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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EKG/ECG Documentation/Coding Emergency Department Outcomes 119

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 128

Mind The Bleep

FEBRUARY 2, 2025

” 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.

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Documentation/Coding COPD EKG/ECG Wellness 95

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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EKG/ECG Resuscitation CPR Emergency Department 135

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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EKG/ECG Ultrasounds EMS Wellness 119

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!

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EKG/ECG Emergency Department Ultrasounds Documentation/Coding 120

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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EKG/ECG Ultrasounds Hospitals Wellness 124

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. Urology took him for orchiopexy.

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Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

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 131

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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EKG/ECG EMS Emergency Department Wellness 107

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.

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Shock EKG/ECG Academics Stroke 97

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? That would likely slow the ventricular rate as well, but would have a higher likilihood of converting to sinus. WHY Did We Think Today's ECG was Supraventricular? As a result — We can not rule out VT on the basis of this single ECG.

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EKG/ECG Stroke Administration Ultrasounds 113

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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EKG/ECG Shock Academics Documentation/Coding 139

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. “Well, this isn’t really the aspect of my specialty that I specialize in.” She follows up at a “highly ranked” west coast academic medical center, near where she lives half the year.

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Stroke Academics EKG/ECG Hospitals 105

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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EKG/ECG Ultrasounds Administration EMS 98

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

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

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. Are the lungs clear?

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EKG/ECG Dehydration Fluid Resuscitation Sepsis 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. She said this was midsternal and felt like a tightness.

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EKG/ECG Ultrasounds Wellness Stroke 109

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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EKG/ECG Wellness Operations Ultrasounds 52

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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EKG/ECG Ultrasounds Resuscitation Wellness 52

EMDocs

APRIL 22, 2024

Point-of-Care-Ultrasound (POCUS) is a bedside modality that can assist Emergency Physicians (EPs) in differentiating PE from other causes of cardiac arrest. Multiorgan POCUS The diagnostic power of POCUS often resides in combining multiple ultrasound exams. 1-3 As many as 25% of acute PE cases present as sudden cardiac death.

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Ultrasounds Advances Cardiac Life Support (ACLS) EKG/ECG Resuscitation 98

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

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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EKG/ECG Operations Wellness Ultrasounds 66

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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EKG/ECG Emergency Department Ultrasounds Hospitals 52

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 It appears to be benign in children as well (see references below). I sent it to my friend, Ken Grauer , who is very meticulous in his ECG reading.

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EKG/ECG Documentation/Coding Ultrasounds Wellness 52

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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EKG/ECG Hospitals EMS Ultrasounds 40

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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EKG/ECG Stroke Ultrasounds Wellness 57

Dr. Smith's ECG Blog

JUNE 2, 2023

She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? She was awake, alert, well perfused, with normal mental status and overall unremarkable physical exam except for a regular tachycardia, possible rales at both bases, some mild RUQ abdominal tenderness. And another example.

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EKG/ECG Wellness Ultrasounds EMS 96

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.

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Stroke Outcomes EKG/ECG Research 93

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. Let’s use the example of the well appearing patient, without significant comorbidities. Do they have edema?

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Shock Emergency Department Pediatrics EKG/ECG 105

Taming the SRU

FEBRUARY 23, 2024

Clinical pathologic case presentation - r1 diagnostics/therapeutics: Lumbar punctures - AIRWAY GROUND ROUNDS- r4 capstone - r3 taming the sru - ultrasound grand rounds Clinical pathologic case presentation WITH Drs. If assessing for SAH, xanthochromia may not appear until 12 hours after onset, though may appear after 2-4 hours.

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Pediatrics Ultrasounds Fractures Wellness 75

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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EKG/ECG Ultrasounds EMS Wellness 40

EM Curious

JULY 8, 2015

ULTRASOUND GOODIE BAG ULTRASOUND FOR LATE PREGNANCY [PODCAST]: While not a routine exam we perform other than confirming fetal heart tones, definitely some great pearls on more advanced US topic. Consider an ultrasound guided ulnar nerve block. Well, this may not be completely true. Part 1 here.

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Infectious Diseases Disaster Management Sepsis Ultrasounds 52

Dr. Smith's ECG Blog

JUNE 20, 2018

A 40 something woman with a history of hyperlipidemia and additional risk factors including a smoking history presented with substernal chest pain radiating to "both axilla" as well as the upper back. The initial tracing (EKG 1) was obtained. Clinician and EKG machine read of acute pericarditis. What do you think?

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EKG/ECG Documentation/Coding Ultrasounds Wellness 52

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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EKG/ECG Shock Fluid Resuscitation Documentation/Coding 40

EM Curious

JULY 1, 2015

ULTRASOUND IN CHEST PAIN: [BLOG]: It is never a bad idea to throw an ultrasound probe on your patient with chest pain. More FOAMed HARDWARE MALFUNCTION PACEMAKER AND AICD MANAGEMENT IN THE ED [BLOG]: EM Docs brings us some well needed cardiac hardware meducation on the patient with AICD/pacemaker issues presenting to the ED.

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EMS Ultrasounds EKG/ECG Fractures 52