Dr. Smith's ECG Blog

DECEMBER 11, 2023

Moreover , the patient has ongoing symptoms and has an unexplained elevated troponin, so she is having an MI and the only question is whether it is type 1 or type 2 due to hypertension. Case continued She was loaded with aspirin 325 mg, and repeat troponin drawn around the time of EKG 1 resulted at 267 ng/L. At midnight. At midnight.

E-9-1-1 126

E-9-1-1 ACS Coronary STEMI 126

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

ECG #1 Interpretation: ECG #1 shows sinus rhythm at a heart rate of 77 bpm. Following more detailed questioning — it turned out the patient had started taking 9 different herbal remedies to ease lethargy and unspecific neurological symptoms. For clarity in Figure-1 — I've reproduced the initial ECG in today's case.

E-9-1-1 110

E-9-1-1 ALS Defibrillator OR 110

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Here is lead I from ECGs 1 and 2 shown side-by-side to highlight the change in axis from borderline right to completely normal. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ). Answer : Bedside ultrasound!

E-9-1-1 117

E-9-1-1 Coronary STEMI ALS 117

REBEL EM

JANUARY 25, 2024

What They Did: Design: Randomized, controlled, blinded-outcome trial Sites: Three emergency departments in Denmark Duration: October 9, 2019 to May 26, 2021. Patients : Compared standard of care to serial US plus stand care in patients with dyspnea. to −0.66) and −1.66 (95% CI −2.09 to −0.78) and -1.97 (95% CI −2.70

ED 128

ED E-9-1-1 Emergency Department ALS 128

Dr. Smith's ECG Blog

JUNE 17, 2024

Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage. C Examination notable for diaphoresis, 1+ bilateral lower extremity edema, regular heart rate and rhythm, and no signs of respiratory distress with normal breath sounds. What do you think? In fact, Kosuge et al. Stein et al.

E-9-1-1 141

E-9-1-1 ACS Emergency Department Coronary 141

Dr. Smith's ECG Blog

AUGUST 14, 2024

R waves 6 through 9 have no preceding P waves and are suspiciously regularly spaced. Impulses E, F, G, H, and I were blocked. Progress in Biophysics and Molecular Biology , 120 (1–3), 164–178. Science Translational Medicine , 9 (400). Janssen, P. & Fedorov, V. link] Li, N., Hansen, B. Ignozzi, A. Zakharkin, S.

E-9-1-1 100

E-9-1-1 OR ALS 100

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Learning Point: 1. Smith's ECG Blog — the evolution of an acute OMI is not necessarily static — but may be "dynamic". For examples of this phenomenon — See My Comment in the February 14, 2018 — July 21, 2020 — and December 22, 2022 posts in Dr. Smith's ECG Blog ). Figure-1: Comparison between the first 3 ECGs in today's case.

E-9-1-1 114

E-9-1-1 Coronary EMS ED 114

EMS 12-Lead

APRIL 28, 2022

Initial vital signs include: NIBP 99/58 HR 150-160 (trend) RR 10 (spontaneous, but shallow) SpO2 86 (RA) BBS CTA The initial rhythm strip is attached: Figure 1 There is a wide complex tachycardia of varying morphology, amplitude, and R-R cycle length. A prominent vertical scar, however, is noted at the sternum.

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

REBEL EM

AUGUST 30, 2023

Epidemiology 1 to 2.4 cases per 100,000 people ( Zimmerli 2010 ) More common in males with M:F of 3:1 Rate is also increasing due to increased number of spinal procedures Typically affects adults, with most cases occurring in patients over 50 years old. Other pathogens include: E. Often used interchangeably with osteomyelitis.

E-9-1-1 102

E-9-1-1 ALS ED OR 102

REBEL EM

NOVEMBER 30, 2023

Article: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM. Guideline-based and restricted fluid resuscitation strategy in sepsis patients with heart failure: A systematic review and meta-analysis [published online ahead of print, 2023 Aug 9]. References: Vaeli Zadeh A, Wong A, Crawford AC, Collado E, Larned JM.

E-9-1-1 120

E-9-1-1 ALS ACS ICU 120

Don't Forget the Bubbles

NOVEMBER 29, 2023

Intensive Care Research , 1 (3-4), pp.60-64. This blog, like the paper cited, is dedicated to him. Tragically, several attempts at resuscitation upon arrival at the emergency department were unsuccessful. This article is based on: Mayberry, H., Burgart, A.M. and Kanaris, C., Intubated, awake, and paralysed: a never event.

E-9-1-1 135

E-9-1-1 Emergency Department ED CPR 135

Dr. Smith's ECG Blog

NOVEMBER 11, 2024

The ECG shows sinus rhythm with a rate of about 78 and 2:1 AV conduction along with right bundle branch block and left anterior fascicular block. 2:1 block is a special case, because the tracing lacks successive PR intervals. I have labeled the P waves below for ease of reference: P waves 8 and 9 both conduct to the ventricles.

OR 75

OR E-9-1-1 Coronary 75

Dr. Smith's ECG Blog

OCTOBER 1, 2024

== MY Comment , by K EN G RAUER, MD ( 8/30 /2024 ): == I was sent the ECG shown in Figure-1 — knowing only that the patient was being seen in the ED ( E mergency D epartment ). Figure-1: The initial ECG in today's case. After seeing ECG #2 — Can you explain: i ) Why no negative P wave was seen in lead V1 of ECG #1? —

E-9-1-1 106

E-9-1-1 STEMI ED OR 106

Dr. Smith's ECG Blog

JANUARY 13, 2024

Spikes 2, 3, 4, 5, 7, 8, and 9 all occur either during or immediately after P waves which should never happen. He had routine follow up for the mitral valve clip approximately 1 month after the procedure, and the note indicated recognition of atrial lead dislodgement on the CT scan from the hospitalization a few weeks prior.

E-9-1-1 108

E-9-1-1 OR Emergency Department 108

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. Figure-1: The initial ECG in today's case — obtained after ROSC.

E-9-1-1 92

E-9-1-1 Defibrillator CPR STEMI 92

Dr. Smith's ECG Blog

JULY 22, 2023

A prior ECG from 1 month ago was available: The presentation ECG was interpreted as STEMI and the patient was transferred emergently to the nearest PCI center. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% He denied chest pain or shortness of breath.

E-9-1-1 73

E-9-1-1 CAD OR STEMI 73

REBEL EM

FEBRUARY 5, 2024

Sites: Investigators recruited patients at 31 French emergency departments at university and nonuniversity hospitals Duration : June 1, 2009 to March 31, 2015. Recurrence of pneumothorax within 1 year. They concluded that more research of higher quality is needed to strengthen the evidence in favor of one technique over the other.

E-9-1-1 104

E-9-1-1 ALS Emergency Department OR 104

REBEL EM

SEPTEMBER 13, 2023

Features Urticaria and pruritis Rapid onset (1-2 hours) IgE Dependent (Type I Hypersensitivity) Reactions An allergen cross-links two or more IgE molecules on mast cells or basophils and initiates a signal cascade leading to degranulation. of people who take NSAIDs ( Nzeako 2010 ). of people who take NSAIDs ( Nzeako 2010 ).

Frozen Plasma 104

Frozen Plasma Allergic Reaction FFP Plasma 104

Dr. Smith's ECG Blog

OCTOBER 15, 2022

LBBB also has discordant STE in V1-V3 and STD in V5, 6 -- I will not be giving examples of this, as they are readily available all over the blog. Missed LAD Occlusion with Swirl, peak trop 80 ng/mL (equivalent to 80,000 ng/L), diagnosed as "Non-STEMI" Case 9. As always, LAD OMI need not meet STEMI criteria and usually does NOT!

OR 52

OR E-9-1-1 STEMI 52

REBEL EM

JULY 3, 2023

Investigators enrollend 660 patients in 9 years in 5 EDs; or approximately 6 patients per month; or 1 patient per /month for each ED. The primary purpose of Table 1 is to provide a summary of baseline characteristics and demographics of the study population, presenting data in a clear and organized manner.

E-9-1-1 98

E-9-1-1 EMR Emergency Department ED 98

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Post cath ECG: Now there are hyperacute T-waves again, and recurrent ST depression in V2 This ECG would normally diagnostic of OMI until proven otherwise No further troponins were measured, but it looks like there is recurrent OMI Next day: A CT Coronary Angiogram was done (CTCA) CARDIAC MORPHOLOGY AND FUNCTION: 1. IMPRESSION: 1.

Coronary 107

Coronary E-9-1-1 STEMI ACS 107

EMDocs

MAY 11, 2024

CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis? On exam, the patient opens eyes to voice, has extraocular movements intact, is unable to speak, and has 0/5 strength in all extremities. The patient was intubated for acute hypercapnic and hypoxic respiratory failure and airway protection.

EMS 89

EMS E-9-1-1 ALS OR 89

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

Over the last 1 week, her exertional chest pain became worse both in intensity and triggering threshold. She underwent exercise echocardiogram in mid October where she exercised for nearly 7 minutes on the standard Bruce protocol and had typical anginal pain and shortness of breath. But the patient has active chest pain. link] Shvilkin et al.

E-9-1-1 82

E-9-1-1 ACS ALS OR 82

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

To me, it was clearly atrial flutter with 1:1 conduction. Continue Eliquis 5mg BID, should be continued for 3 months == MY Comment , by K EN G RAUER, MD ( 9/18 /2024 ): == I found the following aspects of today's case of special interest. Why did Dr. Smith immediately say the rhythm was AFlutter with 1:1 AV conduction?

E-9-1-1 67

E-9-1-1 ALS OR ED 67

FOAMfrat

MAY 19, 2024

This blog is an example of exactly that. While transporting to the emergency department, the patient’s mother informed me that PDCD affects less than 1 in 50,000 individuals and is more common in males than females. But this would be an impossible expectation, especially in the environment in which we practice medicine.

E-9-1-1 98

E-9-1-1 ALS Emergency Department EMT 98

Dr. Smith's ECG Blog

NOVEMBER 14, 2019

I’ve taken th e l ead V 3 examples in Figure-1 from previous cases posted on Dr. Smith’s ECG Blog : T OP in Figure-1 — Despite marked ST elevation in this lead V3 — this is not T-QRS-D, because there is well-defined J-point notching ( BLUE arrow ). Although simple to define — this finding may be subtle!

E-9-1-1 52

E-9-1-1 OR ED 52

EMDocs

FEBRUARY 7, 2024

Despite a plateau in overall union membership of around 10% in 2023 1 , major labor actions shook the U.S. 2023 October 9. 2012 Feb 1;4(1):127-57. Author: Ryan Leone, MSc, Medical Student at Columbia University // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit) What’s the issue? Frequency : In the U.S.,

E-9-1-1 77

E-9-1-1 Ambulance OR 77

Dr. Smith's ECG Blog

MAY 26, 2023

This was a very complex case and the details are too much for an ECG Blog, but suffice it to say that, s hortly thereafter, the patient had an asystolic arrest and was resuscitated. Learning Points: 1. For clarity in Figure-1 — I've reproduced and put these first 2 ECGs together. Figure-1: The first 2 tracings in today's case.

Overdose 91

Overdose E-9-1-1 Coronary OR 91

Dr. Smith's ECG Blog

MAY 30, 2023

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. 1 mg of Atropine was given and the heart rate increased transiently to 60. Atropine usually works in junctional rhythm with a narrow complex 9. What is the atrial activity? What to do?

E-9-1-1 86

E-9-1-1 STEMI Coronary OR 86

Dr. Smith's ECG Blog

SEPTEMBER 27, 2019

These were read by our fantastic chief of radiology, Gopal Punjabi, who has his own blog on Spectral CT: [link] [link] Here is the image using Spectral CT : It is much more obvious with this technique! For clarity — I’ve put these first 2 tracings together in Figure-1. Figure-1: The first 2 ECGs in this case ( See text ).

E-9-1-1 52

E-9-1-1 OR ED 52

Dr. Smith's ECG Blog

DECEMBER 10, 2019

The pain is described as located in the midsternal area, radiating to the right arm, described as 8-9/10 and worse with deep inspirations. In the evening, he became diaphoretic and complained of 9/10 continuous chest pain. Today’s case provides perhaps the best example of s erial E CG e volution of this elusive entity.

E-9-1-1 52

E-9-1-1 Coronary OR ACS 52

Dr. Smith's ECG Blog

MARCH 22, 2022

After having learned about benign T wave inversion pattern years ago on this blog, and having seen many cases on this blog and in my practice since then, I instantly recognize this as BTWI, a fairly common normal variant. see below for more info on this) 1. POINT # 2: The E CG F indings C hanged !

E-9-1-1 52

E-9-1-1 ALS OR 52

Dr. Smith's ECG Blog

JANUARY 30, 2019

The pattern of STE and STD reminded us of Brugada Type 1 morphology. Smith comment: 1) Brugada ECG may have ST shifts in limb leads as well as precordial leads. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% The article is edited by Smith. F (rectal).

E-9-1-1 52

E-9-1-1 CAD STEMI OR 52

Dr. Smith's ECG Blog

SEPTEMBER 10, 2023

References: 1) See this study showing an association between morphine and mortality in Non-STE-ACS: Meine TJ, Roe M, Chen A, Patel M, Washam J, Ohman E, Peacock W, Pollack C, Gibler W, Peterson E. As you take another LOOK at ECG #1 — What is the relevance of the findings that I've labeled in Figure-1 ?

E-9-1-1 82

E-9-1-1 ACS STEMI Coronary 82

Dr. Smith's ECG Blog

MAY 5, 2022

Hyperkalemia and ST Segment Elevation, Post 1 A Tragic Case, related to the last post A patient with chest pain and ST Elevation in V1 and V2 You MUST recognize this pattern, even if it is not common ST Elevation. Figure-1: I've reproduced the initial ECG in today's case. Fluid resuscitation was initiated. What is it?

E-9-1-1 52

E-9-1-1 OR STEMI ED 52

REBEL EM

AUGUST 21, 2023

This trial aimed to assess whether targeted therapeutic mild hypercapnia (TTMH) applied during the initial 24 hours of mechanical ventilation in the ICU can enhance neurological outcomes at the 6-month mark, as compared to standard care, which involves targeted normocapnia (TN). Paper: Eastwood G, et al. N Engl J Med. Epub 2023 Jun 15.

Critical Care 98

Critical Care E-9-1-1 CPR ALS 98

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

4 important features that indicate acute right hear strain: 1. In this study, (quote) "negative T waves in leads III and V 1 were observed in only 1% of patients with ACS compared with 88% of patients with APE (p less than 0.001). They found that only 11% of PE had 1 mm T-wave inversions in both lead III and lead V1, vs. 4.6%

E-9-1-1 52

E-9-1-1 ACS ALS OR 52