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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EKG/ECG Emergency Department Outcomes Documentation/Coding 107

Dr. Smith's ECG Blog

APRIL 22, 2024

EKG from triage: Here is his previous ECG: Normal ST Elevation Resident's interpretation: Reperfusion pattern/Wellens' with biphasic T waves in V2 and V3, and in comparison to an EKG in 2020 this is new. Repeat EKG: Resident interpretation: ST elevation in V2 significantly different than his previous EKG.

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EKG/ECG Outcomes Ultrasounds Hospitals 121

Dr. Smith's ECG Blog

MARCH 14, 2024

Written by Jesse McLaren Three patients presented with acute chest pain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. It is well known that NOMI usually has a normal ECG or nonspecific ECG.

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Dr. Smith's ECG Blog

JUNE 7, 2024

Below are serial ECGs focusing on the inferior leads and aVL. First, what’s the interpretation of each ECG on its own? #1 2 Normal ECG #3. 2 Normal ECG #3. But 90 minutes later troponin returned at 70ng/L (normal <26 in males and <16 in females), and a repeat ECG was done (ECG#2) for recurring chest pain.

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EKG/ECG Documentation/Coding EMS Outcomes 102

ECG Guru

MAY 24, 2024

We will update this post if we receive information about her outcome. ECG Number 1, 11:57 a.m.: There is a wide-complex tachycardia at a rate of about 230 bpm. This photo shows an ECG that is not lying flat, so it is difficult to line up the complexes. She was alert and oriented. Her BP was reported as being “stable”.

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Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

This case comes from Jason Winter, of The Facebook Clinical Electrocardiology ECG Page. Here is her first prehospital ECG: What do you think? However, again, the formula was developed only in ECGs with at lead 1 mm of STE in V2 and V3, so does it apply? Serial ECGs improve the sensitivity of ST elevation on the ECG for MI.

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EKG/ECG EMS Outcomes 125

Dr. Smith's ECG Blog

OCTOBER 18, 2023

All initial ECGs were labeled ‘normal’ or ‘otherwise normal’ by the computer interpretation, and below are the ECGs with the final cardiology interpretation. 1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes.

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EKG/ECG Documentation/Coding Emergency Department Outcomes 122

Dr. Smith's ECG Blog

DECEMBER 22, 2023

The patient with no prior cardiac history presented in the middle of the night with acute chest pain, and had this ECG recorded during active pain: I did not see any ischemia on this electrocardiogram. I think the ECG is normal. OMI is a clinical diagnosis that includes the ECG. This is a case I had quite a while back.

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Dr. Smith's ECG Blog

JUNE 13, 2024

Don't miss his analysis and assessment of the Queen of Hearts AI OMI ECG bot -- that assessment is at the very bottom of the post. Here is her ED EKG: What do you think? I would have very high suspicion for OMI on this ECG. Past medical history included Crohn’s disease, hyperlipidemia, hypothyroidism, and she smoked 1ppd.

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ECG Guru

JULY 24, 2023

This is a "classic" ECG of very good quality for you to use in a classroom setting. The ECG: This ECG could be considered "classic" for an inferior wall ST elevation M.I. The ECG: This ECG could be considered "classic" for an inferior wall ST elevation M.I. He is pale, cool, and diaphoretic.

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EKG/ECG EMS Outcomes 98

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). Here is his first prehospital ECG: 1st Prehospital ECG What do you think?

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EKG/ECG EMS Stroke Outcomes 112

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Serial ECGs remained unchanged. What do you think?

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EKG/ECG EMS Outcomes Wellness 122

Dr. Smith's ECG Blog

DECEMBER 13, 2023

This is the result for this ECG, from MDcalc.com : The most accurate cutpoint is 18.2. Outcome: 100% LAD Occlusion Here the Queen explains why: The dark blue tells us that she is looking especially at the QRS in V3 and the T-wave in V2 and V3. Here is a similar case from Pendell: This ECG was handed over at triage.

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EKG/ECG COPD Wellness Outcomes 119

Dr. Smith's ECG Blog

AUGUST 26, 2024

She had an ECG recorded at triage: What do you think? What was the outcome?" No Previous ECGs Available. But she does label V2 as "OMI High Confidence" and V1 as "OMI Low confidence" Like good physicians, they recorded another ECG at 10 min: What do you think? Learning Points: Serial ECGs are critical.

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EKG/ECG Outcomes 111

Dr. Smith's ECG Blog

JUNE 23, 2024

Here is his presenting ECG: ECG 1, t = 0 What do you think? His transfer packet included notes, labs, cath report, and ECG reports, but no actual ECG images. Smith's ECG Blog. When he reviewed the case, he only had access to the accepting facility ECG. He did not have access to ECG 1.

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Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This ECG was recorded in triage. The computer interpretation is: “Sinus Brady with moderate intraventricular conduction delay, nonspecific t wave abnormality, abnormal EKG” What do you think? Case Continued The ECG findings were not recognized. Therefore, no matter the initial ECG, record serial ECGs.

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EKG/ECG Resuscitation CPR Emergency Department 135

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.

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Dr. Smith's ECG Blog

AUGUST 6, 2024

Written by Magnus Nossen with Edits by Grauer and Smith The ECGs in today’s case are from 3 different patients all presenting with new-onset CP ( Chest Pain ). All ECGs were recorded by EMS, and transferred to a PCI capable center for evaluation. For 2 of the 3 patients — the cath lab was activated based on the ECG.

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EKG/ECG Wellness Hospitals EMS 89

RebelEM

SEPTEMBER 28, 2023

ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% The upper range of this time was 120 minutes from diagnostic ECG in the majority of patients.

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Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? I read this ECG without any history as reperfusing inferior and posterior OMI due to the Q-wave in lead III with minimal STE and reciprocal ST depression in V2-V4 (which should never be there). We send each other EKG by the dozens every day. Most are OMI look alikes (mimics).

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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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EKG/ECG Documentation/Coding Outcomes Hospitals 94

Dr. Smith's ECG Blog

MAY 23, 2023

EMS arrived and recorded this ECG: What do you think? See same ECG below with computer automated interpretation, using the Glasgow ECG algorithm which apparently is used by many different providers and devices Amazing that the computer calls this normal. Next day ECG. And yet it still says "normal". Learning Points: 1.

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EKG/ECG Wellness Emergency Department EMS 91

Dr. Smith's ECG Blog

MAY 31, 2023

I received the following text message with these 3 EKGs (providers text me ECGs all day every day; most are false positives; many are subtle true positives): "Hi Steve, here are 3 EKGs for you (my colleague's case). Opiates are associated with worse outcomes in Myocardial Infarction. Cath attending is aware. Am Heart J.

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EKG/ECG Outcomes Academics Wellness 82

RebelEM

JUNE 1, 2023

Post-ROSC management is nuanced and challenging but helps to ensure good outcomes. In theory, rapid identification of the underlying cause should improve outcomes by allowing clinicians to tailor management. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study.

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Outcomes Resuscitation Hospitals CPR 145

Dr. Smith's ECG Blog

FEBRUARY 11, 2024

The ECG was faxed to a cardiologist. I told him that he could make it legible AND get an OMI diagnosis from the Queen of Hearts and sent this ECG to the Queen right before his eyes: She correctly rules out OMI: And the outcome was Not OMI This was a patient with chest pain. But it was very difficult for him to see.

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EKG/ECG Outcomes 64

ALiEM

NOVEMBER 6, 2023

Wolf-Parkison-White Syndrome (WPW) Case Question: What are the characteristic ECG findings of this condition and how is this condition managed? These particular EKG findings define a “Wolff-Parkinson-White Pattern.” WPW Syndrome consists of characteristic EKG findings as well as symptomatic arrhythmias. Crit Care Nurse.

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EKG/ECG Academics Outcomes Wellness 78

Dr. Smith's ECG Blog

MARCH 30, 2014

The minute this medical student saw the first ECG, he knew the diagnosis without any further information. Reading ECGs is hard, but can be done with commitment to learning, which comes from an awareness of its importance. You need to be interested and understand the value of the ECG. She had this ECG recorded: ECG 1: QTc is 484.

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EKG/ECG Outcomes Shock Sepsis 52

Dr. Smith's ECG Blog

JUNE 5, 2024

The below ECG was recorded. The ECG does not show any definite signs of ischemia. In fact, the ECG was described as normal, and without serial ECGs or prior ECGs for comparison it could be. PEARL: Increased vagal tone is highly likely to be the cause of the abnormal rhythm in ECG #2.

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EKG/ECG Outcomes 112

Taming the SRU

MARCH 10, 2024

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. ECG is a must for EVERY syncope patient. It is not specific enough in defining specific findings on the ECG that should be considered high risk.

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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. Long term outcome is unavailable.

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EKG/ECG EMS Documentation/Coding Shock 121

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Which had the more severe chest pain at the time of the ECG? Patient 2 at the bottom with a very subtle OMI complained of 10/10 chest pain at the time the ECG was recorded. And as we have shown before, morphine leads to slower times to treatment and worse outcomes. 2 middle aged males presented with chest pain.

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EKG/ECG Hospitals Outcomes Wellness 114

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Here's the prior ECG: This confirms thew anterior ST depression is new. The first ECG was labeled “anterior subendocardial ischemia”, but subendocardial ischemia does not localize. So a patient with high pretest probability (prior CABG with new chest pain), had new ECG changes showing posterior OMI. Do you need posterior leads?

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EKG/ECG Outcomes 116

Dr. Smith's ECG Blog

SEPTEMBER 1, 2023

Here is the triage ECG: What do you think? I would activate the cath lab, or at least look for an old one and/or obtain serial ECGs. Case Continued There was an old ECG available from 1.5 Here it is: These T-waves are far smaller, confirming that the above ECG is indeed due to LAD OMI. Accuracy was 91% and AUC was 0.95.

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EKG/ECG Outcomes 129

Dr. Smith's ECG Blog

NOVEMBER 27, 2024

The way to get good at it is to see a lot of them, and also see a lot of fake HATWs (mimics) Here is a difficult pair of ECGs that demonstrate a difference: One ECG is normal variant STE. The more abnormal leads and lead areas you can identify in a given ECG — the more solid the evidence of acute OMI becomes. Which is which?

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EKG/ECG Research Outcomes Wellness 115

Dr. Smith's ECG Blog

APRIL 2, 2024

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. Another ECG was recorded 12 minutes later: Paced rhythm, probable Pacemaker-Mediated Tachycardia ?

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EKG/ECG Shock CPR Stroke 133

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 called 911. What do you think?

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EKG/ECG Academics Shock Outcomes 70

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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