Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?
Submitted and written byDestiny Folk MD, peer reviewed by Meyers, Smith, Grauer, McLarenA man in his early 30s with no significant past medical history was brought to the ED by EMS after being found unresponsive by a friend. EMS arrived and found him awake and alert. He complained of generalized weakness and left lower extremity numbness. He reported that 12 hours prior to arrival he used fentanyl and cocaine. He reported difficulty walking and felt as if his left leg was “asleep.” He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. On arrival in the ED, he wa...
Source: Dr. Smith's ECG Blog - May 5, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Why is there inferior ST elevation, and would you get posterior leads?
Written by Jesse McLaren, with comments by Smith and Grauer A 75 year-old presented with 8 hours of epigastric pain and one episode of vomiting. They had a history of gallstones but no cardiac history. Vitals were normal except a heart rate of 55, and below is the triage ECG.What do you think?There ’s bradycardia but it is not sinus: while the P wave is upright in I it is inverted in II so it is a low atrial rhythm. Conduction is otherwise normal, axis is indeterminate, and voltages are normal. There is early R wave progression with R>S in V1-2, primary ST depression in V2-3, and a Q wave with hyperacute T wave i...
Source: Dr. Smith's ECG Blog - May 3, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A man in his 40s who really needs you to understand his ECG
Written by Pendell MeyersA man in his 40s presented for " left sided chest pain sudden onset yesterday when sneezing and coughing that is worsened with inspiration. " He also complained of associated SOB, dizziness, jaw pain, and back pain, which he described as " muscle spasms. " He has also had rhinorrhea and cough for 1 week. Also, left hand numbness today. He went to urgent care for evaluation. An ECG was performed there (unavailable) which reportedly was abnormal, so EMS was called to urgent care to take him to the ED.On EMS arrival, they noted the patient vomited then became unresponsive. He was reportedly...
Source: Dr. Smith's ECG Blog - May 1, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 40s with RUQ abdominal pain
Conclusion:In hemodynamically stable patients with chest pain, sinus tachycardia aids in the identification of patients unlikely to have type I MI, especially in those with HR greater than 120 bpm.===================================MY Comment by KEN GRAUER, MD (4/28/2020):===================================Insightful case presented by Drs. Goss and Meyers highlighting the importance of recognizing the ECG signs of acute PE. I focus my comments on further dissecting some of these " tell-tale " ECG features.The " theme " of today ' s case was "pattern recognition". Like the ECG diagnos...
Source: Dr. Smith's ECG Blog - April 28, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
RBBB and LAFB: Is there a " concordance " of the ST segment in inferior leads? Is the ST depression in V3 due to RBBB only?
Conclusion:There was indeed OMI of a very small vessel. It may have been due to an embolism. No matter the etiology, it did manifest on the ECG and was easily, but mistakenly, attributed to RBBB and high voltage.Learning Points:1. ST depression is only normal following an R ' -wave in V1-V3. If there is no R ' -wave, then ST depression should be considered ischemic.2. Make sure you identify the end of the QRS in any BBB before attributing deviations to the ST segment.3. Always compare with a previous ECG if one is available.===================================Comment by KEN GRAU...
Source: Dr. Smith's ECG Blog - April 26, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 60s with palpitations
Conclusion:The final tracing in Today ' s Case was obtained the day after the run of ATach that was caught on Telemetry. I found it interesting to compare this last ECG #4 — with the post-cardioversion ECG #2 — and then with QRS morphology in selected leads during full preexcitation that was seen in ECG #1 (these 3 tracings put together in Figure-4):Sinus rhythm is again present in ECG #4 (RED arrows in lead II). However, the PR interval is short — and delta waves are seen.Compared to ECG #2 — there is more preexcitation in...
Source: Dr. Smith's ECG Blog - April 24, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Chest pain, a ‘normal’ ECG, a'normal trop', and low HEART and EDACS scores: Discharge home? Stress test? Many errors here.
Written by Jesse McLaren, with comments from Smith and GrauerA 60 year old presented with three weeks of intermittent non-exertional chest pain without associated symptoms. ECG was labeled ‘normal’ by the computer (confirmed by the overreading cardiologist) and the high-sensitivity Troponin I was normal at a value of 11 ng/L (Abbott Alinity assay, where normal is<26 in males,<16 in females; this assay is nearly identical to the Abbott Architect high sensitivity assay). So the patient was low risk according to HEART and EDACS scores. Should this patient be discharged home? How about a stress test? ...
Source: Dr. Smith's ECG Blog - April 22, 2022 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
What do you think when you see ST elevation or ST depression on the monitor? (A lesson on High Pass filtering from Christopher Watford)
This has an explanation fromChristopher Watford, who is not only a paramedic with amazing EKG skills, but a math and computer wizard. @ECGWatford https://twitter.com/ecgwatford This patient was on a monitor, which showed this:The upper tracing is analogous to V5The lower is analogous to V1What do you think?The ST depression here is about 30% of the height of the R-wave. The ST Elevation is about 30% of the depth of the S-waveI wanted to show the residents how poorly this correlates with a 12-lead ECG, so we recorded one at the same time:The STE in V1 is less than 10% of the S-waveThe STD in V5 is...
Source: Dr. Smith's ECG Blog - April 20, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
What is this ST Elevation?
This patient was sent to the ED because of a potassium of 6.1 mEq/L and some acute renal insufficiency.He had an ECG recorded:This was brought to me for analysis. The computer read " Septal Myocardial Infarction "What do you think?There is saddleback ST Elevation and Q-waves in leads V1 and V2. Whenever I see a saddleback, or Q-waves in V1, V2, I look to see if the leads were placed too high. How would I know? By looking at the P-wave in lead V2, which should always be upright. Furthermore, the P-wave in lead V1 should almost always be biphasic up-down. In this ECG, the P-wave i...
Source: Dr. Smith's ECG Blog - April 17, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 60s with chest pain. Cardiologist refuses to take to the lab. Obvious STEMI, even with criteria. Yet final diagnosis " NSTEMI " . This happens far too often.
Submitted by Anonymous MD, edits by MeyersA man in his 60s with past medical history of multiple sclerosis and hypertension was brought in by EMS from home for chest pain thatstarted acutely just prior to arrival. He rated the pain at 9/10, describes as pressure, radiates towards the left arm with associated shortness of breath, diaphoresis and had one episode of emesis. He did not have a prior history of CAD or other cardiac disease. His pain improved to 6/10 after EMS gave him 3 sprays of sublingual nitroglycerin and 324 mg of aspirin. Prehospital ECGs:What do you think?Both ECGs are diagnostic of acute LAD OMI...
Source: Dr. Smith's ECG Blog - April 15, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
A man in his 50s with acute chest pain and history of prior MI
Written by Pendell MeyersA man in his 50s with prior history of anterior MI with LAD stent presented with acute chest pain similar but more intense than his last MI. He presented around midnight with pain that had started around 9pm the night before. He had taken NTG at home with no improvement, and immediately received morphine on arrival at the ED for severe chest pain (a very bad idea if your accuracy for finding OMI on ECG is low, since ongoing pain will be your last chance to identify those with ongoing untreated OMI).Here is his triage ECG at 0012:What do you think? What is the differential of this ECG?There is sinus...
Source: Dr. Smith's ECG Blog - April 13, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
RBBB with STE in I and aVL. Will the angiogram tell you if this ECG represents Occlusion MI or not?
A middle aged male with history of STEMI and stents presented with one hour of chest pain.Here is his ED ECG:What do you think?Analysis: There is sinus rhythm with RBBB. There is ST Elevation in I and aVL which is discordant to the wide S-wave (a wide S-wave in lateral leads is a feature of RBBB). There is also some ST depression in lead V3 (inferoposterior OMI is suggested). There is no R ' -wave in V2 and so one would not expect the typical discordant ST depression and TW inversion that one often sees in V2. However, V3 does have an R ' -wave, and STD, but the T-wave isconcordantly positive, which...
Source: Dr. Smith's ECG Blog - April 11, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
A woman in her 30s with sudden chest pain, nausea, and diaphoresis. Was her cardiology management appropriate?
Case written and submitted by Brandon Fetterolf MD, edits by MeyersA woman in her early 30s with multiple autoimmune disorders including vasculitis presented with 2-3 hours of mid-left side chest discomfort with radiation to neck and left arm and associated with nausea, diaphoresis and dizziness. Initial ECG on presentation at 1554 (no prior for comparison):What do you think is happening to his 30s woman? The ECG shows NSR with a normal QRS except for poor R wave progression and pathologic QS-waves in V2-3. There is STE and hyperacute T waves in V2, I, and aVL with reciprocal STD in II, III, and aVF. This is...
Source: Dr. Smith's ECG Blog - April 8, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Diffuse ST Depression, with ST Elevation in aVR. Do you see the diagnosis?
This was texted to me from 2000 miles away. It is from a 30-something male with chest pain. There was worry for ischemia.What do you think?Is there any evidence of ischemia?No. There is not. All of the ST-T abnormalities are secondary to the abnormal QRS that is produced by pre-excitation. This is WPW.Notice the very short PR interval. Notice the obvious delta waves. Most, but not all, of the ST elevation and ST depression are discordant to the abnormal QRS, and are not excessively discordant.In contrast, in the ECG below, the discordant ST elevation and ST depression are...
Source: Dr. Smith's ECG Blog - April 5, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs
An asymptomatic man in his 50s with heart rate in the 160s - what is the diagnosis? How will you manage this?
Written by Pendell MeyersA man in his late 50s with history of CAD with CABG, COPD, smoking, cirrhosis, and other comorbidities presented for an outpatient scheduled stress test which had been ordered for some exertional shortness of breath, palpitations, and presyncopal episodes over the past few months. When he presented to the office for the stress test, his screening vitals before any test or intervention were remarkable only for a heart rate of 160 bpm. He denied any symptoms whatsoever.A 12-lead ECG was performed in the office:What do you think?The ECG shows a wide complex regular monomorphic tachycardia. I mea...
Source: Dr. Smith's ECG Blog - April 2, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
