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. hours increased the NNT for a good outcome to 20. The expanded window of 3-4.5

Stroke 93

Stroke Outcomes EKG/ECG Research 93

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.

EKG/ECG 109

EKG/ECG Ultrasounds Wellness Stroke 109

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities. The AHA has a statement with recommendations based on the available data.

EKG/ECG 52

EKG/ECG Academics EMS CPR 52

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

Dr. Smith's ECG Blog

JUNE 14, 2017

A bedside cardiac ultrasound was normal. An ECG was recorded: Avinash was understandably confused by this ECG. He wrote: "ECG 1 - shows wide ???IVCD I sent it to my friend, Ken Grauer , who is very meticulous in his ECG reading. I labeled ECG. His chest was tender. IVCD type rhythm ??

EKG/ECG 52

EKG/ECG Documentation/Coding Ultrasounds Wellness 52

Dr. Smith's ECG Blog

JULY 22, 2012

As part of her workup, this ECG was recorded: What do you think? Hemodynamic instability in trauma is usually due to bleeding, but if ultrasound shows poor contractility, then this may be due to cardiac contusion. The finding of RBBB on this ECG is highly suggestive, if not diagnostic, of myocardial contusion.

Head Injuries 52

Head Injuries EKG/ECG Ultrasounds Outcomes 52

EM Curious

JULY 8, 2015

ULTRASOUND GOODIE BAG ULTRASOUND FOR LATE PREGNANCY [PODCAST]: While not a routine exam we perform other than confirming fetal heart tones, definitely some great pearls on more advanced US topic. Consider an ultrasound guided ulnar nerve block. Part 1 here. US GUIDED ULNAR NERVE BLOCK [BLOG]: Boxer's fracture need a reduction?

Infectious Diseases 52

Infectious Diseases Disaster Management Sepsis Ultrasounds 52

EMDocs

MAY 11, 2024

Semin Ultrasound CT MR. 2013 Apr;34(2):131-41. Endovascular and Clinical Outcomes of Vertebrobasilar Intracranial Atherosclerosis-Related Large Vessel Occlusion. Reference article, Radiopaedia.org (Accessed on 28 Aug 2023) [link] Ortiz de Mendivil A, Alcalá-Galiano A, et al. doi: 10.1053/j.sult.2013.01.004. 2013.01.004. PMID: 23522778.]

Stroke 111

Stroke EMS EKG/ECG Radiology 111

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.

EKG/ECG 52

EKG/ECG Shock Emergency Department Ultrasounds 52

EM Curious

JULY 1, 2015

ULTRASOUND IN CHEST PAIN: [BLOG]: It is never a bad idea to throw an ultrasound probe on your patient with chest pain. ECG PATTERN RECOGNITION CARDIAC ARREST AND ST ELEVATION: [BLOG]: Dr. Smith features a brief cardiac arrest case with an ECG pattern that you must know and be able to recognize! Check out his post here.

EMS 52

EMS Ultrasounds EKG/ECG Fractures 52

Dr. Smith's ECG Blog

APRIL 12, 2023

Prehospital Conventional algorithm interpretation: ANTERIOR INFARCT, STEMI Transformed ECG by PM Cardio: PM Cardio AI Bot interpretation: OMI with High Confidence What do you think? On arrival, lung ultrasound confirmed pulmonary edema (B lines). Outcome : She was diagnosed with stress cardiomyopathy, though it is not entirely classic.

EKG/ECG 52

EKG/ECG COPD Ultrasounds Outcomes 52

Dr. Smith's ECG Blog

JUNE 20, 2018

The initial tracing (EKG 1) was obtained. Clinician and EKG machine read of acute pericarditis. Paper published: Terminal QRS distortion not found in any ECG of Early Repolarization TQRSD is defined as the absence of BOTH an S-wave and a J-wave in leads V2 or V3. She was reportedly "pacing in her room while holding her chest".

EKG/ECG 52

EKG/ECG Documentation/Coding Ultrasounds Wellness 52

Dr. Smith's ECG Blog

APRIL 12, 2013

Here is his prehosptial ECG: There are inferior Q-waves with ST elevation T-wave inversion. He had diffuse crackles on exam and B-lines on chest ultrasound, and chest x-ray also confirmed pulmonary edema. Here is his ED ECG: There is sinus tachycardia. He had no chest pain. There is reciprocal ST depression in aVL and I.

EKG/ECG 52

EKG/ECG Ultrasounds Wellness EMS 52

Taming the SRU

JUNE 3, 2024

CESAR Trial Published in 2009 Found that even those who didn’t get ECMO, but were transported to a tertiary care center had better outcomes No matter where you go, critical care transport will be part of your life as a sending physician, receiving physician, or both. Benefits of transport are evidenced based.

Shock 91

Shock Seizures Airway Management Stroke 91

Dr. Smith's ECG Blog

JANUARY 6, 2023

F Triage ECG: ECG Interpretation: Sinus rhythm with normal QRS. I do not think this ECG is by itself diagnostic of OMI (full thickness, subepicardial ischemia ), b ut comparison to a previous might reveal this ECG as diagnostic of OMI. Cardiology interpretation of the initial ECG: “ST depressions laterally.”

EKG/ECG 52

EKG/ECG Wellness Academics Ultrasounds 52

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.

EKG/ECG 52

EKG/ECG Ultrasounds Outcomes Hospitals 52

Dr. Smith's ECG Blog

NOVEMBER 3, 2017

Beware of using it to reverse your prior opinion that the ECG represents LAD occlusion. I recommend using it when you are worried that an ECG with apparent normal ST Elevation might be LAD occlusion. Case 3 I was reading a stack of ECGs yesterday, and saw this one, with no clinical information. Sensitivity is not perfect.

EKG/ECG 52

EKG/ECG Outcomes Emergency Department Ultrasounds 52

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.

EKG/ECG 52

EKG/ECG Shock Sepsis Emergency Department 52

Dr. Smith's ECG Blog

JUNE 27, 2021

Medics recorded this ECG: There is a lot of artifact, but you can clearly see ST depression in V2 and V3. Here is the first ED ECG (there was no previous ECG on file for comparison): Sinus rhythm and LVH There is some (less than 1 mm) of STD in V3 and V4. There is no significant ST Elevation. This was not recognized.

EKG/ECG 40

EKG/ECG Radiology Radiology Ultrasounds 40

Dr. Smith's ECG Blog

OCTOBER 24, 2019

The ECGs An initial ECG was obtained as the pain was rapidly resolving: Minimal upsloping ST Elevation in III, with a steeply biphasic T wave, and with reciprocal ST depression in leads I and aVL. Often, intravascular ultrasound or intravascular optical coherence tomography is requeried to make the diagnosis. Lobo et al.

EKG/ECG 52

EKG/ECG Shock Wellness Ultrasounds 52

Dr. Smith's ECG Blog

SEPTEMBER 4, 2016

This is his prehospital ECG: There is very subtle ST elevation in I and aVL, with very subtle ST depression in III and aVF. Jason asked me if I thought it is due to occlusion (without either of us knowing the outcome), and this was my answer: This is a posterolateral MI. This ECG is diagnostic of ischemia.

EKG/ECG 40

EKG/ECG Outcomes Ultrasounds Hospitals 40

Taming the SRU

MARCH 17, 2023

mepivacaine (1-3 h) 1% lidocaine +/- epi (2-3h) 0.25% bupivacaine (2-3 h) 0.25-0.5% mg/kg IV Versed: 0.2 mg/kg IM, 0.2 mg/kg IN (may repeat to max of 0.4 mg/kg IN), 0.2 mg/kg IV Versed: 0.2 mg/kg IM, 0.2 mg/kg IN (may repeat to max of 0.4 mg/kg IN), 0.2

Seizures 40

Seizures Fractures Burns Pediatrics 40

EMDocs

JANUARY 11, 2024

Early coronary angiography in post-CA patients with no ST-segment elevation on the presenting ECG may still be of benefit by potentially salvaging myocardium and decreasing the incidence of systolic heart failure in survivors (95.7%, 22/23). Centers managing patients after CA should collect data and evaluate outcomes of care (95.7%, 22/23).

Seizures 98

Seizures Shock Infectious Diseases CPR 98

EB Medicine

JULY 8, 2019

Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status. Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

Mind The Bleep

FEBRUARY 2, 2025

An ECG will also help with anaesthetic planning Bloods: CRP, U&E, FBC, LFTs, INR (if on warfarin), VBG (for lactate, pH and glucose), amylase Group and save: not all surgical procedures need group and saves- these are expensive and in many cases, unnecessary- check first!

Documentation/Coding 95

Documentation/Coding COPD EKG/ECG Wellness 95

Dr. Smith's ECG Blog

AUGUST 9, 2024

These diagnoses were not found in his medical records nor even a baseline ECG. 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. He reported a history of “Wolf-Parkinson-White” and “heart attack” but said neither had been treated.

EKG/ECG 107

EKG/ECG EMS Emergency Department Wellness 107

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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EKG/ECG Emergency Department Ultrasounds Documentation/Coding 120

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

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.

Ultrasounds 52

Ultrasounds Radiology Radiology EKG/ECG 52

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Triage EKG: What do you think? A prior ECG was available for comparison. Prior EKG from 2 months ago was available: Let's put the precordial leads from the 2 ECGs side by side: Now you can really see the difference. Immediately after the second ECG was performed, the patient's pain resolved completely.

EKG/ECG 52

EKG/ECG Ultrasounds EMS Documentation/Coding 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% Markers for severe disease include hypoxemia, increasing respiratory rate or work of breathing, decreasing platelet count and/or Hb, and multilobar involvement on chest radiograph or lung ultrasound.

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Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 104

ACEP Now

MAY 10, 2024

His vital signs are normal and the ECG does not demonstrate a myocardial infarction. While waiting for laboratory investigations, including troponin and d-dimer, you wonder if a quick point-of-care ultrasound (POCUS) examination looking for three sonographic findings could help determine the likelihood of this being an AoD.

Ultrasounds 52

Ultrasounds Outcomes Academics Documentation/Coding 52

ACEP Now

OCTOBER 9, 2024

In the emergency department (ED), physicians face the challenge of making rapid decisions that can significantly impact patient outcomes. Collaborating with one of my ultrasound faculty, we conducted a bedside echocardiogram to explore potential cardiac anomalies. Our workup started with an ultrasound and EKG.

EKG/ECG 52

EKG/ECG Fluid Resuscitation Ultrasounds Burns 52

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.

Shock 52

Shock EKG/ECG Outcomes Hospitals 52

EMDocs

MAY 28, 2024

ECG: Evaluate for ischemia, right heart strain. Ultrasound Sensitivity 88-100%, specificity 68-94% LR+ of 14.6 (95% Markers for severe disease include hypoxemia, increasing respiratory rate or work of breathing, decreasing platelet count and/or Hb, and multilobar involvement on chest radiograph or lung ultrasound. N Engl J Med.

Blood Transfusions 98

Blood Transfusions Fluid Resuscitation Dehydration Ultrasounds 98

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

JULY 18, 2014

Here is his ECG: What is your interpretation? such Q-waves are associated with larger MI and worse outcomes (2. This was the 12-lead ECG. This remains consistent with PIRP, as was the first ECG. If detected early by ultrasound, the patient can be saved. Exact pain history was difficult to ascertain. Very unlikely.

EKG/ECG 52

EKG/ECG Shock Ultrasounds Wellness 52