A man in his 60s with syncope and ST depression. What does the ECG mean?
Written by Sean Trostel MD, peer reviewed by Meyers, Smith, Grauer, etc.A man in his 60s with a history of severe alcohol use disorder and epidural abscess on long-term ciprofloxacin presented to the emergency department after an episode of syncope while standing in line at a grocery store.He did not have chest pain.Here is his triage ECG: What do you think?My interpretation:Sinus rhythm, normal QRS, widespread wavy ST depression leading into late T/U-waves with very prolonged QT. No evidence of OMI. QTc/QUc is in the range of 630 msec.What is the most likely cause of the patient ’s ECG findings, and wha...
Source: Dr. Smith's ECG Blog - October 25, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Does this T wave pattern mean anything?
Written by Michael Doyle DO and Timothy Palmieri MD. Edited by Bracey, Meyers, Grauer, and SmithA 50-something-year-old female with a history of an unknown
personality disorder and alcohol use disorder arrived via EMS following cardiac arrest with return
of spontaneous circulation. The described rhythm was an irregular, wide complex
rhythm. By EMS report, open pill bottles were found nearby at the scene, including quetiapine, fluoxetine, hydroxyzine, and gabapentin. She was successfully revived
after several rounds of ACLS including defibrillation and amiodarone.On arrival to the ED the patient was intubated with normal vi...
Source: Dr. Smith's ECG Blog - October 23, 2023 Category: Cardiology Authors: Bracey Source Type: blogs
VT? Or Supraventricular tachycardic rhythm with aberrancy?
A 70 something male presented in severe respiratory distress.The patient had altered mental status and so he was prepared for intubation. Before intubation, he became hypotensive.On the monitor patient had wide-complex tachycardia. The following 12-lead was obtained:What do you think?Differential is ventricular tachycardia versus supraventricular tachycardia with aberrancy versus sinus tachycardia with a aberrancy. There are possible P waves in lead II. But these could be an extension of the QRS, so sinus tach is not certain. Certainty could come with the use of Lewis leads. Much easi...
Source: Dr. Smith's ECG Blog - October 21, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Four patients with chest pain and ‘normal’ ECG: can you trust the computer interpretation?
Conclusions are identical to those of Dr. McLaren, namely:It isnot safe toavoid interrupting emergency physicians— simply because prior to the QOH (Queen Of Hearts) AI application — no computer interpretation of " normal " from an ECG of a patient with new or recent CP symptoms could be relied on. Emergency physiciansmustbe interrupted to take a quick look atall ECGs of patients who present with new or recent CP.Emergency physicians should (and can!) be expected with training to be able to identify non-stemi OMIs that elude the computer. It is essential that they be ab...
Source: Dr. Smith's ECG Blog - October 19, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A 20-something woman with cardiac arrest.
The patient is a 20 something female. She is healthy with no known cardiac disease. She was admitted to the neurology department due to headache and vomiting. She was found to have a viral CNS infection. A few days into her hospital stay she developedchest discomfort and the following ECG was recorded. What do you think? Why such large T-waves? Are these hyperacute T-waves? Are these ECG changes related to the CNS infection perhaps? What disease processes would you put on your list of differential diagnoses?When I saw the ECG of this patient I saw that there was definitely something " off " . I didn ' t get...
Source: Dr. Smith's ECG Blog - October 18, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Repost from Saturday Oct 14: The Queen gets it right with a better image
This is a case I posted Saturday, October 14.This ECG was texted to me after the fact with no information. What do you think?This is the ECG that I used for the post. It is high quality screenshot of a pdf:I had said that the Queen said this is Not OMI with low confidenceHowever, the image that had been texted to me and submitted to the Queen was not this one above. It was this one below: (photo of computer screen, lower quality):This is the image for which the Queen interpreted " Not OMI with Low Confidence "After posting, I wanted to getexplainability for the ECG, and I was unable to get the explainability fr...
Source: Dr. Smith's ECG Blog - October 17, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
This ECG was handed over at triage. See how the Queen of Hearts AI does with these explainability images.
Submitted by anonymous, written by Pendell MeyersI was at triage when this ECG was presented to me.What do you think?Here ' s what the Queen of Hearts thinks:Note that the Queen has " HIGH " confidence that this is OMI. As noticed by the AI,if the patient presented with chest pain, then even this subtle ECG is diagnostic of OMI. Specifically, this ECG is diagnostic of acuteLAD OMI, with hyperacute T waves likely in V3 and V4, very small but abnormal STE in V2-V4 (because of its there is a lot of STErelative to the very small QRS), and there is also some terminal T wave inversion in V4 which may suggest some elem...
Source: Dr. Smith's ECG Blog - October 15, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
This ECG was texted to me after the fact with no information. What do you think?
This ECG was texted to me with no other information, with this quote: " You will see this in the Queen of Hearts. " I assumed it was in real time.The Queen said " Not OMI with low confidence "What do you think?The conventional algorithm said: SINUS RHYTHMABNORMAL QRS-T ANGLE [QRS-T AXIS DIFFERENCE> 60]ABNORMAL ECG This was my response: " I am not certain that I agree with the queen on this one. Be careful with it. Notice that the Queen has low confidence. "Why am I worried? The T-waves are quite tall. Although most hyperacute T-waves are bulky, wide, fat and symmetric in propo...
Source: Dr. Smith's ECG Blog - October 13, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
What clinical scenario fits best?
Below are 4 ECGs from the same patient. Accompanying the ECGs is some clinical information. Look at the ECGs and consider the timeline and other information. At the bottom will be five alternative clinical scenarios to explain the findings.Which one do you think fits better with the ECGs and their timeline? The patient is a 60 something female. She was admitted to the hospital with clinical signs of infection. She was febrile and hypotensive at presentation. As part of her work up in the ED an ECG was recorded.What do you think?ECG#1 - day 1The above ECG shows sinus rhythm with a narrow QRS and normal axis. There is B...
Source: Dr. Smith's ECG Blog - October 12, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Should we activate the cath lab? A Quiz on 5 Cases.
Imagine you just started your ED shift. It ' s a busy Friday afternoon. Triage is backed up, and 10 minutes into your shift one of the ED nurses brings your several ECGs that has not been overread by a physician. All of the patients presented with chest pain, and they are all in triage.Which, if any, of these patients has OMI, with myocardium at risk and need for emergent PCI?ECG#1ECG#2ECG#3ECG#4ECG#5See outcomes of all 5 below, with the Queen of Hearts AI Bot interpretation.YOU TOO CAN HAVE THE PM Cardio AI BOT!! (THE PM CARDIO OMI AI APP)If you want this bot to help you make the early diagnosis of OMI and...
Source: Dr. Smith's ECG Blog - October 8, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
What is the infarct artery? What does the post PCI ECG show? What does the convalescent ECG show?
What is the infarct artery? I usually don ' t ask this question, as it is rarely relevant to the decision to activate the cath lab. This is one case where it made a difference: Right Ventricular MI seen on ECG helps Angiographer to find Culprit LesionNevertheless, 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. He called 911. Here is the prehospital ECG.What do you think?I think it looks like an inferior posterior OMI. The medics thought so too and activated the cath lab from the prehospital.The Qu...
Source: Dr. Smith's ECG Blog - October 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
An interesting rhythm strip. What is this rhythm?
By Magnus Nossen, from NorwayI was shown this print out of a rhythm strip from a patient on telemetry. I was asked what ' s going on? There are four leads shown (II, dV2, V1 and V5). The three images beneath one and other are consecutive rhythm strips each 10 seconds long. The patient was on telemetry due to acute MI. Can you correctly describe what ' s going on in this interesting rhythm strip?The tracing begins with sinus rhythm with a right bundle branch block pattern. P-waves are not easily discerned in the first beats, but they are present superimposed on the T wave of the preceding QRS. The P wave superimposed on top...
Source: Dr. Smith's ECG Blog - October 3, 2023 Category: Cardiology Authors: Magnus Nossen Source Type: blogs
Expert human ECG interpretation and/or the Queen of Hearts could have saved this patient's anterior wall
This is a re-post of an excellent case from 2021. See it again now, along with our new Queen of Hearts functionality. We ' ve come a long way in 2 years! And the pace only quickens.A man in his mid 60s with history of CAD and stents experienced sudden onset epigastric abdominal pain radiating up into his chest at home, waking him from sleep. He called EMS who brought him to the ED. He had active chest pain at the time of triage at 0137 at night, with this triage ECG:What do you think?I sent this ECG, without any text at all, to Dr. Smith, and he replied: " LAD OMI with low certainty. V3 is the one that is convincing. "&nbs...
Source: Dr. Smith's ECG Blog - October 1, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
Proportionality and Serial ECGs Make the Diagnosis. What does the Queen say?
This case comes from Jason Winter, of The Facebook Clinical Electrocardiology ECG Page.
A 60-something woman called EMS for chest pain.
Here is her first prehospital ECG:What do you think?There is very low voltage in the precordial leads, with a total QRS amplitude of only 3.5 mm in V2 and 4 mm in V3. In spite of this low voltage, there is ST elevation (as measured at the J-point and relative to the PQ junction, and as measured by the computer and shown on the right), of 0.54 mm in V2 and0.65 mm in V3. The ST/QRS ratios in V2 and V3 are, respectively, 0.154 and 0.162. These are a hi...
Source: Dr. Smith's ECG Blog - September 29, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 40s with acute chest pain. What do you think?
Sent by anonymous, written by Pendell Meyers, reviewed by Smith and GrauerA man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chest pain. He was eating lunch when he had sudden onset chest pressure, 9/10, radiating to his back, with sweating and numbness in both hands.Triage ECG:What do you think?It ' s a very " fun " ECG, with initial ectopic atrial tachycardia (negative P waves in inferior leads conducting 1:1 with the QRSs), followed by spontaneous resolution to sinus rhythm. In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteri...
Source: Dr. Smith's ECG Blog - September 29, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
