Resuscitated from ventricular fibrillation: what is the ECG Diagnosis?
A reader (someone in training) sent me this ECG, and asked for my interpretation.Clinical info: "The patient was found down in cardiac arrest, defibrillated with ROSC in the field, was unconscious on arrival. Attached is the initial ED ECG.""I will provide details and outcome to come after your impression." Here is the EKG: Here is my interpretation: Sinus at a rate of about 80, RBBB, LAFB, ST Elevation in aVL, reciprocal ST Depression in II, III, aVF. No precordial ST Elevation, but STE often does not show in precordial leads when there is LAD occlusion with RBBB and LAFB. Proxim...
Source: Dr. Smith's ECG Blog - May 3, 2016 Category: Cardiology Authors: Steve Smith Source Type: blogs
IABP in action
IABP – monitor screenshot
Green tracing: ECG. White tracing: Respiration. Red tracing: Intra arterial blood pressure. Yellow tracing: Pulse oximetry. Displays on right side, from top to bottom: Heart rate, respiratory rate, blood pressure, oxygen saturation (SPO2).
Intra aortic balloon pump (IABP) or intra aortic balloon counterpulsation is used to augment the cardiac output and reduce the afterload to the heart. Classic indication for IABP is cardiogenic shock. It can be either in the setting of acute myocardial infarction, cardiac surgery or in a person undergoing high risk percutaneous coronary intervention. The I...
Source: Cardiophile MD - April 28, 2016 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology Source Type: blogs
Research and Reviews in the Fastlane 129
This study looks at CMAC DL vs CMAC VL and found that 1st pass success rate was not statistically significantly different. The most important insights in this trial are in the discussion where the authors note a high number of protocol violations:
“This may demonstrate that emergency intubation is a dynamic process, and that plans may change second-to-second based on new information gained immediately before or during tracheal intubation.”
Airway management is a complex process and it’s unlikely that we’ll ever have a study looking at one particular facet that has a profound effect on success rates....
Source: Life in the Fast Lane - April 6, 2016 Category: Emergency Medicine Authors: Anand Swaminathan Tags: Airway Cardiology Education Emergency Medicine Pediatrics Resuscitation EBM literature R&R in the FASTLANE recommendations research and reviews Source Type: blogs
"Shark fin" ECG in I, aVL, V4 and V5. Which artery? Hint: patient is in shock and was put on ECMO
This was contributed by Rohin Francis (Twitter: @MedCrisis), a cardiologist from England and FOAM enthusiast.CaseA 55 year old lady initially presented to hospital with an acutely ischaemic arm. An embolic occlusion of her brachial artery was diagnosed by CT and treated with anticoagulation. The following day she developed sudden severe chest pain. This ECG was obtained:Sinus rhythm.The rather alarming appearance of the QRST may be mistaken for a broad complex QRS but, in fact, her QRS complex can be clearly seen in V2, V3 and II and is narrow. What has manifested as triangular complexes is actually huge ST segment...
Source: Dr. Smith's ECG Blog - March 25, 2016 Category: Cardiology Authors: Steve Smith Source Type: blogs
What, besides large anterior STEMI, is so ominous about this ECG?
This article by Widimsky illustrates the danger of this finding:See these cases:Chest Pain and Right Bundle Branch BlockTreatments:1. Aspirin 325 mg2. Ticagrelor 180 mg3. Atorvastatin 80 mg (small studies support this)4. Heparin bolus5. Fluid challenge6. Because cardiogenic shock is likely to get worse, even after reperfusion (because myocardial stunning lasts many days), we intubated the patient.7. Vecuronium paralysis8. Ketamine sedation (to avoid affecting hemodynamics)9. K replacement.10. Should have cardioverted, but did notBy this time, the cath team was ready.A proximal LAD thrombotic occlusion was opened. &nb...
Source: Dr. Smith's ECG Blog - March 21, 2016 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Middle-Aged Woman with 3 days of Chest pain and Posterolateral Injury on the ECG
A middle-aged woman called 911 for burning chest pain and dyspnea. Here is her prehospital ECG:There is clearly acute myocardial injury with ST elevation in high lateral leads.The computer did not read STEMI, but medics were very suspicious and brought the patient to the critical care area.An ED ECG was immediately recorded:There is sinus tachycardia. There is clear high lateral and posterior injury.The cath lab was activated.History:The patient states she has had 3 days of burning chest pain and SOB. She thinks she has the flu and states that she is currently pain free.These are her first vital signs:101...
Source: Dr. Smith's ECG Blog - March 18, 2016 Category: Cardiology Authors: Steve Smith Source Type: blogs
DM / DNB Cardiology Entrance Mock Test 8
This study found that though it is often associated with coronary artery disease (CAD), it can also occur in those without significant CAD. It was not specifically associated with disease of right coronary artery disease.
This cardioinhibitory response may be a manifestation of the Bezold-Jarisch reflex. Bezold-Jarisch reflex inhibits sympathetic activity (sympathetic withdrawal) and increases parasympathetic activity, resulting in bradycardia, which may be associated with vasodilatation, nausea and hypotension. Bezold-Jarisch has been described in the setting of inferior wall infarction and coronary angiography. Origin...
Source: Cardiophile MD - January 26, 2016 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ Cardiology X-ray Featured Source Type: blogs
Inferior STEMI with AV Block, Cardiogenic Shock and ST elevation in V1
This is a case I had with one of our superb internal medicine/emergency medicine residents, Marco Salmen, MD. He wrote it up for this blog, with some help from me.CaseAn elderly woman called 911 for acute onset of nausea and chest pain of 30 minutes duration. A prehospital ECG was identical to this first ED ECG: Rhythm: There is a regular, narrow complex bradycardia, with ventricular rate of ~43 bpm. There appear to be P-waves at irregular intervals, but without relationship to the QRS. Thus, there is third degree (complete) AV block. The escape is narrow, thus junctional or from th...
Source: Dr. Smith's ECG Blog - January 20, 2016 Category: Cardiology Authors: Steve Smith Source Type: blogs
Shouldn't need Modified Sgarbossa rule for cath lab here, but it does make the diagnosis certain!
I received this case from a medic (in quotes):"Wanted to know your thoughts on this ECG." "Woman in early 70's with acute chest pain for the past 30 min. Vomited once. Looked sick. Pale and diaphoretic. Had hx of MI with stents one month ago. No old ECG to compare with. I interpreted the ECG as a LBBB with sinus tach but some thought it was VT. We administered Aspirin and transported to hospital." Here is the prehospital ECG and the only one he sent:Smith comments:There are clear P-waves (see arrows in image below) with a regular rhythm. The computer interpretation is clearly wrong; it is clearly sin...
Source: Dr. Smith's ECG Blog - January 16, 2016 Category: Cardiology Authors: Steve Smith Source Type: blogs
Rupture of Aneurysm of the Sinus of Valsalva Presenting as Cardiogenic Shock and Severe Ischemia
This was sent by Nick Jubert, MD, one of our fine EM residency graduates who works at a facility without a cath lab, so has to transfer patients who need a cardiac cath:Steve, Really interesting case I saw this morning, thought I’d send it your way. CaseA 60 year old female with a history of HTN, DM, hyperlipidemia presented via EMS with crushing central chest pain radiating to her neck, 7/10. Here is the EMS EKG: There is RBBB, with ST elevation in aVR and V1, and diffuse, marked, ST depression in I, II, aVF, aVL and V3-V6. This is severe subendocardial ischemia.I immediately activated the cath lab giv...
Source: Dr. Smith's ECG Blog - January 11, 2016 Category: Cardiology Authors: Steve Smith Source Type: blogs
Research & Reviews in the Fastlane 108
This study had 25 Navy Corpsmen, 6.7% of whom had previously performed pneumothorax on a real patient, needle decompress cadavers at both the 2nd ICS mid-clavicular line and the 5th ICS anterior axillary line. The misplacement rate at the 5th ICS was 22.0% ves 82.0% at the 2nd ICS (p < 0.001). The participants placed the needles closer to the target spot in the 5th ICS and rated it easier. When will decompression at the 5th ICS anterior axillary line become the default spot?
Recommended by Lauren Westafer
Systems and Administration
Jena AB, et al. Physician spending and subsequent risk of malpractice claims: observa...
Source: Life in the Fast Lane - November 11, 2015 Category: Emergency Medicine Authors: Jeremy Fried Tags: Administration Airway Cardiology Education Emergency Medicine Intensive Care Pre-hospital / Retrieval R&R in the FASTLANE Resuscitation Trauma critical care EBM literature recommendations research and reviews Source Type: blogs
If CTO is safe , should we allow all PCI ineligible ATO to evolve as CTO ?
Hot debate in STEMI
Acute total obstruction (ATO) of coronary artery is an emergency .Opening it by pharmacological or catheter is the standard ( logical ) protocol.However, time plays a crucial role in this coronary re-perfusion game.It can either be a sure shot of success or end up in total spoilsport. One more issue as important as time is from the overflowing scientific data fired by different regulators in conflicting directions (Also called knowledge) .
What to do with STEMI coming late ?
ATO with cardiogenic shock is an absolute emergency at any time.
Symptomatic ATO other than CS beyond 24 hrs stil...
Source: Dr.S.Venkatesan MD - October 20, 2015 Category: Cardiology Authors: dr s venkatesan Tags: acute coroanry syndrome cto chronic total occlusion open artery hypothesis ato vs cto management stemi Source Type: blogs
Save more lives in CCU with CPAP : Should be used liberally in LVF to prevent the onset of cardiogenic shock !
Coronary care units are the place, where acute myocardial infarction patients are housed. Thrombolysis is still the primary modality of treatment world over .Large infarcts, , impending or established cardiogenic shock are major source for mortality .
Acute left ventricular failure (LVF ) in CCU has to be swiftly managed in whatever phase of MI .Standard regimen of sedation, diuretics, Nitro glycerine, and Dobutamine are administered are often not good enough .( Its true many of these patients are to be taken for emergency PCI ) Still, medical management of LVF has a huge impact on the outcome.
While cath lab pro...
Source: Dr.S.Venkatesan MD - August 23, 2015 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs
Sudden Severe SOB and ST Segment Elevation: What is the Diagnosis and Treatment?
This case was contributed by Mark Sandefur, MD, one of our great third year residents, with a lot of additions, editing, and commentary by Smith.CaseA middle aged man with history of MI presented by EMS for the sudden onset of difficulty breathing. Prehospital, he was in respiratory distress and tachypneic, and was tachycardic to 130. SpO2 was 85% on high flow oxygen. Prehospital ECG (not available) was read as ***ACUTE MI*** and the cath lab was activated by EMS. He was agitated upon arrival. Lung exam revealed good air movement but no rales or wheezes (clear). &nbs...
Source: Dr. Smith's ECG Blog - August 22, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs
A young healthy male with epigastric pain and tachycardia
A young previously healthy man with no past medical history presented with a complaint of epigastric pain for a few days. He had no other complaints. He appeared well. Vitals were HR 107, BP 140/70, sats 98%, RR 20, Temp 36.7. He had a normal exam except for the mild tachycardia.The physician was planning on discharging the patient except for the tachycardia, which prompted him to obtain an ECG. He was startled by the result. He showed it to me:QRS 105 ms. Sinus tach. RV conduction delay (R'-wave in V1)Diffuse ST depression, diagnostic of ischemia.Not knowing anything else about t...
Source: Dr. Smith's ECG Blog - August 14, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs
