Emergency Medicine Cases

MAY 24, 2022

Is 15 lead ECG better than 12 lead for diagnosing posterior MI or right ventricular infarction? When do you need a 15 lead ECG? Jesse McLaren guides us through 8 cases to highlight the steps and pitfalls in diagnosing posterior MI and RVMI in light of recent ECG literature.

EKG/ECG 52

EKG/ECG EMS 52

Ken Grauer, MD

MAY 20, 2023

The ECG in Figure-1 — was obtained from an older woman with persistent CP ( C hest P ain ) over the previous day. Figure-1: The initial ECG in today's case. Voltage for LVH is satisfied — at least by Peguero Criteria ( Sum of deepest S in any chest lead + S in V4 ≥23 mm in a woman — as discussed in ECG Blog #73 ).

EKG/ECG 342

EKG/ECG Wellness 342

Ken Grauer, MD

JANUARY 5, 2024

Figure-1: The initial ECG in today's case. KEY Clinical Point: If I was the medical provider charged with the care of the patient whose ECG is shown in Figure-1 — I would approach this tracing in the following sequential stages: I’d first establish that the patient was hemodnamically stable with this ECG and this cardiac rhythm.

EKG/ECG 417

EKG/ECG Wellness 417

Ken Grauer, MD

NOVEMBER 18, 2023

15 minutes ) Below are slides used in my video presentation. For full discussion of this case — See ECG Blog #344 — == How would YOU interpret the lead II rhythm strip shown in Figure-1 ? Figure-1: How would YOU interpret this lead II rhythm strip? ECG Blog #168 — A complex dual-level AV Wenckebach ( Laddergram ).

EKG/ECG 239

EKG/ECG 239

Ken Grauer, MD

OCTOBER 13, 2023

The ECG in Figure-1 was obtained from a woman in her 60s — who was seen in the ED ( E mergency D epartment ) as part of her evaluation for trauma following a motor vehicle accident. Figure-1: The initial ECG in today's case. To do this — I apply the P s, Q s, 3 R Approach ( See ECG Blog #185 — for review of my system ).

EKG/ECG 361

EKG/ECG 361

Ken Grauer, MD

SEPTEMBER 1, 2023

Why are there so many shapes for the QRS complex in the long lead II rhythm strip? Figure-1: 12-lead ECG and long lead II rhythm strip obtained after Adenosine was given for a regular SVT rhythm. Figure-3: For clarity — I focus solely on the 17 beats in the long lead II rhythm strip. second in duration.

EKG/ECG 277

EKG/ECG Administration 277

Ken Grauer, MD

FEBRUARY 9, 2024

Imagine the only information provided for the ECG in Figure-1 — is that it was obtained from a 60-year old man with new CP ( C hest P ain ). QUESTIONS: In view of this brief history — How would YOU interpret this ECG in Figure-1 ? Is the cardiac rhythm related to the 12-lead ECG? Figure-1: The initial ECG in today’s case.

EKG/ECG 255

EKG/ECG Operations Wellness 255

Ken Grauer, MD

MAY 26, 2023

The ECG in Figure-1 was obtained from a 60-ish year old man with a history of coronary disease ( including prior CABG ) — who presented to the ED ( E mergency D epartment ) with new CP ( C hest P ain ) of 3 hours duration , diaphoresis and nausea/vomiting. The patient was hypotensive at the time his initial ECG in Figure-1 was obtained.

EKG/ECG 195

EKG/ECG Wellness Resuscitation 195

Ken Grauer, MD

OCTOBER 27, 2023

The ECG in Figure-1 was obtained from an elderly woman — who presented to the ED ( E mergency D epartment ) for dyspnea on exertion over recent weeks. Figure-1: The initial ECG in today's case. ( To improve visualization — I've digitized the original ECG using PMcardio ). What are YOUR "Quick Thoughts" about this case?

EKG/ECG 247

EKG/ECG Resuscitation Hospitals Wellness 247

Ken Grauer, MD

SEPTEMBER 29, 2023

You are asked to interpret the ECG in Figure-1. What is the rhythm in ECG #1 ? MY Thoughts on the ECG in Figure-1: I routinely begin assessment of each 12-lead ECG I encounter — with interpretation of the rhythm. To do this — I apply the P s, Q s, 3 R Approach ( See ECG Blog #185 — for review of my system ).

EKG/ECG 239

EKG/ECG 239

Ken Grauer, MD

MAY 6, 2023

The ECG in Figure-1 — was obtained from an older woman with chest pain. Figure-1: The initial ECG in today’s case. ( To improve visualization — I've digitized the original ECG using PMcardio ). The QRS of sinus beats #3,6,9,12 and 15 looks narrow in this long lead II rhythm strip.

EKG/ECG 195

EKG/ECG 195

Ken Grauer, MD

MARCH 23, 2023

The 12-lead ECG and long lead II rhythm strip shown in Figure-1 — was obtained from a previously healthy, elderly woman who collapsed in the hospital parking lot. A series of cardiac arrhythmias were seen during the course of her resuscitation — including the interesting arrhythmia shown in the long lead II of Figure-1.

EKG/ECG 195

EKG/ECG Resuscitation Hospitals 195

Ken Grauer, MD

JUNE 6, 2023

== P lease N OTE : After today — No new ECG Blog posts for 2- to -3 weeks. — I will also not be prompt in replying to emails. == All material on this ECG Blog site remains open! So IF you are looking for ECG material — There is plenty on this web site! Figure-1: The initial ECG in today's case. I'll be back! —

EKG/ECG 195

EKG/ECG Hospitals Wellness Resuscitation 195

Ken Grauer, MD

AUGUST 18, 2023

He was not symptomatic with the ECG shown in Figure-1. How would YOU interpret this ECG? Extra Credit ( which is a HINT to the Answer! ): How many beats are recorded on the ECG in Figure-1 ? Figure-1: The initial ECG in today’s case. ( To improve visualization — I've digitized the original ECG using PMcardio ).

EKG/ECG 195

EKG/ECG Dehydration Wellness 195

Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. These findings are diagnostic even without comparison with an old ECG.

EKG/ECG 105

EKG/ECG Documentation/Coding Emergency Department 105

ECG Guru

MAY 24, 2024

ECG Number 1, 11:57 a.m.: There is a wide-complex tachycardia at a rate of about 230 bpm. 15 seconds (150 ms). The PRI given is taken from Lead II, which, along with V5, does have P waves. In the other leads, the P waves are buried in preceding T waves. In the other leads, the P waves are buried in preceding T waves.

EKG/ECG 98

EKG/ECG Shock Outcomes 98

Ken Grauer, MD

JULY 9, 2023

The ECG in Figure-1 was obtained from a 60-year old woman — who presented to the ED ( E mergency D epartment ) for “palpitations”. Her vital signs were normal at the time this triage ECG was recorded. How would YOU interpret the ECG in Figure-1 ? Do you see any indication on this ECG of WHY this patient was about to arrest?

EKG/ECG 195

EKG/ECG 195

Ken Grauer, MD

JULY 15, 2023

The ECG in Figure-1 was obtained from a previously healthy middle-aged man — who while performing his regular exercise routine, developed "slight" chest discomfort and "palpitations". Surprisingly — he was hemodynamically stable with minimal discomfort at the time his initial ECG in Figure-1 was recorded. Could the patient have WPW?

EKG/ECG 195

EKG/ECG Shock EMS 195

Ken Grauer, MD

JUNE 2, 2023

QUESTIONS: A total of 9 QRS complexes are seen in the 2 simultaneously-recorded monitoring leads. Why do the QRS complexes of beats #4 and 5 in the bottom lead look different than the other 7 beats? P waves in the upper lead of Figure-2 are upright, albeit small in amplitude. How would YOU interpret the rhythm in Figure-1 ?

EKG/ECG 195

EKG/ECG Wellness 195

Ken Grauer, MD

APRIL 23, 2023

The 12-lead ECG and long lead rhythm strip in Figure-1 — was obtained from a previously healthy 15-year old male , who presented with fever and diarrhea. How would YOU interpret the ECG in Figure-1 ? Figure-1: The initial ECG in today’s case — obtained from a 15-year old male with fever and diarrhea.

EKG/ECG 195

EKG/ECG Wellness Operations Hospitals 195

Ken Grauer, MD

FEBRUARY 4, 2023

The ECG in Figure-1 is from a middle-aged man — who had just received thrombolytic therapy for presumed acute infarction. QUESTIONS: How would YOU interpret this ECG? Figure-1: ECG obtained from a middle-aged man following thrombolytic therapy. ( To improve visualization — I've digitized the original ECG using PMcardio ).

EKG/ECG 195

EKG/ECG 195

Ken Grauer, MD

APRIL 3, 2023

How would YOU interpret this long lead II rhythm strip? Figure-1: The long lead II rhythm strip for today’s case. To improve visualization — I've digitized the original ECG using PMcardio ). As always — I favor a systematic approach to rhythm interpretation, using the P s, Q s, 3 R memory aid ( See ECG Blog #185 ).

EKG/ECG 195

EKG/ECG 195

Dr. Smith's ECG Blog

MAY 22, 2024

Written by Sean Trostel MD I returned to my desk after seeing a patient and saw this screening ECG sitting on my desk to be read. ECG #1 @ 15:30 What do you think? QRS is becoming still narrower Note with each ECG there is progressive narrowing of the QRS and dampening of the peaked T-waves.

EKG/ECG 101

EKG/ECG Shock Resuscitation 101

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

Do you need posterior leads? Here's the prior ECG: This confirms thew anterior ST depression is new. The first ECG was labeled “anterior subendocardial ischemia”, but subendocardial ischemia does not localize. So a patient with high pretest probability (prior CABG with new chest pain), had new ECG changes showing posterior OMI.

EKG/ECG 100

EKG/ECG Outcomes 100

Dr. Smith's ECG Blog

AUGUST 19, 2023

Below is the 15 lead ECG. This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS.

EKG/ECG 75

EKG/ECG Wellness Outcomes Hospitals 75

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

Written by Pendell Meyers First try to interpret this ECG with no clinical context: The ECG shows an irregularly irregular rhythm, therefore almost certainly atrial fibrillation. Here is the initial ECG: A temperature sensing Foley was inserted and reported a core temperature of 26.7 C), with Cardiac Echo -- A Pathognomonic ECG.

Hyperthermia / Hypothermia 118

Hyperthermia / Hypothermia EKG/ECG Wellness 118

Dr. Smith's ECG Blog

APRIL 2, 2024

Here is the initial ED ECG. In lead III, the ST/S ratio is 25% (ST measured at the J-point, relative to the PQ junction, is 4.5 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.

EKG/ECG 114

EKG/ECG Shock CPR Stroke 114

Dr. Smith's ECG Blog

FEBRUARY 18, 2024

ECG is shown below. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it is still critical to determine the atrial rhythm. Cardiology felt that there was baseline artifact and recommended immediate repeat ECG which is shown below. What do you think?

EKG/ECG 78

EKG/ECG Stroke 78

Dr. Smith's ECG Blog

OCTOBER 13, 2023

This ECG was texted to me with no other information, with this quote: "You will see this in the Queen of Hearts." The conventional algorithm said: SINUS RHYTHM ABNORMAL QRS-T ANGLE [QRS-T AXIS DIFFERENCE > 60] ABNORMAL ECG This was my response: "I am not certain that I agree with the queen on this one. Learning Points: 1.

EKG/ECG 95

EKG/ECG Urgent Care Emergency Department Outcomes 95

Dr. Smith's ECG Blog

DECEMBER 19, 2023

That's because this patient has clinical, ECG and Troponin evidence that an acute event did in fact occur ( ie, a more than doubling of Troponin in the context of a changing pattern of CP that correlates temporally with "dynamic" ECG changes — therefore strongly suggesting transient acute occlusion regardless of cath findings in today's case ).

EKG/ECG 104

EKG/ECG EMS Wellness Operations 104

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Both cases had an EMS ECG that was transmitted to the ED physician asking "should we activate the cath lab?" On arrival to the ED, while waiting for cath lab team, he obtained another ECG: You can now see the full voltage of the high-voltage QRS, likely with some degree of LVH. Serial ECGs remained unchanged. What do you think?

EKG/ECG 101

EKG/ECG EMS Outcomes Wellness 101

Dr. Smith's ECG Blog

DECEMBER 27, 2023

The following ECG was obtained. Note that the machine read is "normal sinus rhythm, normal ECG." ECG 1 What do you think? She seems concerned about a few leads. I sent this ECG to Dr. Smith and Dr. Meyers with no clinical context. The patient's old ECG is shown below. ECG 2 What do you think?

EKG/ECG 101

EKG/ECG Documentation/Coding Wellness Emergency Department 101

Dr. Smith's ECG Blog

SEPTEMBER 15, 2023

I said, "Cool, can I see the ECG?' So he showed me the ECG recorded in triage: What did I say? When bizarre, look at leads I, II, and III. When bizarre, look at leads I, II, and III. If one of them does not look bizarre, while all other 11 leads do look bizarre, then it is APTA. That is not a STEMI. He said: "What?

EKG/ECG 114

EKG/ECG Wellness 114

Dr. Smith's ECG Blog

JANUARY 17, 2024

Written by Jesse McLaren Two patients presented with acute chest pain, and below are the precordial leads V1-6 for each. Patient 1 (ECG on the left) was a 45 year-old male, and patient 2 (ECG is on the right) was a 70 year-old male. Using T wave amplitude, can you tell which ECG has hyperacute T waves?

EKG/ECG 86

EKG/ECG Documentation/Coding Wellness Emergency Department 86

Dr. Smith's ECG Blog

OCTOBER 30, 2023

Here is the first prehospital ECG (time 0, after one hour of pain): I do not see evidence of OMI, and neither did the Queen of Hearts Here is the 2nd prehospital ECG (time 10 minutes, after 70 minutes of pain): No change On arrival, the first ED ECG was recorded 20 minutes after the last one (90 minutes after pain onset): What do you think?

EKG/ECG 97

EKG/ECG 97

EMDocs

DECEMBER 11, 2023

The most common diagnostic test to identify patients who might require percutaneous intervention is the electrocardiogram (ECG). Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG.

EKG/ECG 109

EKG/ECG Emergency Department Academics Operations 109

Dr. Smith's ECG Blog

DECEMBER 13, 2023

On the right are the precordial leads stretched vertically, so that the QRS is not tiny. This is the result for this ECG, from MDcalc.com : The most accurate cutpoint is 18.2. Here is a similar case from Pendell: This ECG was handed over at triage. There is some ST Elevation, but it is MINIMAL. But look how small the QRS is!!

EKG/ECG 98

EKG/ECG COPD Wellness Outcomes 98