RebelEM

SEPTEMBER 28, 2023

In non-PCI-capable hospitals this goal is not always achievable due to delays in transfer. ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% In these cases, thrombolysis is recommended to improve morbidity and mortality.

EKG/ECG 137

EKG/ECG Allergic Reactions Shock Stroke 137

Dr. Smith's ECG Blog

MAY 26, 2023

A 20-something presented after a huge verapamil overdose in cardiogenic shock. 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).

Shock 98

Shock EKG/ECG Documentation/Coding Resuscitation 98

Dr. Smith's ECG Blog

JUNE 23, 2024

They shocked him twice before return of spontaneous circulation. He was intubated in the field and sedated upon arrival at the hospital. Here is his presenting ECG: ECG 1, t = 0 What do you think? At his family's request, he was transferred to a hospital closer to his home to continue care. Smith's ECG Blog.

EKG/ECG 120

EKG/ECG CPR EMS Hospitals 120

Dr. Smith's ECG Blog

SEPTEMBER 27, 2023

An ECG was recorded immediately and is shown below. How do you interpret the ECG? ECG#1 There is a regular tachycardia with a ventricular rate of about 180 bpm. After cardioversion, if successful, you can take a few moments to assess the 12-lead in more detail and assess the post conversion ECG. ECG#2 What do you think?

EKG/ECG 134

EKG/ECG Resuscitation Academics EMS 134

Dr. Smith's ECG Blog

JANUARY 1, 2024

AslangerE A 65-year-old gentleman presented to the emergency department after experiencing two recent ICD shocks in the preceding hours. The patient was promptly admitted to the hospital for further evaluation. An initial electrocardiogram (ECG) is provided below. What do you think? What is the rhythm? The rate is 132 bpm.

EKG/ECG 114

EKG/ECG Shock Emergency Department Administration 114

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

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 91

EKG/ECG Hyperthermia / Hypothermia EMS Documentation/Coding 91

Dr. Smith's ECG Blog

JUNE 11, 2023

He states that he has a heart condition which he does not know the name of and that he has felt his heart race like this once before and needed to be shocked. Here is his triage ECG: He had several more ECGs taken in the resuscitation bay over the next few minutes: What do you think? 2 hrs later: Still sinus with subtler WPW.

EKG/ECG 98

EKG/ECG Resuscitation Shock EMS 98

ACEP Now

JANUARY 4, 2025

1 Just one year prior, Dr. Clarke had begun an emergency medicine residency at what was then known as LA CountyUSC Hospital, Los Angeles. Firsthand Account An ambulance bay at the LA County-USC Hospital in 1978. A cross-country move brought him to Delaware, where he served as the director of a hospital ED in Milford, Del.

Forensics 52

Forensics Urgent Care Hospitals Emergency Department 52

Dr. Smith's ECG Blog

JULY 25, 2024

The patient was brought to the ED and had this ECG recorded: What do you think? The ECG shows severe ischemia, possibly posterior OMI. After cardiac arrest, I ALWAYS wait 15 minutes after an ECG like this and record another. == MY Comment , by K EN G RAUER, MD ( 7/5 /2024 ): == Clinical ECG interpretation is a 2-Step process.

Resuscitation 126

Resuscitation EKG/ECG CPR Shock 126

Dr. Smith's ECG Blog

APRIL 2, 2024

He was unidentified and there were no records available After 7 shocks, he was successfully defibrillated and brought to the ED. Here is the initial ED ECG. Another ECG was recorded 12 minutes later: Paced rhythm, probable Pacemaker-Mediated Tachycardia ? Then the patient's electronic record from an outside hospital appeared.

EKG/ECG 134

EKG/ECG Shock CPR Stroke 134

Taming the SRU

MARCH 10, 2024

There are also many costs to hypoglycemia, both in terms of financial burdens on hospitals/caretakers/patients, and in terms of morbidity and mortality. Soon you’ll be able to view our whole pathway on the QI/KT page, but for now, we hope everyone remembers these points: 1) Get labs and an EKG on everyone presenting with hypoglycemia.

EKG/ECG 97

EKG/ECG Shock Wellness EMS 97

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 132

EKG/ECG Shock Hospitals Sepsis 132

Dr. Smith's ECG Blog

JANUARY 8, 2024

I was reviewing ECGs for a study, and came across this one, and was able to get all the clinical information: What do you think? I do not have the EKG, but it was described as "non-diagnostic" (that probably means that the physician did not know how to diagnose it). Medics recorded the above ECG and called a STEMI alert.

EKG/ECG 72

EKG/ECG Resuscitation Hospitals EMS 72

Taming the SRU

JANUARY 10, 2024

There are 38 states where it currently is a felony of some level to assault a healthcare worker BUT there is currently no federal law that protects hospital employees from assault or intimidation. Current bills in progress: US H.R.2663 2663 & S.1176 1176 focuses on violence prevention (introduced for the 3rd time 4/18/23); US H.R.2584

EKG/ECG 93

EKG/ECG Shock Fractures Dislocations 93

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

He had the following EKG recorded: Low voltage, suggests effusion. He underwent CPR, and regained a pulse after epinephrine, with an organized narrow complex rhythm at 140, but still with severe shock. Assessment was severe sudden cardiogenic shock. He remained hypotensive and in shock. He was moderately hypoxic.

Shock 52

Shock EKG/ECG Outcomes Hospitals 52

ACEP Now

JULY 7, 2023

Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. Out-of-hospital cardiac arrest is a commonly encountered entity in U.S. 6 What Can I Do Outside of Repeated Shocks and Standard ACLS?

Resuscitation 98

Resuscitation Shock Stroke Hospitals 98

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 120

EKG/ECG Stroke Hospitals Documentation/Coding 120

RebelEM

MARCH 30, 2023

Background: Previous observational studies published in 2015 (Geri 2015)(Vyas 2015) indicated that early cardiac catheterization in patients with out-of-hospital cardiac arrest (OHCA) might improve mortality and result in more favorable neurological outcomes. Article: How-Berlemont C, Lamhaut L, Diehl J, et al. 1.15; P= 0.32 1.15; P= 0.31

Hospitals 59

Hospitals Outcomes EKG/ECG Resuscitation 59

Dr. Smith's ECG Blog

OCTOBER 6, 2023

This is one case where it made a difference: Right Ventricular MI seen on ECG helps Angiographer to find Culprit Lesion Nevertheless, it is sometimes a fun academic exercise to try to predict the infarct artery: An elderly patient had onset of chest pain one hour prior. Here is the prehospital ECG. He was hospitalized for 16 days.

EKG/ECG 67

EKG/ECG Academics Shock Outcomes 67

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

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. She arrives in the emergency department (ED) with decreased level of consciousness and shock. Date: September 8th, 2021 Reference: Desch et al. The TOMAHAWK Investigators.

EKG/ECG 52

EKG/ECG Academics EMS CPR 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Initial ROSC was obtained, during which this ECG was obtained: What do you think? I sent it to 2 of my ECG nerd colleagues with no clinical information whatsoever, who instantly said: "Looks like afib with subendocardial ischemia and right heart strain pattern." "I CPR was initiated immediately. The rhythm is atrial fibrillation.

EKG/ECG 52

EKG/ECG Resuscitation Ultrasounds CPR 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock. Here was the ECG: There is sinus tachycardia. Referring to Figure-1 — this 53-year old woman who presented in extremis with cardiogenic shock and an initial pH = 6.9, This was sent by a reader. and K was normal.

Shock 52

Shock Hyperthermia / Hypothermia EKG/ECG Hospitals 52

Don't Forget the Bubbles

OCTOBER 7, 2024

Was the patient thrown from the source (suggestive of DC shock and may result in further blunt force trauma)? Children, especially toddlers, may insert objects into outlets, leading to shocks or burns. Electrical devices used near water sources can cause severe shocks. Was the voltage high or low (as below)?

Burns 80

Burns Fluid Resuscitation Shock Resuscitation 80

EMDocs

MAY 24, 2023

The EKG and troponin are normal. He and his physician are shocked at the report and the lack of follow-up. A lawsuit is filed against the emergency physician, radiologists, PCP, and hospital. Plaintiff : You (the hospital) had no system in place regarding non-congruent over-reads by “nighthawk” radiologists. Mueller DK.

Radiology 82

Radiology Radiology EKG/ECG Patient Safety 82

The Skeptics' Guide to EM

FEBRUARY 3, 2023

Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. September 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are working an overnight shift at a small rural hospital. Circulation. Circulation.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Hospitals Documentation/Coding CPR 52

Taming the SRU

JUNE 3, 2024

Myth: Some patients are “too sick to transport” Myth Part B: The receiving hospital gets to decide if a patient is too sick to transport. 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. What drives the concern?

Shock 91

Shock Seizures Airway Management Stroke 91

Dr. Smith's ECG Blog

DECEMBER 14, 2016

Here was his ED ECG: I read this as normal --One might say there is ST depression in II, III, and aVF, but this is merely an atrial repolarization wave. --You We recorded a posterior ECG: V4-V6 are moved around to the back and are really V7-V9. Learning Point Acute coronary occlusion may occur with no ECG findings whatsoever.

EKG/ECG 52

EKG/ECG Shock Hospitals Wellness 52

Dr. Smith's ECG Blog

JANUARY 23, 2023

The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG: What do you think? Close up of V3 with baseline in red Close up of V4 with baseline in red This ECG alone is highly suspicious for posterior OMI! This is a very specific marker of posterior OMI. ng/mL (ULN 0.04).

EKG/ECG 52

EKG/ECG Shock Emergency Department Ultrasounds 52

Mind The Bleep

DECEMBER 19, 2023

ECG: to monitor T wave changes due to hypokalaemia. ECG features of Hypokalaemia: Increased P wave amplitude (peaked P waves) Prolonged PR interval Widespread ST depression T wave flattening or inversion Prominent U waves (most noticeable in the precordial leads) Figure 2 : ECG of a patient with serum K+ of 1.9

Dehydration 98

Dehydration Fluid Resuscitation Shock Resuscitation 98

Dr. Smith's ECG Blog

AUGUST 9, 2019

Some total LAD occlusion manifest on the ECG similarly to some left main occlusions. Depending on where the STE vector of the LM occlusion shows up on the ECG, there may be either STE, or STD, or neither in aVR, and lead aVR will not be the important part of the ECG interpretation in these cases.

EKG/ECG 52

EKG/ECG Shock Emergency Department Wellness 52

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. DISCUSSION: The 12-lead EKG EMS initially obtained for this patient showed severe ischemia, with profound "infero-lateral" ST depression and reciprocal ST elevation in lead aVR. What should be done?

EKG/ECG 40

EKG/ECG Shock Fluid Resuscitation Documentation/Coding 40

Dr. Smith's ECG Blog

MAY 5, 2022

Here is the initial ED ECG: What do you think? The ECG shows peaked T waves, QRS widening, a coved-type ST segment with inverted T waves most prominent in V1 and V2 consistent with Brugada pattern. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. Creatinine elevated at 3.09

EKG/ECG 52

EKG/ECG Fluid Resuscitation EMS Shock 52

EMDocs

JANUARY 8, 2024

Emergent coronary angiography is not recommended over a delayed or selective strategy in patients with ROSC after cardiac arrest in the absence of ST-segment elevation, shock, electrical instability, signs of significant myocardial damage, and ongoing ischemia (Level 3: no benefit). o C recommended (Level 1: strong). COR 2a, LOE B-NR.

Seizures 97

Seizures Shock CPR Hyperthermia / Hypothermia 97

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Past medical history included RBBB without other cardiac history, but old ECG was not available. As for the ECG, it could represent OMI, but RBBB is also a clue that it may be PE. But with prehospital and ED ECGs being ‘STEMI negative’, the ECG was signed off and the patient waited to be seen.

EKG/ECG 75

EKG/ECG EMS Shock Ultrasounds 75

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. First aid done pre-hospital. Establish IV access and begin fluid resuscitation with 250ml boluses of 0.9% Type of chemical and strength.

Burns 52

Burns Fluid Resuscitation PPE Hyperthermia / Hypothermia 52