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Source: Dr. Smith's ECG Blog
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Total 473 results found since Jan 2013.
A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith. Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A 50-something with Regular Wide Complex Tachycardiaa: What to do if electrical cardioversion does not work?
Case submitted by anonymous. Written by Smith. Ken ' s piece at the bottom is excellent.A 50-something presented with sudden onset palpitations 8 hrs prior while sitting at desk at work. He had concurrent sharp substernal chest pain that resolved, but palpitations continued.Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Past medical history includes coronary stenting 17 years prior. A brief chart review revealed his most recent echo in 2018, with LV EF 67%, “very small” inferior wall motion abnormality.Initial ED ECG:What do you think?This wa...
Source: Dr. Smith's ECG Blog - September 20, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
50 year-old in remote rural community with chest pain and ‘normal’ ECG
Submitted by anonymous, edited by Jesse McLarenThe first person " I " and " me " is this anonymous sender. A 50 year old presented to the emergency department of a
remote rural community (where the nearest cath lab is a plane ride away) with
one hour of mild chest pain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. What do you think, and how would you
manage the patient?There ’s normal sinus rhythm, normal conduction, normal axis,
normal R wave progression and normal voltages. There’s clear T wave inversion
in III/aVF, which is reciprocal to subtle ST elevation and h...
Source: Dr. Smith's ECG Blog - September 8, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
A middle-aged man with acute chest pain.
A 50-something male had onset of chest pain 1 hour prior to ED arrival. It is constant, 9/10, left-sided CP that radiates into left arm and jaw. Endorses some associated SOB, but denies back pain, fever, cough, chills, leg swelling, or other new symptoms. Has never had this before. Takes metoprolol for HTN. Here is the triage ECG:What do you think?This was not identified as OMI by either the conventional algorithm nor the triage faculty physician.Smith: I think leads V3 and V4 are highly concerning, and all but diagnostic, for acute LAD occlusion. I would activate the cath lab, or at least look f...
Source: Dr. Smith's ECG Blog - September 1, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
75 year old dialysis patient with nausea, vomiting and lightheadedness
Written by Jesse McLaren A 75 year-old patient with diabetes and end stage renal
disease was sent to the ED after dialysis for three days of nausea, vomiting,
loose stool, lightheadedness and fatigue. RR18 sat 99% HR 90 BP 90/60, afebrile. Below is the 15 lead ECG. What do you think? There ’s normal sinus rhythm, normal conduction, normal axis,
normal R wave progression and normal voltages. There’s subtle inferior ST
elevation with straightening of the ST segment, reciprocal ST depression and T
wave inversion in aVL, and ST depression in V2. This is diagnostic of
infero-posterior OMI, but it is falsely n...
Source: Dr. Smith's ECG Blog - August 19, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Chest pain and T wave inversion, NSTEMI?
Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLarenA 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. The nurse alerted the MD because the patient was still symptomatic, diaphoretic and “looking unwell”. What do you think? ECG interpretation: sinus rhythm, normal conduction (PR, QRS, and QTc), normal axis, delayed R-wave progression, and normal voltages. There ’s primary TWI inferiorly (aVF and III) and V6, with reciprocal tall T-wave in lead I/aVL, and a Q wave in III. The...
Source: Dr. Smith's ECG Blog - August 10, 2023 Category: Cardiology Authors: Jesse McLaren Source Type: blogs
Lecture by Smith: Selected Cases of Occlusion MI (OMI), or not, on the ECG
This may be my best lecture yet. I gave it virtually to the Kaiser group.You can access it also on the " Lectures and Podcasts " link on the Banner above.https://drive.google.com/file/d/1SSe2AmEyfkrQhRJt1FGmVxvnt3g3c4BN/view?usp=drive_link===================================MY Comment, by KEN GRAUER, MD (8/6/2023):===================================Brilliant talk by Dr. Smith on the state of the art addressing the “need for OMI — and the fallacy of STEMI ”. For skeptics (including cardiologists) — Any questions about “Who is Dr. Smith?” are compellingly answered by the several...
Source: Dr. Smith's ECG Blog - August 6, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
OMI Pocket Guide
📕OMI Pocket Guide TheOMI Pocket Guide (https://omiguide.org) is a user-friendly online resource designed to help healthcare professionals learn how to recognize subtle signs of acute coronary occlusion on the ECG which represent occlusion myocardial infarctions (OMI). Learning to recognize OMIs is an important clinical skill because it helps identify the subpopulation of " NSTEMIs " who are likely to be found with total thrombotic occlusion at the time of cardiac catherization.Although there are more criteria to consider when looking for OMIs compared to STEMIs, anyone can learn them, and this guid...
Source: Dr. Smith's ECG Blog - August 3, 2023 Category: Cardiology Authors: Mark Hellerman Source Type: blogs
A man in his 70s with weakness and syncope
DiscussionBrugada Type 1 ECG changes are associated with sudden cardiac death (SCD) and the occurrence of ventricular dysrhythmias. Patients that develop a Type 1 pattern without any precipitating or provoking factors have a risk of SCD of 0.5-0.8% per year. In patients that only have this pattern induced by a sodium channel blocking agent have a lower rate of SCD (0 - 0.35% per year)[1]. Drugs that have been associated with Brugada ECG patterns include tricyclic antidepressants, anesthetics, cocaine, methadone, antihistamines, electrolyte derangements, and even tramadol. [2]. Our patient had a Brugada Type ...
Source: Dr. Smith's ECG Blog - July 22, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
I was reading ECGs on the system when I came across this one, called " normal " by the conventional computer algorithm
I come in early for every shift to read the ECGs on the system that have not yet been " confirmed " . I came across this one:The computer calls is: " SINUS RHYTHM. NORMAL ECG "What do you think? Be VERY careful when the computer calls the ECG " Normal " . I saw the inferior ST depression (which is reciprocal to subtle STE in aVL) and the subtle ST depression in precordial leads and thought:" If this patient came in with chest pain, then it is an acute OMI. "So I looked on the computer. Turns out that it was a 50-something patient with no previous cardiac history who had called 911 for chest pain...
Source: Dr. Smith's ECG Blog - July 12, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
63 year old with " good story for ACS " but negative troponins.....
This was texted to me from a former resident, while working at a small rural hospital, with the statement:" I can ’t convince myself of anything here, but he’s a 63-year-old guy with prior stents and a good story for ACS. " (Chest pain or discomfort)What do you think?Here was my response:" Suspicious for inferior posterior OMI. Get serial ECGs "He then sent a previous from 4 years prior:" This is totally normal, which confirms that the first EKG does indeed represent OMI "Then the patient ' s chest pain resolved and he recorded another:The ST depression in aVL is gone and the T-waves are less hyperacu...
Source: Dr. Smith's ECG Blog - July 2, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Young Man with Very Fast Regular Wide Complex Tachycardia
EMS was dispatched for a 30-something male who feels his heart is racing. Sudden onset.The patient had no previous medical history.Vitals were normal except for a heart rate of 226.A prehospital 12-lead was recorded:There is a regular wide complex tachycardia. The computer diagnosed this as Ventricular Tachycardia.Is it definitely VT??The patient was given 6mg, then 12 mg, of adenosine, without a change in the rhythm.He arrived in the ED and had an immediate bedside cardiac ultrasound while this ECG was being recorded.The bedside ultrasound (video not available) reportedly showed only a slightly reduced LV func...
Source: Dr. Smith's ECG Blog - June 28, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
Wide complex tachycardia and hypotension in a 50-something with h/o cardiomyopathy -- what is it?
A 50-something male with unspecified history of cardiomyopathy presented in diabetic ketoacidosis (without significant hyperkalemia) with a wide complex tachycardia and hypotension.Bedside echo showed " mildly reduced " LV EF.Here is the ED ECG:What do you think?Analysis: there is a wide complex tachycardia. It is regular. There are no P-waves. The morphology is of RBBB and LAFB. The initial part of the QRS is very fast, suggesting that it starts in conducting fibers and not in myocardium. Thus, it is probably SVT with aberrancy (RBBB + LAFB) or it is posterior fascicular VT (which starts in the pos...
Source: Dr. Smith's ECG Blog - June 23, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
A man in his 50s with acute chest pain who is lucky to still be alive.
Sent by Magnus Nossen MD, written by Pendell MeyersA man in his 50s, previously healthy, developed acute chest pain. EMS was called, and they recorded the following ECG on scene at 13:16:What do you think?Below is the version standardized by PM Cardio appMeyers interpretation:Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). There is a relatively normal QRS yet there is STD maximal in V2-V4, which resolves from V4 to V6. The inferior leads may have a slightly full T wave (possibly hyperacute if compared to baseline which...
Source: Dr. Smith's ECG Blog - June 21, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
A man with chest pain off and on for two days, and " No STEMI " at triage.
Written by Kaley El-Arab MD, edits by Pendell Meyers and Stephen SmithA 61-year-old male with hypertension and hyperlipidemia presented to the emergency department for chest tightness radiating to the back of his neck that has been intermittent for the past day or two. Here is his triage ECG which was obtained at 20:34 during active pain.What do you think?This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 mm STE in III, and possibly 0.5 mm in aVF), but there is clear evidence of OMI findings on this ECG. Leads II, III, and aVF hav...
Source: Dr. Smith's ECG Blog - June 19, 2023 Category: Cardiology Authors: Pendell Source Type: blogs
