2023, EKG/ECG and Stroke - Emergency Care Today

EM@3AM: Brainstem Strokes

EMDocs

MAY 11, 2024

Answer : Brainstem stroke specifically in the pons resulting in locked in syndrome. CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis?

Stroke

Stroke EMS EKG/ECG Radiology

Answer : Cerebellar Stroke Epidemiology: 1-4% of cerebrovascular accidents occur in the cerebellum. 2 In the United States, approximately 795,000 people suffer from strokes every year. 3 Cerebellar strokes are associated with high morbidity and mortality. CT head without contrast 1 reveals the following: What is the diagnosis?

Stroke

Stroke EMS Pediatrics EKG/ECG

AF Duration? Another Big Story from 2023

Stop and Think

DECEMBER 29, 2023

For an older patient with stroke risk factors and 3 hours of AF on a cardiac device, pre-2023 thinking would have us leaning toward anticoagulation. Edoxaban reduced the primary endpoint of stroke, systemic embolism, and cardiovascular death by 19% (HR, 0.81; 95% CI, 0.60-1.08; hours) to edoxaban vs placebo. I don’t know.

Stroke

Stroke Research EKG/ECG Wellness

A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

A 90-something year old woman presented with an acute mild stroke. She had a routine ECG as part of her workup: What do you think? Peak trop 62 ng/L (would be very low for acute OMI) Next AM ECG: Still with very ischemic looking T-waves. Always look at old ECGs, even if you think the diagnosis is obvious.

Stroke

Stroke EKG/ECG Wellness

How important are old ECGs in Non-obvious cases of potential OMI?

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 that last post: A 90-something with acute stroke.

EKG/ECG

EKG/ECG EMS Stroke Outcomes

Journal Feed Weekly Wrap-Up

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

Documentation/Coding Stroke Emergency Department Pediatrics

STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?

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

EKG/ECG Allergic Reactions Shock Stroke

A man in his 60s with syncope and ST depression. What does the ECG mean?

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Here is his triage ECG: What do you think? What is the most likely cause of the patient’s ECG findings, and what would be your first step in management? What does the ECG show? What does the ECG show? Figure-1: The initial ECG in this case — and a rapid method for estimating the QTc ( See text ). Is it STEMI?

EKG/ECG

EKG/ECG Seizures Hospitals Stroke

Seizure in a 30 something

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

Seizures EKG/ECG EMS Stroke

SAEM Clinical Images Series: Seeing Double

ALiEM

MARCH 22, 2024

Laboratory Data CBC , CMP , EKG , and Troponins were normal. The two main causes of internuclear ophthalmoplegia are demyelination of the medial longitudinal fasciculus (MLF) from multiple sclerosis (MS) and ischemic cranial nerve damage from stroke. There were no oligoclonal bands. Br Ir Orthopt J. 2022 Nov 7;18(1):152-158.

Stroke

Stroke Urgent Care Head Injuries Emergency Department

Acute dyspnea in an older woman, is it OMI?

Dr. Smith's ECG Blog

FEBRUARY 18, 2024

ECG is shown below. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it is still critical to determine the atrial rhythm. Cardiology felt that there was baseline artifact and recommended immediate repeat ECG which is shown below. What do you think?

EKG/ECG

EKG/ECG Stroke

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Dr. Smith's ECG Blog

DECEMBER 5, 2023

Written by Kirsten Morrissey, MD with edits by Bracey, Grauer, Meyers, and Smith An older teen was transferred from an outside hospital with elevated serum troponin and and ECG demonstrating ST elevations. Acute coronary syndrome in a pediatric patient? He denied drug or alcohol use. He did have a family history notable for early CAD.

Pediatrics

Pediatrics EKG/ECG Hospitals Burns

Diagnostics: Intractable Hiccups

Taming the SRU

NOVEMBER 18, 2024

Other causes include gastritis, gastric malignancy, pancreatitis, hiatal hernia, SBO, large meal, spicy foods, and carbonated drinks Neurologic Stroke, space occupying lesion, epilepsy, CNS infection, demyelinating and neurodegenerative disorders such as multiple sclerosis and Parkinson’s disease are causes of intractable hiccups.

Stroke

Stroke Administration Dehydration COPD

Continuous prolonged generalized weakness, lightheadedness, and presyncope. What might you suspect from the ECG?

Dr. Smith's ECG Blog

OCTOBER 28, 2023

Here is his ECG. See this articles: Heart Failure with Preserved Ejection Fraction (NEJM review) One etiology of LVH on the ECG is Hypertrophic Cardiolmyopathy (HOCM), and sometimes ECGs in patients with HOCM are specific for HOCM. But this ECG is NOT specific for HOCM. Figure-1: The ECG in today's case.

EKG/ECG

EKG/ECG Stroke Ultrasounds Wellness

A young woman with palpitations. What med is she on? With what medication is she non-compliant? What management?

Dr. Smith's ECG Blog

DECEMBER 24, 2023

Here is her triage ECG: What do you think? And so was an appropriate anti-coagulant, since atrial flutter, like fibrillation, can result in thromboembolism and stroke. For clarity and ease of comparison, I've put together in Figure-1 — the 3 serial ECGs in today's case. Atrial flutter with 2:1 conduction.

EKG/ECG

EKG/ECG Stroke Administration Wellness

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

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

EKG/ECG Stroke Hospitals Documentation/Coding

Case Report: Pancreatitis Mimics STEMI

ACEP Now

DECEMBER 11, 2023

The Case FIGURE 1: Initial EKG were notable for a leukocytosis of 23.19 A repeat ECG completed shortly after epigastric pain was controlled showed dynamic STE in aVL, V1 and aVR with diffuse ST depressions (see Figure 2). During the initial work-up, her ECG revealed STE measuring approximately 1 mm in V1, V2.

EKG/ECG

EKG/ECG Hospitals Stroke Emergency Department

An Unusual Bradycardia

Dr. Smith's ECG Blog

MAY 5, 2023

= Case Presentation by K EN G RAUER, MD ( 5/5 /2023 ): — Edits by Drs. Dr. Smith was reading ECGs — and he sent myself and Dr. Meyers the tracing shown in Figure-1. Figure-1: The initial ECG in today's case. The CASE Continues: A little while later — a 2nd ECG was done. Figure-3: The repeat ECG in today's case.

EKG/ECG

EKG/ECG Stroke Operations

A man in his late 30s with acute chest pain and ST elevation

Dr. Smith's ECG Blog

MAY 16, 2023

Here is his triage ECG: What do you think? No prior ECG was available. Pretest probability is crucial in ECG diagnosis of OMI or ECG diagnosis of OMI mimic. As Ken says below, tachycardia is not common in OMI and distorts the ST segment, so managing the tachycardia and repeating the ECG is a good strategy.

EKG/ECG

EKG/ECG Stroke Documentation/Coding Outcomes

Updates in the Management of Refractory Ventricular Tachycardia or Ventricular Fibrillation Arrest

ACEP Now

JULY 7, 2023

Post-resuscitation ECGs demonstrating ST segment elevation are significant in delineating which patients might benefit most from advanced reperfusion techniques. Heart disease and stroke statistics-2022 update: A report from the American Heart Association. Accessed June 16, 2023. References Tsao CW, et al. Circulation.

Resuscitation

Resuscitation Shock Stroke Hospitals

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

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. Stroke-volume:50 ml. Normal wall thickness.

EKG/ECG

EKG/ECG Ultrasounds Wellness Stroke

What is strange about this paroxysmal atrial fibrillation in an otherwise healthy patient? And what happened after giving ibutilide?

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. For more on SSS — See My Comment at the bottom of the page in the July 5, 2018 post in Dr. Smith’s ECG Blog. She was on no medications.

EKG/ECG

EKG/ECG Dehydration Stroke Wellness

Grand Rounds Recap 5.22.24

Taming the SRU

JUNE 3, 2024

Susan Wilcox Increasing regionalization due to: Growth of specialty centers Increasing development of healthcare systems Hub-and-spoke models Development of ECMO, trauma, transplant, and stroke centers The higher the acuity of the centers, the higher the acuity of the patient that needs to get there.

Shock

Shock Seizures Airway Management Stroke

You don’t need labs to medically clear a psych patient

PEMBlog

SEPTEMBER 6, 2023

Life threatening non-psychiatric causes of acute psychosis include hypoglycemia, cerebral hypoxia, drug toxicity, CNS abnormalities (such as brain tumor, meningoencephalitis, injury, seizures, or stroke), metabolic conditions, electrolyte disturbances, hepatic failure, uremia, or thyrotoxicosis. Hosp Pediatr (2023) 13 (1): 66–71

Psychiatric

Psychiatric Pediatrics Emergency Department EKG/ECG

Recognition and Treatment of Thrombotic Thrombocytopenic Purpura

ACEP Now

APRIL 5, 2024

1 However, many clinical features are common: more than 60 percent of patients present with a degree of neurological involvement, ranging from confusion to stroke and coma. 1 25 percent of patients may present with evidence of myocardial ischemia, including abnormal ECGs and elevated troponin levels. Updated April 7, 2023.

Domestic Violence

Domestic Violence Emergency Department Outcomes EKG/ECG

Emergency Medicine Deserves to “Re-Brand” Itself as a Cost Saver

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. In 2023 we must move beyond that title. Accessed June 10, 2023.

Head Injuries

Head Injuries Emergency Department Research Pediatrics

EM@3AM: Hyperthermia

EMDocs

DECEMBER 16, 2023

A 12-lead EKG shows sinus tachycardia but is otherwise normal. Both can result in heat exhaustion and heat stroke and have many overlapping symptoms. Patients with heat stroke have hot, dry skin and altered mental status (e.g., C, and heat stroke occurs at a core temperature > 40°C. Temps greater than 41.5C

Hyperthermia / Hypothermia

Hyperthermia / Hypothermia EMS Stroke Seizures

Policy Playbook: Medicare Part D Drug Pricing Negotiations

EMDocs

OCTOBER 27, 2023

On the monitors and subsequent ECG, you note he is in atrial fibrillation with rapid ventricular response. Further review reveals the patient was unable to afford his refill of Eliquis and abruptly stopped taking it, leading to his acute stroke. Exam shows an uncomfortable-appearing febrile gentleman with a mild cough.

Research

Research Stroke EMS EKG/ECG

Pain Management of Common Chief Complaints in the ED

EMDocs

NOVEMBER 4, 2024

Pain can be associated with a friction rub on cardiac auscultation, a pericardial effusion on a bedside echocardiogram, or diffuse ST elevations on an EKG. 2023 Nov;82(5):615-623. Epub 2023 May 13. Up to two-thirds of rib fractures are missed on initial chest radiographs. Feb 2016;56(2):331-40. doi:10.1111/head.12767

Emergency Department

Emergency Department Fractures Burns EMS

Emergency Care Today

EM@3AM: Brainstem Strokes

EM@3AM: Cerebellar Stroke

Trending Sources

AF Duration? Another Big Story from 2023

A 90-something with acute stroke. She has no chest symptoms. What is the diagnosis?

How important are old ECGs in Non-obvious cases of potential OMI?

Journal Feed Weekly Wrap-Up

STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?

A man in his 60s with syncope and ST depression. What does the ECG mean?

Seizure in a 30 something

SAEM Clinical Images Series: Seeing Double

Acute dyspnea in an older woman, is it OMI?

OMI in a pediatric patient? Teenagers do get acute coronary occlusion, so don't automatically dismiss the idea.

Diagnostics: Intractable Hiccups

Continuous prolonged generalized weakness, lightheadedness, and presyncope. What might you suspect from the ECG?

A young woman with palpitations. What med is she on? With what medication is she non-compliant? What management?

A fascinating electrophysiology case. What is this wide complex tachycardia, and how best to manage it?

Case Report: Pancreatitis Mimics STEMI

An Unusual Bradycardia

A man in his late 30s with acute chest pain and ST elevation

Updates in the Management of Refractory Ventricular Tachycardia or Ventricular Fibrillation Arrest

What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?

What is strange about this paroxysmal atrial fibrillation in an otherwise healthy patient? And what happened after giving ibutilide?

Grand Rounds Recap 5.22.24

You don’t need labs to medically clear a psych patient

Recognition and Treatment of Thrombotic Thrombocytopenic Purpura

Emergency Medicine Deserves to “Re-Brand” Itself as a Cost Saver

EM@3AM: Hyperthermia

Policy Playbook: Medicare Part D Drug Pricing Negotiations

Pain Management of Common Chief Complaints in the ED

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