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

Sensible Medicine

AUGUST 28, 2023

I describe it here for two reasons: it is an example of well-conducted unbiased study, and it deals with an increasingly common problem of short-duration episodes of atrial fibrillation. Some background: In patients with certain risk factors, AF increases the risk of having a stroke. The incidence of stroke was 0.9%

Stroke 92

Stroke Wellness EKG/ECG Outcomes 92

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. That would likely slow the ventricular rate as well, but would have a higher likilihood of converting to sinus.

EKG/ECG 96

EKG/ECG Stroke Administration Wellness 96

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 72

Stroke Outcomes Wellness EKG/ECG 72

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 104

Seizures EKG/ECG EMS Stroke 104

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 74

EKG/ECG Stroke Ultrasounds Wellness 74

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

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. She did well. 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 124

EKG/ECG Stroke Administration Wellness 124

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 82

Shock EKG/ECG Academics Stroke 82

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

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

EM SIM Cases

NOVEMBER 12, 2022

Stephen Jensen, Brandon Bowdoin, and Kristen Whitworth as well as Spring Lutzen. 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. This case as written by Drs.

Resuscitation 40

Resuscitation Stroke EKG/ECG Fractures 40

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

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

Taming the SRU

NOVEMBER 29, 2023

Workup with a negative troponin and EKG reliably rules out BCI. Posterior circulation stroke Patients with posterior strokes will likely have a low NIH. Involve the stroke team if posterior circulation stroke is suspected, as they may be a candidate for TNK, or more rarely, EVT.

Stroke 53

Stroke EKG/ECG Resuscitation Shock 53

Ziqitza HealthCare Ltd

APRIL 29, 2024

Some common types of cardiovascular disease are coronary heart disease, stroke, hypertension, arrhythmia, aortic disease, valve disease, heart failure, and peripheral artery disease. Hypertension can cause types of cardiovascular diseas e , causing effects like heart attack and stroke. Cardiovascular diseases are common.

Stroke 52

Stroke Ambulance Services Burns EKG/ECG 52

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. It looks like he has an old anterior lateral MI as well. He had a h/o ischemic cardiomyopathy and right MCA stroke. Cath lab was cancelled.

EKG/ECG 52

EKG/ECG Shock Stroke Seizures 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Over some time and the pain moved into her other arm as well as her jaw. 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. Stroke-volume:50 ml. Normal wall thickness.

EKG/ECG 102

EKG/ECG Ultrasounds Wellness Stroke 102

ACEP Now

OCTOBER 29, 2024

Does that normal troponin and ECG obviate the need for cardiology consultation for my patient with a concerning story for acute coronary syndrome? 4 However, emergency physicians rely on gestalt to predict outcomes well. The “bundling” heuristic—if I send a troponin, then an ECG is needed. Ann Emerg Med. 2024;84(3):246-258.

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

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. Heart disease and stroke statistics-2022 update: A report from the American Heart Association.

Resuscitation 98

Resuscitation Shock Stroke Hospitals 98

Dr. Smith's ECG Blog

MARCH 15, 2023

Here is her EKG: What is unusual about this? But when you see this, you should suspect that the AV node is not well. Here is the ECG after ibutilide: What do you notice? Here is the post-cardioversion ECG: Sinus rhythm, still with the longer QT interval. I do not know why she did not have a rapid rate.

EKG/ECG 52

EKG/ECG Dehydration Stroke Wellness 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

EM SIM Cases

NOVEMBER 3, 2023

This case comes from Dr. Jared Baylis and Dr. Kelly Huang Dr. Baylis is the Simulation Medical Director at University of British Columbia – Southern Medical Program and Interior Health, as well as an editor of EM Sim Cases. Heat Related Illness Download ECG Curtesy of Life in the Fast Lane, ECG Library for sinus tachycardia.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia EKG/ECG EMS Hospitals 52

Ziqitza HealthCare Ltd

JULY 14, 2023

Often, the blood vessels of such patients become narrow or blocked, leading to chest pain, heart attacks, or strokes, eventually resulting in death. Cardiac Ambulance Price Cardiac ambulances are well-equipped yet very cheap. These diseases affect the patient’s circulatory system, blood vessels, heart muscle, valves, or rhythm.

Ambulance Services 52

Ambulance Services Basic Life Support Operations Stroke 52

Taming the SRU

AUGUST 25, 2023

bicarb <18mEq/L) ketosis (preferably serum beta-hydroxybutyrate >3mmol/L) Risk factors SGLT2 inhibitor use fasting state ketogenic diet intra-abdominal pathology (AGE, pancreatitis, etc.) to 1 mcg/kg/hour procedural sedation loading dose: 0.5-1 1 mcg/kg over 10 minutes followed by continuous infusion: 0.2

Seizures 74

Seizures Fractures EKG/ECG Resuscitation 74

PEMBlog

SEPTEMBER 6, 2023

There is abundant evidence showing that routine lab tests in such patients have a very low yield and are not indicated, in adults as well as in children. These labs were not truly indicated, but it was common practice and viewed as “not a big deal.” Acute onset psychosis is relatively rare.

Psychiatric 52

Psychiatric Pediatrics Emergency Department EKG/ECG 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

When the paramedics arrived, they obtained a 12 lead ECG and confirmed the unstable vital signs. EKG is pictured below: What do you think? Although the shock is no doubt partly a result of poor pump function, with low stroke volume, especially of the RV, it should be compensated for by tachycardia. Why is the patient in shock?

Seizures 52

Seizures EKG/ECG Shock EMS 52

Dr. Smith's ECG Blog

MARCH 6, 2019

This ECG was recorded on arrival: What do you think? Proof that all STE and hyperacute T-waves in the presentation ECG are new. They collected several repeat ECGs at the outside hospital before transport: None of these three ECGs meet STEMI criteria. This ECG shows persistent Occlusion MI but does not meet STEMI criteria.

EKG/ECG 52

EKG/ECG Outcomes Hospitals Wellness 52

Dr. Smith's ECG Blog

JANUARY 5, 2020

Here is the ECG: What do you think? A study of 2298 ECGs from 1085 patients which had a computerized interpretation of AF found that in 442 (19%) of these ECGs, from 382 patients (35%), the interpretation was incorrect, and that, in 92 of these 382 patients, the physician had failed to correct it. Among, 2447 ECGs, Mant et al.

EKG/ECG 52

EKG/ECG COPD Wellness Sepsis 52

Taming the SRU

AUGUST 4, 2024

We discussed some practices to push learners outside of their comfort zone and promote learning, based on their level as well as their goals for the shift.

Emergency Department 84

Emergency Department Dislocations Documentation/Coding Burns 84

Mind The Bleep

JUNE 18, 2023

It is important to complete an ECG prior to initiating pharmacological therapy as drugs, such as antipsychotics can prolong the QT interval, increasing the risk of arrhythmias. – One stroke is prevented for every 37 patients with dementia who avoid 2-3 months of antipsychotic symptoms for their BPSD.

Psychiatric 52

Psychiatric Documentation/Coding Stroke Fractures 52

ACEP Now

APRIL 5, 2024

1 However, many clinical features are common: more than 60 percent of patients present with a degree of neurological involvement, ranging from confusion to stroke and coma. 1 25 percent of patients may present with evidence of myocardial ischemia, including abnormal ECGs and elevated troponin levels.

Domestic Violence 40

Domestic Violence Emergency Department Outcomes EKG/ECG 40

Dr. Smith's ECG Blog

JANUARY 16, 2020

An elderly woman with h/o stroke and aphasia seemed different to her daughter, and was pointing all over her body as if in pain. Also a h/o LV aneurysm with thrombus, on anticoagulation, as well as a dual chamber pacemaker. A Huge Infarct Left Main occlusion can have many different ECG patterns. They called 911.

EKG/ECG 52

EKG/ECG Stroke Wellness 52

Mind The Bleep

NOVEMBER 21, 2023

” Yes, I have seen clerking look like this and I can confirm, it does not go down well. Examples of examination findings you might find helpful to keep in mind (list not exhaustive): GCS 15/15- alert, orientated, looks comfortable, warm and well perfused, in obvious pain, looks pale and clammy etc.

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

Taming the SRU

APRIL 13, 2023

stent, percutaneous nephrostomy) by urology or IR Hypokalemia evaluate for EKG changes assess for underlying cause and factors that may influence ability to replete (i.e. stent, percutaneous nephrostomy) by urology or IR Hypokalemia evaluate for EKG changes assess for underlying cause and factors that may influence ability to replete (i.e.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Poisoning EKG/ECG Seizures 52

Dr. Smith's ECG Blog

AUGUST 3, 2018

Here was his prehospital ECG, which I viewed immediately while the resident performed cardiac ultrasound: What do you think? Here is the cardiac ultrasound which the resident performed as I viewed the ECG: This shows a huge pericardial effusion. An ED ECG was recorded: What do you think? Fluids were started. Is is sinus?

EKG/ECG 52

EKG/ECG Ultrasounds Stroke Shock 52

EB Medicine

NOVEMBER 1, 2018

Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged cardiac monitoring – however several well-designed observational studies, including 1000s of patients, have demonstrated no such evidence. Let’s move on to treatment.

Emergency Department 40

Emergency Department Burns EKG/ECG Shock 40