EMDocs

FEBRUARY 9, 2024

Authors: Adam Roussas, MD, MBA, MSE // Reviewed by: Jamie Santistevan, MD ( @jamie_rae_EMdoc, EM Physician, Presbyterian Hospital, Albuquerque, NM); Manpreet Singh, MD ( @MPrizzleER ); and Brit Long, MD ( @long_brit ) Case A 40-year-old female presents to the emergency department for palpitations and lightheadedness. She denies chest pain.

EKG/ECG 72

EKG/ECG Hyperthermia / Hypothermia EMS Documentation/Coding 72

Dr. Smith's ECG Blog

OCTOBER 23, 2023

Edited by Bracey, Meyers, Grauer, and Smith A 50-something-year-old female with a history of an unknown personality disorder and alcohol use disorder arrived via EMS following cardiac arrest with return of spontaneous circulation. Macroscopic T-Wave Alternans: A Red Flag for Code Blue. No ischemic ST changes. J Am Coll Cardiol.

EKG/ECG 128

EKG/ECG Documentation/Coding Psychiatric EMS 128

Dr. Smith's ECG Blog

JUNE 27, 2024

EMS reports intermittent sinus tachycardia and bradycardia secondary to some type of heart block during transport. This is her first ECG in the ED: What do you see? This ECG shows both a right bundle branch block and a posterior fascicular block. QRS complexes have similar RBBB morphology to the prior ECG.

EKG/ECG 124

EKG/ECG Documentation/Coding Emergency Department Wellness 124

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

Her husband called EMS when the patient experienced new onset seizures accompanied by micturition. 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. All patients with seizures needs an ECG.

Seizures 111

Seizures EKG/ECG EMS Stroke 111

Emergency Medicine Cases

JUNE 21, 2022

In this ECG Cases blog we review 8 cases of patients with prehospital ECGs and explore prehospital ECGs for diagnosing STEMI, Occlusion MI, false STEMI, code STEMI, dynamic ischemic changes, truncated voltages. The post ECG Cases 32 Prehospital ECG pearls and pitfalls appeared first on Emergency Medicine Cases.

EKG/ECG 52

EKG/ECG Documentation/Coding EMS 52

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. Read this post: Idiopathic Ventricular Tachycardias for the EM Physician 2. Definitive diagnosis that ECG #1 is in fact VT is more than academic.

EKG/ECG 141

EKG/ECG Shock Documentation/Coding Academics 141

EMDocs

SEPTEMBER 26, 2024

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. An attorney is consulted and a lawsuit filed against the hospital, the first ED physician, the EM group, and the PCP.

Radiology 74

Radiology Radiology EKG/ECG Documentation/Coding 74

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Triage EKG: What do you think? Today’s pain lasted around 20 mins, but was severe enough that the patient called EMS. Pain largely resolved prior to EMS arrival but completely subsided after prehospital NTG and aspirin. A prior ECG was available for comparison. There is STE present in leads V2-V5. ng/mL (undetectable).

EKG/ECG 52

EKG/ECG Ultrasounds EMS Documentation/Coding 52

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. 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. This is lucky!

EKG/ECG 122

EKG/ECG Shock Hospitals Sepsis 122

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 92

EKG/ECG EMS Emergency Department Outcomes 92

EMDocs

SEPTEMBER 19, 2023

Episode 86: Tricky Cases Part 2 Case 3: 56-year-old female with history of seizures, actively seizing, EMS called. Patient seized for approximately 20 minutes prior to EMS arrival. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents. They administer two doses of 10 mg midazolam IM.

Seizures 72

Seizures Documentation/Coding EKG/ECG Emergency Department 72

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 87

EKG/ECG Shock Documentation/Coding Academics 87

Dr. Smith's ECG Blog

JULY 7, 2024

Written by Jesse McLaren A previously healthy 60 year old developed exertional chest pain with diaphoresis, and called EMS. Here’s the EMS ECG, digitized with PM cardio. The final blinded cardiology interpretation noted only the minimal inferior ST depression, but the ECG is still diagnostic of proximal LAD occlusion.

EKG/ECG 70

EKG/ECG Documentation/Coding EMS Wellness 70

Dr. Smith's ECG Blog

JANUARY 30, 2019

She was ventilated by bag-valve-mask by EMS on arrival and was quickly intubated with etomidate and succinylcholine. An initial EKG was obtained: Computer read: sinus tachycardia, early acute anterior infarct. What is the differential for this EKG? She was obtunded, not following commands, hypoxic, and in respiratory distress.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia EKG/ECG Wellness Documentation/Coding 52

Dr. Smith's ECG Blog

JUNE 17, 2023

Written by Pendell Meyers A middle aged man called EMS for acute chest pain. EMS recorded this ECG during active symptoms and transmitted it to the ED: I had no information when I was shown the ECG. I said "Not OMI. Some probably thought the inferior leads showed findings of OMI, but that's a fake."

Documentation/Coding 52

Documentation/Coding EKG/ECG EMS 52

Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

She took an oxycodone and called EMS. 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. The ECG was interpreted as showing diffuse STD with some STE in aVR. I sent this to Drs.

EKG/ECG 70

EKG/ECG Operations Wellness Ultrasounds 70

ACEP Now

JUNE 6, 2023

ECG, CXR, and troponin are negative. A medical student reports a murmur, not documented by either the emergency physician or the cardiologist. Troponins #1 and #2 are borderline and ECG is non-specific. EMS is called and finds his blood pressure 175/100. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal.

EKG/ECG 85

EKG/ECG Stroke Documentation/Coding Operations 85

Dr. Smith's ECG Blog

DECEMBER 14, 2022

EMS arrived and administered aspirin and nitroglycerin. Here are his three EMS ECGs: EMS1 at 0735 This was sent to Dr. Smith with no other information. Meyers sent this ECG to Smith without any other info and this was the response: Smith interpretation: "A very rare anterior OMI w high S-wave voltage." Do not miss them!

EKG/ECG 52

EKG/ECG EMS Documentation/Coding Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. An immediate 12-lead EKG was obtained: There is ST elevation in leads aVR and V1, with marked ST depression in I, II, III, aVF, V3-V6. What should be done?

EKG/ECG 40

EKG/ECG Shock Fluid Resuscitation Documentation/Coding 40

The Skeptics' Guide to EM

MAY 2, 2020

A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. The EMS crew arrives and performs a 3 lead EKG that does not show an ST elevated myocardial infarction. Date: April 24th, 2020 Reference: Watanabe et al.

Documentation/Coding 40

Documentation/Coding EMS EKG/ECG Outcomes 40

Taming the SRU

AUGUST 4, 2024

Know your audience, and tailor your presentation to them in terms of humor, pop culture references, and dress code Err on the side of making your presentation slightly shorter than the alloted time to allow room for questions. It is better to finish early than rushing through your presentation

Emergency Department 85

Emergency Department Dislocations Documentation/Coding Burns 85

Dr. Smith's ECG Blog

APRIL 15, 2020

An elderly woman with history of coronary disease presented with CP and SOB and hypotension by EMS. EMS had attempted adenosine x 2 without success. Here is her ED ECG: Here is the ED physician's interpretation: IMPRESSION UNCERTAIN REGULAR RHYTHM, wide complex tachycardia, likely p-waves.

EKG/ECG 52

EKG/ECG EMS Documentation/Coding 52

Taming the SRU

JULY 31, 2024

However, believers in this superstition will perceive crazier shifts if the word is uttered so you probably shouldn’t say it, or use cautiously Full moons have no impact on ED, EMS, or HEMS volumes or acuity. Nice people are not more likely to get cancer.

EKG/ECG 52

EKG/ECG Sepsis Documentation/Coding Stroke 52

Dr. Smith's ECG Blog

FEBRUARY 13, 2023

(photocopy of prehospital ECGs digitized by PMcardio) ECG #1 (top): there’s normal sinus rhythm, normal conduction, normal axis, normal R wave progression, and normal voltages. ECG # 2 (bottom): there’s sinus rhythm with normal conduction, normal axis, loss of R wave in V2, normal voltages. Will be missed easily.”

EKG/ECG 52

EKG/ECG Documentation/Coding EMS Wellness 52

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

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

NOVEMBER 11, 2022

Written by Pendell Meyers Family of an elderly woman with many comorbidities called EMS when she suddenly experienced shortness of breath, nausea, vomiting, and near syncope. A 12 lead ECG was obtained by EMS and is shown below: What do you think? This one of the highest risk OMI patterns possible to see on an ECG.

EKG/ECG 52

EKG/ECG Shock EMS Documentation/Coding 52

Dr. Smith's ECG Blog

JULY 24, 2018

They stated that the patient was coded for 20 minutes, including multiple doses of epinephrine, and they also gave glucose, calcium, and bicarb. We asked for the ECGs to be faxed over while they prepared to transfer him. Prior ECG on file: Sinus tachycardia, imperfect baseline, otherwise unremarkable. mEq/L, with creatine 3.0

EKG/ECG 52

EKG/ECG Dehydration Resuscitation Documentation/Coding 52

Dr. Smith's ECG Blog

APRIL 14, 2023

Sent by Anonymous, written by Pendell Meyers A man in his 60s with history of CAD and 2 prior stents presented to the ED complaining of acute heavy substernal chest pain that began while eating breakfast about an hour ago, and had been persistent since then, despite EMS administering aspirin and nitroglycerin. Triage 1104: What do you think?

EKG/ECG 52

EKG/ECG Documentation/Coding Wellness EMS 52

ACEP Now

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. Per EMS, the patient was found at the bottom of a high voltage line with diffuse burns and amputation of his left forearm. Emerg Med Pract.

Burns 52

Burns Fluid Resuscitation EKG/ECG EMS 52

Taming the SRU

OCTOBER 30, 2024

Debrief codes and odd encounters for yourself, your team, and your hospital system. Wilson Have a resource that can be your external brain that you can reference quickly to make you more comfortable in an uncomfortable situation. When breaking bad news follow a structure for your conversation and practice your plain language ahead of time.

Hospitals 52

Hospitals Emergency Department Documentation/Coding EKG/ECG 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. Jeff: And don’t forget to get the crash details from the EMS crew before they depart!

Emergency Department 40

Emergency Department EKG/ECG Operations Fractures 40

RebelEM

MARCH 2, 2023

For More Thoughts on This Topic Checkout: REBEL EM: The DETO2X Trial: Do Patients with AMI Need Supplemental O2? REBEL EM: The Death of MONA in ACS – Part II – Oxygen REBEL Cast: Ep13 – The AVOID Trial & The FLORALI Trial References: Stewart, RAH et al. appeared first on REBEL EM - Emergency Medicine Blog.

Outcomes 52

Outcomes EMS EKG/ECG Hospitals 52

PEMBlog

OCTOBER 18, 2024

Always consider the risk of arrhythmia, which can occur despite relatively normal ECG findings. These documents should be reviewed promptly upon presentation, as they often contain critical information about the patient’s DNR status, preferred ventilation strategies, and other key management instructions. Orphanet J Rare Dis.

Emergency Department 52

Emergency Department Fractures Best Practices Documentation/Coding 52

RebelEM

MARCH 9, 2023

Document at each reassessment and always have a low threshold to add on a CTH or labs if the patient is not progressing appropriately. As always, document clinical sobriety before discharge. After your primary ABCs assessment, consider “D” for dextrose and check for occult hypoglycemia.

Psychiatric 52

Psychiatric Emergency Department Documentation/Coding Fractures 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? This patient was reported to have distant heart sounds but was not hypotensive and did not have JVD according to documentation. For clarity in Figure-1 — I've reproduced her initial ECG.

EKG/ECG 40

EKG/ECG Ultrasounds Documentation/Coding COPD 40

Taming the SRU

FEBRUARY 22, 2023

EMS Grand Rounds with Dr. Connelly - R4 Case Follow up with Dr. Broadstock - R1 Clinical Knowledge: Vitamin Deficiencies WITH Dr. de Castro - Lecture R3 Small Groups Tox,Tasks,Rashes WITH Dr. Fabiano, Dr. Kein, and Dr. Martella4 - Palliative Medicine Consultation WITH Dr. Kiser EMS Grand Rounds WITH Dr. ConnelLy What I learned in my time with Sydney (..)

Hospice 40

Hospice EKG/ECG Wellness Resuscitation 40