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 166

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 115

Cardiac Arrest Ischemia Tachycardia Defibrillator 115

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.

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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 131

Dr. Smith's ECG Blog

FEBRUARY 22, 2024

There was concern that the rhythm might represent ventricular tachycardia, so lidocaine was given and one attempt at cardioversion was performed. 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.

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Cardiac Arrest Bradycardia Tachycardia Chest Pain 139

Dr. Smith's ECG Blog

OCTOBER 10, 2022

He had multiple cardiac arrests with ROSC regained each time. Then there is loss of pulses with continued narrow complex on the monitor ("PEA arrest") Learning Points: Sudden witnessed Cardiac Arrest due to ACS is almost always due to dysrhythmia. This patient arrested shortly after hospital arrival.

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Cardiac Arrest Chest Pain Embolism Pulmonary 52

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. There is a regular, wide complex, (mostly) monomorphic tachycardia. He was estimated to be in his 50s, with no known PMHx.

Cardiac Arrest 52

Cardiac Arrest Tachycardia Defibrillator ICU 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. Final Diagnosis: Cardiac Arrest due to Torsades from long QT of unknown etiology.

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Cardiac Arrest Defibrillator Ischemia Tachycardia 52

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. This sinus tachycardia ( at ~130/minute ) — is consistent with the patient’s worsening clinical condition, with development of cardiogenic shock.

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Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JULY 24, 2018

We received 4 ECGs, including his baseline on file, and three from today, including triage, peri-arrest, and post-ROSC (sorry for the poor quality due to scanning). Prior ECG on file: Sinus tachycardia, imperfect baseline, otherwise unremarkable. Unfortunately, this was not recognized at this time.

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Cardiac Arrest Tachycardia Chest Pain ICU 52

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

Although one may have all kinds of ischemic findings as a result of cardiac arrest (rather than cause of cardiac arrest), this degree of ST elevation and HATW is all but diagnostic of acute proximal LAD occlusion. See Discussion in the June 29, 2024 post of Dr. Smith' ECG Blog ). This prompted cath lab activation.

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Cardiac Arrest STEMI Ischemia SCAD 84

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. T wave alternans is a harbinger of cardiac instability and TdP. (3) No ischemic ST changes.

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Tachycardia Cardiac Arrest ICU Blog 125

Dr. Smith's ECG Blog

JANUARY 8, 2024

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG == MY Comment , by K EN G RAUER, MD ( 12/31 /2023 ): == My only hope about today's tragic case — is that the involved providers learn from mistakes made. . == The 2 ECGs in Today's CASE: Figure-1: I've labeled the 2 ECGs shown in today's case. Junctional tachycardia? ).

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Chest Pain Pulmonary Embolism STEMI 71

Dr. Smith's ECG Blog

OCTOBER 25, 2023

ECG is consistent with severe hypokalemia and/or hypomagnesemia causing prolonged QT (QU) at high risk of Torsades (which is polymorphic ventricular tachycardia in the setting of a long QT interval). Polymorphic Ventricular Tachycardia Long QT Syndrome with Continuously Recurrent Polymorphic VT: Management Cardiac Arrest.

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Ischemia Chest Pain Cardiac Arrest Blog 117

Dr. Smith's ECG Blog

JULY 21, 2024

This progressed to electrical storm , with incessant PolyMorphic Ventricular Tachycardia ( PMVT ) and recurrent episodes of Ventricular Fibrillation ( VFib ). 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.

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Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 118

Dr. Smith's ECG Blog

APRIL 15, 2019

Here was his initial ED ECG: There is sinus tachycardia at a rate of about 140 There is profound ST Elevation across all precordial leads, as well as I and aVL. If a patient presents with chest pain and a normal heart rate, or with shockable cardiac arrest, then ischemic appearing ST elevation is STEMI until proven otherwise.

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Tachycardia STEMI Chest Pain Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 20, 2024

This patient is actively dying from a left main coronary artery OMI and cardiac arrest from VT/VF or PEA is imminent! Complete LMCA occlusion is associated with clinical shock and/or cardiac arrest. The arterial blood gas showed a lactic acidosis with a lactate level of 17mmol/L.

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Cardiogenic Shock Ischemia Chest Pain Cardiac Arrest 127

Dr. Smith's ECG Blog

FEBRUARY 27, 2023

We've presented numerous examples of hyperkalemia on Dr. Smith's ECG Blog. Descriptive analysis of the ECG in today's case reveals a regular, narrow tachycardia at ~130/minute , without clear sign of sinus P waves. But the rate is ~130/minute — which is a bit fast for sinus tachycardia. WHY Isn't the QRS Wide?

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Dr. Smith's ECG Blog

OCTOBER 17, 2024

There was 100% proximal LAD occlusion with TIMI 0 flow, and cardiac arrest in the cath lab. Among others — See My Comment at the bottom of the page in the September 13, 2024 post of Dr. Smith's ECG Blog ). There is sinus tachycardia at ~100/minute. For clarity in Figure-1 — I've labeled the initial ECGs for both patients.

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Dr. Smith's ECG Blog

NOVEMBER 11, 2022

There is sinus tachycardia (do not be fooled into thinking this is VT or another wide complex tachycardia!) Plus recommendations from a 5-member panel on cardiac arrest. This feature is invaluable for assessing QRS morphology with wide tachycardias in the differentiation between SVT vs VT rhythms.

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Cardiogenic Shock Chest Pain Tachycardia Ischemia 52

Dr. Smith's ECG Blog

OCTOBER 11, 2020

Other than tachycardia, Other than slight tachycardia, vitals were within normal limits (including oxygen saturation). About two hours after admission, he suffered a cardiac arrest (whether it was VF/VT or PEA is not available) and expired. Apparently he denied chest pain. Here is his first ED ECG: What do you see?

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Dr. Smith's ECG Blog

NOVEMBER 4, 2022

Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. We’ve presented many variations on this theme on Dr. Smith’s Blog — with today’s case being distinguished by its discovery on abdominal exam ! Results Emergent angiography was performed in 80% (79/99) of patients.

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Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

NOVEMBER 30, 2019

Is it ventricular tachycardia (VT) due to hyperK or is it a supraventricular rhythm with hyperK? Here are other posts on hyperK, large calcium doses for hyperK, and ventricular tachycardia in hyperK Weakness, prolonged PR interval, wide complex, ventricular tachycardia Very Wide and Very Fast, What is it? How would you treat?

Cardiac Arrest 52

Cardiac Arrest Tachycardia Nursing Ultrasound 52

Dr. Smith's ECG Blog

MAY 5, 2022

After initiating treatment for hyperkalemia, repeat ECG showed resolution of Brugada pattern: The ECG shows sinus tachycardia. Steve, what do you think of this ECG in this Cardiac Arrest Patient?" A woman in her 50s with dyspnea and bradycardia A patient with cardiac arrest, ROSC, and right bundle branch block (RBBB).

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Chest Pain Bradycardia Cardiac Arrest STEMI 52

Dr. Smith's ECG Blog

JULY 27, 2023

His prehospital ECG showed "inferior" ST depression and high voltage, with tachycardia. I suspected no OMI, that this could be due to LVH plus tachycardia. Conclusion: Type II MI probable due to hypoxia and tachycardia from resp arrest and amphetamine use. On arrival to the ED, the patient was diaphoretic, tachycardic.

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Tachycardia Ischemia Cardiac Arrest Echocardiogram 52

Dr. Smith's ECG Blog

SEPTEMBER 7, 2020

Here is his 12-lead: There is a wide complex tachycardia with a rate of 257, with RBBB and LPFB (right axis deviation) morphology. Read about Fascicular VT here: Idiopathic Ventricular Tachycardias for the EM Physician Case Continued He was completely stable, so adenosine was administered. See Learning point 1 below. Arch Intern Med.

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Dr. Smith's ECG Blog

JANUARY 21, 2023

The relationship between J wave and ventricular tachycardia during Takotsubo cardiomyopathy. The final letter in the SLOWED mnemonic is " D " for "Dead" ( resulting from VT/VF or asystolic cardiac arrest ). This is the 2nd ECG from the February 8, 2022 post in Dr. Smith's ECG Blog ).

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STEMI Bradycardia Arrhythmia Cardiac Arrest 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

The ECG shows sinus tachycardia, a narrow, low voltage QRS with alternating amplitudes, no peaked T waves, no QT prolongation, and some minimal ST elevation in II, III, and aVF (without significant reciprocal STD or T wave inversion in aVL). It is difficult to tell if there is collapse during diastole due to the patient’s tachycardia.

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Pericarditis Tachycardia Ultrasound Blood Pressure 52

Dr. Smith's ECG Blog

NOVEMBER 25, 2022

As we've discussed on numerous other posts in Dr. Smith's ECG Blog ( See My Comment at the bottom of the page in the May 5, 2022 post) — a growing number of conditions other than Brugada Syndrome have been found to temporarily produce a Brugada-1 ECG pattern. What are the ECG Findings of Cardiac Contusion?

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Arrhythmia Blog Chest Pain Cardiac Arrest 52

Dr. Smith's ECG Blog

SEPTEMBER 21, 2020

This blog is full of cases in which OMI that did not meet STEMI millimeter criteria were dismissed. Series of Prehospital ECGs Showing Reperfusion == MY Comment by K EN G RAUER, MD ( 9/21/2020 ): == I wish those cardiologists who continue to strictly adhere to STEMI millimeter criteria would begin reading Dr. Smith’s ECG Blog.

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Dr. Smith's ECG Blog

OCTOBER 8, 2023

Smith: This bizarre ECG looks like a post cardiac arrest ECG with probable acidosis or hyperkalemia in addition to OMI. The patient died of cardiogenic shock within 24 hours despite mechanical circulatory support. Below the J-point is marked out showing the ST pathologic deviations. What was the pH and K?

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Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 114

Dr. Smith's ECG Blog

JANUARY 30, 2019

Otherwise vitals after intubation were only notable for tachycardia. An initial EKG was obtained: Computer read: sinus tachycardia, early acute anterior infarct. She was ventilated by bag-valve-mask by EMS on arrival and was quickly intubated with etomidate and succinylcholine. A rectal temperature was obtained which read 107.9

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Heart Rhythm Sudden Cardiac Death Arrhythmia STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 18, 2019

Low body magnesium is often encountered in association with other electrolyte abnormalities ( ie, low sodium, potassium, calcium or phosphorus ) ; acute MI; cardiac arrest; digoxin/diuretic use; alcohol use and abuse; renal impairment. Figure-2: Sequential development of ST-T wave changes with hypokalemia. second ).

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Chest Pain Cardiac Arrest Bradycardia Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 5, 2019

There is sinus tachycardia and also a large R-wave in aVR. Drug toxicity , especially diphenhydramine , which has sodium channel blocking effects, and also anticholinergic effects which may result in sinus tachycardia, hyperthermia, delirium, and dry skin. Her temperature was 106 degrees. As part of the workup, she underwent an ECG.

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