Ken Grauer, MD

FEBRUARY 28, 2023

The ECG and long lead II rhythm strip in Figure-1 — was obtained from a COVID positive patient with persistent tachycardia not responding to Diltiazem. Figure-1: The initial ECG — obtained from a patient with persistent tachycardia. ( To improve visualization — I've digitized the original ECG using PMcardio ).

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EKG/ECG Documentation/Coding Sepsis COPD 195

Dr. Smith's ECG Blog

OCTOBER 20, 2024

The ECG below was recorded about 20 minutes after he regained consciousness. ECG #1 The above ECG shows sinus rhythm at about 60 bpm. Figure A It now becomes apparent that there is ST segment depression in almost every lead of the ECG (V1-V6, I, II, aVL and aVF). In the initial ECG (ECG# 1) aVR had ST elevation.

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EKG/ECG Shock Emergency Department Ambulance Services 125

Dr. Smith's ECG Blog

MAY 30, 2023

A 50-something man presented in shock with severe chest pain. His prehospital ECG was diagnostic of inferior posterior OMI. The patient was in clinical shock with a lactate of 8. Here is his ED ECG: There is bradycardia with a junctional escape. RVMI explains part of the shock. What is the atrial activity?

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Shock EKG/ECG Academics Stroke 82

Dr. Smith's ECG Blog

JUNE 9, 2024

As the medics arrived, they handed me this ECG: What medication did I call for IMMEDIATELY when I saw this? Here is the transesophageal echo (TEE) at the same time as this 2nd ECG: Excellent LV Function. The ECG above is bizarrely wide. A fundamental and lifesaving ECG interpretation that everyone must recognize instantly.

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EKG/ECG Resuscitation Shock Wellness 131

Dr. Smith's ECG Blog

MAY 26, 2023

A 20-something presented after a huge verapamil overdose in cardiogenic shock. mg/dL (sorry, Europeans, for the weird units) Here was the initial ED ECG: There is a junctional rhythm with retrograde P-waves (see the dip in the T-wave in lead II across the bottom; you can follow that up to all the other leads and see the retrograde P wave).

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Shock EKG/ECG Documentation/Coding Resuscitation 88

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

Here is her triage ECG: What do you think? There are 2 key points to making this diagnosis on the ECG: 1) There is T-wave inversion which you might think is due to Wellens' waves, but the patient has active symptoms, so it is not Wellens' sydrome 2) The T-wave inversion in V1-V4 is accompanied by T-wave inversion in lead III.

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EKG/ECG Shock Ultrasounds Wellness 71

EMDocs

FEBRUARY 9, 2024

She is well appearing, and while being placed on the monitor becomes anxious stating the symptoms are recurring. An ECG is performed and is shown below: Figure 1. Adapted from Dr. Smith’s EKG Blog. Another ECG is obtained and shown below. If the response is appropriate, get another EKG and assess the QT interval.

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EKG/ECG Hyperthermia / Hypothermia EMS Documentation/Coding 71

Dr. Smith's ECG Blog

SEPTEMBER 27, 2023

An ECG was recorded immediately and is shown below. How do you interpret the ECG? ECG#1 There is a regular tachycardia with a ventricular rate of about 180 bpm. After cardioversion, if successful, you can take a few moments to assess the 12-lead in more detail and assess the post conversion ECG. ECG#2 What do you think?

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EKG/ECG Resuscitation Academics EMS 128

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

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

Dr. Smith's ECG Blog

JANUARY 8, 2024

I was reviewing ECGs for a study, and came across this one, and was able to get all the clinical information: What do you think? Since that moment, she had had shortness of breath as well as pressure-like chest pain. Patient was given aspirin, sublingual nitro as well as heparin. She also has had some coughing at night.

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EKG/ECG Resuscitation Hospitals EMS 71

RebelEM

SEPTEMBER 28, 2023

The STREAM-1 trial found that for [2] patients with STEMI presenting within 3 hours of symptom onset and unable to attain PCI within 1 hour of first medical contact, a pharmaco-invasive strategy resulted in similar rates of death, shock, heart failure, or reinfarction compared to primary PCI. Primary PCI: 95.7% Primary PCI: 95.7%

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EKG/ECG Allergic Reactions Shock Stroke 138

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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EKG/ECG Wellness Point-of-Care Testing Shock 64

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Her ECG is shown below: What do you think? The conventional machine algorithm interpreted this ECG as STEMI. Alternatively, with STE in V1 and III, and STD in I and aVL, this ECG could represent proximal RCA OMI with right ventricular involvement. What do you do clinically when the ECG looks like this?

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EKG/ECG Ultrasounds Shock EMS 110

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

He had the following EKG recorded: Low voltage, suggests effusion. He was admitted on oxygen and was doing fairly well with saturations of 100% on 2 L nasal cannula. He underwent CPR, and regained a pulse after epinephrine, with an organized narrow complex rhythm at 140, but still with severe shock. He was moderately hypoxic.

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Shock EKG/ECG Outcomes Hospitals 52

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. Warning: if this is VT, a calcium channel blocker can result in shock and death. Why did I say that? What to do now?

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EKG/ECG Shock Academics Documentation/Coding 136

EM SIM Cases

SEPTEMBER 19, 2024

WHY IT MATTERS Patients in hemorrhagic shock require blood products expeditiously as well as identification and definitive management of the source of bleeding. This case provides an opportunity to practice identification and treatment of multiple sources of blood loss in hemorrhagic shock.

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Shock Emergency Nursing Administration Operations 52

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 66

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. So the cath lab was activated.

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EKG/ECG EMS Documentation/Coding Shock 116

EMDocs

NOVEMBER 19, 2024

1,2 Neuroleptic malignant syndrome (NMS) (hyperthermia, autonomic instability, rigidity, altered mental status [AMS]) can occur as well and is most often seen with clozapine but has been observed with other atypicals. 1,2 Cardiovascular: Obtain an initial EKG to determine the patient’s baseline and repeat. 1 Class IA (e.g.,

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Poisoning Hyperthermia / Hypothermia EKG/ECG Seizures 77

Dr. Smith's ECG Blog

MARCH 26, 2024

Here is his ECG: Original image, suboptimal quality Quality improved with PM Cardio digitization The ECG is highly suggestive of acute right heart strain, with sinus tachycardia, S1Q3T3, and T wave inversions in anterior and inferior with morphology consistent with acute right heart strain. Moreover, there is tachycardia.

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EKG/ECG Shock Ultrasounds Wellness 69

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Initial ROSC was obtained, during which this ECG was obtained: What do you think? In addition to all of the above, there are T wave inversions in III and aVF, as well as T wave inversions in V2-V4. When the ECG differential is between OMI on the one hand, and PE/type II OMI on the other, the absence of VT/VF strongly favors PE.

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EKG/ECG Resuscitation Ultrasounds CPR 52

Don't Forget the Bubbles

OCTOBER 7, 2024

Was the patient thrown from the source (suggestive of DC shock and may result in further blunt force trauma)? Children, especially toddlers, may insert objects into outlets, leading to shocks or burns. Electrical devices used near water sources can cause severe shocks. Was the voltage high or low (as below)?

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Burns Fluid Resuscitation Shock Resuscitation 80

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 113

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 85

Dr. Smith's ECG Blog

AUGUST 28, 2020

I was texted these ECGs. Now appears to be in cardiogenic shock." This insistence on calling it lateral is due to a paper by Bayes de Luna -- [link] ] Case Continued I could only see the ECGs, not the echo. By the ECG, it is not necessarily subacute, but could be. By the ECG, it is not necessarily subacute, but could be.

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Shock EKG/ECG Wellness Outcomes 52

EMDocs

JANUARY 23, 2024

Episode 93: BRASH syndrome Background: Brash syndrome has 5 components: bradycardia, renal failure, AV nodal blocker, shock, hyperkalemia. With BRASH, the major ECG change is mainly bradycardia and not all the typical hyperkalemia changes. ECG change is mainly bradycardia, not all of the typical hyperkalemia changes.

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Shock Dehydration Sepsis EKG/ECG 87

EMDocs

OCTOBER 8, 2024

Tachycardia may be present both from many medications or drugs, as well as withdrawal. 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?

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Shock Emergency Department Pediatrics EKG/ECG 94

AED Leader

JULY 10, 2024

It offers advanced features such as ECG monitoring and multiple rescue capabilities. Their Lifeline series includes the Lifeline DCF-100, Lifeline View, and Lifeline ECG. The Lifeline ECG is a professional-grade AED that offers the added benefit of ECG monitoring. Its AEDs are known for their quality and reliability.

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CPR EKG/ECG Shock Pediatrics 52

Dr. Smith's ECG Blog

FEBRUARY 16, 2020

A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock. Here was the ECG: There is sinus tachycardia. Well, don't we see diffuse ST Elevation in Myo-pericarditis (with STD in aVR)? This was sent by a reader. and K was normal. This is "Shark Fin" morphology. So this is STEMI, right?

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Shock Hyperthermia / Hypothermia EKG/ECG Hospitals 52

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.

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Hyperthermia / Hypothermia EKG/ECG Wellness Shock 109

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 96

Dr. Smith's ECG Blog

MAY 8, 2023

Triage ECG: What do you think? Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. There is concordant ST elevation in I, aVL with reciprocal concordant STD in inferior leads, as well as excessively discordant TE in V2-V4. EKG and CT head were performed.

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EKG/ECG Documentation/Coding Outcomes Shock 52

Dr. Smith's ECG Blog

OCTOBER 28, 2022

Cortland Ashbrook from Spokane County, Washington, sent this message: Hey doctor Smith, I wondered if you’d give me your opinion on these ECG tracings I took as a paramedic in the field? I believed this met modified Sgarbossa in II, III and aVF with excessive discordance as well as reciprocal in aVL.

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EKG/ECG EMS Shock Wellness 52

Dr. Smith's ECG Blog

DECEMBER 10, 2022

I was texted this ECG by one of my partners, with the following history: A 60-something male with diabetes and HTN presented with syncope. A formal echo showed 80% EF and no wall motion abnormality The patient ruled out for MI by troponins Here is the post angiogram EKG: No change, proving that this is the baseline ECG.

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EKG/ECG Operations Shock EMS 52

ACEP Now

JULY 7, 2023

1 Ventricular tachycardia (VT) and ventricular fibrillation (VF) represent the most common initial rhythms for patients presenting to the ED in out-of-hospital cardiac arrest, as well as for patients who develop cardiac arrest while in the ED. 6 What Can I Do Outside of Repeated Shocks and Standard ACLS? amiodarone or lidocaine).

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Resuscitation Shock Stroke Hospitals 98

Dr. Smith's ECG Blog

AUGUST 9, 2019

Some total LAD occlusion manifest on the ECG similarly to some left main occlusions. Depending on where the STE vector of the LM occlusion shows up on the ECG, there may be either STE, or STD, or neither in aVR, and lead aVR will not be the important part of the ECG interpretation in these cases.

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EKG/ECG Shock Emergency Department Wellness 52