Dr. Smith's ECG Blog

JANUARY 27, 2024

Below is the triage ECG, with a computer interpretation (Marquette 12 SL) of “normal” which was confirmed by the over-reading cardiologist. Should this patient continue to stay in the waiting room, without interruption of the physician to interpret the ECG, because the computer interpretation is normal? What do you think?

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Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. 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.

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Dr. Smith's ECG Blog

JUNE 11, 2024

Many systems now refrain from showing computer "normal" ECGs to the busy emergency physicians at triage because of very poorly conceived articles that say that if the computer algorithm says "normal," the emergency physician should not be bothered. Queen of Hearts is available and performs well. No further follow up is available.

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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.

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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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Dr. Smith's ECG Blog

JANUARY 2, 2025

She had an ECG recorded: This is left bundle branch block (LBBB), with appropriate proportional discordance. In the middle of the night, a "code" was called, and multiple rhythms like this were recorded. Here is one of the strips This is clearly polymorphic VT and probably torsade de pointes Subsequent ECGs. J Am Coll Cardiol.

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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.

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Mind The Bleep

FEBRUARY 2, 2025

” 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.

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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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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.

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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. 2005.08.066.

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Dr. Smith's ECG Blog

JUNE 15, 2023

Here was his triage ECG: What do you think? I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2.

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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.

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Dr. Smith's ECG Blog

JUNE 27, 2024

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. Another ECG is taken about twenty minutes later and shows this: The rhythm is complex and variable, but overall shows various degrees of AV block. By the end of the ECG, there is 1:1 conduction.

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Dr. Smith's ECG Blog

MAY 26, 2023

mg/dL (sorry, Europeans, for the weird units) Here was the initial ED ECG: There is a junctional rhythm with retrograde P-waves (see the dip in the T-wave in lead II across the bottom; you can follow that up to all the other leads and see the retrograde P wave). The ECG must always be interpreted in clinical context.

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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.

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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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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.

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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.

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Cook County EM Blog

MAY 15, 2023

Figure 1: Initial EKG The Case: 45-year-old Spanish speaking male with no known past medical history presented to the ED with 2-3 hours of severe back pain and throat pain. What does this EKG suggest? His EKG suggested a posterior MI as well as other signs of ischemia. Unfortunately, this EKG was not recorded in the EMR.

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Dr. Smith's ECG Blog

JULY 7, 2024

Here’s the EMS ECG, digitized with PM cardio. They arrived in the ED 30 minutes later to meet the cardiology team, where an ECG was repeated: Again no STEMI criteria, and there has been improvement in the deWinter and swirl pattern. What do you think? There’s sinus arrhythmia with normal conduction, normal axis and normal voltages.

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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.

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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)?

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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?

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EKG/ECG Documentation/Coding Outcomes Wellness 52

Dr. Smith's ECG Blog

JANUARY 13, 2025

An ECG was recorded quickly before any further history or physical exam: What do you think? When I saw this (presented at a conference), I immediately thought it looked like Thype 1 Brugada phenocopy (in other words, Type 1 Brugada ECG pattern ). This criterion is perplexing and not well explained. Clinical History 2.a.

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Hyperthermia / Hypothermia EKG/ECG Wellness Documentation/Coding 74

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.

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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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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.

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Sensible Medicine

AUGUST 21, 2023

Administrative data sets are often collected for the purpose of billing, or costing, or administrative organization, and thus are extremely vulnerable to up coding or intentional or accidental omissions. Next week I am going to show you what a well-done medical study looks like. It is our goal. Thanks for your support.

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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. There is concordant ST elevation in I, aVL with reciprocal concordant STD in inferior leads, as well as excessively discordant TE in V2-V4. EKG and CT head were performed.

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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.

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Dr. Smith's ECG Blog

MAY 28, 2013

He was intubated, and this ECG was recorded: Time zero: QRS duration = 162 ms, QRS axis = 147. But the ECG also looks like classic type I Brugada pattern, in V1 and V2 but especially in V2: there is an rSR' with downsloping ST elevation. Without Brugada pattern on the baseline ECG, there is no Brugada syndrome.

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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?

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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?

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Dr. Smith's ECG Blog

AUGUST 26, 2009

He called 911 and paramedics recorded a prehospital 12 lead ECG which showed a clear inferior STEMI (not shown, tracing could not be found). On arrival, the following ECG was recorded. In this case the diagnosis was clear due to the prehospital ECG. But suppose there had been no prehospital ECG? There is 0.5

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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.

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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).

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