Dr. Smith's ECG Blog

AUGUST 4, 2024

Written by Pendell Meyers Try first to interpret the ECG without any clinical context: What do you think? Overall, this looks like one of the rare ECGs that is actually specific for pericarditis in my opinion. There was no prior ECG for comparison. To improve visualization — I've digitized the original ECG using PMcardio ).

EKG/ECG 98

EKG/ECG Wellness Emergency Department Operations 98

Ken Grauer, MD

FEBRUARY 24, 2023

The ECG in Figure-1 was obtained from a previously healthy 30-ish year old man — who presented to medical attention for vasovagal syncope. Based on this initial ECG — the patient was transferred to a PCI-capable center: Do YOU agree with the need for transfer? Figure-1: The initial ECG in today's case.

EKG/ECG 195

EKG/ECG Hospitals Wellness 195

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

Written by Pendell Meyers First try to interpret this ECG with no clinical context: The ECG shows an irregularly irregular rhythm, therefore almost certainly atrial fibrillation. Here is the initial ECG: A temperature sensing Foley was inserted and reported a core temperature of 26.7 He did well and was discharged.

Hyperthermia / Hypothermia 134

Hyperthermia / Hypothermia EKG/ECG Wellness 134

EMDocs

DECEMBER 11, 2023

The most common diagnostic test to identify patients who might require percutaneous intervention is the electrocardiogram (ECG). Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG.

EKG/ECG 110

EKG/ECG Emergency Department Academics Operations 110

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Hope you’re doing well! Here is the ED ECG (a photo of the paper printout) What do you think? You taught us well!" The "good news" — is that a cardiac-related cause of syncope is unlikely if the initial ECG is normal, and cardiac monitoring in the ED fails to reveal significant arrhythmia. No Chest Pain, but somnolent.

EMS 107

EMS CPR EKG/ECG Wellness 107

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. And she learned it well: She is not highly confident, but she does diagnose OMI. Here is a similar case from Pendell: This ECG was handed over at triage. A value above 18.2 (LAD A value above 19 is about 97% specific for LAD OMI.

EKG/ECG 116

EKG/ECG COPD Wellness Outcomes 116

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. What do you think, and how would you manage the patient? The Need for Immediate Transport?

EKG/ECG 131

EKG/ECG Emergency Department Wellness 131

Dr. Smith's ECG Blog

OCTOBER 18, 2023

All initial ECGs were labeled ‘normal’ or ‘otherwise normal’ by the computer interpretation, and below are the ECGs with the final cardiology interpretation. 1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes.

EKG/ECG 121

EKG/ECG Documentation/Coding Emergency Department Outcomes 121

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

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 112

EKG/ECG Documentation/Coding Wellness Resuscitation 112

Dr. Smith's ECG Blog

AUGUST 18, 2024

Here is his triage ECG with minimal symptoms: What do you think? The ECG shows pacemaker failure with inability to capture or sense, with either underlying atrial fibrillation or junctional escape rhythm. He did well. Today's CASE: For clarity in Figure-1 — I've reproduced today's ECG. large boxes ).

EKG/ECG 92

EKG/ECG Fractures Burns Wellness 92

Dr. Smith's ECG Blog

AUGUST 16, 2024

Here is his triage ECG: What do you think? The ECG shows massively hyperacute T waves of LAD OMI, plus WPW. Here is the Queen of Hearts (version 1) interpretation, of course: Click here to sign up for Queen of Hearts Access Luckily for this NSTEMI patient, the ECG was recognized as LAD OMI despite lack of formal STEMI criteria.

EKG/ECG 104

EKG/ECG Wellness 104

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. But he did well.

EKG/ECG 119

EKG/ECG EMS Outcomes Wellness 119

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 70

EKG/ECG Operations Wellness Ultrasounds 70

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.

EKG/ECG 67

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

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). It is one of the few OMI patterns that is really well described: de Winter’s T-waves.

EKG/ECG 79

EKG/ECG Outcomes Academics Wellness 79

EMergucate

JULY 6, 2022

The patient is well known to the department, with frequent presentations with chest pain. A 50 year old female presents to ED complaining of chest pain.

EKG/ECG 52

EKG/ECG Wellness EMS 52

EMergucate

JULY 3, 2022

The patient is well known to the department, with frequent presentations with chest pain. A 50 year old female presents to ED complaining of chest pain.

EKG/ECG 52

EKG/ECG Wellness EMS 52

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

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

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

SEPTEMBER 5, 2024

Since serial ECGs are not available so either of the two patterns described above could be present (only serial ECG could differentiate). Post infarction regional pericarditis (PIRP) can be suspected from the ECG and is associated with an increased risk of myocardial rupture. Oliva PB, Hammill SC, Edwards WD.

Shock 105

Shock EKG/ECG Hospitals Wellness 105

EMergucate

JUNE 1, 2022

The patient is otherwise well on no current … Continue reading → A 57 year old male presents o ED c/o pleuritic chest pain.

EKG/ECG 52

EKG/ECG Wellness EMS 52

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. 2022 — and — Kontos et al; 2022 ACC Expert Consensus — JACC 80(20):1925-1960, 2022 ).

EKG/ECG 70

EKG/ECG Documentation/Coding EMS Wellness 70

Dr. Smith's ECG Blog

OCTOBER 23, 2023

An Initial ECG was performed: Initial ECG: Sinus tachycardia with prolonged QT interval (QTc of 534 ms by Bazett). A repeat ECG was performed 2 hours after arrival: QTc prolongation ato 722 ms now with alternating T wave pattern (T wave alternans) I texted this to Smith who responded: “T wave alternans and long QT.

EKG/ECG 123

EKG/ECG Documentation/Coding Psychiatric EMS 123

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 RV is supplied during systole as well as diastole.

Shock 81

Shock EKG/ECG Academics Stroke 81

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

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. Normal vital signs.

EKG/ECG 76

EKG/ECG Outcomes Wellness 76

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 121

EKG/ECG Documentation/Coding Emergency Department Wellness 121

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 ). Troponins are highly specific to cardiac myocytes but do exist in other muscle types as well. Bonus Pearls: SVT ECGs will often demonstrate diffuse ST depressions.

EKG/ECG 143

EKG/ECG Sepsis EMS Outcomes 143

EMergucate

MAY 29, 2022

The patient is otherwise well on no current … Continue reading → A 57 year old male presents o ED c/o pleuritic chest pain.

EKG/ECG 40

EKG/ECG Wellness EMS 40

Ken Grauer, MD

SEPTEMBER 6, 2024

You are shown the ECG in Figure-1 — told only that the patient had a “continuous" tachycardia. QUESTIONS: How would YOU interpret the ECG in Figure-1 ? Figure-1: The initial ECG in today's case. ( To improve visualization — I've digitized the original ECG using PMcardio ). What is the differential diagnosis?

EKG/ECG 252

EKG/ECG Administration Wellness Operations 252

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

AUGUST 2, 2024

His ECG is shown below. The LCx and OM branches are not as well seen. How does RCA occlusion fit with the ECG? The answer is that the ECG really shows right ventricular OMI. 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

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

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.

CDC 130

CDC Poisoning Pediatrics Shock 130

Dr. Smith's ECG Blog

NOVEMBER 19, 2022

EKG was obtained in triage and read as ventricular bigeminy. On my first read of the EKG, I agreed with the initial interpretation. In context of our original EKG, the patient appears to be alternating conduction through the AV node and accessory pathway - a condition previously described as Wolf-Parkinson-White Alternans.[1]

EKG/ECG 52

EKG/ECG Stroke Emergency Department Wellness 52