Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. He had a previous ECG on file: Proving the findings are new The cath lab was activated. Bedside cardiac ultrasound with no obvious wall motion abnormalities. Bedside cardiac ultrasound with no obvious wall motion abnormalities.

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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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Dr. Smith's ECG Blog

JANUARY 5, 2024

The following ECG was obtained. ECG 1 What do you think? The ECG shows sinus bradycardia but is otherwise normal. There is TWI in lead III, but this can be seen in normal ECGs. The following ECG was obtained around midnight. The machine read was "Normal sinus rhythm, normal ECG." ECG 2 What do you think?

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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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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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Dr. Smith's ECG Blog

APRIL 14, 2024

Here is his first ECG (1/10 pain): Smith: sinus rhythm with RBBB and normal ST-T. An ECG from 4 years prior was the same. In the absence of clear ECG signs of OMI, one should always start with aspirin and NTG, perhaps intravenous NTG, and see if the pain can be managed. He presented on this day because it did not go away.

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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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Dr. Smith's ECG Blog

MARCH 28, 2024

Bedside ultrasound showed volume depletion and no pulmonary edema. Here is the prehospital ECG: First ED ECG What do you think? But I changed my mind after seeing the old ECG (below) I later sent it to Ken Grauer, who annotated as below with the red Xs: The "Y" in lead II across the bottom appears to be a PVC.

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Dr. Smith's ECG Blog

NOVEMBER 17, 2023

I was texted this ECG just as I was getting into bed. Ken (below) is appropriately worried about pulmonary embolism from the ECG. What I had not told him before he made that judgement is that the patient also had ultrasound B-lines of pulmonary edema. Figure-1: I've labeled the initial ECG in today's case.

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Dr. Smith's ECG Blog

APRIL 2, 2024

Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. 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. What do you think?

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Dr. Smith's ECG Blog

OCTOBER 2, 2021

Triage EKG: What do you think? A prior ECG was available for comparison. Prior EKG from 2 months ago was available: Let's put the precordial leads from the 2 ECGs side by side: Now you can really see the difference. Immediately after the second ECG was performed, the patient's pain resolved completely.

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Dr. Smith's ECG Blog

DECEMBER 16, 2024

She had this ECG recorded: Obvious massive anterior STEMI She was quickly brought to the critical care area and the cath lab was activated. No ECG was recorded after pain resolution. Here is the ECG at 25 minutes: Terrible LAD STEMI (+) OMI So a CT scan was done which of course showed a normal aorta. She was a walk-in at triage.

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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. Pads were placed with ultrasound guidance, so they were in the correct position. Definitive diagnosis that ECG #1 is in fact VT is more than academic.

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Taming the SRU

JANUARY 10, 2024

R4 Case Follow-up: SCAD WITH dr. Martella Spontaneous Coronary Artery Dissection (SCAD) is a diagnosis confirmed via imaging: Coronary Angiography, Optical Coherence Tomography, Intravascular Ultrasound Therefore, treatment in the ED is the same as atherosclerotic ACS: ASA, heparin gtt and possible statin.

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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.

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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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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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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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EMDocs

APRIL 2, 2024

Check the pulse RSI= Resuscitation Sequence Intubation Hypoxia, Hypotension, and Acidosis are the reason patients code during/post intubation These patients are super high risk for all 4 Optimize first pass success – Induction agent + paralytic Unconscious patients will still have muscle tone Induction Ketamine or Etomidate at half doses (i.e.,

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Dr. Smith's ECG Blog

JUNE 28, 2023

He arrived in the ED and had an immediate bedside cardiac ultrasound while this ECG was being recorded. The bedside ultrasound (video not available) reportedly showed only a slightly reduced LV function. Here is the ECG: What do you think? Here is the post cardioversion ECG: What do you think?

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Dr. Smith's ECG Blog

JUNE 18, 2011

The medics recorded this prehospital ECG at 1535 : There is ST elevation and tall T-waves in precordial leads, with reasonably good R-wave progression. First, if an old ECG is available, then compare. 1.196 x STE60 in V3 in mm) + (0.059 x computerized QTc) - (0.326 x RA in V4 in mm) Third, one can do an immediate cardiac ultrasound.

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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? A formal ultrasound later showed reasonably good LV function, and so he later received carvedilol and diltiazem, Unfortunately, those led to hypotension at 80/40 with a HR 40. WHY Did We Think Today's ECG was Supraventricular?

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Dr. Smith's ECG Blog

FEBRUARY 14, 2009

Interestingly, they found that this was not a transient feature that later progressed to ST elevation, but that it remained static until angiography up to 50 minutes after the initial ECG. This is the EKG of a previously healthy 40 year old man with one hour of chest pain and profound weakness and sense of "doom". K levels were normal.

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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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Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

We will start with his baseline EKG: There is voltage suggestive of LVH. This is his presenting EKG (T= 26min): What do you think? Hence, the term "pseudonormalization", because it is not really normal - LVH should have repolarization changes seen in the baseline EKG. Thus, there is relative ST depression.

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Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

Here is the prehospital ECG at 1935: Sinus rhythm with left bundle branch block (LBBB). In Sgarbossa's study, just 1 mm concordant STE in just 1 lead was 92% specific for MI and earned the ECG 5 points. Just 1 mm concordant ST depression in just 1 lead of V1-V3 was 96% specific for MI and would earn the ECG 3 points.

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Dr. Smith's ECG Blog

OCTOBER 26, 2010

He had this ECG recorded. He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. But, remember, we do not evaluate and treat ECGs, we evaluate and treat patients.

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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

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.

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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. I don't know if her pain was getting better or not.

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Dr. Smith's ECG Blog

OCTOBER 23, 2022

The ECG told the story. EMS recorded these prehospital ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 Time = 24 min S-wave depth is diminishing These prehospital ECGs were lost and not seen. This patient has a non-diagnostic ECG by most rules. She called 911. STE 60 V3 = 1.5

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Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This case was provided by Spencer Schwartz, an outstanding paramedic at Hennepin EMS who is on Hennepin EMS's specialized "P3" team, a team that receives extra training in advanced procedures such as RSI, thoracostomy, vasopressors, and prehospital ultrasound. Our first 12 lead ECG was then recorded at 0926. What do you think?

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Dr. Smith's ECG Blog

APRIL 20, 2018

This is her pre-hospital ECG: This is her first ECG in the ED: What do you think? However, the prehospital ECG is more worrisome: the T-wave inversion in V5 and V6 is preceded by ST Elevation. When I say " relative ," I mean relative to the previous ECG, which is the baseline, chronic, non-ischemic ECG.

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The Skeptics' Guide to EM

SEPTEMBER 11, 2021

The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities. The AHA has a statement with recommendations based on the available data.

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Broome Docs

MARCH 28, 2024

If you want to see Justin in the video format and his new Youtube series then click here: [link] If you would like to check out my current ultrasound training project then click here: WACHS Ultrasound Otherwise – enjoy the show and see you in a few weeks. Myth 3: The ECG changes from hyperkalemia are predictable and reliable.

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Dr. Smith's ECG Blog

SEPTEMBER 9, 2024

Her presenting ECG is shown below: ECG 1 What do you think? I had previously run this ECG through QOH in the PMcardio app environment and she reported mid confidence, shown below. You can see that version 2 has a higher number than version 1, hence she sees the ECG as more OMI-like than version 1. I sent this to Drs.

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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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