Dr. Smith's ECG Blog

JANUARY 2, 2025

Bedside cardiac ultrasound showed moderately decreased LV function. She had an ECG recorded: This is left bundle branch block (LBBB), with appropriate proportional discordance. Here is one of the strips This is clearly polymorphic VT and probably torsade de pointes Subsequent ECGs. She was intubated. No wall motion abnormality.

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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

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

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

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

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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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

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

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

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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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

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

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

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

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

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

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

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

MARCH 21, 2011

This ECG was recorded. Compare with baseline ECG below. The physician (one of our fine EM residents) caring for the patient did an immediate bedside ultrasound. He complained of chest pain. The previous is below. There is also excessively discordant ST elevation in V5 (ST/S ratio 2:5 = 40%; excessive is > 20%).

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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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Sensible Medicine

JUNE 28, 2024

The plan was that she would get a two-week, continuous EKG monitor placed and have a sleep study at this hospital. She follows up at a “highly ranked” west coast academic medical center, near where she lives half the year. 1 What did the medical center do? They did the Zio patch and sleep study.

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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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Dr. Smith's ECG Blog

JUNE 14, 2017

A bedside cardiac ultrasound was normal. An ECG was recorded: Avinash was understandably confused by this ECG. He wrote: "ECG 1 - shows wide ???IVCD I sent it to my friend, Ken Grauer , who is very meticulous in his ECG reading. I labeled ECG. His chest was tender. IVCD type rhythm ??

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Taming the SRU

JUNE 26, 2024

Factors that improve survival rates include cardiac activity on ultrasound, initial shockable rhythm, witnessed arrest, extremity only trauma, and bystander CPR. Patients with AML may develop severe lactic acidosis called the Warburg effect, which carries a poor prognosis. Hypovolemia is the most common reversible cause of traumatic arrest.

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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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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

MARCH 28, 2017

EMS recorded these ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 The pain completely resolved after nitroglycerine Moments later, the this ECG was recorded in the ED when she had been pain free for moments only: Computer read: Normal ECG. E EKG: a negative ECG (score = 0) 3.

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Dr. Smith's ECG Blog

DECEMBER 20, 2010

This case was posted on the [link] ultrasound site, of which this ECG blog is a part. However, only the first ECG was shown, and it was recorded before the patient became ill. I refer you to the video case presentation by one of my colleagues, Dr. Rob Reardon (who has, by the way, a fantastic collection of ED ultrasound cases).

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The Skeptics' Guide to EM

SEPTEMBER 28, 2024

Annals of Emergency Medicine, May 2024 Guest Skeptic: Dr. Casey Parker is a Rural Generalist from Australia who is also an ultrasounder. There are no abnormalities in the blood work, ECG, or chest x-ray. Diagnostic Accuracy of D-Dimer for Acute Aortic Syndromes: Systematic Review and Meta-Analysis. Her pain seems to have settled.

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Dr. Smith's ECG Blog

DECEMBER 6, 2010

He had no previous history of CAD, and presented with very typical waxing and waning chest pain, much worse with exertion but also present at rest and on presentation, though his pain was minimal at the time of the ECG. A posterior ECG was done and showed no ST elevation, not even 0.5 The ECG normalized overnight.

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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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ACEP Now

JUNE 6, 2023

ECG, CXR, and troponin are negative. Troponins #1 and #2 are borderline and ECG is non-specific. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. ECG, CXR, and troponin are all normal. An ECG and CXR are negative. An ECG, CXR, and two troponins are normal. She is given morphine for pain.

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ACEP Now

OCTOBER 9, 2024

Collaborating with one of my ultrasound faculty, we conducted a bedside echocardiogram to explore potential cardiac anomalies. Our workup started with an ultrasound and EKG. EKGs will have abnormalities in about 90 percent, but they are typically nonspecific findings. Eur J Cardiothorac Surg. 2012;41(6):1260-1270.

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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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