An undergraduate (not yet in medical school) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly arrived at work and happened to glance down and see this previously recorded ECG on a table in the ED.  It was recorded at 0530: What do you think? The young ED tech immediately suspected LAD OMI. He interprets here: "This EKG is diagnostic of right bundle branch block and transmural ischemia of the anterior wall, most likely from an occlusion of the proximal LAD. There is a hyperacute distribution of T waves fro ..read more

A 60-something woman complained of sudden severe abd pain. She was found by medics agitated, hypotensive, diaphoretic, and in shock. There were 2 prehospital ECGs: What do you think? Smith: Uncertain supraventricular rhythm with PVCs. (See Ken Grauer's analysis below). There is "shart fin" in I and aVL, which is due to a combination of a large R-wave due to left anterior fascicular block plus downsloping ST elevation due to OMI.  There is reciprocal STD in inferior leads.  There is a rather large R-wave in lead V1 and a very large R-wave in V2, suggesting an atypical RBBB.&n ..read more

A patient was found down approximately 30 minutes after taking methamphetamine.  Bystander CPR.  Medics found patient in PEA arrest.  He was resuscitated into a perfusing rhythm.  He went in and out of arrest until arrival at the ED.   Here is the only prehospital 12-lead: Sinus tachycardia, somewhat wide QRS, Ischemia Here is the first ED ECG: What is the rhythm here? This ECG is pathognomonic of hyperkalemia, with wide QRS, very SHARPLY peaked T-waves, flat ST segments, RBBB pattern and large R-wave in aVR.   What does that say about the r ..read more

Written by Pendell Meyers and Steve Smith Here are two cases of middle-aged men with chest pain who had prehospital ECGs. Patient 1, ECG 1: What do you think?   Patient 2, ECG 2: What do you think? Queen of Hearts interpretation of ECG 1: Queen of Hearts interpretation for ECG 2: Interpretation of ECG 1 (OMI): Sinus rhythm, normal QRS, with easily diagnostic signs specific for inferior and posterior wall transmural ischemia, with the most likely etiology of course being acute coronary occlusion MI. Inferior T waves are hyperacute, with reciprocal negative hyper ..read more

Quiz The PM Cardio Queen of Hearts AI model for ECG interpretation from Powerful Medical is still in its early days.  Do you think you can outperform the toddler version of the AI model?  Version 2.0 will soon be available with four times the training data. The QoH groups ECGs into OMI and NOT OMI. Each category is subdivided into three levels of confidence.  Thus you can get a reading of NOT OMI (low, mid or high). Or you can get sa reading of OMI (low, mid or high).  In other words there are six outputs with NOT OMI high confidence on one end a ..read more

A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chest pain that is worse with exertion, which takes many minutes to resolve after resting and never occurs at rest.  It is associated with mild dyspnea on exertion.  At times the pain does go to his left neck.  It was present on arrival at triage but then resolved before bed placement in the ED. EKG from triage:   Here is his previous ECG: Normal ST Elevation Resident's interpretation: Reperfusion pattern/Wellens' with biphasic T waves in V2 and V3, and in ..read more

This was sent to me by an inpatient nurse who reads this blog but wants to remain anonymous. An inpatient rapid response was called for a patient with hypotension.   The patient was originally admitted for pneumonia and had been transferred out of the ICU a day prior. He had a history of HFrEF, HTN, and AML.  "When I arrived his blood pressure was 70s/40s and he was pale and profusely diaphoretic."  "He spoke Spanish but we did deduce that he had 7/10 chest pain radiating to the back."  "We couldn’t initially get a hold of the primary physician but our hospital allows ..read more

A 56 year old male with PMHx significant for hypertension had chest pain for several hours, then presented to the ED in the middle of the night. He reported chest pain that developed several hours prior to arrival and was 5/10 in intensity.  The pain was located in the mid to left chest and developed after riding his bike.   There was associated fatigue when symptoms developed and mild shortness of breath at onset of chest pain however that has since resolved.   The patient states he experienced similar 7/10 chest pain 2 days prior when he had to hurry to catch t ..read more

By Magnus Nossen This ECG is from a young man with no risk factors for CAD, he presented with chest pain. How would you assess this ECG? How confident are you in your assessment? What is your next step? Note: lead format is Cabrera I was sent this ECG in real time. The patient is a young adult male with chest pain. The chest pain was described as pressure like and radiation to both arms and the jaw. Symptoms were on and off. The pain was worse in the night and better when moving. The patient sought medical attention when the pain recurred for a second straight night accompanied by arm numbn ..read more

This case came from a friend whose sister was the patient. She knew I was interested in ECGs, so she took a photo of this one. A young woman presented with acute chest pain. This was her presenting ECG: What do you think? This is clearly Brugada phenotype.  There is downsloping ST Elevation in V1 and V2.  To an experienced interpreter, it is clearly not due to OMI.  And it is clearly Brugada phenotype. The conventional algorithm did not interpret Brugada.  In fact, it read: ** **ACUTE MI / STEMI ** ** The physicians caring for the patient activated the cath lab f ..read more