Ken Grauer, MD

OCTOBER 21, 2023

PEARL # 1: Although seeing an elevated Troponin would provide additional support for immediate cardiac catheterization — the clinical reality is that the initial Troponin reading will not always be elevated in patients with acute coronary occlusion ( See March 24, 2023 post in Dr. Smith's ECG Blog ).

Blog 102

Blog Chest Pain Ischemia STEMI 102

ECG Cases

JANUARY 29, 2019

In this CritCases blog Michael Misch takes us through a case of accidental hypothermia and cardiac arrest, reviewing the controversies in management as well as the guidelines for rewarming, the role of ECMO and the alterations to ACLS cardiac arrest medications, CPR and defibrillations.

Cardiac Arrest 52

Cardiac Arrest Defibrillator Blog 52

Dr. Smith's ECG Blog

JULY 25, 2024

But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. After cardiac arrest, I ALWAYS wait 15 minutes after an ECG like this and record another. See these related cases: Cardiac arrest, defibrillated, diffuse ST depression and ST Elevation in aVR.

Cardiac Arrest 110

Cardiac Arrest Ischemia Tachycardia Defibrillator 110

HCM Beat

JANUARY 7, 2023

Sudden cardiac arrest (SCA) has had a moment in the public eye this week. Damar Hamlin's misfortune shined a public light on the grim reality that we as HCM patients live with every day: the possibility we could suffer an SCA at any moment without warning.

Cardiac Arrest 52

Cardiac Arrest Cardiomyopathy Blog 52

Ken Grauer, MD

MAY 26, 2023

At some point ~1-2 hours after the initial ECG — the patient developed runs of VT, leading to cardiac arrest. ECG Blog #185 — Review of the P s, Q s, 3 R Approach for systematic rhythm interpretation. ECG Blog #271 — Reviews the concept of diffuse Subendocardial Ischemia. ECG Blog #316 — The patient died.

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Blog Ischemia STEMI Cardiac Arrest 78

HCM Beat

JANUARY 12, 2023

TMZ is reporting that singer Lisa Marie Presley, daughter of Elvis, suffered a cardiac arrest at her home and is now at a local hospital.

Cardiac Arrest 40

Cardiac Arrest Hospital Cardiomyopathy Blog 40

Ken Grauer, MD

MARCH 23, 2023

What is the cardiac rhythm shown in the long lead II rhythm strip? Figure-1: The initial ECG in today’s case — obtained from an elderly woman following successful resuscitation from cardiac arrest. ( These are reviewed in ECG Blog #343. I reviewed the concept of Echo beats in ECG Blog #239.

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Blog Tachycardia Arrhythmia Atrial Flutter 78

Ken Grauer, MD

APRIL 9, 2023

The Long Lead II Rhythm Strip: As always — I favor a systematic approach to rhythm interpretation, using the P s, Q s, 3 R memory aid ( See ECG Blog #185 ). As I have often emphasized — it takes a little time to get good at drawing laddergrams ( See ECG Blog #188 ). ECG Blog #108 — Reviews the concept of AIVR.

Blog 78

Blog Chest Pain Arrhythmia Cardiac Arrest 78

Dr. Smith's ECG Blog

JUNE 9, 2024

This is obviously severe hyperkalemia and the patient is near cardiac arrest. There was no IV access, so we obtained intraosseous (IO) access, but she arrested before we could give her all the calcium. Hyperkalemia and Cardiac Arrest Could you have prevented this young man's cardiac arrest?

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Cardiac Arrest Defibrillator Cardiac Function Tachycardia 133

Dr. Smith's ECG Blog

JUNE 27, 2024

A patient had a cardiac arrest with ventricular fibrillation and was successfully defibrillated. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. N Engl J Med [Internet] 2019;Available from: [link] Should all patients with shockable arrest be taken to angiography regardless of STEMI or No STEMI?

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Defibrillator Cardiac Arrest STEMI Chest Pain 91

Dr. Smith's ECG Blog

APRIL 6, 2018

Written by Pendell Meyers, with edits by Steve Smith Thanks to my attending Nic Thompson who superbly led this resuscitation We received a call that a middle aged male in cardiac arrest was 5 minutes out. He was estimated to be in his 50s, with no known PMHx. He arrived with chest compressions ongoing, intubated, and being bagged.

Cardiac Arrest 52

Cardiac Arrest Tachycardia Defibrillator ICU 52

Dr. Smith's ECG Blog

FEBRUARY 22, 2024

A woman in her 50s with dyspnea and bradycardia A patient with cardiac arrest, ROSC, and right bundle branch block (RBBB). HyperKalemia with Cardiac Arrest. Steve, what do you think of this ECG in this Cardiac Arrest Patient?" Is this just right bundle branch block?

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Cardiac Arrest Bradycardia Tachycardia Chest Pain 135

Heart Sisters

DECEMBER 31, 2023

The most-popular HEART SISTERS posts from 2023 were all over the map - from 'Struggle Care' to sweating, hanging up that iconic Red Dress, or cardiac arrest on the toilet!

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Article Cardiac Arrest Heart Disease Blog 87

Dr. Smith's ECG Blog

JULY 9, 2024

Written by Pendell Meyers A man in his 50s was found by his family in cardiac arrest of unknown duration. Meyers and Smith in the October 15, 2022 post of Dr. Smith's ECG Blog ). His family started CPR and called EMS, who arrived to find him in ventricular fibrillation. Restoration of sinus rhythm is evident in Figure-1.

Defibrillator 101

Defibrillator STEMI Cardiac Arrest Cardiogenic Shock 101

Dr. Smith's ECG Blog

FEBRUARY 2, 2024

See our other blog posts of hypothermia and Osborn waves -- Massive Osborn Waves of Severe Hypothermia (23.6 C), with Cardiac Echo -- A Pathognomonic ECG. His temperature was brought back to normal over time in the ICU. He was extubated and had normal neurologic function. He did well and was discharged.

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Cardiac Arrest Blog Atrial Fibrillation AFIB 132

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

NOTE: For those interested — I review in detail determination of the artifact “culprit extremity” in My Comment in the September 27, 2019 post of Dr. Smith’s ECG Blog. POINT #2: Overall QRS amplitude ( voltage ) is dramatically reduced in ECG #1. True Low Voltage is defined as a QRS amplitude of ≤5 mm in all limb leads.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JUNE 5, 2024

IMPRESSION: The finding of sinus bradycardia with 1st-degree AV block + marked sinus arrhythmia + the change in PR interval from beat #5-to-beat #6 — suggests a form of vagotonic block ( See My Comment in the October 9, 2020 post in Dr. Smith's ECG Blog ). As a result — an ICD may need to be considered in selected cases.

Chest Pain 106

Chest Pain Cardiac Arrest Blog Cardiomyopathy 106

Dr. Smith's ECG Blog

APRIL 2, 2024

I was there and said, "No, I think this is all due to severe chronic cardiomyopathy and cardiac arrest due to primary ventricular fibrillation, not due to ACS." _ Why did I say that? Here is the troponin profile overnight: This is consistent with cardiac arrest without acute coronary occlusion. The QRS is extremely wide.

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Tachycardia Pacemaker Cardiac Arrest Cardiomyopathy 129

Dr. Smith's ECG Blog

JULY 24, 2018

One hour later (labs not yet returned), here is the ECG recorded just after the team noticed a sudden wide complex with precipitous decompensation, just before cardiac arrest: Bizarre, Brady, and Broad (wide QRS). Unfortunately, this was not recognized at this time. I believe it was this point when hyperkalemia was first suspected.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Tachycardia ICU 52

Ken Grauer, MD

JULY 29, 2023

The ECG in Figure-1 was obtained from an 18-year old woman — who moments before been resuscitated from out-of-hospital cardiac arrest. Does this ECG in Figure-1 provide clue(s) to the etiology of this patient's cardiac arrest? I suspected the answer resides in the reason why an 18-year woman might have a cardiac arrest.

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Blog Cardiac Arrest Cardiomyopathy Hospital 145

Dr. Smith's ECG Blog

JULY 14, 2023

Two recent interventions have proven in randomized trials to improve neurologic survival in cardiac arrest: 1) the combination of the ResQPod and the ResQPump (suction device for compression-decompression CPR -- Lancet 2011 ) and 2) Dual Sequential defibrillation. First — Some thoughts on the post -resuscitation ECG.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 85

Dr. Smith's ECG Blog

JUNE 23, 2024

The electrophysiologist is a reader of Dr. Smith's ECG Blog. Simply by correlating the history of cardiac arrest with serial ECGs recorded after the event — it became obvious that the 60% lesion on cardiac cath, despite its surprisingly good TIMI 3 flow — was indeed the "culprit" artery that had spontaneously reperfused after the event.

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Chest Pain Cardiac Arrest Sudden Cardiac Death Stents 107

Dr. Smith's ECG Blog

OCTOBER 24, 2013

Appreciation of these subtle ECG findings could have helped to avoid a cardiac arrest and its resulting permanent disability 3. Ischemia on the ECG can be very subtle and is easily missed. Accurate interpretation requires a lot of skill, practice, and experience.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

Dr. Smith's ECG Blog

SEPTEMBER 12, 2023

Figure-2: A rapid method for estimating the QTc ( Figure from My Comment in the March 19, 2019 post in Dr. Smith's ECG Blog ). == Clinical Implications of a Short QTc: The differential diagnosis for today's tracing, with its short QTc ~360 msec. ) — but as can be seen, my estimate of ~360 msec.

Cardiac Arrest 71

Cardiac Arrest Blog Atrial Fibrillation AFIB 71

EMS 12-Lead

MARCH 30, 2024

TCP In Transit: A case reviewing transcutaneous pacing, false electrical capture, and re-arrest. Josh Kimbrell, NRP @joshkimbre Judah Kreinbrook, EMT-P @JMedic2JDoc This is the first installment of a blog series showing how transcutaneous pacing (TCP) can be difficult, and how you can improve your skills. Current 85mA.

Cardiac Arrest 124

Cardiac Arrest Pacemaker Pulmonary Bradycardia 124

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

This 80 year old with a history of CABG had a cardiac arrest. Now, it is true that shortly after a non-ACS cardiac arrest, there can be transient diffuse ST depression, but not ST elevation in a coronary distribution, and there should not be a wall motion abnormality. This is as clear a STEMI as you can get.

Cardiac Arrest 52

Cardiac Arrest STEMI Ultrasound Chest Pain 52

Ken Grauer, MD

OCTOBER 27, 2023

Given this patient's older age — if nothing "fixable" is found, she most likely has SSS ( S ick S inus S yndrome ) and will need a pacemaker ( See ECG Blog #342 for more on SSS ). See ECG Blog #188 for review on how to read and/or draw Laddergrams ). See ECG Blog #347 for more on dual-level AV Wenckebach ).

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Blog Pacemaker Bradycardia Arrhythmia 106

Ken Grauer, MD

JUNE 6, 2023

== P lease N OTE : After today — No new ECG Blog posts for 2- to -3 weeks. — I will also not be prompt in replying to emails. == All material on this ECG Blog site remains open! IF you scroll down a little on the right-hand column of this blog — You'll see a lot of icons. Figure-1: The initial ECG in today's case.

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Blog Pulmonary Hypertension Aortic 78

EMS 12-Lead

MAY 15, 2024

TCP in the ROSC Patient: False Electrical Capture at 75mA Josh Kimbrell, NRP @joshkimbre Judah Kreinbrook, EMT-P @JMedic2JDoc This is the second installment of a blog series showing how transcutaneous pacing (TCP) can be difficult and how you can improve your skills. Patient had an unwitnessed cardiac arrest without bystander CPR performed.

Atrial Fibrillation 132

Atrial Fibrillation Bradycardia Pacemaker Cardiac Arrest 132

Dr. Smith's ECG Blog

OCTOBER 23, 2023

Edited by Bracey, Meyers, Grauer, and Smith A 50-something-year-old female with a history of an unknown personality disorder and alcohol use disorder arrived via EMS following cardiac arrest with return of spontaneous circulation. The described rhythm was an irregular, wide complex rhythm. What is ELECTRICAL ALTERNANS?

Tachycardia 120

Tachycardia Cardiac Arrest ICU Blood Pressure 120

Dr. Smith's ECG Blog

JUNE 21, 2023

Two hours later , the patient returned to this same urgent care facility with worsening chest pain, and this ECG was performed: While getting another ECG, the patient suffered cardiac arrest: After multiple defibrillations, ROSC was achieved with ongoing "STEMI".

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Chest Pain Cardiac Arrest STEMI Defibrillator 95

Dr. Smith's ECG Blog

JULY 21, 2024

As we've often emphasized on Dr. Smith's ECG Blog — it is rare in practice to see LMCA occlusion, because most such patients die before reaching the hospital. As I review in My Comment in the January 16, 2020 post of Dr. Smith's ECG Blog ( and have reproduced in Figure-2 below ) — the ECG of patients with acute LMCA occlusion may be varied.

Arrhythmia 112

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 112

Dr. Smith's ECG Blog

DECEMBER 13, 2023

For technical reasons — P waves are not well visible in this tracing — BUT — the P wave in lead I appears to be larger than the P wave in lead II , which is often a tip-off to LA-LL Reversal ( See My Comment in the November 19, 2020 and the May 24, 2022 posts in Dr. Smith's ECG Blog ).

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Blog Chest Pain Cardiac Arrest Hemorrhage 112

Ken Grauer, MD

OCTOBER 6, 2023

MY Approach to the Rhythm in Figure-1: As per ECG Blog #185 — I favor the P s, Q s, 3 R Approach for interpretation of the cardiac rhythm — beginning with whichever of these 5 KEY Parameters is easiest to assess for the tracing in front of me: At least in the single lead II rhythm strip seen in Figure-1 — The Q RS complex appears to be narrow.

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Blog Arrhythmia Cardiac Arrest Tachycardia 151

Dr. Smith's ECG Blog

JULY 14, 2010

A 56 yo f with h/o HTN and hypercholesterolemia called EMS from home after onset of L chest pain radiating to the left arm. Before EMS arrived, she had "seizure activity" and became unresponsive. She was defibrillated successfully from ventricular fibrillation and developed a perfusing rhythm. She was intubated.

Cardiac Arrest 52

Cardiac Arrest Cardiogenic Shock Chest Pain Defibrillator 52

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

We've presented numerous examples of hyperkalemia on Dr. Smith's ECG Blog. As a reminder of why determination of the cardiac rhythm can be so challenging when there is significant hyperkalemia — I've reproduced Figure-1 from My Comment in the January 16, 2022 post in Dr. Smith's ECG Blog. WHY Isn't the QRS Wide?

Tachycardia 52

Tachycardia Document Blog Bradycardia 52

Dr. Smith's ECG Blog

OCTOBER 4, 2010

This young male had ventricular fibrillation during a triathlon. He was resuscitated with chest compressions and defibrillation and 1 mg of epinephrine. On his bib it stated that he had a congenital heart disorder. He arrived in the emergency department hemodynamically stable. His initial ECG is shown here.

Cardiac Arrest 52

Cardiac Arrest Ischemia Stenosis Echocardiogram 52