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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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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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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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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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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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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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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Dr. Smith's ECG Blog

MARCH 28, 2024

Bedside ultrasound showed volume depletion and no pulmonary edema. Here is the prehospital ECG: First ED ECG What do you think? But I changed my mind after seeing the old ECG (below) I later sent it to Ken Grauer, who annotated as below with the red Xs: The "Y" in lead II across the bottom appears to be a PVC.

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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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Dr. Smith's ECG Blog

APRIL 2, 2024

Bedside ED ultrasound showed exceedingly poor global LV function, and no B lines. 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. What do you think?

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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.

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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 Hospitals Ultrasounds Wellness 101

The Skeptics' Guide to EM

SEPTEMBER 11, 2021

The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves. Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities. The AHA has a statement with recommendations based on the available data.

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Dr. Smith's ECG Blog

MARCH 6, 2023

If you saw this ECG only knowing that it is an acute chest pain patient, what would be your interpretation? But you can make a diagnosis here, and Pendell and I do this all the time when reading ECGs from databases. The patient had this ECG recorded at 7 minutes after registration at triage as a walk-in (not by EMS): What do you think?

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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. During a short period of ROSC an ECG was performed. EKG RV strain.

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Dr. Smith's ECG Blog

JANUARY 23, 2023

The screening physician ordered an EKG and noted his ashen appearance and moderate distress. Triage EKG: What do you think? Close up of V3 with baseline in red Close up of V4 with baseline in red This ECG alone is highly suspicious for posterior OMI! This is a very specific marker of posterior OMI. Epub 2021 Nov 15.

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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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Dr. Smith's ECG Blog

APRIL 20, 2018

This is her pre-hospital ECG: This is her first ECG in the ED: What do you think? However, the prehospital ECG is more worrisome: the T-wave inversion in V5 and V6 is preceded by ST Elevation. When I say " relative ," I mean relative to the previous ECG, which is the baseline, chronic, non-ischemic ECG.

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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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Dr. Smith's ECG Blog

APRIL 12, 2023

Prehospital Conventional algorithm interpretation: ANTERIOR INFARCT, STEMI Transformed ECG by PM Cardio: PM Cardio AI Bot interpretation: OMI with High Confidence What do you think? On arrival, lung ultrasound confirmed pulmonary edema (B lines). The ECG findings are focal to the anterior and high lateral wall.

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ALiEM

FEBRUARY 28, 2024

We also must recognize the important contributions of media such as clinical photographs, radiology images, and ECGs. Photographs, ECGs, Radiology Images These fall into the category of “other multimedia” in the AMA Manual of Style, and here is my best attempt to interpret this to clinical media. Accessed February 20, 2024. 11th ed.

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Dr. Smith's ECG Blog

NOVEMBER 15, 2023

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. In comparison with the first ECG, I would guess that the artery is reperfusing. I don't know if her pain was getting better or not.

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Dr. Smith's ECG Blog

DECEMBER 18, 2022

Here is her ECG on arrival to the ED: What is your differential? The ECG is quickly reviewed and shows sinus rhythm with normal QRS complexes. Her prior ECG on file is shown below: What are your next steps? Learning Points: The ECG is always just one piece of the clinical puzzle. What are your next steps?

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Pediatric EM Morsels

MAY 10, 2024

EKG Reasonable screen for cardiac etiology [ Kane, 2010 ]: Chest Pain with Exertion? Ultrasound diagnosis of occult pneumothorax. The role of point-of-care ultrasound in the diagnosis of pericardial effusion: a single academic center retrospective study. Ultrasound J. Abnormal exam (ex, murmurs, hepatomegaly)?

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Emergency Medicine Cases

OCTOBER 18, 2021

The post EM Quick Hits 33 Polytrauma Tips & Tricks, Toxic Megacolon, ECG in PE, Patch Calls, CT Before LP, Nebulized Ketamine appeared first on Emergency Medicine Cases.

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Dr. Smith's ECG Blog

APRIL 25, 2023

No pericardial effusion on ultrasound." ECG diffuse ST elevation, but lacking pericarditis features, and very concerning for acute injury." It peaked at 21,000 ng/L Post angiogram ECG: The fact that there is near normalization suggests that this may have been a thrombus with complete lysis. What do you think?

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Dr. Smith's ECG Blog

JANUARY 10, 2020

He had this ECG at time 0 What do you think? There was an old ECG for comparison: Very normal Interpretation: There is serious widespread ST elevation that could easily by due to a wraparound LAD with anterior and inferior MI. Another ECG was recorded at 1.5 ng/mL Another ECG was recorded at 3.5 Learning Points: 1.

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ACEP Now

JUNE 6, 2023

ECG, CXR, and troponin are negative. 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. An ECG and CXR are negative. An ECG, CXR, and two troponins are normal. She is given morphine for pain.

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EMDocs

MAY 15, 2024

ECG: Evaluate for ischemia, right heart strain. Ultrasound Sensitivity 88-100%, specificity 68-94% Positive likelihood ratio of 14.6 (95% Markers for severe disease include hypoxemia, increasing respiratory rate or work of breathing, decreasing platelet count and/or Hb, and multilobar involvement on chest radiograph or lung ultrasound.

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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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Dr. Smith's ECG Blog

MARCH 15, 2023

Here is her EKG: What is unusual about this? Her bedside cardiac ultrasound was normal We decided to cardiovert her since the time of onset was very recent. Here is the ECG after ibutilide: What do you notice? Here is the post-cardioversion ECG: Sinus rhythm, still with the longer QT interval. She was on no medications.

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Dr. Smith's ECG Blog

FEBRUARY 23, 2023

It is unclear whether he had active pain at the time of the first ECG: What do you think? 0.20 (above which, the ECG likely represents OMI). The team was concerned about possibly ischemic ST elevations on the ECG above, so they took it to Dr. Nossen for consultation. Vitals were within normal limits.

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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 I sent it to my friend, Ken Grauer , who is very meticulous in his ECG reading. I labeled ECG. His chest was tender. IVCD type rhythm ??

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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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Critical Care Now

JUNE 21, 2022

His main areas of interest are Critical Care, Ultrasound, Prehospital Resuscitation, and Medical Education. The first prehospital EKG showed Polymorphic Ventricular Tachycardia (PVT) that responded to defibrillation. Reading Time: 3 minutes Mohamed Hagahmed, MD, EMT-P Mohamed is an Emergency Medicine Physician and EMS director.

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Dr. Smith's ECG Blog

JANUARY 4, 2021

An ECG was recorded during pain: What do you think? link] This newly recognized ECG pattern is defined as " (1) any STE in III, but not in other inferior leads, (2) STD in any of leads V4 to V6, ( but not in V2 ) with a positive or terminally positive T-wave, (3) ST in lead V1 higher than ST in V2."

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AED Leader

OCTOBER 25, 2023

These tests can include: Electrocardiogram (Resting ECG). Typically, ECG results appear normal during rest periods. Exercise Stress Test with ECG. Continuous Portable ECG Monitoring. For a more extended assessment, you may need to wear a portable ECG monitoring device for approximately 30 days. Event Monitoring.

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