Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

This ECG was texted to me with no other information. The first ECG was recorded at 53 minutes after pain onset. The pain began to improve and this ECG was recorded: T-waves are not quite as tall, though still have a large AUC. An old ECG was found: As you can see, this patient has zero baseline STE, and normal T-waves.

EKG/ECG 131

EKG/ECG Wellness Documentation/Coding 131

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. Another ECG was recorded after the nitroglycerine and now without pain: All findings are resolved. No other symptoms.

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EKG/ECG Ultrasounds Documentation/Coding Wellness 122

EMDocs

FEBRUARY 9, 2024

She is well appearing, and while being placed on the monitor becomes anxious stating the symptoms are recurring. An ECG is performed and is shown below: Figure 1. Adapted from Dr. Smith’s EKG Blog. Another ECG is obtained and shown below. If the response is appropriate, get another EKG and assess the QT interval.

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EKG/ECG Hyperthermia / Hypothermia EMS Documentation/Coding 97

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.

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EKG/ECG Documentation/Coding Wellness Resuscitation 128

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

Don't Forget the Bubbles

JULY 26, 2023

Add into this that the majority of children will be in normal sinus rhythm (NSR) by the time of assessment so to truly identify those who have something wrong we have to be confident in identifying arrhythmias where they are present and critical when analysing an ECG in NSR. All were examined and 98% had an ECG. Family history.

EKG/ECG 98

EKG/ECG Hospitals Shock Documentation/Coding 98

EMDocs

SEPTEMBER 23, 2023

Physical exam reveals a well-appearing female in no acute distress. Her presenting EKG is shown below. Clinical features Patients often present after an episode of sudden syncope, although Brugada syndrome can also be found on a routine EKG. ECG to evaluate for arrhythmia. Neurological exam is also unremarkable.

EMS 105

EMS EKG/ECG Documentation/Coding Emergency Department 105

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. So the cath lab was activated.

EKG/ECG 121

EKG/ECG EMS Documentation/Coding Shock 121

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 131

EKG/ECG Documentation/Coding Psychiatric EMS 131

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

JULY 21, 2024

The below ECG was recorded. The ECG shows obvious STEMI(+) OMI due to probable proximal LAD occlusion. This ECG does not have the typical ST-vector of an LAD occlusion. See below for Ken Grauer Comment on the initial ECG: == On arrival, another ECG was recorded: There appears to have been quite a bit of spontaneous reperfusion!

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EKG/ECG Shock Hospitals Sepsis 131

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

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

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

Stop and Think

JANUARY 1, 2024

Well, that can be a problem. Sometimes things we do are well grounded in evidence. Things like reading ECGs, echocardiograms, as well as learning to do procedures. Well, do you know the actual trials underpinning this evidence? They sit in a Google document. It will be a working document.

Documentation/Coding 98

Documentation/Coding Wellness EKG/ECG Hospitals 98

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 113

Seizures EKG/ECG EMS Stroke 113

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. Pretest probability: Even before the ECG, a patient with a history of coronary stent has a 90% chance that his wide complex tachycardia is VT.

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EKG/ECG Shock Academics Documentation/Coding 139

Dr. Smith's ECG Blog

JULY 22, 2023

An ECG was performed in the ED at 1554: Original image unavailable, this is the only recorded scanned ECG available. In a patient with syncope and fever, this ECG looks more like Brugada. Smith comment: the ECG in question could be due to Brugada, even though there is a change from baseline. PM Cardio digitized version.

EKG/ECG 92

EKG/ECG Hyperthermia / Hypothermia Documentation/Coding Wellness 92

Dr. Smith's ECG Blog

MARCH 22, 2024

His ECG is shown: What do you think? The history thus far is highly suggestive of OMI, so we must study the ECG very closely to see if we can confirm this. The Queen of Hearts does not care about rhythm analysis, she simply looks at the ECG and decides whether it represents OMI or not. He pointed out the precordial swirl sign.

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EKG/ECG Wellness Documentation/Coding 114

Northwestern EM Blog

MARCH 1, 2025

In this study, they found that prone positioning resulted in significant improvement in oxygenation, as well as a 50% decrease in mortality at 28 days (Guerin et. Remove ECG leads and patches. Reattach EKG leads to back. Document thorough skin assessment every nursing shift, and inspect weight-bearing ventral surfaces.

Emergency Department 52

Emergency Department Fractures EKG/ECG Wellness 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

I remember Allie well from her days in the Research volunteer program at Hennepin. An initial EKG was obtained: Computer read: sinus tachycardia, early acute anterior infarct. Here is her prior EKG: When compared to the old EKG – Q waves present before, TWI in aVR present before, but all other changes are new.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia EKG/ECG Wellness Documentation/Coding 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.

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EKG/ECG Documentation/Coding Research Outcomes 80

Mind The Bleep

OCTOBER 29, 2024

Alkali burns result in liquefaction necrosis, allowing for deeper tissue injury as well as vascular injury that can lead to both local and systemic toxicity [1]. Circulation Assess heart rate, blood pressure, peripheral and central CRT, pulses and 3 lead ECG. Establish IV access and begin fluid resuscitation with 250ml boluses of 0.9%

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52

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 It appears to be benign in children as well (see references below). I sent it to my friend, Ken Grauer , who is very meticulous in his ECG reading. I labeled ECG. His chest was tender.

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. 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

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 66

EKG/ECG Operations Wellness Ultrasounds 66

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. And ECGs can change and evolve even when there is no ischemia. Is this Wellens' pattern A?

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Wellness 52

Dr. Smith's ECG Blog

JANUARY 31, 2020

Here is his initial ECG: What do you think? Although diagnostic of MI, it is highly suspicious for " Old inferior MI with persistent ST Elevation" or "inferior aneurysm morphology" because of the well-formed Q-waves and the flat T-waves. The patient's chest pain had resolved by the time of the ECG 2. The T-waves are flat.

EKG/ECG 52

EKG/ECG Wellness Documentation/Coding Hospitals 52

Dr. Smith's ECG Blog

AUGUST 8, 2020

Here is her prior baseline ECG (first), and her ED ECG (second): Baseline: ED ECG: What do you think? Do you agree with the computer's interpretation of "Normal ECG"? The ECG shows sinus rhythm with normal QRS and R wave progression. This ECG clearly meets STEMI criteria by the way, regardless of age or gender.

EKG/ECG 52

EKG/ECG Documentation/Coding Wellness 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

It radiated to both shoulders and both upper extremities, and there was shortness of breath and diaphoresis as well. Triage ECG (no prior for comparison): Computer algorithm read: "Sinus rhythm, low voltage QRS, inferior myocardial infarction, probably old." Every note says "no ischemic changes on ECG." Day 2: No ECGs recorded.

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EKG/ECG Outcomes Academics Documentation/Coding 78

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

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. The initial tracing (EKG 1) was obtained. Clinician and EKG machine read of acute pericarditis. What do you think?

EKG/ECG 52

EKG/ECG Documentation/Coding Ultrasounds Wellness 52

Dr. Smith's ECG Blog

MARCH 19, 2023

This ECG was texted to me in real time, but I did not notice the message until about an hour after it came. "50 This was my response: "This looks like a worrisome EKG. But by now you must have a repeat ECG. But by now you must have a repeat ECG. Another ECG was recorded while waiting for the cath team (it was nighttime).

EKG/ECG 52

EKG/ECG Documentation/Coding 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

Mind The Bleep

NOVEMBER 21, 2023

” Yes, I have seen clerking look like this and I can confirm, it does not go down well. 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.

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

RebelEM

JULY 3, 2023

Currently, the infusion of IV calcium before diltiazem is not well understood, and more studies have focused on administering IV calcium prior to verapamil than diltiazem. Patients confirmed on ECG to have atrial fibrillation or atrial flutter Patients with HR >120 bpm. Article: Rossi N et al.

Administration 98

Administration Outcomes Documentation/Coding Emergency Department 98

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

Here is her 12-Lead ECG: There’s a sinus rhythm at around 70 bpm. It is difficult to answer this question based on this single ECG alone. We don’t see excessive ST Elevations (“Tombstones”) that would suggest acute STEMI, but clearly acute STEMI can certainly present with moderate ST Elevation as well.

EKG/ECG 52

EKG/ECG Wellness Documentation/Coding Emergency Department 52