2023, EKG/ECG and Ultrasounds - Emergency Care Today

Acute chest pain and an abnormal ECG. Do precordial leads show benign T-wave inversion or ischemia?

Dr. Smith's ECG Blog

NOVEMBER 17, 2024

ECG 1 What do you think? Benign T-wave Inversion -- Countless Examples (1) The Queen of Hearts Active OMI model (aOMI) is shown below: Willy : My initial impression looking at this ECG was that it was not ischemic. He concluded by saying that "History and concern should win regardless of EKG." It is imperfect.

EKG/ECG

EKG/ECG Operations Ultrasounds Wellness

Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

It appears EMS obtained two EKGs, but unfortunately these were not saved in the medical record. The EMS crew was only BLS certified, so EKG interpretation is not within their scope of practice. The patient arrived just after 10 AM, and the following EKG was obtained. There are no further EKGs or troponin measurements.

EKG/ECG

EKG/ECG EMS Wellness Operations

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Dr. Smith's ECG Blog

JUNE 17, 2024

Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. If this EKG were handed to you to screen from triage without any clinical information, what would you think? Do you appreciate any dynamic changes compared to the patient’s prior EKG? What do you think? In fact, Kosuge et al.

EKG/ECG

EKG/ECG Emergency Department Shock Ultrasounds

Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall

Dr. Smith's ECG Blog

OCTOBER 1, 2023

He had active chest pain at the time of triage at 0137 at night, with this triage ECG: What do you think? I sent this ECG, without any text at all, to Dr. Smith, and he replied: "LAD OMI with low certainty. Back to the case: Unfortunately, the ECG was not understood by the provider. V3 is the one that is convincing."

EKG/ECG

EKG/ECG EMS Ultrasounds Wellness

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He had a previous ECG on file: Proving the findings are new The cath lab was activated. Bedside cardiac ultrasound with no obvious wall motion abnormalities. Bedside cardiac ultrasound with no obvious wall motion abnormalities.

EKG/ECG

EKG/ECG Ultrasounds Documentation/Coding Wellness

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

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

EKG/ECG Documentation/Coding Emergency Department Outcomes

Acute artery occlusion -- which one?

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?

EKG/ECG

EKG/ECG Ultrasounds Shock EMS

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Dr. Smith's ECG Blog

JANUARY 5, 2024

The following ECG was obtained. ECG 1 What do you think? The ECG shows sinus bradycardia but is otherwise normal. There is TWI in lead III, but this can be seen in normal ECGs. The following ECG was obtained around midnight. The machine read was "Normal sinus rhythm, normal ECG." ECG 2 What do you think?

EKG/ECG

EKG/ECG Burns Urgent Care Documentation/Coding

Noisy, low amplitude ECG in a patient with chest pain

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

EKG/ECG Wellness Point-of-Care Testing Shock

A 50-something with chest pain.

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

EKG/ECG Resuscitation CPR Emergency Department

First10EM Journal Club: March 2024

Broome Docs

MARCH 28, 2024

If you want to see Justin in the video format and his new Youtube series then click here: [link] If you would like to check out my current ultrasound training project then click here: WACHS Ultrasound Otherwise – enjoy the show and see you in a few weeks. doi: 10.1136/emermed-2023-213285. 2023 Sep 21:ciad571.

PPE

PPE Ultrasounds Resuscitation Administration

Acute Dyspnea and Right Bundle Branch Block

Dr. Smith's ECG Blog

NOVEMBER 17, 2023

I was texted this ECG just as I was getting into bed. Ken (below) is appropriately worried about pulmonary embolism from the ECG. What I had not told him before he made that judgement is that the patient also had ultrasound B-lines of pulmonary edema. Figure-1: I've labeled the initial ECG in today's case.

EKG/ECG

EKG/ECG Hospitals Ultrasounds Wellness

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

Grand Rounds Recap 1.3.24

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

EKG/ECG Shock Fractures Emergency Department

A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?

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. Pads were placed with ultrasound guidance, so they were in the correct position. Definitive diagnosis that ECG #1 is in fact VT is more than academic.

EKG/ECG

EKG/ECG Shock Documentation/Coding Academics

Young Man with Very Fast Regular Wide Complex Tachycardia

Dr. Smith's ECG Blog

JUNE 28, 2023

He arrived in the ED and had an immediate bedside cardiac ultrasound while this ECG was being recorded. The bedside ultrasound (video not available) reportedly showed only a slightly reduced LV function. Here is the ECG: What do you think? Here is the post cardioversion ECG: What do you think?

EKG/ECG

EKG/ECG Ultrasounds Administration EMS

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

Dr. Smith's ECG Blog

MARCH 6, 2023

If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation? But you can make a diagnosis here, and Pendell and I do this all the time when reading ECGs from databases. The patient had this ECG recorded at 7 minutes after registration at triage as a walk-in (not by EMS): What do you think?

EKG/ECG

EKG/ECG Emergency Department Ultrasounds EMS

How to Cite Videos, Podcasts, Apps, Media, and Blogs in a Publication or CV (AMA style 11th edition)

ALiEM

FEBRUARY 28, 2024

We also must recognize the important contributions of media such as clinical photographs, radiology images, and ECGs. Photographs, ECGs, Radiology Images These fall into the category of “other multimedia” in the AMA Manual of Style, and here is my best attempt to interpret this to clinical media. September 18, 2023. Media title.

Radiology

Radiology Radiology Academics Fractures

Chest pain, and Cardiology didn't take the hint from the ICD

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. Epub 2021 Nov 15.

EKG/ECG

EKG/ECG Shock Emergency Department Ultrasounds

What is going on in V2 and V3, with a troponin I rising to 1826 ng/L at 4 hours?

Dr. Smith's ECG Blog

FEBRUARY 12, 2023

I was reading EKGs on the system before a shift, and saw this one: What do you think? So I thought it probably is not posterior OMI and I just moved on and kept reading EKGs. So I thought it probably is not posterior OMI and I just moved on and kept reading EKGs. So we did a bedside cardiac ultrasound.

EKG/ECG

EKG/ECG Sepsis Ultrasounds

EM@3AM: Brainstem Strokes

EMDocs

MAY 11, 2024

Reference article, Radiopaedia.org (Accessed on 28 Aug 2023) [link] Ortiz de Mendivil A, Alcalá-Galiano A, et al. Semin Ultrasound CT MR. 2013 Apr;34(2):131-41. Updated 2023 Jun 24]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Updated November 9, 2023. Accessed November 19, 2023. 2013.01.004.

Stroke

Stroke EMS EKG/ECG Radiology

POCUS findings of hemodynamically unstable PE with cardiac arrest

EMDocs

APRIL 22, 2024

Point-of-Care-Ultrasound (POCUS) is a bedside modality that can assist Emergency Physicians (EPs) in differentiating PE from other causes of cardiac arrest. Multiorgan POCUS The diagnostic power of POCUS often resides in combining multiple ultrasound exams. During a short period of ROSC an ECG was performed. EKG RV strain.

Ultrasounds

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

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. I don't know if her pain was getting better or not.

EKG/ECG

EKG/ECG Ultrasounds Wellness Stroke

A 20-something with intermittent then acute chest pain

Dr. Smith's ECG Blog

APRIL 25, 2023

No pericardial effusion on ultrasound." ECG diffuse ST elevation, but lacking pericarditis features, and very concerning for acute injury." It peaked at 21,000 ng/L Post angiogram ECG: The fact that there is near normalization suggests that this may have been a thrombus with complete lysis. What do you think?

EKG/ECG

EKG/ECG Ultrasounds

A woman in her 50s with acute chest pain

Dr. Smith's ECG Blog

JANUARY 6, 2023

F Triage ECG: ECG Interpretation: Sinus rhythm with normal QRS. I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Cardiology interpretation of the initial ECG: “ST depressions laterally.”

EKG/ECG

EKG/ECG Wellness Academics Ultrasounds

A man in his 40s with epigastric pain and ST Elevation

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

EKG/ECG Ultrasounds Outcomes Hospitals

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? Her bedside cardiac ultrasound was normal We decided to cardiovert her since the time of onset was very recent. Here is the ECG after ibutilide: What do you notice? Here is the post-cardioversion ECG: Sinus rhythm, still with the longer QT interval. She was on no medications.

EKG/ECG

EKG/ECG Dehydration Stroke Wellness

A young lady with wide complex tachycardia. My first time actually making this diagnosis de novo in real life in the ED!

Dr. Smith's ECG Blog

JUNE 2, 2023

She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? My bedside ultrasound was of insufficient quality, but showed somewhat reduced overall EF, distended IVC without respiratory variation, no pericardial effusion, and diffuse bilateral B lines. == What do you think of her ECG?

EKG/ECG

EKG/ECG Wellness Ultrasounds EMS

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Dr. Smith's ECG Blog

JANUARY 9, 2023

Meyers ECG Interpretation: Easily diagnostic of LAD occlusion. The ECG easily meets STEMI criteria in all leads V2-V6, as well. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. The ECG was interpreted as "benign early repolarization." Beware a negative Bedside ultrasound.

EKG/ECG

EKG/ECG Wellness Ultrasounds Outcomes

Bubble Wrap PLUS – February 2024

Don't Forget the Bubbles

FEBRUARY 5, 2024

2024 Jan 12:archdischild-2023-326225. 2024 Jan 23:archdischild-2023-325984. 2024 Jan 11:fetalneonatal-2023-325829. 2024 Jan 11:fetalneonatal-2023-326383. Assessing fluid responsiveness with ultrasound in the neonatal intensive care setting: the mini-fluid challenge. 2024 Jan 17:fetalneonatal-2023-326099.

Pediatrics

Pediatrics Research Resuscitation Outcomes

Grand Rounds Recap 5.22.24

Taming the SRU

JUNE 3, 2024

Knowing the capabilities of your system BEFORE disaster strikes is crucial top 10 air care cases of 2023-2024 with drs. If you or your patient do not have a watch capable of providing you with an ECG, consider asking those on board to allow you to borrow theirs. Some newer AED's have the capability of providing you with a rhythm strip.

Shock

Shock Seizures Airway Management Stroke

AHA/NCS Statement on Critical Care Management of Post ROSC Patients

EMDocs

JANUARY 11, 2024

Author: Brit Long, MD (@long_brit) // Reviewed by Alex Koyfman, MD (@EMHighAK) The American Heart Association (AHA) and Neurocritical Care Society (NCS) released their 2023 Scientific Statement on the critical care management of post ROSC patients. 2023 Dec 1. Pulmonary Management Takeaway: Use lung-protective ventilation.

Seizures

Seizures Shock Infectious Diseases CPR

EM@3AM: Takotsubo Cardiomyopathy

EMDocs

JANUARY 20, 2024

ECG shows ST-segment elevation in V3-V6 only with depression in aVR. Bedside ultrasound shows hypokinesis of the basal portion of the left ventricle with an apparent sigmoid-shaped septum and a dilated inferior vena cava. Initial vital signs include BP of 157/80, HR of 96, RR 14, SpO2 of 97% on RA, T 37.5. The oral mucosa is moist.

EMS

EMS Fluid Resuscitation Shock EKG/ECG

EM@3AM: Crush Injury

EMDocs

OCTOBER 7, 2023

neurologic damage and thrombosis) 20,21 Resuscitation Lactated ringers > Normal saline due to reduced need for urinary alkalinization 22 Place foley and target urine output >300 mL/hr Electrolyte abnormalities Hyperkalemia: Obtain an ECG Stabilization: Calcium gluconate 2 g over 5-10 min. Accessed February 3, 2023.

EMS

EMS Fluid Resuscitation Fractures Resuscitation

Evaluating Chronic Obstructive Pulmonary Disease

ACEP Now

JUNE 14, 2024

Ultrasound evaluates for global heart function, right heart strain, pulmonary edema, and lung sliding. ECG evaluates for dysrhythmias, acute coronary syndrome, or signs of right heart strain. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2023 report). Updated Feb.

COPD

COPD Hospitals Emergency Department Outcomes

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. Evaluation by ultrasound of traumatic rib fractures missed by radiography. 2023 Nov;82(5):615-623. Epub 2023 May 13. Journal of Osteopathic Medicine. doi:10.7556/jaoa.2020.109

Emergency Department

Emergency Department Fractures Burns EMS

Emergency Care Today

Acute chest pain and an abnormal ECG. Do precordial leads show benign T-wave inversion or ischemia?

Concerning EKG with a Non-obstructive angiogram. What happened?

Trending Sources

Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall

Dynamic OMI ECG. Negative trops and negative angiogram does not rule out coronary ischemia or ACS.

Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?

Acute artery occlusion -- which one?

Three normal high sensitivity troponins over 4 hours with a "normal ECG"

Noisy, low amplitude ECG in a patient with chest pain

A 50-something with chest pain.

First10EM Journal Club: March 2024

Acute Dyspnea and Right Bundle Branch Block

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

Grand Rounds Recap 1.3.24

A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?

Young Man with Very Fast Regular Wide Complex Tachycardia

What do you think of this ECG?? Is this during pain, or after pain resolution? Also, see the CT image of the heart.

How to Cite Videos, Podcasts, Apps, Media, and Blogs in a Publication or CV (AMA style 11th edition)

Chest pain, and Cardiology didn't take the hint from the ICD

What is going on in V2 and V3, with a troponin I rising to 1826 ng/L at 4 hours?

EM@3AM: Brainstem Strokes

POCUS findings of hemodynamically unstable PE with cardiac arrest

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

A 20-something with intermittent then acute chest pain

A woman in her 50s with acute chest pain

A man in his 40s with epigastric pain and ST Elevation

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

A young lady with wide complex tachycardia. My first time actually making this diagnosis de novo in real life in the ED!

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Bubble Wrap PLUS – February 2024

Grand Rounds Recap 5.22.24

AHA/NCS Statement on Critical Care Management of Post ROSC Patients

EM@3AM: Takotsubo Cardiomyopathy

EM@3AM: Crush Injury

Evaluating Chronic Obstructive Pulmonary Disease

Pain Management of Common Chief Complaints in the ED

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