Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). As per Dr. Frick — sinus tachycardia is usually not seen with acute OMI unless the patient is in cardiogenic shock. Additionally, there is borderline right axis deviation. Both were wrong.

Cardiogenic Shock 128

Cardiogenic Shock Ultrasound Tachycardia Pulmonary 128

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. Today's patient did make it to the hospital — but was in cardiogenic shock, and despite valiant attempt at treatment, succumbed soon after.

Cardiogenic Shock 127

Cardiogenic Shock Cardiac Arrest Hospital Ischemia 127

ECG Cases

JANUARY 2, 2023

The post Top 10 of 2022 – EM Cases Podcasts & Blogs Highlights of the Year appeared first on Emergency Medicine Cases. Based on a blend of number of listens, feedback from listeners, website visits and my personal faves, here is EM Cases Top 10 of 2022.

Blog 52

Blog Cardiogenic Shock Stroke Strokes 52

Dr. Smith's ECG Blog

JULY 21, 2024

The patient in today’s case presented in cardiogenic shock from proximal LAD occlusion, in conjunction with a subtotally stenosed LMCA. 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. RCA — 100% proximal occlussion.

Arrhythmia 131

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator 131

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

Heparin bolus (4000u), infusion Plan for rate control 25 mg IV diltiazem given HR = 143 25 mg IV repeat dose diltiazem given HR = 143 Diltiazem drip 10 mg/ hr for ~20 min HR remained 140 - 155 Then the patient developed Cardiogenic shock and echo had poor contractility Amiodarone load given. Patient intubated.

Tachycardia 139

Tachycardia Cardiogenic Shock Angina Coronary Angiogram 139

Dr. Smith's ECG Blog

JULY 9, 2024

Here is the Queen of Hearts (version 1) interpretation: Click here to sign up for Queen of Hearts Access Angiogram images before and after intervention: Another view (before and after intervention): The patient was confirmed to be in cardiogenic shock, placed on ECMO, also with impella assist device.

Defibrillator 117

Defibrillator STEMI Cardiac Arrest Cardiogenic Shock 117

Dr. Smith's ECG Blog

OCTOBER 26, 2010

ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. Then ACS (STEMI) might be primary; this might be cardiogenic shock. Even if this ECG is the first thing one sees (as it was for me), one should stop and think: "This is an unusual STEMI." Are the lungs clear? Is the patient cool and pale?

STEMI 52

STEMI Cardiogenic Shock Tachycardia Aneurysm 52

Dr. Smith's ECG Blog

NOVEMBER 16, 2010

He was in cardiogenic shock. The patient died 8 hours later of cardiogenic shock. Here are more examples of wide complex tachycardia: these are all a mix of ventricular tachycardia and SVT with aberrancy. This 51 yo male complained of chest pain, then had a v fib arrest. There is tachycardia, and there is a wide complex.

Tachycardia 52

Tachycardia Cardiogenic Shock Chest Pain STEMI 52

Dr. Smith's ECG Blog

OCTOBER 8, 2024

A temporary pacemaker was implanted, and she was admitted to the ICU with cardiogenic shock. For more on Precordial Swirl — See the October 15, 2022 post in Dr. Smith's ECG Blog ). She was taken to the cath lab, where she was found to have 100% in-stent restenosis of the proximal LAD. She could not be resuscitated.

Cardiac Arrest 123

Cardiac Arrest Myocardial Infarction STEMI Cardiogenic Shock 123

Dr. Smith's ECG Blog

NOVEMBER 3, 2023

The notes now refer to the patient being in cardiogenic shock, on pressors. hours from presentation, where he was found to have an acute thrombotic LAD occlusion which was stented with resulting TIMI 3 flow, but still the patient was in severe cardiogenic shock. Time = 3 hours: the next troponin returns at 60 ng/L.

Chest Pain 83

Chest Pain Cardiogenic Shock Ischemia Myocardial Infarction 83

Dr. Smith's ECG Blog

JULY 14, 2010

She arrived comatose and in cardiogenic shock and the following ECG was recorded. 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

OCTOBER 1, 2024

The patient died of cardiogenic shock: Go to the post to see the full explanation. These were catastrophically missed (EM cath lab activation cancelled both times by the interventionalist) Here is a case of Sinus with RBBB and LAFB that was diagnosed correctly by the emergency physicians as acute STEMI.

Tachycardia 113

Tachycardia Cardiogenic Shock Arrhythmia STEMI 113

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

Authors' commentary: Cardiogenic shock in the setting of severe aortic stenosis. This patient’s severe aortic stenosis (AS) and associated severe cardiogenic shock likely created the ECG pattern, resulting in a very difficult challenge for our inpatient team. If you can use Doppler, then you can diagnose it. Circulation.

Ischemia 40

Ischemia Cardiogenic Shock Aortic Stenosis 40

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

Smith : LAD OMI with RBBB/LAFB is not only subtle on the ECG, but most of these patients are extremely ill: most I have seen are post-ROSC, in cardiogenic shock, or arrested shortly after.

Chest Pain 121

Chest Pain STEMI Cardiogenic Shock Heart Failure 121

Dr. Smith's ECG Blog

JANUARY 15, 2024

Tachycardia is unusual for OMI, unless the patient is in cardiogenic shock (or getting close). ECG 2 Especially in the context of the first ECG, readers of this blog will readily appreciate the ST elevations and hyperacute T waves in II, III, aVF, V6, and to a lesser extent V5. link] I also texted the ECG to Dr. Smith.

Chest Pain 64

Chest Pain Blog Arrhythmia Critical Care 64

Dr. Smith's ECG Blog

OCTOBER 28, 2022

I’m an avid reader of your blog, and wanted your valued opinion on this. He went into cardiogenic shock and is intubated in the cardiac ICU. Both the patient and his wife attributed it to spicy food a couple hours prior, and I had to talk him in to being transported. Cortland : Thank you so much for your reply!

Chest Pain 52

Chest Pain Myocardial Infarction Pacemaker Cardiogenic Shock 52

Dr. Smith's ECG Blog

NOVEMBER 11, 2022

This pattern is essentially always accompanied by cardiogenic shock and high rates of VT/VF arrest, etc. The patient arrived to the ED in cardiogenic shock but awake. With so much STD in leftward and inferior leads V4-V6, II, III, and aVF, of course there must be STE in aVR. Code STEMI was activated.

Chest Pain 52

Chest Pain Cardiogenic Shock Tachycardia Ischemia 52

The Beat Blog

APRIL 8, 2022

As physicians, we know the value of placing a hand on someone’s calf, detecting a subtle drop in body temperature, and knowing that they have decompensated into a low output cardiogenic shock. Yet, not every patient or situation requires in person care — and those visits can be avoidably wasteful in time, effort, and cost.

Cardiogenic Shock 52

Cardiogenic Shock Blood Pressure Heart attacks Heart Attack 52

Dr. Smith's ECG Blog

SEPTEMBER 17, 2023

Smith's book : Learning points: 1) OMI can be very subtle and RV infarction may manifest poorly on the standard ECG. 2) Typical persistent chest pain with a sigificantly elevated troponin is OMI until proven otherwise, regardless of the ECG. Our THANKS to Dr. Magnus Nossen for sharing this case with us.

Pulmonary 117

Pulmonary Tricuspid Chest Pain Cardiogenic Shock 117

Dr. Smith's ECG Blog

MARCH 30, 2014

My most talented blog readers are paramedics because they have to put themselves on the line every time they activate the cath lab. Then the notes mention "cardiogenic shock" but without any reference to a cardiac echo or to a chest x-ray. And they teach me a lot. Was there pulmonary edema? Not mentioned in physicians' notes.

Outcomes 52

Outcomes Cardiogenic Shock STEMI Chest Pain 52

Dr. Smith's ECG Blog

MAY 30, 2023

OTHER Examples of Lead Reversal on Dr. Smith's Blog: Technical errors featuring a variety of lead reversal placements remain a surprisingly common “mishap” of everyday practice. The virtually identical QRST morphology in the limb leads between these 2 tracings confirms that there was LA-RA Lead Reversal in ECG #2a.

Chest Pain 97

Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

Dr. Smith's ECG Blog

OCTOBER 8, 2023

The patient died of cardiogenic shock within 24 hours despite mechanical circulatory support. The axis is to the right and QRS complexes in lead I and aVL are predominantly negative suggesting LPFB. This patient at cath had a large CX occlusion with a massive troponin release. Troponin T >42.000ng/L.

Ischemia 123

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest 123

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Among others — See My Comment at the bottom of the page in the September 13, 2024 post of Dr. Smith's ECG Blog ). As often emphasized by Dr. Smith — sinus tachycardia is not a common finding with acute OMI unless something else is going on (ie, cardiogenic shock ). Patient # 1: The "Tricky" Findings in the Initial ECG.

Chest Pain 74

Chest Pain STEMI Pulmonary Embolism 74

Dr. Smith's ECG Blog

OCTOBER 6, 2023

His included cardiogenic shock, V Tach, AV block. This poor echo can be seen even after very good reperfusion because myocardium that is still viable can be "stunned" and take weeks to recover. But the ECG is telling us that the myocardium will probably not recover. Such large infarcts have many complications.

Aneurysm 67

Aneurysm Chest Pain Cardiogenic Shock Blog 67

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

Assessment was severe sudden cardiogenic shock. 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. Clinically — the patient was felt to be in cardiogenic shock. What is it? There is STE in V2-V6.

Cardiac Arrest 52

Cardiac Arrest COVID-19 Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

AUGUST 13, 2020

Because of the tachcardia, I would expect her to be very poor left ventricular function and maybe Cardiogenic shock. For another example of intermittent RBBB conduction, in which a similar initial deflection with terminal delay facilitated recognition of RBBB Conduction — Please SEE the June 25, 2020 post in Dr. Smith's Blog.

Tachycardia 52

Tachycardia AFIB Cardiogenic Shock Myocardial Infarction 52

Dr. Smith's ECG Blog

APRIL 24, 2020

Just prior to transport, the patient became confused and agitated and, although blood pressure and pulse were OK, I was worried about cardiogenic shock. Diagnosis : Posterior MI, right? We intubated him. Cath lab The BP was 70/40 on arrival to the cath lab and received a balloon pump and norepinephrine.

Ischemia 52

Ischemia Chest Pain Stenosis STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 23, 2022

He was in cardiogenic shock requiring an impella for several days after cath. We've shown many cases on Dr. Smith's ECG Blog of subtle ECG findings that rapidly evolve into dramatic ST-T wave changes. No further troponins were measured. But we should not be surprised.

Chest Pain 52

Chest Pain Cardiac Arrest Cardiogenic Shock Heart attacks 52

Dr. Smith's ECG Blog

OCTOBER 7, 2019

Why is the patient in shock? He was in profound cardiogenic shock. During transport, I had debated giving atropine for his bradycardia and cardiogenic shock, but was worried about making an already profoundly ischemic heart more ischemic, and chose instead to optimize preload with pressure bagging 1L NS.

Bradycardia 40

Bradycardia Cardiogenic Shock STEMI Ischemia 40

Dr. Smith's ECG Blog

JULY 18, 2014

Case Continued 2 days later the patient became increasingly tachycardic, hypotensive, ashen, clammy (in cardiogenic shock) and had a new murmur. The initial troponin I was 23.7 ng/ml and was falling, confirming infarction days ago. This was the 12-lead ECG. No resolution of ST elevation. The T-waves are persistently positive.

STEMI 52

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock 52

Dr. Smith's ECG Blog

JUNE 11, 2021

But by this time the patient went into cardiogenic shock and passed away. But the first two ECGs met Modified Sgarbossa Criteria in leads V3-4, and bedside echo found anteroseptal wall motion abnormalities corresponding with the LAD occlusion.

Chest Pain 52

Chest Pain Cardiac Arrest Ischemia Cardiogenic Shock 52

Dr. Smith's ECG Blog

JUNE 19, 2023

The patient is started on epinephrine infusion for cardiogenic shock and cardiology took the patient to the cath lab. The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. The patient’s second troponin results at 273 ng/L and third troponin results at 320 ng/L.

Chest Pain 52

Chest Pain STEMI Cardiogenic Shock Bradycardia 52

Dr. Smith's ECG Blog

MARCH 12, 2018

When there is tachycardia, the patient is in cardiogenic shock with very poor LV function on bedside echo. We hope you can see the difference: See these cases for more examples: Syncope, Shock, AV block, Large RV, "Anterior" ST Elevation. In this case we have a crashing patient while T-wave inversion is ongoing!

Chest Pain 40

Chest Pain Pulmonary Embolism Tachycardia 40

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

An elderly man with sudden cardiogenic shock, diffuse ST depressions, and STE in aVR Literature 1. 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 ! 2 cases of Aortic Stenosis: Diffuse Subendocardial Ischemia on the ECG. Left main?

Ischemia 52

Ischemia STEMI Stenosis Chest Pain 52

Dr. Smith's ECG Blog

JUNE 17, 2018

I have always said that tachycardia should argue against acute MI unless there is cardiogenic shock or 2 simultaneous pathologies. Sinus tachycardia, which exaggerates ST segments and implies that there is another pathology. We showed this in a recent analysis of UTROPIA data (see abstract below).

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

Dr. Smith's ECG Blog

FEBRUARY 28, 2020

Tachycardia is unusual in ACS unless there is cardiogenic shock or a second simultaneous pathology. To explain my opinion — I’ve added E CG # 2 to Figure-1 , which is taken from the March 12, 2018 post on Dr. Smith’s ECG blog — in which this woman in her 40s with progressively worsening dyspnea was found to have massive acute PE.

Chest Pain 52

Chest Pain Pulmonary Tachycardia Embolism 52

Dr. Smith's ECG Blog

AUGUST 9, 2019

TIMI flow 0) is rare in the ED, as most either die before arrival or are recognized clinically due to cardiogenic shock. 67) Less than 3% of anterior STEMI has LM OMI, and most are recognized clinically due to cardiogenic shock. (68, Of those who do get to the ED, many present with clear STE.(65,

Myocardial Infarction 52

Myocardial Infarction Ischemia STEMI Cardiogenic Shock 52