Ken Grauer, MD

APRIL 9, 2023

No chest pain. Figure-1: The initial ECG in today's case — obtained from an 86-year old man with presyncope, but no chest pain. ( 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 ). What is the rhythm ?

Blog 78

Blog Chest Pain Arrhythmia Cardiac Arrest 78

Dr. Smith's ECG Blog

JUNE 5, 2024

The patient presented due to chest pain that was typical in nature, retrosternal and radiating to the left arm and neck. He denied any exertional chest pain. It is unclear if the patient was pain free at this time. He has a medical hx notable for hypertension, hyperlipidemia and previous tobacco use disorder.

Chest Pain 109

Chest Pain Cardiac Arrest Blog Cardiomyopathy 109

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?

Defibrillator 94

Defibrillator Cardiac Arrest STEMI Chest Pain 94

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Submitted and written by Quinton Nannet, MD, peer reviewed by Meyers, Grauer, Smith A woman in her 70s recently diagnosed with COVID was brought in by EMS after she experienced acute onset sharp midsternal chest pain without radiation or dyspnea. She felt nauseous and lightheaded with no neurologic deficits.

Chest Pain 52

Chest Pain Ischemia Aortic Aortic valve 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? What is it?

Cardiac Arrest 137

Cardiac Arrest Bradycardia Tachycardia Chest Pain 137

Dr. Smith's ECG Blog

JANUARY 25, 2017

A 20-something male drank heavily of ethanol and used cocaine, then was involved in a stressful verbal altercation, at which time he developed chest pain. See this post and associated case reports: Cardiac arrest, severe acidosis, and a bizarre ECG The patient was admitted and ruled out for acute MI by serial troponins.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 19, 2014

A male in late middle age with a history of RCA stent 8 years prior complained of chest pain. Here are three more dramatic cases that illustrate RBBB + LAFB Case 1 of cardiac arrest with unrecognized STEMI, died. EMS recorded the following ECG: What do you see?

Chest Pain 52

Chest Pain Cardiac Arrest Myocardial Infarction Angioplasty 52

Dr. Smith's ECG Blog

MAY 6, 2019

The patient presented with chest pain. I was taught that the tell-tale sign of ischemia vs an electrical abnormality was in the hx, i.e. chest pain for the ischemia and potential syncope for brugada. Only 5-18% of ED patients with chest pain have a myocardial infarction of any kind. Is it Brugada pattern?

Chest Pain 52

Chest Pain STEMI Ischemia Myocardial Infarction 52

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.

Cardiac Arrest 87

Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 87

Dr. Smith's ECG Blog

AUGUST 19, 2023

Because the patient had no chest pain or shortness of breath, they were initially diagnosed as gastroenteritis. But because the patient had no chest pain or shortness of breath, it was not deemed to be from ACS. Potassium was normal. Cardiology did not think it was "STEMI", but repeated the troponin. Take home 1.

Chest Pain 85

Chest Pain STEMI Myocardial Infarction Blog 85

Dr. Smith's ECG Blog

OCTOBER 24, 2013

There is no way to tell the difference between GI etiology of chest pain and MI. Such T-waves are almost always reciprocal to ischemia in the region of aVL (although aVL looks n ormal here) , and in a patient with chest pain are nearly diagnostic of ischemia. Could this have been avoided? Lesson : 1.

Cardiac Arrest 52

Cardiac Arrest Myocardial Infarction Chest Pain Ischemia 52

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). Given the absence of chest pain — cardiac contusion is also unlikely.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Tachycardia ICU 52

Dr. Smith's ECG Blog

DECEMBER 23, 2014

The patient was diagnosed with esophageal reflux and was being discharged by the nurse when he had a cardiac arrest. Formula : There is not enough ST elevation in V2-V4 to be applying the LAD/early repol formula, but if it is applied, one gets 1.5 The formula results in 23.43, just above the 23.4 He was defibrillated.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia STEMI 52

Dr. Smith's ECG Blog

SEPTEMBER 20, 2011

This 80 year old with a history of CABG had a cardiac arrest. He did not state he had chest pain, but, then again, he couldn't remember anything. He was resuscitated after fairly prolonged down time, but regained consciousness, though he was confused. There is concordant ST elevation in all inferior leads.

Cardiac Arrest 52

Cardiac Arrest STEMI Ultrasound Chest Pain 52

Dr. Smith's ECG Blog

JUNE 11, 2021

Jesse McLaren (@ECGcases), of Emergency Medicine Cases Reviewed by Pendell Meyers and Steve Smith An 85yo with a history of hypertension developed chest pain and collapsed, and had bystander CPR. On arrival, GCS was 13 and the patient complained of ongoing chest pain. Vitals were HR 58 BP 167/70 R20 sat 96%.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

DECEMBER 13, 2023

This middle aged patient presented with chest pain: What do you think? As review — I've copied the Table in Figure-2 from previous discussions of potential causes of Low Voltage ( See My Comment in the October 15, 2023 — the November 12, 2020 — and the January 24, 2020 posts in Dr. Smith's ECG Blog ). There is VERY low voltage.

Blog 116

Blog Chest Pain Cardiac Arrest Hemorrhage 116

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 ).

Blog 104

Blog Pacemaker Bradycardia Arrhythmia 104

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case is a previously healthy 40-something male who contacted EMS due to acute onset crushing chest pain. The pain was 10/10 in intensity radiating bilaterally to the shoulders and also to the left arm and neck. Written By Magnus Nossen — with edits by Ken Grauer and Smith. The below ECG was recorded.

Arrhythmia 116

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 116

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.

Blog 78

Blog Pulmonary Hypertension Aortic 78

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

Case submitted by Rachel Plate MD, written by Pendell Meyers A man in his 70s presented with chest pain which had started acutely at rest and has lasted for 2 hours. The pain was still ongoing at arrival. His initial troponin T was 15 ng/L (only two hours since pain onset). He stated it was similar to prior heart attacks.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart Attack 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

Other cases of LAD OMI with RBBB/LAFB: A man in his 40s who really needs you to understand his ECG Cardiac Arrest at the airport, with an easy but important ECG for everyone to recognize A woman in her 60s with 6 hours of chest pain, dyspnea, tachycardia, and hypoxemia Ventricular Fibrillation, ROSC after perfusion restored by ECMO, then ECG.

Cardiogenic Shock 52

Cardiogenic Shock Chest Pain Tachycardia Ischemia 52

Dr. Smith's ECG Blog

JANUARY 8, 2024

Let me tell you about her hospitalization, discharged 1 day prior, but it was at another hospital (I wish I had the ECG from that hospitalization): The patient is 40 years old and presented to another hospital with chest pain and SOB. She had been sitting doing work when she experienced "waves of chest tightness". Sats were 88%.

Chest Pain 75

Chest Pain Pulmonary Embolism STEMI 75

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

AUGUST 1, 2020

He has done a lot of great work on cardiac arrest, including as co-author of our study on esmolol in refractory cardiac arrest, and much more with Keith Lurie. A 40-something woman was in a remote alpine location when she complained of crushing chest pain. See his Google Scholar profile here.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography.

Ischemia 52

Ischemia STEMI Stenosis Coronary Artery Disease 52

Dr. Smith's ECG Blog

OCTOBER 8, 2023

All of the patients presented with chest pain , and they are all in triage. Smith: This bizarre ECG looks like a post cardiac arrest ECG with probable acidosis or hyperkalemia in addition to OMI. Which, if any, of these patients has OMI, with myocardium at risk and need for emergent PCI? What was the pH and K?

Ischemia 112

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 112

Dr. Smith's ECG Blog

JUNE 15, 2013

There was no chest pain. Unfortunately, the patient had a cardiac arrest on arrival to the cath lab, before return of the potassium. A patient who does not present with chest pain should be particularly scrutinized for other causes of the ECG abnormalities. The computer read inferior MI.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest 52

Dr. Smith's ECG Blog

OCTOBER 10, 2022

Written by Pendell Meyers and Peter Brooks MD A man in his 30s with no known past medical history was reported to suddenly experience chest pain and shortness of breath at home in front of his family. He had multiple cardiac arrests with ROSC regained each time. Submitted by a Med Student, with Great Commentary on Bias!

Cardiac Arrest 52

Cardiac Arrest Chest Pain Embolism Pulmonary 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

No chest pain. His inpatient clinicians did not think that an urgent angiogram was warranted given that he was chest pain free, his EKG appeared nondiagnostic, and serial troponins were not elevating beyond 2 ug/L. Patients on dialysis often do not have chest pain in the setting of acute MI. Why is this?

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

FEBRUARY 17, 2023

This patient had many complaints including chest pain. Comment by K EN G RAUER, MD ( 2/11 /2023 ): = Today’s case is from a patient with “many complaints”, including chest pain — and, an ECG that raised concern about acute anterior OMI. The computer called this Acute STEMI What do you think? The ioninzed calcium was 6.5

Chest Pain 52

Chest Pain Cardiac Arrest STEMI Arrhythmia 52

Dr. Smith's ECG Blog

MAY 13, 2017

He complained of severe chest pain and was extremely agitated, so much so that he was throwing chairs in triage. On this blog, the warning is this : It is critical to use it only when the differential is subtle LAD occlusion vs. early repol. His chest pain resolved. He had an ECG recorded and was brought to a room.

Chest Pain 52

Chest Pain STEMI Cardiac Arrest Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 29, 2020

A 60-something woman presented after a witnessed cardiac arrest. This is commonly found after epinephrine for cardiac arrest, but could have been pre-existing and a possible contributing factor to cardiac arrest. A recent similar case: A 40-something with chest pain. Is this inferior MI?

Cardiac Arrest 52

Cardiac Arrest Defibrillator Ischemia Tachycardia 52

Dr. Smith's ECG Blog

FEBRUARY 25, 2009

He was at the gym when he had the onset of chest pain. Were it not for this prehospital ECG and the cardiac arrest, the diagnosis may have been significantly delayed. Had this happened, the artery may have re-occluded prior to angiography, with resultant recurrent cardiac arrest and/or shock and death.

Cardiac Arrest 52

Cardiac Arrest Chest Pain Defibrillator STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2018

A 50-something presented with epigastric and chest pain. Epigastric pain, Syncope, and Saddleback ST Elevation A 65 Year Old Man with Chest pain and Precordial ST Elevation Non-Vagal Syncope and Saddleback Morphology in V2 Is this STEMI? Here is his ECG: What do you think? QTc 388 ms. A value less than 18.2

STEMI 52

STEMI Chest Pain Cardiac Arrest Anatomy 52

Dr. Smith's ECG Blog

OCTOBER 3, 2017

This is another case written by Pendell Meyers (who is helping to edit the blog and has many great recent posts) Case A 45 year old man was driving to work when he experienced acute onset sharp left sided chest pain with paresthesias of the left arm. A repeat ECG was recorded with pain 2/10: Not much change.

Chest Pain 52

Chest Pain STEMI Defibrillator Stents 52

Dr. Smith's ECG Blog

SEPTEMBER 16, 2015

Case 3 : Male in 30's with chest pain, cough, and fever. A male in late middle age with a history of RCA stent 8 years prior complained of chest pain. Here are three more dramatic cases that illustrate RBBB + LAFB Case 1 of cardiac arrest with unrecognized STEMI, died. What do you think? Called 911.

STEMI 52

STEMI Chest Pain Cardiac Arrest Stents 52

Dr. Smith's ECG Blog

JANUARY 4, 2021

FYI : 52 ng/L is the threshold for "rule in" by European studies as it has a high positive predictive value in the setting of chest pain. Case continued The patient was placed on a nitroglycerin drip and chest pain gradually resolved. Top right is colored iodine overlay; Blue areas of myocardium are ischemia.

Ischemia 52

Ischemia Pulmonary STEMI Chest Pain 52