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. And she learned it well: She is not highly confident, but she does diagnose OMI. 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.

EKG/ECG 121

EKG/ECG COPD Wellness Outcomes 121

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. But he did well.

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EKG/ECG EMS Outcomes Wellness 124

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 123

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 91

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 137

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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EKG/ECG Hospitals Shock Documentation/Coding 98

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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EKG/ECG Allergic Reactions Shock Stroke 138

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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EKG/ECG Shock Wellness EMS 96

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

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 96

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 93

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 117

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). It is one of the few OMI patterns that is really well described: de Winter’s T-waves. Am Heart J.

EKG/ECG 85

EKG/ECG Outcomes Academics Wellness 85

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

SEPTEMBER 11, 2024

Hope you’re doing well! Here is the ED ECG (a photo of the paper printout) What do you think? Smith : "What was the outcome?" You taught us well!" The "good news" — is that a cardiac-related cause of syncope is unlikely if the initial ECG is normal, and cardiac monitoring in the ED fails to reveal significant arrhythmia.

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EMS CPR EKG/ECG Wellness 113

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

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 116

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 123

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The following ECG was obtained. Note that the machine read is "normal sinus rhythm, normal ECG." ECG 1 What do you think? I sent this ECG to Dr. Smith and Dr. Meyers with no clinical context. Smith comment: this troponin alone should be enough data to activate the cath lab, regardless of the ECG. <0.049 ng/mL).

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EKG/ECG Documentation/Coding Wellness Emergency Department 125

RebelEM

SEPTEMBER 21, 2023

ECG shows a regular, narrow-complex, tachycardia at 190 bpm consistent with SVT. Troponins are highly specific to cardiac myocytes but do exist in other muscle types as well. After conversion to sinus rhythm, do a good history, physical and analysis of the ECG. He has no medical problems and denies any prior similar symptoms.

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EKG/ECG Sepsis EMS Outcomes 143

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 116

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. If the LAD is completely occluded, then why does the ECG show reperfusion? What are we seeing here?

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EKG/ECG EMS Emergency Department Outcomes 92

Dr. Smith's ECG Blog

OCTOBER 8, 2023

Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECG s that has not been overread by a physician. ECG#1 ECG#2 ECG#3 ECG#4 ECG#5 See outcomes of all 5 below, with the Queen of Hearts AI Bot interpretation. (THE True Positive ECG#2 : Also sinus rhythm.

Hyperthermia / Hypothermia 118

Hyperthermia / Hypothermia EKG/ECG Wellness Shock 118

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

JANUARY 3, 2024

On arrival, EMS recorded relatively normal vital signs and this EMS ECG: What do you think? However, saddlebacks are only true saddlebacks when there is a well-formed normal voltage S-wave. The EMS crew recorded another ECG about 10 minutes later (unknown if pain changed): New LAFB. No further ECGs were recorded.

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EMS EKG/ECG Wellness Outcomes 91

Dr. Smith's ECG Blog

AUGUST 2, 2024

His ECG is shown below. The LCx and OM branches are not as well seen. How does RCA occlusion fit with the ECG? The answer is that the ECG really shows right ventricular OMI. the investigators reviewed outcomes in 118 patients presenting with NSTEMI. Pretty obvious anterior current of injury.

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EKG/ECG Fluid Resuscitation Academics Resuscitation 117

Dr. Smith's ECG Blog

MAY 30, 2023

His prehospital ECG was diagnostic of inferior posterior OMI. Here is his ED ECG: There is bradycardia with a junctional escape. We recorded an ECG in which V1-V3 were put in the position of V4R-V6R, and V4-6 were placed in V7-9 to (academically) confirm posterior OMI. The RV is supplied during systole as well as diastole.

Shock 86

Shock EKG/ECG Academics Stroke 86

Dr. Smith's ECG Blog

JULY 14, 2024

Here is his ECG at triage: What do you think? See this post if you dont know that pattern yet: Precordial Swirl -- 20 cases of Swirl or Look-Alikes Here was a repeat ECG done within 20 minutes (still with ongoing pain): It still looks like active OMI to me, but perhaps slightly improved from the first one. Outcome of case 2?

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EKG/ECG Outcomes Wellness 76

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

The following ECG was recorded. The presenting ECG shows SR with narrow QRS complexes. There is some upwards concave ST segment elevation in the inferior leads with what seems to be well formed J-waves. First troponin I returned 3174 ng/l, at which point a repeat ECG was ordered. Not much difference from 1st ECG.

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EKG/ECG COPD Wellness Shock 104

Don't Forget the Bubbles

JUNE 30, 2023

You request a 12 lead ECG and repeat a blood gas, asking for it to be run on the PICU analyser. Your trusted nurse hands you the ECG: Paediatric ECG interpretation has never been your strong suit. What is the likely cause of Elsa’s ECG changes? You look at her monitor, and an arterial blood gas performed moments ago.

Hyperthermia / Hypothermia 145

Hyperthermia / Hypothermia Military CPR EKG/ECG 145

Dr. Smith's ECG Blog

AUGUST 26, 2019

She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? This ECG was texted to me with no clinical information, with the sender being concerned for possible hyperacute T-waves and STE in the inferior leads.

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EKG/ECG Emergency Department Outcomes Hospitals 52

Dr. Smith's ECG Blog

OCTOBER 18, 2023

A few days into her hospital stay she developed chest discomfort and the following ECG was recorded. Are these ECG changes related to the CNS infection perhaps? When I saw the ECG of this patient I saw that there was definitely something "off". I sent the top ECG to Dr Smith with no information and without the baseline ECG.

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EKG/ECG Hospitals Academics Outcomes 113

Dr. Smith's ECG Blog

JUNE 18, 2013

I want all to know that, with the right mind preparation, and the use of the early repol/LAD occlusion formula, extremely subtle coronary occlusion can be detected prospectively, with no other information than the ECG. His ECG was repeated at this point: This shows a well developed anterior STEMI. His first troponin was normal.

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EKG/ECG Outcomes Emergency Department Hospitals 52

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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EKG/ECG Outcomes Academics Documentation/Coding 83

Dr. Smith's ECG Blog

DECEMBER 11, 2018

Prehospital EKG and strips (not shown) had "heart rate 156" (according to the computer interpretation) and "Bigeminal PVCs" The prehospital 12-lead looked just like the first ED ECG: What do you think? This ECG is pathognomonic for severe hyperK, and the long ST segment is all but pathognomonic for hypocalcemia.

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EKG/ECG Dehydration Burns Outcomes 52

Dr. Smith's ECG Blog

AUGUST 19, 2023

Below is the 15 lead ECG. The ECG above was only done an hour after arrival, when the first high sensitivity troponin I returned at 300ng/L (normal <26 in males and <16 in females). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. RR18 sat 99% HR 90 BP 90/60, afebrile.

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EKG/ECG Wellness Outcomes Hospitals 90

Sensible Medicine

JUNE 28, 2024

There were no personal crises or untoward patient outcomes. The plan was that she would get a two-week, continuous EKG monitor placed and have a sleep study at this hospital. “Well, this isn’t really the aspect of my specialty that I specialize in.” Last week was one of them. 1 What did the medical center do?

Stroke 94

Stroke Academics Hospitals EKG/ECG 94