Dr. Smith's ECG Blog

APRIL 2, 2024

Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. Here is the initial ED ECG. Other thought this was due to hyperkalemia, but the ECG does not have the appearance of hyperkalemia but does have the appearance of severe cardiomyopathy -- LBBB with very wide QRS) 3. What do you think?

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EKG/ECG Shock CPR Stroke 134

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 132

Dr. Smith's ECG Blog

JUNE 18, 2011

The medics recorded this prehospital ECG at 1535 : There is ST elevation and tall T-waves in precordial leads, with reasonably good R-wave progression. First, if an old ECG is available, then compare. 1.196 x STE60 in V3 in mm) + (0.059 x computerized QTc) - (0.326 x RA in V4 in mm) Third, one can do an immediate cardiac ultrasound.

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EKG/ECG Hospitals Ultrasounds 52

Sensible Medicine

JUNE 28, 2024

A 76-year-old woman presents to a community hospital after waking with garbled speech and right-sided weakness. Case 1: Excess An elderly woman is admitted to a community hospital with a minor stroke. The hospital does an excellent job. By the time she leaves the hospital, she has no residual symptoms. I love my job.

Stroke 105

Stroke Academics EKG/ECG Hospitals 105

ACEP Now

DECEMBER 7, 2024

A submassive PE does not result in hypotension but does result in right ventricular (RV) dysfunction (as evidenced by CT or ECG) and/or signs of myocardial injury, such as elevated B-type natriuretic peptide, elevated troponin, or new ECG changes. 6 The second common catheter-directed approach is mechanical thrombectomy.

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Ultrasounds Radiology Radiology EKG/ECG 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Triage EKG: What do you think? He had been seen several weeks ago at an outside hospital for a similar issue and had been discharged home, presumably after unremarkable workup. A prior ECG was available for comparison. Immediately after the second ECG was performed, the patient's pain resolved completely.

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EKG/ECG Ultrasounds EMS Documentation/Coding 52

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

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EKG/ECG Shock Fractures Dislocations 93

ACEP Now

OCTOBER 29, 2024

Does that normal troponin and ECG obviate the need for cardiology consultation for my patient with a concerning story for acute coronary syndrome? The “bundling” heuristic—if I send a troponin, then an ECG is needed. A testicular ultrasound confirmed restored blood flow. Mary’s Hospital in Leonardtown, Maryland.

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Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

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.

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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. The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Date: September 8th, 2021 Reference: Desch et al.

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Dr. Smith's ECG Blog

NOVEMBER 15, 2023

She has no previous cardiac history of which she is aware 911 was called and here is her Prehospital ECG: What do you think? link] Case continued She arrived in the ED and here is the first ED ECG. In comparison with the first ECG, I would guess that the artery is reperfusing. I don't know if her pain was getting better or not.

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EKG/ECG Ultrasounds Wellness Stroke 110

Dr. Smith's ECG Blog

OCTOBER 23, 2022

The ECG told the story. EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 Time = 24 min S-wave depth is diminishing These prehospital ECGs were lost and not seen. This patient has a non-diagnostic ECG by most rules. She called 911. STE 60 V3 = 1.5

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EKG/ECG Hospitals EMS Ultrasounds 40

EMDocs

APRIL 22, 2024

1-3 VTE is responsible for hospitalizing over 250,000 Americans every year, and there are an estimated 100,000 deaths annually associated with these conditions. 1-3 VTE is responsible for hospitalizing over 250,000 Americans every year, and there are an estimated 100,000 deaths annually associated with these conditions. EKG RV strain.

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Ultrasounds Advances Cardiac Life Support (ACLS) EKG/ECG Shock 97

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Our first 12 lead ECG was then recorded at 0926. What do you think?

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EKG/ECG Emergency Department Ultrasounds Hospitals 52

Broome Docs

MARCH 28, 2024

If you want to see Justin in the video format and his new Youtube series then click here: [link] If you would like to check out my current ultrasound training project then click here: WACHS Ultrasound Otherwise – enjoy the show and see you in a few weeks. Myth 3: The ECG changes from hyperkalemia are predictable and reliable.

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PPE Ultrasounds Resuscitation Emergency Department 96

Dr. Smith's ECG Blog

APRIL 20, 2018

This is her pre-hospital ECG: This is her first ECG in the ED: What do you think? However, the prehospital ECG is more worrisome: the T-wave inversion in V5 and V6 is preceded by ST Elevation. When I say " relative ," I mean relative to the previous ECG, which is the baseline, chronic, non-ischemic ECG.

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Dr. Smith's ECG Blog

JUNE 14, 2017

This case was sent by Dr Avinash Krishnamurthy, a fine emergency medicine resident from Australia Cairns base hospital Case : An adolescent male had a mechanical fall and injured his left shoulder and arm. A bedside cardiac ultrasound was normal. An ECG was recorded: Avinash was understandably confused by this ECG.

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EKG/ECG Documentation/Coding Ultrasounds Wellness 52

EMDocs

MAY 15, 2024

ECG: Evaluate for ischemia, right heart strain. Ultrasound Sensitivity 88-100%, specificity 68-94% Positive likelihood ratio of 14.6 (95% Consider risk factors for multi-drug resistant microbes: Recent IV antibiotics Hospitalization within 90 days. Overestimates arterial oxygen saturation. Consider CT with IV contrast.

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Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 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.

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EKG/ECG EMS Shock Ultrasounds 75

ACEP Now

JUNE 6, 2023

ECG, CXR, and troponin are negative. Troponins #1 and #2 are borderline and ECG is non-specific. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. ECG, CXR, and troponin are all normal. An ECG and CXR are negative. An ECG, CXR, and two troponins are normal. She is given morphine for pain.

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EKG/ECG Stroke Documentation/Coding Operations 85

Taming the SRU

AUGUST 7, 2023

The patient needs a transvaginal ultrasound w/ doppler with gynecology consult and possible laparotomy TVUS is not just for torsion, it can also be used for ectopic pregnancies or pregnancy of unknown location Acute Ischemic Stroke Updates WITH Drs.

Stroke 93

Stroke Outcomes EKG/ECG Research 93

EMDocs

MAY 28, 2024

ECG: Evaluate for ischemia, right heart strain. Ultrasound Sensitivity 88-100%, specificity 68-94% LR+ of 14.6 (95% Consider risk factors for multi-drug resistant microbes: Recent IV antibiotics Hospitalization within 90 days. COVID-19 and ACS COVID increases the risk of hospitalization, pneumonia, pain, and ACS in SCD patients.

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Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 94

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. Epub 2021 Nov 15.

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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. Smith comment: This patient did not have a bedside ultrasound. The ECG cannot diagnose the etiology of ischemia; it only the presence of ischemia, from whatever etiology. What should be done?

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EKG/ECG Shock Fluid Resuscitation Documentation/Coding 40

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

A prehospital ECG was recorded: Limb leads: Precordial Leads What is the therapy? On arrival, the patient was in shock, was intubated, and had an immediate cardiac ultrasound. What does a heart look like on ultrasound when the EKG looks like that? The followup ECG is here: Now the QRS is only slightly prolonged.

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Dr. Smith's ECG Blog

APRIL 26, 2017

Note 2 other similar cases at the bottom that come from my book, The ECG in Acute MI. Case While I was busy seeing patients, a resident brought me this ECG of a 60-something with a history of syncope only. There was no chest pain or SOB at the tim of the ECG: Computerized QTc is 464 ms A previous ECG from 8 years prior was normal.

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EKG/ECG Ultrasounds Dehydration Stroke 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?

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Dr. Smith's ECG Blog

NOVEMBER 12, 2020

He had the following EKG recorded: Low voltage, suggests effusion. A bedside cardiac ultrasound was normal, with no effusion. He was started on Extracorporeal Life Support ("VA ECMO") Here is the ECG on ECMO: Very low voltage On Day 3, the EF recovered (that seems quick!) He was moderately hypoxic. 3–8 Shi et al.

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Shock EKG/ECG Outcomes Hospitals 52

Taming the SRU

AUGUST 4, 2024

In select patient populations (such as those with poor outpatient follow-up), screening with a BMP to evaluate their serum creatinine may be beneficial Patients with asymptomatic hypertension should be referred to their PCP for outpatient follow-up.

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Dislocations Emergency Department Documentation/Coding Burns 85

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. Below is the first ED ECG, labeled LBBB by the machine. Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings.

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Dr. Smith's ECG Blog

DECEMBER 18, 2022

Here is her ECG on arrival to the ED: What is your differential? The ECG is quickly reviewed and shows sinus rhythm with normal QRS complexes. Her prior ECG on file is shown below: What are your next steps? Learning Points: The ECG is always just one piece of the clinical puzzle. What are your next steps?

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Ultrasounds EKG/ECG EMS Radiology 40

Dr. Smith's ECG Blog

FEBRUARY 23, 2023

It is unclear whether he had active pain at the time of the first ECG: What do you think? 0.20 (above which, the ECG likely represents OMI). The team was concerned about possibly ischemic ST elevations on the ECG above, so they took it to Dr. Nossen for consultation. Vitals were within normal limits.

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EKG/ECG Ultrasounds Outcomes Hospitals 52

Urgent Care Ultrasounds

JANUARY 17, 2019

Her ECG did not show any concerning features. The patient was referred to hospital to further investigate the cause of her collapse, in light of the uncertain aetiology of the echo findings. HH has been associated with post-prandial syncope, chest pain, and ECG changes suggestive of ischaemia. Cardiovascular ultrasound.

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Dr. Smith's ECG Blog

NOVEMBER 4, 2022

What is your ECG interpretation and what would you do next? This ECG shows a normal sinus rhythm with a normal conduction pattern (normal PR, normal QRS, and normal QTc), normal axis, late R wave progression (and misplaced V2), normal voltages, ST-elevation in aVR and global ST-depressions. BP was 110 and oxygen saturation was normal.

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Dr. Smith's ECG Blog

JANUARY 9, 2023

Meyers ECG Interpretation: Easily diagnostic of LAD occlusion. The ECG easily meets STEMI criteria in all leads V2-V6, as well. I sent this ECG to Dr. Smith, with the only information that it is a 17 year old with chest pain. The ECG was interpreted as "benign early repolarization." Coxsackie serologies negative.

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EKG/ECG Wellness Ultrasounds Outcomes 52

Dr. Smith's ECG Blog

APRIL 8, 2016

Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. Here is his ED ECG: There is obvious infero-posterior STEMI. This subsequent ECG was recorded after the K was up to 2.2 These two rhythms are often indistinguishable on the monitor or ECG. This was stented.

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Resuscitation EKG/ECG Hospitals Administration 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

When the paramedics arrived, they obtained a 12 lead ECG and confirmed the unstable vital signs. EKG is pictured below: What do you think? They did not have an ultrasound on the ambulance (some local crews are starting to utilize POC limited US in our service areas). A right sided ECG was not recorded.

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Seizures EKG/ECG Shock EMS 40