023

Ahmed 2008, Meyers 2022) Of course, treat any other systemic symptoms (like respiratory failure, hypotension) as you typically would. If you are managing a snake bite from a snake that does not typically reside in the U.S., please utilize other resources and local Toxicology experts for help with management protocols.

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CDC Poisoning Pediatrics Shock 130

Taming the SRU

JANUARY 10, 2024

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 Additionally, ED boarding is a now a larger factor than in 2018.

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EKG/ECG Shock Fractures Emergency Department 92

Dr. Smith's ECG Blog

JANUARY 8, 2024

I was reviewing ECGs for a study, and came across this one, and was able to get all the clinical information: What do you think? I do not have the EKG, but it was described as "non-diagnostic" (that probably means that the physician did not know how to diagnose it). Medics recorded the above ECG and called a STEMI alert.

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EKG/ECG Resuscitation Hospitals EMS 75

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Her ECG is shown below: What do you think? The conventional machine algorithm interpreted this ECG as STEMI. Alternatively, with STE in V1 and III, and STD in I and aVL, this ECG could represent proximal RCA OMI with right ventricular involvement. What do you do clinically when the ECG looks like this?

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EKG/ECG Ultrasounds Shock EMS 111

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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EKG/ECG Shock Documentation/Coding Academics 87

EMDocs

NOVEMBER 19, 2024

Recommend obtaining multiple EKGs to aid in the diagnosis of cardiotoxic effects such as dysrhythmias or interval widening, even if not apparent immediately after the overdose. 1,2 Cardiovascular: Obtain an initial EKG to determine the patient’s baseline and repeat. Published 2022. 1 Class IA (e.g., procainamide), IC (e.g.,

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Poisoning EKG/ECG Hyperthermia / Hypothermia Seizures 90

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!

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EKG/ECG Shock Hospitals Sepsis 118

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?

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EKG/ECG Academics Shock Outcomes 70

ACEP Now

JULY 7, 2023

However, between four and five percent of cases of VT or VF will be refractory to standard management, with nonperfusing arrhythmia persisting despite repeated shocks. Initial guidelines defined “refractory” as VT or VF occurring despite three shocks from a cardiac defibrillator. amiodarone or lidocaine). References Tsao CW, et al.

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Resuscitation Shock Stroke Hospitals 98

Dr. Smith's ECG Blog

JANUARY 15, 2024

Colin is an emergency medicine resident beginning his critical care fellowship in the summer with a strong interest in the role of ECG in critical care and OMI. An ECG was obtained shortly after arrival: ECG 1 What do you think? The ECG has a lot of artifact, and the amplitude is very small, making interpretation challenging.

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EKG/ECG Wellness Point-of-Care Testing Shock 67

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Initial ROSC was obtained, during which this ECG was obtained: What do you think? I sent it to 2 of my ECG nerd colleagues with no clinical information whatsoever, who instantly said: "Looks like afib with subendocardial ischemia and right heart strain pattern." "I CPR was initiated immediately. The rhythm is atrial fibrillation.

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EKG/ECG Resuscitation Ultrasounds CPR 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?

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EKG/ECG Stroke Hospitals Documentation/Coding 97

Mind The Bleep

DECEMBER 19, 2023

ECG: to monitor T wave changes due to hypokalaemia. ECG features of Hypokalaemia: Increased P wave amplitude (peaked P waves) Prolonged PR interval Widespread ST depression T wave flattening or inversion Prominent U waves (most noticeable in the precordial leads) Figure 2 : ECG of a patient with serum K+ of 1.9

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Dehydration Fluid Resuscitation Shock Resuscitation 98

EB Medicine

AUGUST 6, 2022

In this episode, Sam Ashoo, MD interviews Adam Sigal, MD and Stephanie Costa, MD - the authors of the August 2022 EMP article on Managing Acute Cardiac Valvular Emergencies in the Emergency Department. Managing Acute Cardiac Valvular Emergencies in the Emergency Department EMplify - August 2022 Episode Outline: Why Valvular disease?

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COPD Emergency Department Shock EKG/ECG 52

EMDocs

OCTOBER 8, 2024

Glucose POC ECG: Is this actually sinus tachycardia? Looking at the initial or even repeating the ECG will be helpful here. Additional resuscitation Have we addressed all potential sources of shock for the patient in front of us? Does the patient require blood, a procedure to address obstructive shock, or other source control?

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Shock Emergency Department Pediatrics EKG/ECG 95

Dr. Smith's ECG Blog

MAY 5, 2022

Here is the initial ED ECG: What do you think? The ECG shows peaked T waves, QRS widening, a coved-type ST segment with inverted T waves most prominent in V1 and V2 consistent with Brugada pattern. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. Creatinine elevated at 3.09

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EKG/ECG Fluid Resuscitation EMS Shock 52

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).

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EKG/ECG Shock Emergency Department Ultrasounds 52

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Past medical history included RBBB without other cardiac history, but old ECG was not available. As for the ECG, it could represent OMI, but RBBB is also a clue that it may be PE. But with prehospital and ED ECGs being ‘STEMI negative’, the ECG was signed off and the patient waited to be seen.

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EKG/ECG EMS Shock Ultrasounds 77

Dr. Smith's ECG Blog

DECEMBER 10, 2022

I was texted this ECG by one of my partners, with the following history: A 60-something male with diabetes and HTN presented with syncope. A formal echo showed 80% EF and no wall motion abnormality The patient ruled out for MI by troponins Here is the post angiogram EKG: No change, proving that this is the baseline ECG.

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EKG/ECG Operations Shock EMS 52

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.

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EKG/ECG Documentation/Coding Outcomes Shock 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.

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EKG/ECG Shock Sepsis Emergency Department 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? I am sure you already shocked it, right?" ECG analysis: T his is a regular wide complex tachycardia. ventricular tachycardia ( VT ) or 2. Antidromic WPW). Final analysis: 1.

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EKG/ECG Shock Operations EMS 52

EMDocs

APRIL 22, 2024

However, as shock resolved and hemodynamic stability improved, RV strain and underfilling of the LV remained apparent 30 minutes after ROSC (Vid 4). During a short period of ROSC an ECG was performed. The findings of RV strain on the ECG also supported the POCUS echo findings in this case. EKG RV strain. Epub 2022 Jun 30.

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Ultrasounds Advances Cardiac Life Support (ACLS) EKG/ECG Resuscitation 82

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

Here is his triage ECG: PM Cardio version: With no other information at all, I sent this ECG to Dr. Smith, who replied: "I think it is real. In other words, this ECG shows sinus rhythm, normal QRS complex, and: --Inferior OMI: STE in III, hyperacute T waves in lead III, reciprocal STD and TWI in aVL. STD in V4-5 too."

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EKG/ECG Shock CPR Outcomes 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.

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EKG/ECG Outcomes Wellness Shock 52

AED Leader

JULY 19, 2023

According to 2022 statistics from the American Heart Association, there are more than 356,000 out-of-hospital cardiac arrests in the United States every year and just over 10% of EMS-treated victims survive to hospital discharge. What Are the Benefits of a WiFi AED? A metronome helps the user to follow the optimal pace for chest compressions.

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CPR Shock EKG/ECG Hospitals 52

Northwestern EM Blog

JANUARY 24, 2022

Written by: Elizabeth Stulpin, MD (NUEM ‘23) Edited by: Aaron Wibberly, MD (NUEM ‘22) Expert Commentary by : Joshua Zimmerman, MD (NUEM ‘17) Non-Response to Vasopressors Shock is defined as a state of cellular and tissue hypoxia resulting in end organ dysfunction. And for most forms, EM physicians are not typically shocked by shock.

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Anaphylaxis Shock Sepsis Resuscitation 52

Dr. Smith's ECG Blog

MARCH 15, 2023

Here is her EKG: What is unusual about this? Here is the ECG after ibutilide: What do you notice? Here is the post-cardioversion ECG: Sinus rhythm, still with the longer QT interval. We designed a step-up protocol in which shocks at 50, 100, 200, 300, and 360 J were used for transthoracic cardioversion.

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EKG/ECG Dehydration Stroke Wellness 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. The patient is in ventricular fibrillation, and you achieve return of spontaneous circulation (ROSC) on the second shock.

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Hyperthermia / Hypothermia Hospitals Documentation/Coding Outcomes 52

ACEP Now

MARCH 14, 2024

Electrical injuries—excluding lightning injuries—account for roughly 10,000 nonfatal shock incidents a year and 500 deaths a year. 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. Am J Emerg Med.

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Burns Fluid Resuscitation EKG/ECG EMS 52

RebelEM

MARCH 30, 2023

However, there are no clear guidelines for management in post-cardiac arrest patients without ST-segment elevations on ECG. Clinical Question : In patients who suffer an OHCA without ST-segment elevation on the post-resuscitation ECG, will early coronary angiogram (CAG) vs. delayed CAG improve outcomes? Published online June 08, 2022.

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Hospitals Outcomes EKG/ECG Resuscitation 60

Mind The Bleep

OCTOBER 29, 2024

Circulation Assess heart rate, blood pressure, peripheral and central CRT, pulses and 3 lead ECG. Sodium Chloride or Hartmanns if indicated, monitoring for signs of shock. 2022 Mar 2;83(3):1-12. Epub 2022 Mar 4. Establish IV access and begin fluid resuscitation with 250ml boluses of 0.9% Kirkpatrick JJ, Enion DS, Burd DA.

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Burns Fluid Resuscitation PPE Resuscitation 52

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).

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Emergency Department Research Shock EKG/ECG 40

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Here is her ECG on arrival to the ED: What is your differential? The ECG is quickly reviewed and shows sinus rhythm with normal QRS complexes. Her prior ECG on file is shown below: What are your next steps? Learning Points: The ECG is always just one piece of the clinical puzzle. What are your next steps?

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Ultrasounds EKG/ECG EMS Radiology 40