EMDocs

SEPTEMBER 26, 2024

This story, while unlikely to reflect the standards of most readers, has a somewhat surprising outcome. EKG, labs, and a CXR are interpreted by the EP as normal. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. Too much weight was given to the EKG, CXR, and labs.

Radiology 97

Radiology Radiology EKG/ECG Documentation/Coding 97

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Here are his EMS ECGs along with the Queen of Hearts interpretations below each one: EMS1 0650 EMS2 0707 Click here to sign up for Queen of Hearts Access The ECGs show RBBB and LAFB, with small but important concordant STE in V2. In EMS2 ECG, the T waves in V5 is possibly hyperacute. Long term outcome is unavailable.

EKG/ECG 121

EKG/ECG EMS Documentation/Coding Shock 121

Dr. Smith's ECG Blog

MAY 13, 2024

Here is the initial ECG at 13:17 with no prior ECG in the patient’s chart for comparison: What do you think? This is another version of the same ECG, lower quality, and with an additional filter applied. See Ken Grauer's additional comments about this ECG at the end of the post! The culprit mid LAD lesion was stented.

EKG/ECG 120

EKG/ECG Emergency Department Ultrasounds Documentation/Coding 120

Dr. Smith's ECG Blog

MARCH 19, 2024

This was the ECG obtained at triage. This ECG was recorded and was reviewed remotely by a cardiologist: What do you think? The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." Next trop in AM.

EKG/ECG 111

EKG/ECG Hospitals Documentation/Coding Outcomes 111

Dr. Smith's ECG Blog

AUGUST 9, 2024

These diagnoses were not found in his medical records nor even a baseline ECG. He had no previously documented medical problems except polysubstance use. An ECG was obtained shortly after arrival: What do you think? There is no evidence of WPW on this ECG, but it is diagnostic for OMI. What are we seeing here?

EKG/ECG 107

EKG/ECG EMS Emergency Department Wellness 107

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

ACEP Now

DECEMBER 6, 2024

During initial assessment, an ECG was obtained and revealed ST-segment elevation (STE) in the inferior leads with ST depression anteriorly. Initial ECG demonstrating inferolateral ST segment elevation and anteroseptal depression, just prior to cardiac arrest. The ECG showed ST-segment elevation without obstructive coronary disease.

Resuscitation 98

Resuscitation EKG/ECG Documentation/Coding COPD 98

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Triage EKG: What do you think? A prior ECG was available for comparison. Prior EKG from 2 months ago was available: Let's put the precordial leads from the 2 ECGs side by side: Now you can really see the difference. Immediately after the second ECG was performed, the patient's pain resolved completely.

EKG/ECG 52

EKG/ECG Ultrasounds EMS Documentation/Coding 52

EMDocs

OCTOBER 10, 2024

Exam is normal except for tenderness as documented in the diagram. EKG shows atrial fibrillation with a rate of 169. She never had a documented abdominal exam. I just failed to document it. The EP documented seeing the patient and agreed with the ARNP’s plan. Temp is 98.7 and pulse 121. It was benign.

Documentation/Coding 97

Documentation/Coding Hospitals Sepsis Infectious Diseases 97

RebelEM

JULY 3, 2023

Patients confirmed on ECG to have atrial fibrillation or atrial flutter Patients with HR >120 bpm. Pregnant or incarcerated patients Documentation for systolic BP is incomplete Intervention: Administration of IV calcium within 60 min prior to or 30 min after IV diltiazem administration in patients with AF/AFL with RVR.

Administration 98

Administration Outcomes Documentation/Coding Emergency Department 98

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Triage ECG (no prior for comparison): Computer algorithm read: "Sinus rhythm, low voltage QRS, inferior myocardial infarction, probably old." I texted this ECG with no information to Dr. Smith, who immediately said: "If CP, then anterior OMI until proven otherwise." Every note says "no ischemic changes on ECG." Deemed "NSTEMI."

EKG/ECG 78

EKG/ECG Outcomes Academics Documentation/Coding 78

Dr. Smith's ECG Blog

JUNE 14, 2017

An ECG was recorded: Avinash was understandably confused by this ECG. He wrote: "ECG 1 - shows wide ???IVCD I sent it to my friend, Ken Grauer , who is very meticulous in his ECG reading. I labeled ECG. As we see in ECG #3 — the regular rhythm is NOT sinus, because the P wave is negative in lead II.

EKG/ECG 52

EKG/ECG Documentation/Coding Ultrasounds Wellness 52

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. Full case details and outcomes are below. His triage at 0127 is the ECG above. Repeat ECG at 0221: Basically unchanged. Physician: "No STEMI."

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Psychiatric 52

Dr. Smith's ECG Blog

JUNE 30, 2023

Queen: #1: NOT OMI, HIGH CONFIDENCE Queen: #2: NOT OMI, HIGH CONFIDENCE ECG 1 Interpretation: there is terminal T-wave in V3-V6. See 2 dozen examples here: Understanding this pathognomonic ECG would have greatly benefitted the patient. Outcome: Patient ruled out for MI by troponins. Is this Wellens' pattern A?

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Wellness 52

Mind The Bleep

OCTOBER 29, 2024

Circulation Assess heart rate, blood pressure, peripheral and central CRT, pulses and 3 lead ECG. Provide detailed documentation of the initial assessment, treatment provided, and the patient’s response to interventions. Proper stabilization and detailed communication with the burns centre are essential for optimal patient outcomes.

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52

Dr. Smith's ECG Blog

MARCH 27, 2025

Below is the first ECG, signed off by the over-reading cardiologist agreeing with the computer interpretation: ST elevation, consider early repolarization, pericarditis, or injury. Emergency physician: STEMI neg but with elevated troponin = Non-STEMI The first ECG was signed off. Repeat blood work and ECG 0845: repeat trop over 7000.

EKG/ECG 52

EKG/ECG Documentation/Coding Research Outcomes 52

Dr. Smith's ECG Blog

OCTOBER 6, 2018

At 3:55 AM during that kind of a night shift, this ECG (among many others) was brought from triage for review by my team. We knew only that the ECG belonged to a man in his 50s with chest pain and normal vitals. Here is the computer interpretation: So we have a triage-computer-normal ECG. No prior available.

EKG/ECG 40

EKG/ECG Seizures Documentation/Coding Outcomes 40

Dr. Smith's ECG Blog

JUNE 20, 2018

The initial tracing (EKG 1) was obtained. Clinician and EKG machine read of acute pericarditis. Paper published: Terminal QRS distortion not found in any ECG of Early Repolarization TQRSD is defined as the absence of BOTH an S-wave and a J-wave in leads V2 or V3. She was reportedly "pacing in her room while holding her chest".

EKG/ECG 52

EKG/ECG Documentation/Coding Ultrasounds Wellness 52

Mind The Bleep

NOVEMBER 21, 2023

Unless you’re documenting something hilarious, please keep it brief and to the point. History of Presenting Complaint In this section use SOCRATES to document the pain. Drugs/Allergies When documenting drugs – try to get the dose and frequency (this can be found on Summary Care Records from the GP if you have access).

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

Here is the first ED ECG, with no pain: Sinus rhythm. The ECG in the chart was read as "no obvious ST changes," (even though no previous ECG was available) and the formal read by the emergency physicians was: "ST deviation and moderated T-wave abnormality, consider lateral ischemia." Computerized QTc = 419. It was stented.

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Wellness 52

Dr. Smith's ECG Blog

JULY 3, 2018

Here is his initial ECG: 00:04 What do you think? With no other information other than the first ECG above, I texted this to Dr. Smith and he responded: ST elevation in lead V2 and terminal QRS distortion in V3. Therefore, this ECG would not have met the criteria for ACO by this formula. LAD occlusion. Great case.

EKG/ECG 52

EKG/ECG Documentation/Coding Administration Outcomes 52

Dr. Smith's ECG Blog

APRIL 4, 2023

Below is the old ECG, showing that all these changes are new – including the Q waves. This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion.

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Wellness 52

Taming the SRU

JUNE 3, 2024

CESAR Trial Published in 2009 Found that even those who didn’t get ECMO, but were transported to a tertiary care center had better outcomes No matter where you go, critical care transport will be part of your life as a sending physician, receiving physician, or both. Benefits of transport are evidenced based.

Shock 91

Shock Seizures Airway Management Stroke 91

RebelEM

MARCH 2, 2023

Essentially there was no difference, meaning we wouldn’t expect to find a difference in outcomes Although not patient oriented, why is there no breakdown of how many patients had cardiogenic shock, congestive heart failure, echocardiographic findings, or even troponin levels. Low O2 protocol: 3.1% aOR 0.96, 95% CI 0.86 Low O2 protocol: 10.6%

Outcomes 52

Outcomes EMS EKG/ECG Hospitals 52

EB Medicine

MARCH 1, 2019

Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes. New EKG findings requires admission for monitoring. of those patients.

Emergency Department 40

Emergency Department EKG/ECG Operations Fractures 40

Dr. Smith's ECG Blog

MAY 16, 2023

Here is his triage ECG: What do you think? No prior ECG was available. Other outcome information is not available. Pretest probability is crucial in ECG diagnosis of OMI or ECG diagnosis of OMI mimic. For clarity in Figure-1 — I’ve reproduced the only ECG in today’s case. Figure-1: Today's ECG. (

EKG/ECG 52

EKG/ECG Stroke Documentation/Coding Outcomes 52

ACEP Now

MAY 10, 2024

His vital signs are normal and the ECG does not demonstrate a myocardial infarction. Primary Outcome: Diagnostic accuracy of identifying Stanford type A and Stanford type B AoDs Secondary Outcomes: Test characteristics of each of the three individual sonographic findings for diagnosing Stanford type A and Stanford type B AoDs.

Ultrasounds 52

Ultrasounds Outcomes Academics Documentation/Coding 52

AENJ: Current Issue

SEPTEMBER 30, 2023

The overuse of computed tomographic (CT) scans for patients who present to the emergency department (ED) after mild traumatic brain injury (mTBI) has been well-documented. The outcomes measured were the number of CT scans ordered, ED length of stay, and the cost of avoidable CT scans. Cost of care was also estimated.

Emergency Department 52

Emergency Department Documentation/Coding Outcomes Wellness 52

The Skeptics' Guide to EM

MAY 2, 2020

The EMS crew arrives and performs a 3 lead EKG that does not show an ST elevated myocardial infarction. Yes * Was the outcome accurately measured to minimize bias? Case:You are visiting with your father, a 64-year-old overweight man with hypertension. Yes * Did the authors use an appropriate method to answer their question?

Documentation/Coding 40

Documentation/Coding EMS EKG/ECG Outcomes 40

Dr. Smith's ECG Blog

JUNE 27, 2021

Medics recorded this ECG: There is a lot of artifact, but you can clearly see ST depression in V2 and V3. Here is the first ED ECG (there was no previous ECG on file for comparison): Sinus rhythm and LVH There is some (less than 1 mm) of STD in V3 and V4. ng/mL, and another ECG was recorded and was identical.

EKG/ECG 40

EKG/ECG Radiology Radiology Ultrasounds 40

Dr. Smith's ECG Blog

APRIL 8, 2016

Here is his ED ECG: There is obvious infero-posterior STEMI. This subsequent ECG was recorded after the K was up to 2.2 The QT is much shorter There are now clear U-waves in V2 and V3 2 days later, this ECG was recorded with a K of 3.5: The patient stabilized and had a good outcome. He appeared to be in shock.

Resuscitation 52

Resuscitation EKG/ECG Hospitals Administration 52

EMDocs

JANUARY 11, 2024

Early coronary angiography in post-CA patients with no ST-segment elevation on the presenting ECG may still be of benefit by potentially salvaging myocardium and decreasing the incidence of systolic heart failure in survivors (95.7%, 22/23). Centers managing patients after CA should collect data and evaluate outcomes of care (95.7%, 22/23).

Seizures 97

Seizures Shock Infectious Diseases CPR 97

EB Medicine

JUNE 6, 2019

Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. An EKG and troponin should be considered.

Ultrasounds 40

Ultrasounds Radiology Radiology Sepsis 40

EB Medicine

JULY 8, 2019

Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS. A normal ekg of course does not rule out a cardiac cause of their presentation. Jeff: Still, the complication rate is low - about 2.3%

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

EB Medicine

AUGUST 1, 2018

In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. Nachi: Interestingly, there are a number of medications that are associated with false positive cannabinoid screenings.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

Dr. Smith's ECG Blog

APRIL 8, 2015

Cardiac Syncope ("True Syncope") Independent Predictors of Adverse Outcomes condensed from multiple studies 1. Abnormal ECG – looks for cardiac syncope. Abnormal Electrocardiogram (ECG): Defined (San Fran syncope rule) as any new changes when compared to the last ECG or presence of non-sinus rhythm.

Emergency Department 52

Emergency Department EKG/ECG Outcomes Seizures 52

Taming the SRU

JUNE 6, 2023

then need further evaluation Usually with CTA imaging If normal physical exam & ABI>0.9, then need further evaluation Usually with CTA imaging If normal physical exam & ABI>0.9,

Documentation/Coding 64

Documentation/Coding Seizures Psychiatric Wellness 64