Dr. Smith's ECG Blog

FEBRUARY 11, 2024

The ECG was faxed to a cardiologist. I told him that he could make it legible AND get an OMI diagnosis from the Queen of Hearts and sent this ECG to the Queen right before his eyes: She correctly rules out OMI: And the outcome was Not OMI This was a patient with chest pain. But it was very difficult for him to see.

EKG/ECG 59

EKG/ECG Outcomes 59

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 111

EKG/ECG Documentation/Coding Emergency Department Outcomes 111

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

This case comes from Jason Winter, of The Facebook Clinical Electrocardiology ECG Page. Here is her first prehospital ECG: What do you think? However, again, the formula was developed only in ECGs with at lead 1 mm of STE in V2 and V3, so does it apply? Serial ECGs improve the sensitivity of ST elevation on the ECG for MI.

EKG/ECG 117

EKG/ECG EMS Outcomes 117

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

In the last post, we saw how important old ECGs are in assessing the current ECG in a patient without atypical presentation (in this previous case, the patient had no chest pain, and the apparent inferior OMI did not have reciprocal ST depression in lead aVL). Here is his first prehospital ECG: 1st Prehospital ECG What do you think?

EKG/ECG 97

EKG/ECG EMS Stroke Outcomes 97

ALiEM

NOVEMBER 6, 2023

Wolf-Parkison-White Syndrome (WPW) Case Question: What are the characteristic ECG findings of this condition and how is this condition managed? These particular EKG findings define a “Wolff-Parkinson-White Pattern.” WPW Syndrome consists of characteristic EKG findings as well as symptomatic arrhythmias. Crit Care Nurse.

EKG/ECG 78

EKG/ECG Academics Outcomes Wellness 78

Dr. Smith's ECG Blog

DECEMBER 13, 2023

This is the result for this ECG, from MDcalc.com : The most accurate cutpoint is 18.2. Outcome: 100% LAD Occlusion Here the Queen explains why: The dark blue tells us that she is looking especially at the QRS in V3 and the T-wave in V2 and V3. Here is a similar case from Pendell: This ECG was handed over at triage.

EKG/ECG 101

EKG/ECG COPD Wellness Outcomes 101

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 104

EKG/ECG EMS Outcomes Wellness 104

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.

EKG/ECG 87

EKG/ECG Documentation/Coding Outcomes Hospitals 87

Dr. Smith's ECG Blog

MAY 31, 2023

I received the following text message with these 3 EKGs (providers text me ECGs all day every day; most are false positives; many are subtle true positives): "Hi Steve, here are 3 EKGs for you (my colleague's case). Opiates are associated with worse outcomes in Myocardial Infarction. Cath attending is aware. Am Heart J.

EKG/ECG 74

EKG/ECG Outcomes Academics Wellness 74

Dr. Smith's ECG Blog

OCTOBER 6, 2023

This is one case where it made a difference: Right Ventricular MI seen on ECG helps Angiographer to find Culprit Lesion Nevertheless, it is sometimes a fun academic exercise to try to predict the infarct artery: An elderly patient had onset of chest pain one hour prior. Here is the prehospital ECG. He called 911. What do you think?

EKG/ECG 63

EKG/ECG Academics Shock Outcomes 63

Dr. Smith's ECG Blog

MAY 23, 2023

EMS arrived and recorded this ECG: What do you think? See same ECG below with computer automated interpretation, using the Glasgow ECG algorithm which apparently is used by many different providers and devices Amazing that the computer calls this normal. Next day ECG. And yet it still says "normal". Learning Points: 1.

EKG/ECG 83

EKG/ECG Wellness Emergency Department EMS 83

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.

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes 52

Dr. Smith's ECG Blog

JULY 2, 2023

Get serial ECGs" He then sent a previous from 4 years prior: "This is totally normal, which confirms that the first EKG does indeed represent OMI" Then the patient's chest pain resolved and he recorded another: The ST depression in aVL is gone and the T-waves are less hyperacute, so this is consistent with reperfusion.

EKG/ECG 52

EKG/ECG Outcomes Hospitals 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.

EKG/ECG 52

EKG/ECG Ultrasounds EMS Documentation/Coding 52

Taming the SRU

MARCH 10, 2024

Soon you’ll be able to view our whole pathway on the QI/KT page, but for now, we hope everyone remembers these points: 1) Get labs and an EKG on everyone presenting with hypoglycemia. ECG is a must for EVERY syncope patient. It is not specific enough in defining specific findings on the ECG that should be considered high risk.

EKG/ECG 86

EKG/ECG Shock Wellness EMS 86

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.

EKG/ECG 120

EKG/ECG Resuscitation CPR Emergency Department 120

RebelEM

SEPTEMBER 28, 2023

ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3% The upper range of this time was 120 minutes from diagnostic ECG in the majority of patients.

EKG/ECG 127

EKG/ECG Allergic Reactions Shock Stroke 127

Dr. Smith's ECG Blog

DECEMBER 6, 2022

Vital signs were normal and first ECG was labeled as normal by the computer and confirmed by the treating emergency physician and cardiology over-read. Repeat troponin declined to 2,500 and repeat ECG ECG was done after another 2 hours, also interpreted as normal. C ircumflex occlusions can have subtle to no ECG changes 3.

EKG/ECG 52

EKG/ECG Outcomes 52

Dr. Smith's ECG Blog

APRIL 21, 2023

Written by Jesse McLaren, with comments from Smith A 50-year old patient on the medical wards developed acute chest pain, with an ECG labeled (see computer interpretation at the top) and confirmed as normal. I sent the ECG to Dr. Meyers without any other information. What do you think? This is diagnostic of inferoposterior OMI.

EKG/ECG 52

EKG/ECG Outcomes Research Hospitals 52

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 77

Documentation/Coding Stroke Emergency Department Pediatrics 77

Emergency Medicine Journal

APRIL 22, 2024

Participants included those with symptoms of suspected AMI (without ST-segment elevation MI on presentation ECG). The primary outcome was index AMI, including type 1 or 2 non-ST segment elevation MI (NSTEMI) or ST-elevation MI (STEMI) following presentation.

Emergency Department 98

Emergency Department Outcomes EKG/ECG Hospitals 98

Dr. Smith's ECG Blog

FEBRUARY 9, 2024

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. Do you need posterior leads?

EKG/ECG 103

EKG/ECG Outcomes 103

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. And as we have shown before, morphine leads to slower times to treatment and worse outcomes. 2 middle aged males presented with chest pain.

EKG/ECG 97

EKG/ECG Hospitals Outcomes Wellness 97

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.

EKG/ECG 64

EKG/ECG Emergency Department Ultrasounds Documentation/Coding 64

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.

Shock 75

Shock EKG/ECG Academics Stroke 75

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. Full case details and outcomes are below. His triage at 0127 is the ECG above. Repeat ECG at 0221: Basically unchanged. Physician: "No STEMI."

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Psychiatric 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

He had a triage ECG at time zero: Here is the computer interpretation (Normal) This was the Veritas algorithm. This ECG is DIAGNOSTIC of acute LAD Occlusion. He came to me with the ECG and I said, "Yup, this is an LAD Occlusion." But even this ECG by itself is quite suspicious. What do you think? She gets it again.

EKG/ECG 52

EKG/ECG Wellness Emergency Department Outcomes 52

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.

EKG/ECG 78

EKG/ECG Shock Documentation/Coding Academics 78

Dr. Smith's ECG Blog

APRIL 2, 2024

Here is the initial ED ECG. 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. Another ECG was recorded 12 minutes later: Paced rhythm, probable Pacemaker-Mediated Tachycardia ?

EKG/ECG 118

EKG/ECG Shock CPR Stroke 118

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. No labs were performed.

EKG/ECG 52

EKG/ECG Documentation/Coding Outcomes Shock 52

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.

EKG/ECG 80

EKG/ECG Hospitals Documentation/Coding Outcomes 80

Dr. Smith's ECG Blog

AUGUST 26, 2019

She was brought to the Emergency Department and this ECG was recorded while she was still feeling nauseous but denied chest pain, shortness of breath, or other symptoms: What do you think? This ECG was texted to me with no clinical information, with the sender being concerned for possible hyperacute T-waves and STE in the inferior leads.

EKG/ECG 52

EKG/ECG Emergency Department Outcomes Hospitals 52

RebelEM

JUNE 1, 2023

Post-ROSC management is nuanced and challenging but helps to ensure good outcomes. In theory, rapid identification of the underlying cause should improve outcomes by allowing clinicians to tailor management. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study.

Outcomes 133

Outcomes Resuscitation Hospitals CPR 133

Taming the SRU

JANUARY 26, 2024

Wosiski-Kuhn and Stothers BP cuff sizing: Using a cuff too large results in lower SBP, using too small results in higher BP VTE risk with hormonal contraception and NSAIDS Isolated use + and contraception leads to IRR of 7.2 10 or greater days and high or moderate risk hormonal contraception amplifies risk to IRR of 44.8

Stroke 59

Stroke EKG/ECG Outcomes Seizures 59

Dr. Smith's ECG Blog

JANUARY 3, 2024

On arrival, EMS recorded relatively normal vital signs and this EMS ECG: What do you think? Here is the Queen of Hearts interpretation: This ECG was transmitted to the nearest PCI center, where it was simply called "Not STEMI, just follow your protocol." No further ECGs were recorded. So the cath lab was not activated.

EMS 79

EMS EKG/ECG Wellness Outcomes 79

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."

EKG/ECG 73

EKG/ECG Outcomes Academics Documentation/Coding 73

Dr. Smith's ECG Blog

MARCH 30, 2014

The minute this medical student saw the first ECG, he knew the diagnosis without any further information. Reading ECGs is hard, but can be done with commitment to learning, which comes from an awareness of its importance. You need to be interested and understand the value of the ECG. She had this ECG recorded: ECG 1: QTc is 484.

EKG/ECG 52

EKG/ECG Outcomes Shock Sepsis 52