Ken Grauer, MD

MARCH 7, 2023

You are given this ECG to review. QUESTION: Is there a potential problem with this ECG? Figure-1: The initial ECG in today's case. == N OTE : Many of us are charged with reviewing ECGs that have been interpreted by other clinicians — often without the benefit of much ( or any ) history. The rhythm in ECG #1 is sinus.

EKG/ECG 195

EKG/ECG Wellness 195

Ken Grauer, MD

FEBRUARY 3, 2024

The ECG in Figure-1 was obtained following successful resuscitation. QUESTIONS: In view of the above history — How would YOU interpret the ECG in Figure-1 ? Is this ECG finding present in today’s initial ECG? Figure-1: The initial ECG in today's case — obtained after successful resuscitation from cardiac arrest. (

EKG/ECG 393

EKG/ECG Resuscitation Hospitals Wellness 393

Ken Grauer, MD

APRIL 29, 2023

The patient whose initial ECG is shown in Figure-1 — is a middle-aged man who presented to the ED ( E mergency D epartment ) for new-onset CP ( C hest P ain ). QUESTIONS: In view of the above history — How would YOU interpret the initial ECG? WHY is it important to correlate severity of this patient’s CP with ECG #1 ?

EKG/ECG 195

EKG/ECG 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

Ken Grauer, MD

MARCH 15, 2024

What if you were asked to interpret 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 ). By the P s, Q s, 3 R Approach ( which I review in ECG Blog #185 ): Lots of P waves are present — being well seen in the long lead II rhythm strip.

EKG/ECG 390

EKG/ECG Wellness 390

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

JULY 22, 2023

The ECG in Figure-1 was obtained from an elderly man with a history of coronary disease — who contacted EMS for "burning" chest discomfort that woke him at 3am. Some amount of time passed at home — during which his chest discomfort persisted The patient was hemodynamically stable at the time he was seen by EMS, when ECG #1 was recorded.

EKG/ECG 195

EKG/ECG Burns EMS Wellness 195

Ken Grauer, MD

JANUARY 20, 2024

I was sent the tracing shown in Figure-1 — told only that this was a preoperative ECG obtained from an asymptomatic older woman scheduled for non-cardiac surgery. How would YOU interpret this ECG? Figure-1: Preoperative ECG from an asymptomatic older woman scheduled for non-cardiac surgery. The 12-lead ECG is very concerning.

EKG/ECG 231

EKG/ECG 231

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

DECEMBER 23, 2023

The ECG in Figure-1 — was obtained from a patient with palpitations. Why is QRS morphology changing ? Figure-1: The initial ECG in today's case. My Interpretation of the ECG in Figure-1: Since the patient is hemodynamically stable — there is time for systematic assessment of the rhythm. Figure-2 ).

EKG/ECG 430

EKG/ECG Wellness 430

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! which is concerning for LAD occlusion.

EKG/ECG 93

EKG/ECG Emergency Department Ultrasounds Documentation/Coding 93

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

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.

EKG/ECG 108

EKG/ECG Documentation/Coding Emergency Department Outcomes 108

Dr. Smith's ECG Blog

SEPTEMBER 1, 2023

Here is the triage ECG: What do you think? I would activate the cath lab, or at least look for an old one and/or obtain serial ECGs. Case Continued There was an old ECG available from 1.5 Here it is: These T-waves are far smaller, confirming that the above ECG is indeed due to LAD OMI. Significant change.

EKG/ECG 109

EKG/ECG Outcomes 109

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

Dr. Smith's ECG Blog

SEPTEMBER 8, 2023

A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. The ST elevation in the other high-lateral lead ( = lead I ) is also abnormal.

EKG/ECG 115

EKG/ECG Emergency Department Wellness 115

Dr. Smith's ECG Blog

APRIL 9, 2024

By Magnus Nossen This ECG is from a young man with no risk factors for CAD, he presented with chest pain. How would you assess this ECG? Note: lead format is Cabrera I was sent this ECG in real time. The above ECG was recorded. How confident are you in your assessment? What is your next step? HR about 90-100/min.

EKG/ECG 78

EKG/ECG Wellness 78

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

This ECG was recorded: What do you think? There is widespread ST depression. This is ischemic ST depression, and could be due to increasing tachycardia, with a heart rate over 130, but that is unlikely given that the patient is now complaining of crushing chest pain and that there was tachycardia all along.

EKG/ECG 88

EKG/ECG Emergency Department Wellness Hospitals 88

Dr. Smith's ECG Blog

SEPTEMBER 3, 2023

This ECG was recorded in triage. This is my interpretation: there is subtle STE in III and aVF. There is ischemic ST depression in V4-V6. Although the findings are VERY subtle, they are diagnostic. Although the findings are VERY subtle, they are diagnostic. Case Continued The ECG findings were not recognized.

EKG/ECG 116

EKG/ECG Resuscitation CPR Emergency Department 116

Dr. Smith's ECG Blog

MAY 3, 2024

There were 2 prehospital ECGs: What do you think? There is "shark fin" in I and aVL, which is due to a combination of a large R-wave due to left anterior fascicular block plus downsloping ST elevation due to OMI. There is huge ST depression across the precordial leads. Thus, there is high lateral OMI with diffuse ST depression.

Shock 98

Shock EKG/ECG Hospitals EMS 98

Dr. Smith's ECG Blog

MAY 5, 2024

An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED. V1 has inappropriate ST elevation with a terminally negative T wave.

EKG/ECG 99

EKG/ECG Wellness 99

Dr. Smith's ECG Blog

APRIL 18, 2024

What do you think of the ECG, and does it matter? I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. 2] This is because, contrary to Bayesian reasoning, the STEMI paradigm is named after and defined by one part of one test: ST elevation on ECG.

EKG/ECG 105

EKG/ECG Documentation/Coding Fractures Emergency Department 105

Dr. Smith's ECG Blog

OCTOBER 15, 2023

Submitted by anonymous, written by Pendell Meyers I was at triage when this ECG was presented to me. As noticed by the AI, if the patient presented with chest pain , then even this subtle ECG is diagnostic of OMI. Normal baseline ECG on file. Here are her ECGs after PCI, showing anterolateral reperfusion findings.

EKG/ECG 87

EKG/ECG 87

Dr. Smith's ECG Blog

JANUARY 27, 2024

Below is the triage ECG, with a computer interpretation (Marquette 12 SL) of “normal” which was confirmed by the over-reading cardiologist. Should this patient continue to stay in the waiting room, without interruption of the physician to interpret the ECG, because the computer interpretation is normal? What do you think?

EKG/ECG 88

EKG/ECG Emergency Department Outcomes Wellness 88

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Willy is a cardiology fellow with a keen interest in the ECG in OMI. She seems a little concerned about some very subtle depression in the high lateral leads, but otherwise sees a pretty benign tracing. A patient with OMI can have a totally normal ECG!" The subtle ST depressions in the high lateral leads have resolved.

EKG/ECG 110

EKG/ECG Outcomes Documentation/Coding Academics 110

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

The abnormal depolarization from the IVCD can produce secondary repolarization abnormalities, but here there appears to be superimposed primary ST depression V2-4 indicating posterior OMI. Here's the prior ECG: This confirms thew anterior ST depression is new. If so, how will they change management?

EKG/ECG 100

EKG/ECG Outcomes 100

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

The following ECG was recorded. The presenting ECG shows SR with narrow QRS complexes. There is some upwards concave ST segment elevation in the inferior leads with what seems to be well formed J-waves. First troponin I returned 3174 ng/l, at which point a repeat ECG was ordered. Not much difference from 1st ECG.

EKG/ECG 84

EKG/ECG COPD Wellness Shock 84

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

Dr. Smith's ECG Blog

MARCH 14, 2024

Written by Jesse McLaren Three patients presented with acute chest pain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. It is well known that NOMI usually has a normal ECG or nonspecific ECG.

EKG/ECG 93

EKG/ECG Documentation/Coding Patient Safety Outcomes 93

Dr. Smith's ECG Blog

JULY 12, 2023

I come in early for every shift to read the ECGs on the system that have not yet been "confirmed". NORMAL ECG" What do you think? Be VERY careful when the computer calls the ECG "Normal". After the ECG was recorded, he was placed in the waiting room where he had been for over an hour. He was given aspirin and heparin.

EKG/ECG 65

EKG/ECG Wellness 65

Dr. Smith's ECG Blog

SEPTEMBER 26, 2023

Which had the more severe chest pain at the time of the ECG? Patient 2 at the bottom with a very subtle OMI complained of 10/10 chest pain at the time the ECG was recorded.

EKG/ECG 93

EKG/ECG Hospitals Outcomes Wellness 93

Dr. Smith's ECG Blog

DECEMBER 15, 2023

The ECG below was recorded and electronically transferred to our PCI center for evaluation. ECG #1 I think many providers might be reassured viewing this ECG. There is slight baseline wander on this ECG which does make the interpretation more challenging. This ECG was recorded roughly 3 minutes after the first ECG.

EKG/ECG 59

EKG/ECG EMS Wellness 59

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? I sent this ECG to Dr. Smith and Dr. Meyers with no clinical context. Smith comment: this troponin alone should be enough data to activate the cath lab, regardless of the ECG. <0.049 ng/mL).

EKG/ECG 101

EKG/ECG Documentation/Coding Wellness Emergency Department 101

Dr. Smith's ECG Blog

JANUARY 17, 2024

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? What other parts of the ECG would you like to see, and how will you use this to refine your interpretation?

EKG/ECG 86

EKG/ECG Documentation/Coding Wellness Emergency Department 86

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

DECEMBER 7, 2023

We would have taught her "acute reperfused" for this ECG. So even though it is an ECG clearly diagnostic of reperfused OMI, the Queen only says "OMI -- high confidence". EKG 2 What changes do you see? Notice that the precordial T waves are not quite as deep, and there’s a bit more convexity to the ST segments.

EKG/ECG 92

EKG/ECG Poisoning Hospitals 92

Dr. Smith's ECG Blog

AUGUST 19, 2023

Below is the 15 lead ECG. There’s subtle inferior ST elevation with straightening of the ST segment, reciprocal ST depression and T wave inversion in aVL, and ST depression in V2. They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. What do you think?

EKG/ECG 75

EKG/ECG Wellness Outcomes Hospitals 75