How will you save this critically ill patient? A fundamental and lifesaving ECG interpretation that everyone must recognize instantly.
Written by Pendell MeyersA woman in her 30s called EMS for acute symptoms including near-syncope, nausea, diaphoresis, and abdominal pain. EMS arrived and found her to appear altered, critically ill, and hypotensive. An ECG was performed:What do you think?Extremely wide complex monomorphic rhythm just over 100 bpm. The QRS is so wide andsinusoidal that the only real possibilities left are hyperkalemia or Na channel blockade. Hyperkalemia is by far more common.Indeed, further history revealed two missed dialysis sessions. And of course on exam she has a dialysis fistula.EMS reportedly gave 4 grams of calcium (unknown w...
Source: Dr. Smith's ECG Blog - February 22, 2024 Category: Cardiology Authors: Pendell Source Type: blogs

Three normal high sensitivity troponins over 4 hours with a " normal ECG "
Written byWilly FrickA 46 year old man with a history of type 2 diabetes mellitus presented to urgent care with complaint of " chest burning. " The documentation does not describe any additional details of the history. The following ECG was obtained.ECG 1What do you think?The ECG shows sinus bradycardia but is otherwise normal. There is TWI in lead III, but this can be seen in normal ECGs. No labs were obtained. The patient was given a prescription for albuterol and a referral to cardiology.Smith comment:No patient over 25 years of age with unexplained chest burning should be discharged without a troponin rule out, no matt...
Source: Dr. Smith's ECG Blog - January 5, 2024 Category: Cardiology Authors: Willy Frick Source Type: blogs

What do you think of this " Ventricular Bigeminy " ?
Written by Bobby Nicholson MD, with edits by MeyersA woman in her 50s with past medical history of heart failure, prior stroke, atrial fibrillation on Eliquis, lung cancer in remission, and CKD, presented to the emergency department for evaluation of cough and shortness of breath. EKG was obtained in triage and read as ventricular bigeminy. What do you think?On my first read of the EKG, I agreed with the initial interpretation. Pendell Meyers then recommended that I take a second look at the morphology of the QRS complexes. I think it was easiest for me to see in the rhythm strip, but there are clearly P waves in front of ...
Source: Dr. Smith's ECG Blog - November 19, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

Assessment and Scope of Practice
It’s never comfortable to be placed under a microscope. Especially when the dude looking through the microscope is The Rogue Medic, Tim Noonan. Tim’s a great dude, but he’s not the guy you want picking through your knowledge sock drawer. He’s thorough, he’s smart and he’s willing to analyze the details long after you and I have gone to bed. If you don’t already read Tim’s blog you should. He’s a fantastic EMS blogger. That being said, I wasn’t terribly excited when he posted a comment on my post “I’m Only An EMT Basic” announcing that his comments on the piece could be found over...
Source: The EMT Spot - November 9, 2022 Category: Emergency Medicine Authors: Steve Whitehead Tags: EMT Source Type: blogs

Unstable Angina still exists. It can be missed especially high sensitivity troponin is not used. Sometimes you can catch it on the ECG.
A 50-something woman with H/o HTN, ESRD, CAD S/p complex PCI to ostial LAD and ramus (10/2020) and CABG x3 (LIMA to LAD, SVG to OM, SVG to ramus)She complained of intermittent episodes of substernal chest pain, radiating to left shoulder, lasting 2-3 minutes.This had been worked up before at another ED on 3 occasions for the same chest discomfort.--The 1st time, she was " ruled out " with a point of care (POC) troponin <0.03 ng/mL.--The 2nd time, she was " ruled out " again with a POC troponin <0.03 ng/mL.--The 3rd time, she " ruled out " with a laboratory-based 4th generation troponin at 0.018 ng/m...
Source: Dr. Smith's ECG Blog - September 5, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

The Nihilistic AAP Bronchiolitis Guidelines
​Not only has the COVID-19 pandemic killed millions of people, but it has also caused disruptions in every imaginable aspect of our lives. One has been the seasonality of other diseases like influenza and respiratory syncytial virus infection. RSV infection is typically a winter disease, but here we are in the summer months and our pediatric emergency department is flooded with infants infected with RSV.I expressed concern about the 2014 American Academy of Pediatrics bronchiolitis guidelines three years ago. (EMN. 2019;41[1]:31; http://bit.ly/2TlwNj9.) Those comments have proven to have real-life clinical releva...
Source: M2E Too! Mellick's Multimedia EduBlog - August 5, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Does a Single Troponin below the 99th percentile URL Rule out Acute MI if the Chest pain is very prolonged?
A 66 y.o. male who presented for chest pain that started this AM when he woke up, and has  persisted throughout the day prompting him to call 911. He says the pain is dull in nature and located across the chest, does not radiate, that it isworse with exhalation. He denies worsening with activity or positioning.  He endorses SOB and requested to sit up. He says this has not happened to him before. He endorses cough productive of yellow sputum.  He denies any edema. Denies history of venous thromboembolism.  He endorses a 50 pack year history of smoking. He denies recent illness or recent s...
Source: Dr. Smith's ECG Blog - May 26, 2022 Category: Cardiology Authors: Steve Smith Source Type: blogs

Chest pain, shortness of breath, T wave inversion, and rising troponin in a young healthy runner.
In this study, 40 presumably healthy male marathon runners had their cardiac troponin and other findings measured before and after running a marathon. 39 pts (97.5%) had baseline cTnT values below the reference limit (less than 14 ng/L). 38 pts (95%) of participants had post-marathon cTnT concentration rise above this reference limit. The median post-marathon cTnT was 41 ng/L, and the 95th percentile concentration was 90 ng/L. None reported " cardiac symptoms " after the race.See this single post for many examples of BTWI:Understanding this pathognomonic ECG would have greatly benefitted the patient.More cases involving BT...
Source: Dr. Smith's ECG Blog - May 19, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.
 Written by Pendell Meyers with edits by SmithA man in his 60s called EMS apparently for shortness of breath. EMS found him in distress and hypoxemic requiring 4 L nasal cannula to maintain oxygen saturation greater than 93%.Here is his triage ECG:What do you think?An old ECG was available on file, from 2 years ago:RBBB, otherwise normal.The triage ECG is diagnostic of life threatening hyperkalemia (sodium channel blockade would also produce this pattern, but the patient was not known to be on any sodium blocking medications). There is the very common brugada pattern STEMI mimic seen in V1 and partially in V3 and aVR....
Source: Dr. Smith's ECG Blog - January 16, 2022 Category: Cardiology Authors: Pendell Source Type: blogs

This ECG Pattern Told the Story When the Patient Could Not
 Submitted by Spencer Lord MD, written by Alex Bracey with edits by Meyers and SmithA patient presents as a transfer from an outside facility. On arrival, he appeared air hungry, volume overloaded, and agitated. EMS was not available for a history at the time and the patient was unable to provide any details regarding his circumstances. During the initial minutes of his resuscitation the following ECG was performed:This ECG is pathognomonic. What is it?Sinus bradycardia with first degree AV blockWide, bizarre QRS complexes with STE in V1 and aVRPeaked T waves in I, II, V4-V6QRS duration is nearly 200 ms.There is a lar...
Source: Dr. Smith's ECG Blog - July 2, 2021 Category: Cardiology Authors: Bracey Source Type: blogs

May 2021: The Asphyxiants that Cause Pulmonary Toxicity
​The American Association of Poison Control Centers reported more than 37,000 exposures to gas, fumes, and vapors in 2019, and those were the most common exposures in pediatric deaths. Toxicity from gas, fume, and vapor exposures can be categorized by their mechanism: simple asphyxiants, pulmonary irritants, and systemic asphyxiants.Simple AsphyxiationSimple asphyxiants work by displacing oxygen from ambient air. Patients may be exposed to these chemicals by huffing. A 2010 survey reported that more than two million adolescents in the United States ages 12-17 reported using inhalants at least once, including noble ga...
Source: The Tox Cave - April 30, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

What happens if you do not recognize this ECG instantly?
Written by Pendell MeyersA young man in his 20s with history of end stage renal disease and dialysis presented for acute chest pain. His last dialysis was 4 days ago. He was very hypertensive and short of breath, but oxygen saturation was normal.Triage ECG:What do you think?Pathognomonic for severe, life threatening hyperkalemia. QRS widening, PR interval prolongation (I believe those are P waves best seen in V1 and V2, but it matters not), and peaked T waves are apparent.  There is also a large R-wave in aVR, which is typical of severe hyperkalemia.Prior ECG on file from 12 days ago:Baseline LVH with repolarization a...
Source: Dr. Smith's ECG Blog - October 21, 2020 Category: Cardiology Authors: Pendell Source Type: blogs

A patient with chest pain and ST Elevation in V1 and V2
A 56 year old male complained of chest pain and called 911.They recorded a prehospital ECG:As you can see, at the top it says ***Meet ST Elevation MI Criteria***The medics activated the cath lab prehospital.It is a pathognomonic ECG.What is it?This is hyperkalemia, severe.  Surprisingly, there appear to be P-waves, which are often extinguished when the K is so high.Severe hyperkalemia often presents with STE in V1 and V2, often with a Brugada-like morphology (tall R in V1, or rSR ' ; downsloping ST segment; negative T-wave.  There is a very wide QRS and very peaked T-waves.  Especially in V4 and V5, T-waves ...
Source: Dr. Smith's ECG Blog - September 4, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs

Bread, paper, and other indigestible objects
Olivia posted this incredible story of wheat-free release in the comments on this blog some time back. Her story so powerfully encapsulates how far off course health can go by consuming this thing called “wheat,” that I thought it was worth sharing with everybody again. During her wheat-consuming days, Olivia was clearly suffering body-wide inflammation and other effects that were being ineffectively “treated” by her doctor, effects largely due to the indigestible or only partially-digestible proteins from the seeds of grasses AKA wheat. As often happens, she managed to reverse the entire collection...
Source: Wheat Belly Blog - April 29, 2020 Category: Cardiology Authors: Dr. Davis Tags: Open gluten-free grain-free grains wheat belly Source Type: blogs

Another Shark Fin. With a twist.
I was reading stacks of ECGs for a study, without any clinical information.I came across this one and immediately recognized it and knew the diagnosis (Pendell did too when I sent it to him):There is a Shark Fin!What is the diagnosis?But this is not the kind Shark Fin we usually see, which is due to STEMI! This ECG is pathognomonic for severe hyperkalemia.  Wide QRS, large R-wave in aVR, Brugada-like ST Elevation in V1-V3 with inverted T-waves, extremely peaked T-waves (in many leads).I went to the chart to find the case:56 y.o. type 1 diabetic presented for evaluation of hyperglycemia. He had stopped t...
Source: Dr. Smith's ECG Blog - April 24, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs