Wide complex tachycardia, resistant to cardioversion
Dr. Smith's ECG Blog
by Steve Smith
9h ago
An elderly dialysis patient presented with chest pain. She has poor LV function. Previous echo 4 months ago (confirmed with ED bedside echo): The estimated left ventricular ejection fraction is 30%.   Severely decreased LV function. Regional wall motion abnormality-inferior, inferolateral, septum, anterolateral, anterior and apex, lateral. Here is her ECG: Regular Wide Complex Tachycardia.   What do you think? What do you want to do? --Regular means it can't be atrial fibrillation --Most regular wide complex tachcardia are VT, especially if the patient has poor LV ..read more
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Handed this ECG from triage. What will you do?
Dr. Smith's ECG Blog
by Pendell
3d ago
 Written by Sean Trostel MD I returned to my desk after seeing a patient and saw this screening ECG sitting on my desk to be read. The patient was a man in his 80s with chief complaint listed as: "hyperglycemia, weakness, ground level fall." ECG #1 @ 15:30 What do you think? Slow, irregular rhythm - likely slow atrial fibrillation Very wide QRS measuring ~180 ms in some leads, not fitting LBBB morphology and wider than vast majority of LBBB No signs of OMI, no modified Sgarbossa criteria Peaked T-waves in the lateral precordial leads Together, these findings are ..read more
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An undergraduate who is an EKG tech sees something. The computer calls it completely normal. How about the physicians?
Dr. Smith's ECG Blog
by Steve Smith
5d ago
This was sent by an undergraduate (not yet in medical school, but applying now) who works as an ED technician (records all EKGs, helps with procedures, takes vital signs) and who reads this blog regularly. Edited by Smith He also sent me this great case. A 63 year old man with a history of hypertension, hyperlipidemia, prediabetes, and a family history of CAD developed chest pain, shortness of breath, and diaphoresis after consuming a large meal at noon.  He called EMS, who arrived on scene about two hours after the onset of pain to find him hypertensive at 220 systolic.  He arr ..read more
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Early repol or anterior OMI?
Dr. Smith's ECG Blog
by Pendell
1w ago
Chest Pain – Benign Early Repol or OMI? Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain. He reported substernal chest pressure with radiation to his left arm that started at work several hours prior to arrival and had somewhat improved since onset. He noted that his father died from a heart attack in his early 50s prompting his presentation to the emergency department. Here is the initial ..read more
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Crushing Chest Pain and Can't see OMI on the ECG? Just give morphine, right?
Dr. Smith's ECG Blog
by Willy Frick
1w ago
Submitted anonymously, written by Willy Frick A man in his late 30s with a 10 pack-year smoking history presented with acute substernal chest pressure radiating into his left shoulder with associated nausea, vomiting, and diaphoresis which began suddenly while he was getting ready for work. He described it as feeling like "a bulldozer on [his] chest." He rated it 10/10 intensity. With no additional information, the HPI puts this patient at very high pre-test probability of OMI. ECG 1 What do you think of his presenting ECG? Queen of Hearts interpretation with explainability: Alth ..read more
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Two patients with diffuse ST depression and reciprocal ST elevation in aVR: do either/both/neither have Occlusion MI?
Dr. Smith's ECG Blog
by Jesse McLaren
1w ago
Written by Jesse McLaren, with additions from Smith Two patients presented with chest pain with ST elevation in aVR, and the same final ECG interpretation: “repolarization abnormality, severe global ischemia (LM/MVD).” Do either, both, or neither require the cath lab? Patient 1: 75 year old, history of aortic stenosis, with recent cough accompanied by shortness of breath and chest pain, then syncopal episode. There’s sinus tachycardia, first degree AV block, borderline right axis, and normal voltages. There’s significant ischemic STD in I/II/II/aVF and V4-6 (maximal V5-6) with rec ..read more
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Why is this patient in shock?
Dr. Smith's ECG Blog
by Steve Smith
2w ago
This ECG was handed to one of my partners who was working in triage.   The conventional algorithm stated "Nonspecific ST-T wave abnormalities." What do you think? My partner immediately diagnosed inferior OMI.  (Do you see: the subtle STE in III and aVF?  The terminal QRS distortion in aVF?  The ST depression in aVL?  The ST depression in V2-V4 of posterior OMI?  There is terminal T-wave inversion in III with terminal upright T-wave in aVL -- This strongly suggests reperfusion IF the patient's symptoms have subsided.  But they had not ..read more
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A young man with palpitations.
Dr. Smith's ECG Blog
by Steve Smith
2w ago
A 30-something presented with chest pain, palpitations, and SOB.  He has had similar symptoms for 4 years, but has never been evaluated. Here is his presenting ECG, which was sent to me real time, along with the 2nd ECG below: Regular Narrow Fast without P-waves.  PSVT.   It is very difficult to tell if this is:  1) AVNRT or  2) orthodromic AVRT  (Orthodromic AVRT = WPW with orthograde conduction down the AV node and retrograde up an accessory pathway) See Ken Grauer's discussion below in differentiating AVNRT from orthodromic AVRT. Shortly after arrival, t ..read more
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Do you need to be a trained health care professional to diagnose subtle OMI on the ECG?
Dr. Smith's ECG Blog
by Steve Smith
2w ago
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
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Sudden shock with a Nasty looking ECG. What is it?
Dr. Smith's ECG Blog
by Steve Smith
3w ago
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
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