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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Documentation/Coding CPR EKG/ECG Sepsis 90

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 76

Documentation/Coding Stroke Emergency Department Pediatrics 76

Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. 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.

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EKG/ECG Burns Urgent Care Documentation/Coding 95

Emergency Medicine Cases

JUNE 21, 2022

In this ECG Cases blog we review 8 cases of patients with prehospital ECGs and explore prehospital ECGs for diagnosing STEMI, Occlusion MI, false STEMI, code STEMI, dynamic ischemic changes, truncated voltages. The post ECG Cases 32 Prehospital ECG pearls and pitfalls appeared first on Emergency Medicine Cases.

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EKG/ECG Documentation/Coding EMS 52

Dr. Smith's ECG Blog

MARCH 7, 2024

But he did get an EKG: What is this? Here are 4 more ECGs recorded over the ensuing hours: Another irregular AIVR Back to sinus rhythm This is a normal regular AIVR Another normal regular AIVR On that first ECG, I was not entirely certain, since I have never seen nor heard of irregular AIVR, nor can I find a report of it in the literature.

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Shock EKG/ECG Documentation/Coding 103

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

Here is the ECG: Computer interpretation: Normal ECG Interventionalist after doing PCI: SUBTLE STT CHANGES IN LIMB LEADS To me, this first ECG is diagnostic of inferior OMI. I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: YOU TOO CAN HAVE THE PM Cardio AI BOT!! He walked in to triage.

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EKG/ECG Documentation/Coding Emergency Department 76

Dr. Smith's ECG Blog

DECEMBER 1, 2023

Pendell and I have taught the queen on over 40,000 EKGs so far. Version 2 will be coming out soon, also taught on an additional 20,000 EKGs. For version 3, we have started teaching her on yet more EKGs. These ones are EKG that the Queen's users uploaded, and on the comments and outcomes that they give.

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EKG/ECG Documentation/Coding Outcomes 52

JournalFeed

MAY 4, 2024

Friday 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 52

Documentation/Coding EKG/ECG 52

Dr. Smith's ECG Blog

SEPTEMBER 22, 2023

This ECG was texted to me with no other information. The first ECG was recorded at 53 minutes after pain onset. The pain began to improve and this ECG was recorded: T-waves are not quite as tall, though still have a large AUC. An old ECG was found: As you can see, this patient has zero baseline STE, and normal T-waves.

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EKG/ECG Wellness Documentation/Coding 112

Dr. Smith's ECG Blog

JUNE 4, 2019

Here is the ED ECG (no previous ECG was available for comparison). Computer interpretation: Normal ECG Cardiology overread: Normal ECG QTc-Bazett by computer = 479 ms Computer algorithm name unavailable What do you think? T his is a systematic failure that has been documented in the following study: Garg A, Lehmann MH.

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EKG/ECG Documentation/Coding 52

EMDocs

SEPTEMBER 23, 2023

Her presenting EKG is shown below. The exact mechanisms by which these genetic mutations lead to the characteristic ECG and arrhythmias seen in Brugada Syndrome are not yet fully understood, but they are thought to involve abnormalities in cardiac ion channels that affect the flow of sodium and calcium ions across cardiac cell membranes 6.

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EMS EKG/ECG Documentation/Coding Emergency Department 82

Dr. Smith's ECG Blog

JUNE 15, 2023

Here was his triage ECG: What do you think? I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2.

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EKG/ECG Documentation/Coding Outcomes Hospitals 87

Cook County EM Blog

MAY 15, 2023

Figure 1: Initial EKG The Case: 45-year-old Spanish speaking male with no known past medical history presented to the ED with 2-3 hours of severe back pain and throat pain. What does this EKG suggest? His EKG suggested a posterior MI as well as other signs of ischemia. Unfortunately, this EKG was not recorded in the EMR.

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EKG/ECG Documentation/Coding Wellness 52

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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EKG/ECG Ultrasounds EMS Documentation/Coding 52

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

I was reading EKGs on the system and came across this one: What do you think? No followup EKG was recorded!! See many examples of Pseudo STEMI due to hyperkalemia at these two posts: Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.

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EKG/ECG Documentation/Coding Administration 52

Dr. Smith's ECG Blog

APRIL 17, 2023

Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. The Queen of Hearts correctly says: Smith : Why is this ECG which manifests so much ST Elevation NOT a STEMI (even if it were a 60 year old with chest pain)?

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EKG/ECG Documentation/Coding Emergency Department Psychiatric 52

Dr. Smith's ECG Blog

OCTOBER 23, 2023

An Initial ECG was performed: Initial ECG: Sinus tachycardia with prolonged QT interval (QTc of 534 ms by Bazett). A repeat ECG was performed 2 hours after arrival: QTc prolongation ato 722 ms now with alternating T wave pattern (T wave alternans) I texted this to Smith who responded: “T wave alternans and long QT. 2005.08.066.

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EKG/ECG Documentation/Coding Psychiatric EMS 108

Dr. Smith's ECG Blog

MARCH 19, 2024

This was the ECG obtained at triage. This ECG was recorded and was reviewed remotely by a cardiologist: What do you think? The Queen of Hearts agrees: Here the Queen explains why: However, it was not interpreted correctly by the providers: ED interpretation of ECG: "paced rhythm, LBBB but no STEMI pattern." Next trop in AM.

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EKG/ECG Hospitals Documentation/Coding Outcomes 80

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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EKG/ECG Emergency Department Ultrasounds Documentation/Coding 64

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The baseline ECG is basically normal with no ischemia. Here is what the Queen of Hearts says about the Baseline ECG: Active chest pain triage ECG also read as not OMI: She says "not OMI", but she does not have access to the baseline ECG. In the future, we will be able to have her compare with previous and serial ECGs.

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EKG/ECG Shock Documentation/Coding Academics 78

Dr. Smith's ECG Blog

MAY 8, 2023

Triage ECG: What do you think? Code STEMI was activated by the ED physician based on the diagnostic ECG for LAD OMI in ventricular paced rhythm. Queen of Hearts interpretation: The cardiologist initially was not convinced, stating the ECG was not diagnostic or could not be diagnostic because it was paced.

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EKG/ECG Documentation/Coding Outcomes Shock 52

EMDocs

SEPTEMBER 19, 2023

Reference: emDOCs – NCSE Journal of Emergency Medicine – Review Case 4: 52-year-0ld male brought in by EMS with “code STEMI” ECG demonstrates ST depressions with rocket like T waves in V2-V4. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

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Seizures Documentation/Coding EKG/ECG Emergency Department 71

Dr. Smith's ECG Blog

JUNE 17, 2023

EMS recorded this ECG during active symptoms and transmitted it to the ED: I had no information when I was shown the ECG. Some prior ECGs were available for comparison: Prior 1: Prior 2: Here is his post cath ECG: Post Cath: I showed all three of these ECGs to QOH, she said NOT OMI with high confidence on all three.

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EKG/ECG Documentation/Coding EMS 52

Dr. Smith's ECG Blog

DECEMBER 23, 2022

This ECG was recorded: The computer called it "Normal" except for "Possible right ventricular conduction delay" What do you think? The team was there and I showed them the ECG and said "I am 80% certain this is OMI. While waiting for the cath team, a 3rd ECG was recorded: Now there is STE in V6, with large T-waves in V4-V6.

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EKG/ECG Documentation/Coding 52

Dr. Smith's ECG Blog

APRIL 4, 2023

Below is the old ECG, showing that all these changes are new – including the Q waves. This patient could have very easily been overlooked, both because the ECG was STEMI negative and because the Q waves were attributed to an “old infarct”. Fortunately, Dr. Cho was not looking for STEMI ECG criteria but for an acute coronary occlusion.

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EKG/ECG Documentation/Coding Outcomes Wellness 52

Mind The Bleep

NOVEMBER 21, 2023

Unless you’re documenting something hilarious, please keep it brief and to the point. History of Presenting Complaint In this section use SOCRATES to document the pain. Drugs/Allergies When documenting drugs – try to get the dose and frequency (this can be found on Summary Care Records from the GP if you have access).

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Documentation/Coding COPD Wellness EKG/ECG 52

Ken Grauer, MD

JULY 29, 2023

The ECG in Figure-1 was obtained from an 18-year old woman — who moments before been resuscitated from out-of-hospital cardiac arrest. How would YOU interpret her post-resuscitation ECG? Does this ECG in Figure-1 provide clue(s) to the etiology of this patient's cardiac arrest? QUESTIONS: In light of the above clinical history.

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EKG/ECG Resuscitation Documentation/Coding Hospitals 366

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. Pretest probability: Even before the ECG, a patient with a history of coronary stent has a 90% chance that his wide complex tachycardia is VT.

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EKG/ECG Shock Documentation/Coding Academics 127

Dr. Smith's ECG Blog

DECEMBER 29, 2023

Below is the old ECG (on top) and then new ECG (on bottom). The old ECG has proportional ST elevation and T waves. But the new ECG has new Q waves in aVL and V2 (the distribution of the first diagonal artery) – and in the next context of Q waves, the T wave in V2 is upright and relative large. What do you think?

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EKG/ECG Documentation/Coding Emergency Department 66

Stop and Think

JANUARY 1, 2024

Things like reading ECGs, echocardiograms, as well as learning to do procedures. They sit in a Google document. It will be a working document. The results ought not apply to the patients we see now. Here’s another discovery: cardiology training is technical. Learners have to spend oodles of time learning how to do stuff.

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Documentation/Coding Wellness EKG/ECG Hospitals 75

Dr. Smith's ECG Blog

MARCH 22, 2024

His ECG is shown: What do you think? The history thus far is highly suggestive of OMI, so we must study the ECG very closely to see if we can confirm this. The Queen of Hearts does not care about rhythm analysis, she simply looks at the ECG and decides whether it represents OMI or not.

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EKG/ECG Wellness Documentation/Coding 102

Dr. Smith's ECG Blog

MARCH 19, 2023

This ECG was texted to me in real time, but I did not notice the message until about an hour after it came. "50 This was my response: "This looks like a worrisome EKG. But by now you must have a repeat ECG. But by now you must have a repeat ECG. Another ECG was recorded while waiting for the cath team (it was nighttime).

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EKG/ECG Documentation/Coding Wellness 52

Dr. Smith's ECG Blog

JUNE 8, 2023

Here’s the paramedic ECG (digitized by PMcardio). I sent the ECG to Dr. Meyers without any information, and he immediately replied, “inferior OMI.” Here’s the first and repeat paramedic ECG: According to some interpretations of the literature on “transient STEMI”, this patient doesn’t need the cath lab because ST segments improved.

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EKG/ECG Documentation/Coding EMS Emergency Department 60

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

Triage ECG (no prior for comparison): Computer algorithm read: "Sinus rhythm, low voltage QRS, inferior myocardial infarction, probably old." I texted this ECG with no information to Dr. Smith, who immediately said: "If CP, then anterior OMI until proven otherwise." Every note says "no ischemic changes on ECG." Deemed "NSTEMI."

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EKG/ECG Outcomes Academics Documentation/Coding 73

Dr. Smith's ECG Blog

JULY 27, 2023

He had a prehospital ECG that was worrisome to the medics, so they called me to see him at the door. His prehospital ECG showed "inferior" ST depression and high voltage, with tachycardia. His prehospital ECG showed "inferior" ST depression and high voltage, with tachycardia. and had dilated pupils. He was alert and oriented.

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EKG/ECG Documentation/Coding Wellness 52

ACEP Now

JUNE 6, 2023

ECG, CXR, and troponin are negative. A medical student reports a murmur, not documented by either the emergency physician or the cardiologist. 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.

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EKG/ECG Stroke Documentation/Coding Operations 85

Dr. Smith's ECG Blog

JULY 26, 2023

This patient presented with vertigo and had an ECG recorded What do you think? So upright T-waves in the presentation ECG do NOT mean there is any re-occlusion. When I was given this case — I initially saw only ECG #1 — and I had not been given any clinical information. Over time, T-waves normalize in the absence of new OMI.

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EKG/ECG Documentation/Coding Wellness 52