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 that last post: A 90-something with acute stroke.

EKG/ECG 115

EKG/ECG EMS Stroke Outcomes 115

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.

EKG/ECG 138

EKG/ECG Allergic Reactions Shock Stroke 138

Dr. Smith's ECG Blog

OCTOBER 25, 2023

Here is his triage ECG: What do you think? What is the most likely cause of the patient’s ECG findings, and what would be your first step in management? What does the ECG show? What does the ECG show? Figure-1: The initial ECG in this case — and a rapid method for estimating the QTc ( See text ). Is it STEMI?

EKG/ECG 120

EKG/ECG Seizures Hospitals Stroke 120

Dr. Smith's ECG Blog

NOVEMBER 11, 2023

A 90-something year old woman presented with an acute mild stroke. She had a routine ECG as part of her workup: What do you think? Peak trop 62 ng/L (would be very low for acute OMI) Next AM ECG: Still with very ischemic looking T-waves. Always look at old ECGs, even if you think the diagnosis is obvious.

Stroke 74

Stroke EKG/ECG Wellness 74

EM SIM Cases

NOVEMBER 20, 2023

WHY IT MATTERS Classic heat stroke is a potentially deadly diagnosis that effects some of the most vulnerable of our populations. There are some key differences between exertional and classic heat stroke management and this case gives the opportunity to practice and discuss these skills.

Stroke 52

Stroke Hyperthermia / Hypothermia EMS EKG/ECG 52

Dr. Smith's ECG Blog

DECEMBER 24, 2023

Here is her triage ECG: What do you think? And so was an appropriate anti-coagulant, since atrial flutter, like fibrillation, can result in thromboembolism and stroke. For clarity and ease of comparison, I've put together in Figure-1 — the 3 serial ECGs in today's case. Atrial flutter with 2:1 conduction.

EKG/ECG 130

EKG/ECG Stroke Administration Wellness 130

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 ?

EKG/ECG 135

EKG/ECG Shock CPR Stroke 135

Stop and Think

DECEMBER 29, 2023

For an older patient with stroke risk factors and 3 hours of AF on a cardiac device, pre-2023 thinking would have us leaning toward anticoagulation. Edoxaban reduced the primary endpoint of stroke, systemic embolism, and cardiovascular death by 19% (HR, 0.81; 95% CI, 0.60-1.08; The doctor would do an ECG and that would diagnose AF.

Stroke 90

Stroke Research EKG/ECG Wellness 90

The Skeptics' Guide to EM

OCTOBER 5, 2019

Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomized, sham-controlled, blinded, phase 3 trial. His 12-lead ECG shows a normal sinus rhythm without ST abnormality or ectopy. This episode will not debate the use of tPA for acute ischemic stroke.

Stroke 52

Stroke Hospitals EMS Outcomes 52

Dr. Smith's ECG Blog

JULY 5, 2024

Her heart rate was very fast, so we obtained an ECG immediately: ECG: What do you think? But the duration of symptoms was prolonged and so to avoid the risk of stroke, AV nodal blockade (rate control) was preferred. We want to avoid a stroke. WHY Did We Think Today's ECG was Supraventricular?

EKG/ECG 104

EKG/ECG Stroke Administration Wellness 104

EMDocs

MAY 4, 2024

. #1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.

Documentation/Coding 78

Documentation/Coding Stroke Emergency Department Pediatrics 78

Dr. Smith's ECG Blog

DECEMBER 5, 2023

Written by Kirsten Morrissey, MD with edits by Bracey, Grauer, Meyers, and Smith An older teen was transferred from an outside hospital with elevated serum troponin and and ECG demonstrating ST elevations. Acute coronary syndrome in a pediatric patient? He denied drug or alcohol use. He did have a family history notable for early CAD.

Pediatrics 120

Pediatrics EKG/ECG Hospitals Burns 120

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

The ECG below was recorded by EMS. ECG #1 Interpretation: ECG #1 shows sinus rhythm at a heart rate of 77 bpm. At first glance, the ECG does not look too abnormal. In my experience, the pathologic finding in the above ECG is the easiest one to overlook — especially if you are in a rush and do not do a systematic review.

Seizures 111

Seizures EKG/ECG EMS Stroke 111

Sensible Medicine

JUNE 28, 2024

She is admitted with suspected stroke. Case 1: Excess An elderly woman is admitted to a community hospital with a minor stroke. The plan was that she would get a two-week, continuous EKG monitor placed and have a sleep study at this hospital. Sensible Medicine is a reader-supported publication. I love my job.

Stroke 94

Stroke Academics Hospitals EKG/ECG 94

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 patient was in clinical shock with a lactate of 8.

Shock 86

Shock EKG/ECG Academics Stroke 86

Dr. Smith's ECG Blog

JANUARY 9, 2024

The ECG below was recorded. The ECG was interpreted as showing atrial flutter with 2:1 conduction. Answer : The ECG above shows a regular wide complex tachycardia. Said differently, the ECG shows a rather slow ventricular tachycardia with a 2:1 VA conduction. How do you interpret the below ECG?

EKG/ECG 107

EKG/ECG Stroke Hospitals Documentation/Coding 107

Dr. Smith's ECG Blog

FEBRUARY 18, 2024

ECG is shown below. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it is still critical to determine the atrial rhythm. Cardiology felt that there was baseline artifact and recommended immediate repeat ECG which is shown below. What do you think?

EKG/ECG 97

EKG/ECG Stroke 97

Sensible Medicine

FEBRUARY 13, 2024

In brief, the trial compared apixaban vs aspirin in patients who had had a stroke of unknown source and evidence of atrial cardiopathy. Recurrent stroke (the primary endpoint) occurred in 40 patients in each group. Apixaban did not reduce the rate of recurrent stroke over aspirin in these patients. The hazard ratio was 1.00.

Stroke 79

Stroke Outcomes Wellness EKG/ECG 79

Sensible Medicine

AUGUST 28, 2023

Some background: In patients with certain risk factors, AF increases the risk of having a stroke. The increase in risk parallels the presence of risk factors, such as age, high blood pressure, diabetes, coronary disease, and previous stroke. Net benefit means stroke reduction > bleeding increase. We call this clinical AF.

Stroke 90

Stroke Wellness EKG/ECG Outcomes 90

Dr. Smith's ECG Blog

JANUARY 8, 2020

A former resident texted me this ECG, done for epigastric pain in an 18 year old. I put it on Facebook EKG club and this is the response: No one knew for certain what that was, but Ken Grauer suspected artifact (due to lead placement over an artery) or a Crochetage sign, which is strongly associated with atrial septal defect.

EKG/ECG 52

EKG/ECG Stroke Pediatrics 52

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

Stroke 93

Stroke Outcomes EKG/ECG Research 93

Taming the SRU

JANUARY 26, 2024

Morbidity & MOrtality - Mini Lit Blitz - Post-Rosc Care - Qi/KT Morbidity & Mortality WITH Dr. Yates Case 1: Stroke and Stroke Mimics Early diagnosis of stroke improves stroke outcomes, where misdiagnosis is associated with an upwards of 4-time higher likelihood of mortality Missed strokes most often occur with atypical symptoms, in younger (..)

Stroke 59

Stroke EKG/ECG Outcomes Seizures 59

Dr. Smith's ECG Blog

MARCH 19, 2019

This patient presented with weakness, decreased urine output, and vomiting: What is the ECG diagnosis? Here was a repeat ECG: QTc 523. The value of recognizing this particular ECG pattern — is that it may expedite your clinical diagnosis even before laboratory results return. This is pathognomonic for hypocalcemia.

EKG/ECG 52

EKG/ECG Seizures Stroke Operations 52

Taming the SRU

OCTOBER 5, 2023

morbidity and mortality - quality improvement - research grand rounds - r1 clinical knowledge: pres/rcvs - r4 case follow-up: compartment syndrome Morbidity and Mortality WITH dr. finney Takotsubo Cardiomyopathy with COVID-19 Increasing incidence of Takotsubo Cardiomyopathy with the COVID-19 pandemic Morbidity and mortality is similar to that of ACS (..)

Stroke 90

Stroke EKG/ECG Seizures CPR 90

ALiEM

MARCH 22, 2024

Laboratory Data CBC , CMP , EKG , and Troponins were normal. The two main causes of internuclear ophthalmoplegia are demyelination of the medial longitudinal fasciculus (MLF) from multiple sclerosis (MS) and ischemic cranial nerve damage from stroke. There were no oligoclonal bands.

Stroke 67

Stroke Urgent Care Head Injuries Emergency Department 67

Dr. Smith's ECG Blog

OCTOBER 28, 2023

Here is his ECG. See this articles: Heart Failure with Preserved Ejection Fraction (NEJM review) One etiology of LVH on the ECG is Hypertrophic Cardiolmyopathy (HOCM), and sometimes ECGs in patients with HOCM are specific for HOCM. But this ECG is NOT specific for HOCM. Figure-1: The ECG in today's case.

EKG/ECG 61

EKG/ECG Stroke Ultrasounds Wellness 61

The Skeptics' Guide to EM

MARCH 2, 2024

His vital signs are all normal and the ECG done at triage does not show an occlusive myocardial infarction. Symptoms may include more severe chest pain radiating to the back, loss of consciousness, or symptoms of stroke if the blood supply to the brain is affected. It is described as a ripping sensation that radiates to his back.

Emergency Department 118

Emergency Department Stroke Operations Hospitals 118

ACEP Now

JUNE 6, 2023

ECG, CXR, and troponin are negative. Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. ECG, CXR, and troponin are all normal.

EKG/ECG 85

EKG/ECG Stroke Documentation/Coding Operations 85

Dr. Smith's ECG Blog

NOVEMBER 18, 2019

Here is the ECG: The computer reads a long QT at 449 ms, and a Hodges QTc of 506 ms. From EMCrit: Taking control of severe hyponatremia with DDAVP An ECG recorded 2 days later with a K of 4.1: Figure-1: Both ECGs that were done in this case ( See text ). This patient presented with status epilepticus. What do you think?

EKG/ECG 52

EKG/ECG Seizures Stroke Wellness 52

Dr. Smith's ECG Blog

DECEMBER 26, 2020

An ECG was recorded quickly on return to the ED: (sorry for poor quality, cannot get originals) What do you think? They called their transfer center cardiologist on call, who reviewed the case on the phone with them, as well as the ECG. In my opinion this makes the flutter waves slightly easier to recognize in this ECG.

EKG/ECG 52

EKG/ECG Stroke Administration Seizures 52

Dr. Smith's ECG Blog

FEBRUARY 29, 2016

In accordance with the last case (in which the patient presented only with vomiting and diarrhea), an ECG was recorded : (Figure 1) Someone thought this was slow VT with a "northwest" axis (towards aVR, or -135 degrees), but there are definite P-waves (with a long PR interval). But in the above ECG, V5 and V6 only have a Q-wave.

EKG/ECG 52

EKG/ECG Dehydration Stroke Wellness 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2022

Written by Bobby Nicholson MD, with edits by Meyers A woman in her 50s with past medical history of heart failure, prior stroke, atrial fibrillation on Eliquis, lung cancer in remission, and CKD, presented to the emergency department for evaluation of cough and shortness of breath. EKG was obtained in triage and read as ventricular bigeminy.

EKG/ECG 52

EKG/ECG Stroke Emergency Department Wellness 52

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. Stroke-volume:50 ml. Normal wall thickness.

EKG/ECG 108

EKG/ECG Ultrasounds Wellness Stroke 108

Dr. Smith's ECG Blog

AUGUST 13, 2020

Then I looked into the patient's chart and found an old EKG: This shows a previous QR-wave in V2, diagnostic of old anterior MI. I wrote back: "I am looking at his old EKG. He had a h/o ischemic cardiomyopathy and right MCA stroke. The cath lab had been activated and then they sent me the ECG. Cath lab was cancelled.

EKG/ECG 52

EKG/ECG Shock Stroke Seizures 52

ACEP Now

JULY 7, 2023

Post-resuscitation ECGs demonstrating ST segment elevation are significant in delineating which patients might benefit most from advanced reperfusion techniques. Heart disease and stroke statistics-2022 update: A report from the American Heart Association. References Tsao CW, et al. Circulation. 2022;145(8):e153-e639. Circulation.

Resuscitation 98

Resuscitation Shock Stroke Hospitals 98

Sensible Medicine

JULY 5, 2023

” “… but you could have a stroke or heart failure if you don’t get to the right place, so let’s get an EKG to confirm.” I was ecstatic to tell her the good news, “You do not have a rheumatologic condition!”

EKG/ECG 85

EKG/ECG Stroke Academics 85

EM SIM Cases

NOVEMBER 12, 2022

The exact moment these orders are completed, a stroke activation will be called for a patient eligible for tPA. Stroke protocol needs to be followed and tPA will need to be given. As soon as tPA is pushed, the resident will be handed an EKG with signs of hyperkalemia and told that a patient with depression has checked in.

Resuscitation 40

Resuscitation Stroke EKG/ECG Fractures 40