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%.

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Chest Pain Pulmonary Embolism STEMI 71

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.

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Chest Pain Cardiac Arrest Cardiogenic Shock Heart Attack 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. Just as important is pretest probability: did the patient report chest pain prior to collapse?

Cardiac Arrest 110

Cardiac Arrest Ischemia Tachycardia Defibrillator 110

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 103

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

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 ?

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Blog Chest Pain Arrhythmia Cardiac Arrest 78

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!

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Cardiac Arrest Chest Pain Embolism Pulmonary 52

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.

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Chest Pain Blog Cardiac Arrest Cardiomyopathy 107

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

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

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?

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Cardiac Arrest Bradycardia Tachycardia Chest Pain 136

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.

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Chest Pain STEMI Defibrillator Stent 52

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?

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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.

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Cardiac Arrest Chest Pain Defibrillator Atrial Flutter 89

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.

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Chest Pain STEMI Myocardial Infarction Blog 86

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.

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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?

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Cardiac Arrest Defibrillator Ischemia Tachycardia 52

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.

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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.

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Cardiac Arrest Tachycardia Chest Pain ICU 52

Dr. Smith's ECG Blog

OCTOBER 25, 2023

He did not have chest pain. Polymorphic Ventricular Tachycardia Long QT Syndrome with Continuously Recurrent Polymorphic VT: Management Cardiac Arrest. Chest pain in high risk patient. Here is his triage ECG: What do you think? What does the ECG show? Also see the bizarre Bigeminy. Is it STEMI?

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Ischemia Chest Pain Cardiac Arrest Blog 112

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

OCTOBER 20, 2024

He woke up alert and with chest pain which he also had experienced intermittently over the previous few days. The history in today's case with sudden loss of consciousness followed by chest pain is very suggestive of ACS and type I ischemia as the cause of the ECG changes. What do you think?

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 125

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.

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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%.

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Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

OCTOBER 9, 2018

We record ECGs in triage on every patient with chest pain, and some other indications, and this amounts to 8000 ECGs in triage each year, costing at most $200,000 (8000 x $20.00). Given the dire consequences of missing a STEMI or OMI, including cardiac arrest (see cases below), $5700 is extremely cheap.

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Chest Pain STEMI Cardiac Arrest Blog 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.

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Blog Chest Pain Cardiac Arrest Hemorrhage 113

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Apparently he denied chest pain. About two hours after admission, he suffered a cardiac arrest (whether it was VF/VT or PEA is not available) and expired. Like other cases on this blog who died before cath was done, I cannot prove that this patient had OMI. Here is his first ED ECG: What do you see? Canto et al.

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Chest Pain STEMI Blog Tachycardia 52

Dr. Smith's ECG Blog

MAY 3, 2024

Some patients have baseline RBBB with LAFB, but in patients with likely ACS, these are associated with severe infarction with cardiac arrest, cardiogenic shock or impending shock. Here are some cases of RBBB with LAFB: What is the Diagnosis in this 70-something with Chest Pain?

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Cardiogenic Shock Cardiac Arrest Hospital Ischemia 114

Dr. Smith's ECG Blog

FEBRUARY 8, 2022

Although in the context of chest pain such ST depression would be all but diagnostic of posterior OMI, one should make no conclusions in such an unusual case. This Transesophageal ED Echo was recorded: Cardiac POCUS.mov from Stephen Smith on Vimeo. In all leads, there is a 2nd wave after the initial QRS. This is an Osborn wave.

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Cardiac Arrest Bradycardia Chest Pain Ischemia 52

Dr. Smith's ECG Blog

JULY 22, 2023

Written by Pendell Meyers A man in his 70s with no cardiac history presented with acute weakness, syncope, and fever. He denied chest pain or shortness of breath. In the clinical context of weakness and fever, without chest pain or shortness of breath, the likelihood of Brugada pattern is obviously much higher.

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Chest Pain Heart Rhythm Sudden Cardiac Death Dysrhythmia 70

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.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 113

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.

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Cardiogenic Shock Chest Pain Tachycardia Ischemia 52

Dr. Smith's ECG Blog

MAY 5, 2022

He denied any chest pain or shortness of breath and stated he felt at his baseline yesterday prior to drug use. They recommended repeating his ECG and awaiting troponin since the patient did not have any chest pain. Steve, what do you think of this ECG in this Cardiac Arrest Patient?" What is it?

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Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2022

This patient, who is a mid 60s female with a history of hypertension, hyperlipidemia and GERD, called 911 because of chest pain. A mid 60s woman with history of hypertension, hyperlipidemia, and GERD called 911 for chest pain. It is also NOT the clinical scenario of takotsubo (a week of intermittent chest pain).

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Plaque Chest Pain Thrombosis Stenosis 52

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.

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Cardiac Arrest Cardiogenic Shock Chest Pain Defibrillator 52