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 119

EKG/ECG Documentation/Coding Emergency Department Outcomes 119

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.

EKG/ECG 123

EKG/ECG COPD Wellness Outcomes 123

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 116

EKG/ECG EMS Stroke Outcomes 116

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 125

EKG/ECG EMS Outcomes Wellness 125

EMDocs

JANUARY 8, 2024

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association 2023 Guideline Updates for 2023 were just published. Magnesium does not improve ROSC, survival, or neurologic outcomes, no matter the presenting rhythm (Level 3: no benefit). 2023 Dec 18. Circulation.

Seizures 98

Seizures Shock CPR Hyperthermia / Hypothermia 98

Dr. Smith's ECG Blog

JUNE 5, 2024

The below ECG was recorded. The ECG does not show any definite signs of ischemia. In fact, the ECG was described as normal, and without serial ECGs or prior ECGs for comparison it could be. PEARL: Increased vagal tone is highly likely to be the cause of the abnormal rhythm in ECG #2.

EKG/ECG 122

EKG/ECG Outcomes 122

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 104

EKG/ECG Wellness Hospitals EMS 104

Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? I read this ECG without any history as reperfusing inferior and posterior OMI due to the Q-wave in lead III with minimal STE and reciprocal ST depression in V2-V4 (which should never be there). We send each other EKG by the dozens every day. Most are OMI look alikes (mimics).

EKG/ECG 96

EKG/ECG Research Outcomes 96

RebelEM

SEPTEMBER 28, 2023

ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% neoplasm, aneurysm, intracranial or spinal surgery) or recent trauma to head or cranium (i.e. Primary PCI: 95.7%

EKG/ECG 138

EKG/ECG Allergic Reactions Shock Stroke 138

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This ECG was recorded in triage. The computer interpretation is: “Sinus Brady with moderate intraventricular conduction delay, nonspecific t wave abnormality, abnormal EKG” What do you think? Case Continued The ECG findings were not recognized. Therefore, no matter the initial ECG, record serial ECGs.

EKG/ECG 135

EKG/ECG Resuscitation CPR Emergency Department 135

RebelEM

JUNE 1, 2023

Post-ROSC management is nuanced and challenging but helps to ensure good outcomes. In theory, rapid identification of the underlying cause should improve outcomes by allowing clinicians to tailor management. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study.

Outcomes 145

Outcomes Resuscitation Hospitals CPR 145

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.

EKG/ECG 96

EKG/ECG Outcomes Academics Wellness 96

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 98

EKG/ECG Wellness Emergency Department EMS 98

ALiEM

NOVEMBER 6, 2023

Wolf-Parkison-White Syndrome (WPW) Case Question: What are the characteristic ECG findings of this condition and how is this condition managed? These particular EKG findings define a “Wolff-Parkinson-White Pattern.” WPW Syndrome consists of characteristic EKG findings as well as symptomatic arrhythmias. Crit Care Nurse.

EKG/ECG 78

EKG/ECG Academics Outcomes Wellness 78

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Which had the more severe chest pain at the time of the ECG? Patient 2 at the bottom with a very subtle OMI complained of 10/10 chest pain at the time the ECG was recorded. And as we have shown before, morphine leads to slower times to treatment and worse outcomes. 2 middle aged males presented with chest pain.

EKG/ECG 119

EKG/ECG Hospitals Outcomes Wellness 119

EMDocs

MAY 4, 2024

. #1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.

Documentation/Coding 98

Documentation/Coding Stroke Emergency Department Pediatrics 98

Dr. Smith's ECG Blog

SEPTEMBER 1, 2023

Here is the triage ECG: What do you think? I would activate the cath lab, or at least look for an old one and/or obtain serial ECGs. Case Continued There was an old ECG available from 1.5 Here it is: These T-waves are far smaller, confirming that the above ECG is indeed due to LAD OMI. Accuracy was 91% and AUC was 0.95.

EKG/ECG 128

EKG/ECG Outcomes 128

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 131

EKG/ECG Documentation/Coding Wellness Emergency Department 131

RebelEM

MAY 27, 2024

The primary outcomes are patient-centered and objectively measured, potentially ensuring relevance and reliability. The unblinded nature of the study could influence outcomes due to observer bias. Employing P-values to compare demographics between groups could mislead interpretations of the data’s relevance to the primary outcomes.

Outcomes 137

Outcomes Research Operations Hospitals 137

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

Here is the ED ECG (a photo of the paper printout) What do you think? Smith : "What was the outcome?" Acute MI per se usually does not depress cardiac function and blood pressure enough to cause syncope ( Mostafa et al — J Com Hosp Intern Med Perspect 13(4):9-12, 2023 - ). No Chest Pain, but somnolent.

EMS 114

EMS CPR EKG/ECG Wellness 114

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.

Hyperthermia / Hypothermia 145

Hyperthermia / Hypothermia Military CPR EKG/ECG 145

EMDocs

NOVEMBER 29, 2023

2023 May 25;388(21):1931-1941. Included 584 patients > 18 years admitted to ICU with severe PNA based on IDSA/ATS criteria Primary Outcome: 60-day all-cause mortality Hydrocortisone 16% vs. placebo 18%, adjusted OR 0.90 (95% CI 0.57-1.40) 2023 Jul 8;27(1):274. 2023 May 31;27(1):212. #4: 2023 Jul;188:109785.

Resuscitation 96

Resuscitation Outcomes EKG/ECG 96

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 66

EKG/ECG Academics Shock Outcomes 66

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 119

EKG/ECG Fluid Resuscitation Academics Resuscitation 119

Dr. Smith's ECG Blog

OCTOBER 8, 2023

Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECG s that has not been overread by a physician. ECG#1 ECG#2 ECG#3 ECG#4 ECG#5 See outcomes of all 5 below, with the Queen of Hearts AI Bot interpretation. (THE True Positive ECG#2 : Also sinus rhythm.

Hyperthermia / Hypothermia 123

Hyperthermia / Hypothermia EKG/ECG Wellness Shock 123

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

The following ECG was recorded. The presenting ECG shows SR with narrow QRS complexes. First troponin I returned 3174 ng/l, at which point a repeat ECG was ordered. Not much difference from 1st ECG. At this point an old ECG on file was found for comparison. Upon admission she had ongoing slight chest discomfort.

EKG/ECG 116

EKG/ECG COPD Shock Wellness 116

Dr. Smith's ECG Blog

JANUARY 29, 2024

This was sent by Sam Ghali @EM_RESUS A 44 year old man presented with chest pain The tech came running with the ECG as the computer called "STEMI!" Tell me the outcome! I learned that from you!) --I also had the benefit of old ECGs on this guy, which at baseline he has very concerning "Hyperacute" T waves! " What do you think?

EKG/ECG 97

EKG/ECG Outcomes 97

Dr. Smith's ECG Blog

OCTOBER 18, 2023

A few days into her hospital stay she developed chest discomfort and the following ECG was recorded. Are these ECG changes related to the CNS infection perhaps? When I saw the ECG of this patient I saw that there was definitely something "off". I sent the top ECG to Dr Smith with no information and without the baseline ECG.

EKG/ECG 122

EKG/ECG Hospitals Academics Outcomes 122

EMDocs

MAY 11, 2024

Reference article, Radiopaedia.org (Accessed on 28 Aug 2023) [link] Ortiz de Mendivil A, Alcalá-Galiano A, et al. Updated 2023 Jun 24]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Updated November 9, 2023. Accessed November 19, 2023. Accessed December 15, 2023. Updated 2023 Aug 28].

Stroke 110

Stroke EMS EKG/ECG Radiology 110

Taming the SRU

JANUARY 10, 2024

2768 aka the SAVE act (introduced for the 3rd time 9/12/2023) which establishes a new criminal offense for knowingly assaulting or intimidating hospital personnel during the performance of their official duties in a manner that interferes with their performance of the duties or limits their ability to perform the duties. 2663 & S.1176

EKG/ECG 93

EKG/ECG Shock Fractures Emergency Department 93

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. His ECG was repeated at this point: This shows a well developed anterior STEMI. His first troponin was normal.

EKG/ECG 52

EKG/ECG Outcomes Emergency Department Hospitals 52

Dr. Smith's ECG Blog

AUGUST 14, 2024

Written by Willy Frick I was reading through ECGs in the queue when I saw the following. At first glance there seems to be a lot of variation happening, but by focusing on one part of the ECG at a time we can make sense of it. So why does the sinus node apparently stop pacing for a few seconds in the middle of the ECG?

EKG/ECG 110

EKG/ECG Outcomes Wellness 110

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 83

EKG/ECG Shock Documentation/Coding Academics 83

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 98

Resuscitation EKG/ECG CPR Outcomes 98

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 98

EKG/ECG Wellness Outcomes Hospitals 98

Broome Docs

MARCH 28, 2024

doi: 10.1136/emermed-2023-213285. PMID: 38050078 Bottom line: High dose nitroglycerin seems to result in better outcomes in SCAPE, at least according to this small, single center, unblinded trial. 2023 Sep 21:ciad571. 2023 Sep 19:S0196-0644(23)00671-6. 2023 Dec;193:109991. 2023 Aug 21:S0012-3692(23)05350-3.

PPE 96

PPE Ultrasounds Resuscitation Emergency Department 96

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. Updated 2023 Jul 17]. Updated 2023 Jul 17]. Chemical Burns. In: StatPearls [Internet]. 1982 May;22(5):420-3.

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52