Tachycardia and hyperkalemia. What will happen after therapy with 1 gram of Ca gluconate and some bicarbonate?
A 20-something type, 1 diabetic presented by EMS with altered mental status.  Blood pressure was 117/80, pulse 161, Resp 45, SpO2 100 on oxygen.Here is the 12-lead ECG:Wide complex tachycardiaWhat do you think?The providers thought that this wide QRS was purely due to (severe) hyperkalemia.  They treated with 4 ampules (200 mL) of bicarb and 1 gram of calcium gluconate. Note: 1 g of calcium gluconate is insufficient. 1 g of calcium chloride has 3x as much calcium and is indeed a good start.His pulse on the monitor suddenly went down to 140 and another 12-lead ECG was recorded:Sinus tachycardia at a rate...
Source: Dr. Smith's ECG Blog - February 20, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

Acute dyspnea in an older woman, is it OMI?
 Written by Willy FrickA woman in her 90s with a history of end stage renal disease and complete heart block status post dual chamber pacemaker presented from home with acute onset dyspnea. ECG is shown below.What do you think?The ST and T wave abnormalities jump off the page, but let ' s set that aside just for a moment to review the tracing systematically. The rate is 60 (and remember, slower heart rates are often seen in OMI). Close inspection revealsventricular pacing spikes, best seen in aVL. Many ECG readers will not comment any further on rhythm once ventricular pacing has been identified, but it...
Source: Dr. Smith's ECG Blog - February 18, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs

A young man with persistent palpitations
Written by Pendell MeyersA teenager was playing basketball when he suddenly developed palpitations and lightheadedness. He presented soon afterward at the Emergency Department with ongoing symptoms. Mentation and blood pressure were normal. He had no chest pain or shortness of breath. Heart rates on the monitor fluctuated from 180-250 bpm.Here is his triage ECG:What do you think?The ECG shows an irregularly irregular polymorphic wide complex rhythm, with some R-R intervals as short as approximately 220 msec or even less. But it is not disorganized enough to be polymorphic ventricular tachycardia. The rhythm is therefo...
Source: Dr. Smith's ECG Blog - February 16, 2024 Category: Cardiology Authors: Pendell Source Type: blogs

A 40-something with 2 hours of new active chest pain and new T-wave inversion
A 41-year-old male who presents to the emergency department with chest pain. Patient reports approximately 2 hours prior to arrival he developed a sharp chest pain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling.  No shortness of breath. No recent travel. No cough. No cardiac history. Here is his ECG:He had a previous ECG on file, from many years prior:What do you think?There is new T-wave inversion in inferior leads and V3-V6.  This is recorded during pain.  The faculty physician thought this is highlylikely to be ACS.  ...
Source: Dr. Smith's ECG Blog - February 14, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

Vomiting, Diarrhea, and " Bubbles in my Chest "
A 60-something complained of vomiting, diarrhea overnight, and " bubbles in my chest " that started just prior to calling 911.He had this ECG recorded prehospital:Smith interpretation:There are hyperacute T-waves in III and aVF, and reciprocal STD in aVL with a reciprocally inverted T-wave in aVL.  There are also hyperacute T-waves in V3 and V4.  There is STD in V1 and V2.  So it appears to be diagnostic of OMI, but it is hard to figure out what exact territory and artery.  It could be a proximal RCA with both inferior OMI, posterior OMI (pulling ST down in V1/V2), and RV OMI causing large ischemic...
Source: Dr. Smith's ECG Blog - February 12, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

See What PM Cardio Digitization can do with this ECG
This was a patient with chest pain. The ECG was faxed to a cardiologist. But it was very difficult for him to see.He showed this to me the next day.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 (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - February 11, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

Chest pain with anterior ST depression: look what happens if you use posterior leads.
Don ' t forget to watch theWebinar: Smith and Pendell Meyers interpret ECGs for OMI or not OMI on Monday Feb 12 at 11 AM U.S. Central time.  Register here:https://zoom.us/webinar/register/7617067094184/WN_LMN0vPb1Rz-HZu12K-QuYQWritten by Jesse McLarenA 65 year old with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented with 3 days of fluctuating chest pain, which was ongoing at triage. What do you think? Do you need posterior leads?There ’s atrial flutter with controlled ventricular response, a non-specific intra-ventricular conduction delay, borderline right axis, normal R wave...
Source: Dr. Smith's ECG Blog - February 9, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

A teenager involved in a motor vehicle collision with abnormal ECG
Written by Pendell MeyersA teenager was involved in a motor vehicle collision and presented to the Emergency Department via EMS altered and potentially critically ill. He was intubated for altered mental status. Chest trauma was suspected on initial exam. Here is his initial ECG around 1330:What do you think?The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. It is very unlikely that a previously healthy teenager would have such disease of the conduction system, bringing up the possibility of blunt cardiac injury in this clinical setting.Trauma CTs showed a " mi...
Source: Dr. Smith's ECG Blog - February 6, 2024 Category: Cardiology Authors: Pendell Source Type: blogs

What will happen if you implement the Queen of Hearts in your Hospital?
This case was sent by Dr. Jean-christophe Reiters, an interventionalist in Belgium.  He has been following the blog for 4 years.He has now implemented the Queen of Hearts in his hospital.  He wanted to share one of the first cases.A 55 year old with no previous cardiac history presented with 3 hours of chest pain.  The pain was persistent and reportedly still present at the time of the ECG.Here is the EKG:Smith: It looks like a reperfused inferior lateral OMI.  (Inverted T-waves in inferior and lateral leads, with reciprocally upright (pseudo-hyperacute) T-waves in I and aVL.  But if the pain ...
Source: Dr. Smith's ECG Blog - February 2, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

What is this ECG finding? Do you understand it before you hear the clinical context?
Written by Pendell MeyersFirst try to interpret this ECG with no clinical context:The ECG shows an irregularly irregular rhythm, therefore almost certainly atrial fibrillation. After an initially narrow QRS, there is a very large abnormal extra wave at the end of the QRS complex. These are Osborn waves usually associated with hypothermia. There is also large T wave inversion and long QT.Clinical context:A man in his 50s was found down outside in the cold, unresponsive but with intact vital signs. He was intubated on arrival at the ED for mental status and airway protection due to vomiting. Initial vitals included...
Source: Dr. Smith's ECG Blog - February 2, 2024 Category: Cardiology Authors: Pendell Source Type: blogs

Chest pain, ST Elevation, well-formed Q-waves, and infarction with peak hs troponin I over 1000 ng/L. Is it OMI?
A 60-something male presented stating that he had had chest pain that morning which awoke him from sleep but then resolved after several minutes.  He has had similar pain in the past which he attributed to acid reflux.  He has a history of untreated hypertension.He is pain free now.His systolic BP was 200.The patient is pain free at the time of this ECG:What do you think?The conventional algorithm said:SINUS RHYTHMANTERIOR MYOCARDIAL INFARCTION , PROBABLY RECENT [40+ ms Q WAVE AND/OR ST/T ABNORMALITY IN V3/V4]***ACUTE MI*** There are well-formed Q-waves in precordial leads.  The T-waves are inverted.&nb...
Source: Dr. Smith's ECG Blog - January 31, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

A 40-something with chest pain
This was sent by Sam Ghali @EM_RESUSA 44 year old man presented with chest painThe tech came running with the ECG as the computer called " STEMI! "The conventional computer algorithm read: ***STEMI***The cardiologist overread was: " ST Elevation. Consider Anterolateral Injury or Acute Infarct "What do you think?Sam sent this to me and asked: " What do you think, Steve? "My answer:--Tough one!--But I ' m going to stick my neck out and say " Not OMI "--STE in V2 has a near " saddleback " configuration, and that is a sign of false positive STE.--Tell me the outcome!He responded:--You nailed it!--The Saddleback in V2 isexactly...
Source: Dr. Smith's ECG Blog - January 29, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

Chest pain and a computer ‘normal’ ECG. Therefore, there is no need for a physician to look at this ECG.
This article,published this month (!), tells us that we physicians do not need to even look at this ECG until the patient is placed in a room because the computer says it is normal:Validity of Computer-interpreted “Normal” and “Otherwise Normal” ECG in Emergency Department Triage PatientsI reviewed this article for a different journal and recommended rejection and it was rejected.  There were zero patients in this study with a " normal " ECG who had any kind of ACS!  This defies all previous data on acute MI which would show that even undetectable troponins do not have a 100% negative predictive value.&nb...
Source: Dr. Smith's ECG Blog - January 27, 2024 Category: Cardiology Authors: Jesse McLaren Source Type: blogs

Acute chest pain in a patient with LVH and known coronary disease. What does the ECG show?
A 40-something with severe diabetes on dialysis and with known coronary disease presented with acute crushing chest pain.Here is his ED ECG:What do you think?There is a flat and downsloping ST segment in V2 and V3.  This could be due to posterior OMI.  Is there an old ECG for comparison?Here is the most recent previous ECG:Indeed, there was some normal ST elevation in V2 and V3, discordant to a relatively deep S-wave which could be due to some LVH.Here is another previous ECG:So it looks like a posterior OMI.2 years prior he had an angiogram which showed 90% proximal stenosis of the circumflex.  It...
Source: Dr. Smith's ECG Blog - January 25, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs

What kind of AV block is this? And why does she develop Ventricular Tachycardia?
Discussion: The initial ECG in today ' s case is pathological for any patient, especially for a 50-year old previously heathy female. Extensive conduction system abnormalities can have various causes (ischemia, genetic, infectious, amyloid, etc). Usually the medical history will provide clues to the cause. Even though the primary suspicion was not ischemic heart disease, a CT angiogram was performed, and it revealed normal coronary arteries. This ruled out coronary disease as the cause of conduction system disease. When assessing patients with early onset high grade conduction disorders and ventricular tachydysrhythmi...
Source: Dr. Smith's ECG Blog - January 23, 2024 Category: Cardiology Authors: Magnus Nossen Source Type: blogs