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

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.

EKG/ECG 98

EKG/ECG Hospitals Shock Documentation/Coding 98

ACEP Now

JANUARY 4, 2025

A closer look, though, also shows the technology of the daya bulky, two-way radio for communicating with EMS, metal gurneys, glass saline bottles, and portable ECG monitors the size of a small shopping cart. Notice the use of the medical anti-shock trousers and the ECG machine. Click to enlarge.) I like the excitement.

Forensics 52

Forensics Urgent Care Emergency Department Hospitals 52

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!

EKG/ECG 131

EKG/ECG Shock Hospitals Sepsis 131

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

He had the following EKG recorded: Low voltage, suggests effusion. A Rising Troponin That afternoon, he complained of increased shortness of breath and was noted to have oxygen saturations in the 70s, prompting a mini code to be called. Assessment was severe sudden cardiogenic shock. He remained hypotensive and in shock.

Shock 52

Shock EKG/ECG Outcomes Hospitals 52

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 83

EKG/ECG Shock Documentation/Coding Academics 83

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

NOVEMBER 30, 2019

She was in shock with thready pulses. A prehospital ECG was recorded: Limb leads: Precordial Leads What is the therapy? The rate is not fast enough to be causing shock, so if it is VT, the priority is still to treat hyperK and secondarily to cardiovert. They thought it was VT, but did not shock. The K returned at 7.4

Shock 40

Shock EKG/ECG Resuscitation Ultrasounds 40

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 119

EKG/ECG Stroke Hospitals Documentation/Coding 119

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

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. Clinical Course The paramedic activated a “Code STEMI” alert and transported the patient nearly 50 miles to the closest tertiary medical center. What should be done? Should the cath lab be activated?

EKG/ECG 40

EKG/ECG Shock Fluid Resuscitation Documentation/Coding 40

Taming the SRU

JUNE 3, 2024

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. Get a blood gas when possible to help guide your ventilation. Some newer AED's have the capability of providing you with a rhythm strip.

Shock 91

Shock Seizures Airway Management Stroke 91

Mind The Bleep

OCTOBER 29, 2024

Circulation Assess heart rate, blood pressure, peripheral and central CRT, pulses and 3 lead ECG. Sodium Chloride or Hartmanns if indicated, monitoring for signs of shock. Provide detailed documentation of the initial assessment, treatment provided, and the patient’s response to interventions.

Burns 52

Burns Fluid Resuscitation PPE Resuscitation 52

Dr. Smith's ECG Blog

MAY 8, 2023

Triage ECG: What do you think? Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Queen of Hearts interpretation: The cardiologist initially was not convinced, stating the ECG was not diagnostic or could not be diagnostic because it was paced.

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Shock 52

Taming the SRU

JULY 31, 2024

morbidity and mortality - faculty case follow-up - R4 Capstone - high-risk, low prevalence diseases in pediatrics morbidity and mortality WITH dr. moulds Syncope Complete heart block is a rare but important cause of syncope P waves outnumbering QRS complexes should clue to you to high grade heart block Triage EKGs are often obtained to screen for cardiac (..)

EKG/ECG 52

EKG/ECG Sepsis Documentation/Coding Stroke 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

A 12 lead ECG was obtained by EMS and is shown below: What do you think? The ECG is diagnostic of LAD occlusion (or even left main occlusion possibly), with the classic pattern of RBBB and LAFB with huge concordant STE in V1-V2, I, and aVL, with reciprocal depression in most other leads (and/or a component of subendocardial ischemia pattern).

EKG/ECG 52

EKG/ECG Shock EMS Documentation/Coding 52

Dr. Smith's ECG Blog

JUNE 11, 2021

The paramedics found the patient with ROSC and a GCS 7, and an ECG showing LBBB with possible lateral ST elevation. The patient was brought to the ED as a possible Code STEMI and was seen directly by cardiology. Below is the first ED ECG, labeled LBBB by the machine. Vitals were HR 58 BP 167/70 R20 sat 96%.

EKG/ECG 52

EKG/ECG Documentation/Coding CPR Shock 52

Dr. Smith's ECG Blog

JUNE 17, 2018

He had an ECG in clinic which worried the providers because of possible inferior MI, and they sent him to the ED. Here is that ECG: What do you think? He was sent to the ED and had this ECG at t = 1 hour: Similar There are several issues which mitigate against acute inferior MI, and these are the Learning Points: 1.

EKG/ECG 52

EKG/ECG Documentation/Coding Shock Ultrasounds 52

EMDocs

JANUARY 11, 2024

Individualize the choice of using inotropes, vasopressors, or fluids to treat post-CA hypotension and to target the likely cause(s) contributing to the shock and hemodynamic state (100%, 23/23). In patients with enteral intolerance or shock, start with trophic EN (rates of 10–20 mL/h) and adjust according to tolerance (91%, 19/21).

Seizures 97

Seizures Shock Infectious Diseases CPR 97

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

An ECG was texted to me (Smith) without any clinical information: What did I say? Some providers were worried about ACS because of this ECG. It turns out there was a previous ECG for comparison, which I did not see for weeks afterwards: Sinus rhythm with PACs, one is aberrantly conducted. This is NOT Wellens. The answer was yes.

EKG/ECG 52

EKG/ECG COPD Documentation/Coding Shock 52

EB Medicine

MARCH 1, 2019

Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. New EKG findings requires admission for monitoring. of those patients.

Emergency Department 40

Emergency Department EKG/ECG Operations Fractures 40

The Skeptics' Guide to EM

FEBRUARY 3, 2023

You are tidying your things in anticipation of the arrival of the dayshift when a code blue is called. The patient is in ventricular fibrillation, and you achieve return of spontaneous circulation (ROSC) on the second shock. A post-arrest ECG doesn’t show any signs of STEMI. The patient is still unconscious.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Hospitals Documentation/Coding CPR 52

ACEP Now

MARCH 14, 2024

Electrical injuries—excluding lightning injuries—account for roughly 10,000 nonfatal shock incidents a year and 500 deaths a year. 1,4-5 Thus, an electrocardiogram (ECG) and cardiac monitoring should be performed for unstable, electrical injury patients. 7 Thus, an ECG is recommended for all electrical injuries. Emerg Med Pract.

Burns 52

Burns Fluid Resuscitation EKG/ECG EMS 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

Here is the ECG: What do you think? See below how this has been documented. Shah and Rubin studied the computer rhythm interpretation of 2160 12-lead ECGs, compared to 2 cardiologists [ 18 ]. noted computer over-interpretation (false positives) of AF in 9 to 19% of ECGs [ 19 ]. Among, 2447 ECGs, Mant et al.

EKG/ECG 52

EKG/ECG COPD Wellness Sepsis 52

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

Dr. Smith's ECG Blog

APRIL 15, 2019

A prehospital ECG was recorded (not shown and not seen by me) which was worrisome for STEMI. Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. A near 60 year old male called 911 for increasingly severe fever and SOB.

EKG/ECG 40

EKG/ECG Sepsis Documentation/Coding Shock 40

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? Given her tachycardia and episodes of syncope, the patient was judged to be in compensated obstructive shock with very high risk of imminent decompensation. For clarity in Figure-1 — I've reproduced her initial ECG.

EKG/ECG 40

EKG/ECG Ultrasounds Documentation/Coding COPD 40

Dr. Smith's ECG Blog

APRIL 8, 2016

He appeared to be in shock. 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: He was managed medically with Clopidogrel.

Resuscitation 52

Resuscitation EKG/ECG Hospitals Administration 52

Pediatric Emergency Playbook

JUNE 1, 2017

Electrocardiography (ECG) should be performed on any patient with significant blunt chest injury. A negative ECG is highly consistent with no significant blunt myocardial injury. Any patient with a new abnormality on ECG (dysrhythmia, heart block, or signs of ischemia) should be admitted for continuous ECG monitoring.

Pediatrics 52

Pediatrics EKG/ECG Wellness Seizures 52

EB Medicine

JUNE 6, 2019

Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. The greatest value of a lactate level is to detect occult shock and sepsis. In one study, a SI > 0.7

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. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

EB Medicine

AUGUST 1, 2018

Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 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.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

Dr. Smith's ECG Blog

DECEMBER 5, 2019

As part of the workup, she underwent an ECG. Thus, Brugada is the likely diagnosis _ A very nice explanation of this is given in the document quoted below on current ECG criteria for Brugada pattern. We repeated the ECG: Brugada pattern is mostly resolved. Is this Type 2 Brugada syndrome/ECG pattern?

EKG/ECG 52

EKG/ECG Hyperthermia / Hypothermia Seizures Documentation/Coding 52

Taming the SRU

JUNE 6, 2023

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

Documentation/Coding 64

Documentation/Coding Seizures Psychiatric Wellness 64

Dr. Smith's ECG Blog

MARCH 25, 2025

High enough that a bland ECG is not immediately reassuring. ECG 1 What do you think? To me, this ECG is not diagnostic. But if you call every ECG that looks like this OMI, you are going to have a lot of false positives. No further ECGs were obtained for the rest of the day. in absolute terms!

EKG/ECG 63

EKG/ECG Shock Documentation/Coding Hospitals 63

Dr. Smith's ECG Blog

DECEMBER 31, 2024

Here is her triage ECG: What do you think? The ECG shows sinus rhythm with normal QRS complex morphology and significant subendocardial ischemia (SEI) pattern (ST depression in many leads, worst in lateral areas including leads II, V5-6, with reciprocal STE in aVR). Here is her ECG 8 hours later: Almost back to normal.

EKG/ECG 119

EKG/ECG Documentation/Coding Emergency Department Resuscitation 119

Dr. Smith's ECG Blog

MARCH 17, 2025

His ECG obtained around 8 AM is shown: ECG 1 My guess is most blog readers will make this diagnosis without too much difficulty. There was no repeat ECG. There is very scarce documentation, but the next ECG was obtained around 1 PM. ECG 2 Diagnostic for inferoposterior reperfusion. ECG 3 Re-occlusion.

EKG/ECG 81

EKG/ECG Documentation/Coding Burns Research 81

Dr. Smith's ECG Blog

MARCH 8, 2025

Her first ECG is shown. After this ECG was obtained, the ER physician received word that the patient's husband had died in the crash. Repeat ECG was obtained immediately, just 24 minutes after the prior ECG: Given the context, my top differential diagnosis would be stress cardiomyopathy AKA takotsubo. Overall bland.

EKG/ECG 75

EKG/ECG CPR Resuscitation Wellness 75