Dr. Smith's ECG Blog

DECEMBER 15, 2015

No shock was ever delivered. He was in profound shock. A bedside cardiac ultrasound was recorded: Here is a still image of the echo: The red arrows outline the right ventricle and the yellow arrows outline the left ventricle chamber. There is no pericardial fluid to account for shock. Sixth: Severe shock (e.g.,

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Dr. Smith's ECG Blog

JANUARY 15, 2024

Colin is an emergency medicine resident beginning his critical care fellowship in the summer with a strong interest in the role of ECG in critical care and OMI. An ECG was obtained shortly after arrival: ECG 1 What do you think? The ECG has a lot of artifact, and the amplitude is very small, making interpretation challenging.

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EMDocs

OCTOBER 8, 2024

Glucose POC ECG: Is this actually sinus tachycardia? Looking at the initial or even repeating the ECG will be helpful here. Additional resuscitation Have we addressed all potential sources of shock for the patient in front of us? Does the patient require blood, a procedure to address obstructive shock, or other source control?

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The Skeptics' Guide to EM

SEPTEMBER 11, 2021

She arrives in the emergency department (ED) with decreased level of consciousness and shock. The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients.

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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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Taming the SRU

JUNE 3, 2024

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. Get a blood gas when possible to help guide your ventilation. Some newer AED's have the capability of providing you with a rhythm strip.

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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

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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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.

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ACEP Now

JANUARY 4, 2025

A closer look, though, also shows the technology of the daya bulky, two-way radio for communicating with EMS, metal gurneys, glass saline bottles, and portable ECG monitors the size of a small shopping cart. Notice the use of the medical anti-shock trousers and the ECG machine. Now, we have ultrasound or CT scans to confirm.

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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

JULY 18, 2014

Here is his ECG: What is your interpretation? Case Continued 2 days later the patient became increasingly tachycardic, hypotensive, ashen, clammy (in cardiogenic shock) and had a new murmur. This was the 12-lead ECG. This remains consistent with PIRP, as was the first ECG. Exact pain history was difficult to ascertain.

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Dr. Smith's ECG Blog

MAY 19, 2020

In this case, profound shock for 1 hour would result in the same degree of infarction. A followup ECG was recorded 2 days later: No definite evidence of infarction. The Type 2 MI would then have been a result of the prolonged severe shock while in arrest. For clarity — I’ll again show the initial ECG done in the ED in Figure-1.

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Dr. Smith's ECG Blog

MAY 13, 2020

Here is the EMS ECG: Obviously massive diffuse subendocardial ischemia, with profound STD and STE in aVR Of course this pattern is most often seen from etoliogies other than ACS. The ECG only tells you there is ischemia, not the etiology of it. This was a point of care ultrasound, not a bubble contrast echo.

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Dr. Smith's ECG Blog

JULY 7, 2013

Here is his ECG: There is atrial fibrillation at a rate of 95. Rupture can be either free wall rupture (causing tamonade) or septal rupture, causing ventricular septal defect with left to right flow and resulting pulmonary edema and shock. If detected early by ultrasound, the patient can be saved. This was the 12-lead ECG.

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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

JUNE 17, 2018

He had an ECG in clinic which worried the providers because of possible inferior MI, and they sent him to the ED. Here is that ECG: What do you think? He was sent to the ED and had this ECG at t = 1 hour: Similar There are several issues which mitigate against acute inferior MI, and these are the Learning Points: 1.

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AED Leader

OCTOBER 25, 2023

AEDs are designed to safely deliver the required life-saving shocks to restore a normal heart rhythm during this type of cardiac emergency. These tests can include: Electrocardiogram (Resting ECG). Typically, ECG results appear normal during rest periods. Exercise Stress Test with ECG. Continuous Portable ECG Monitoring.

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AED Leader

OCTOBER 25, 2023

AEDs are designed to safely deliver the required life-saving shocks to restore a normal heart rhythm during this type of cardiac emergency. These tests can include: Electrocardiogram (Resting ECG). Typically, ECG results appear normal during rest periods. Exercise Stress Test with ECG. Continuous Portable ECG Monitoring.

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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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Dr. Smith's ECG Blog

APRIL 24, 2020

Here was his ED ECG, which was identical to the prehospital ECG. ST vector In this ECG, the ST vector is both posterior (away from V3 and V4), upward, away from aVF, and rightward (away from I, II, V5, V6 and towards aVR. This is unfortunate in my view, as it complicates the retrospective analysis of the ECG!!

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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.

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EMDocs

JANUARY 11, 2024

Individualize the choice of using inotropes, vasopressors, or fluids to treat post-CA hypotension and to target the likely cause(s) contributing to the shock and hemodynamic state (100%, 23/23). In patients with enteral intolerance or shock, start with trophic EN (rates of 10–20 mL/h) and adjust according to tolerance (91%, 19/21).

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Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? A bedside cardiac ultrasound was performed with a parasternal long axis view demonstrated below: There is a large pericardial effusion with collapse of the right ventricle during systole. This patient is only pseudo-stable.

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Taming the SRU

MAY 1, 2023

Patients must have EKG findings and meet one of a few other criteria (ie family history of sudden death, VF or VT episode, syncope, nocturnal agonal respirations) Most common in patients of Southeast Asian descent and the mean age of death from arrhythmia if untreated is in the 4th decade of life.

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Pediatric Emergency Playbook

JUNE 1, 2017

Electrocardiography (ECG) should be performed on any patient with significant blunt chest injury. A negative ECG is highly consistent with no significant blunt myocardial injury. Any patient with a new abnormality on ECG (dysrhythmia, heart block, or signs of ischemia) should be admitted for continuous ECG monitoring.

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Dr. Smith's ECG Blog

JUNE 17, 2024

Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. If this EKG were handed to you to screen from triage without any clinical information, what would you think? Do you appreciate any dynamic changes compared to the patient’s prior EKG? What do you think? In fact, Kosuge et al.

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Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Initial ED ECG: What do you think? Then we must consider clinical data other than the ECG, for a pretest probability : Of all wide complex tachydysrhythmias, the majority are VT. Shocked x 2 without effect. Pads were placed with ultrasound guidance, so they were in the correct position. Why did I say that? What to do now?

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Rural Doctors Net

AUGUST 30, 2013

Intubation for humanitarian reasons is also reasonable – he’ll be in pain and this is not the time to be faffing around with the ultrasound or nerve stimulator doing blocks! Ultrasound can be useful – I am a fan of the SUSS-IT examination (seconary ultrasonographic survey in trauma). How to intubate?

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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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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

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EMDocs

APRIL 22, 2024

Point-of-Care-Ultrasound (POCUS) is a bedside modality that can assist Emergency Physicians (EPs) in differentiating PE from other causes of cardiac arrest. Multiorgan POCUS The diagnostic power of POCUS often resides in combining multiple ultrasound exams. 1-3 As many as 25% of acute PE cases present as sudden cardiac death.

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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. Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. Here is the initial ED ECG. ECG with LBBB and QRS of > 210 ms. What do you think? The QRS is extremely wide.

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EB Medicine

MARCH 1, 2019

Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made.

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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.

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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 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. What is it?

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Dr. Smith's ECG Blog

MARCH 15, 2023

Here is her EKG: What is unusual about this? Her bedside cardiac ultrasound was normal We decided to cardiovert her since the time of onset was very recent. Here is the ECG after ibutilide: What do you notice? Here is the post-cardioversion ECG: Sinus rhythm, still with the longer QT interval. She was on no medications.

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