Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. The patient continued having chest pain. This has been discussed many times before on this blog. Is there STEMI?

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Chest Pain Arrhythmia Myocardial Infarction STEMI 82

Dr. Smith's ECG Blog

MARCH 9, 2024

Written by Willy Frick A 67 year old man with a history of hypertension presented with three days of chest pain radiating to his back. Due to the chest pain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection. He had associated nausea, vomiting, and dyspnea.

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Chest Pain Pericarditis Aortic Echocardiogram 105

Dr. Smith's ECG Blog

AUGUST 10, 2023

Case submitted and written by Dr. Mazen El-Baba and Dr. Emily Austin, with edits from Jesse McLaren A 50 year-old patient presented to the Emergency Department with sudden onset chest pain that began 14-hours ago. The pain improved (6/10) but is persisting, which prompted him to visit the Emergency Department. What do you think?

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Chest Pain STEMI Ischemia Nursing 82

Ken Grauer, MD

MAY 20, 2023

Voltage for LVH is satisfied — at least by Peguero Criteria ( Sum of deepest S in any chest lead + S in V4 ≥23 mm in a woman — as discussed in ECG Blog #73 ). This point is particularly relevant regarding ECG #2 — because sinus tachycardia is seen on this earlier ECG. In the October 15, 2022 post of Dr. Smith's ECG Blog — Drs.

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Blog Chest Pain Ischemia STEMI 129

Dr. Smith's ECG Blog

JANUARY 15, 2024

They had difficulty describing their symptoms, but complained of severe weakness, nausea, vomiting, headache, and chest pain. They described the chest pain as severe, crushing, and non-radiating. We can see enough to make out that the rhythm is sinus tachycardia. It was not worse with exertion or relieved by rest.

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Chest Pain Blog Critical Care Arrhythmia 66

Dr. Smith's ECG Blog

NOVEMBER 9, 2023

A 60-something yo female presented w/ exertional chest pain for 3 days. Pain was 8/10 and constant. She has been experiencing progressively worsening exertional dyspnea and chest tightness mostly when climbing up flights of stairs since early September. But the patient has active chest pain.

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Chest Pain Echocardiogram Exercise Ischemia 80

Dr. Smith's ECG Blog

FEBRUARY 6, 2023

Sent by anonymous, written by Pendell Meyers A man in his 60s presented with acute chest pain with diaphoresis. The Importance of the History: As noted above — the onset of chest pain in today's case was acute. He had received aspirin and nitroglycerin by EMS, with some improvement. His vitals were within normal limits.

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Chest Pain Physiology Stent Stents 52

Dr. Smith's ECG Blog

MARCH 1, 2023

Shortly after receiving epinephrine, the patient developed new leg cramps and chest pain. The chest pain was described as sharp and radiated to both arms. During active chest pain an ECG was recorded: Meyers ECG interpretation: Sinus tachycardia, normal QRS complex, STD in V2-V6, I, II, III and aVF.

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Chest Pain Ischemia Stenosis Tachycardia 52

Dr. Smith's ECG Blog

MAY 25, 2024

An elderly dialysis patient presented with chest pain. Here is her ECG: Regular Wide Complex Tachycardia. Here is her ECG: Regular Wide Complex Tachycardia. Could it be atrial tachycardia with RBBB and LPFB aberrancy? Here it is: There is sinus with normal conduction, very different from her tachycardia.

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Tachycardia Atrial Fibrillation Dysrhythmia Chest Pain 114

Ken Grauer, MD

FEBRUARY 18, 2023

The presenting complaint was chest pain — and the patient collapsed soon after arrival in the ED. The finding of a fairly regular, wide tachycardia without clear sign of atrial activity ( especially when seen in an acutely symptomatic patient ) — should immediately prompt a diagnosis of VT until proven otherwise.

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Blog AFIB Chest Pain STEMI 78

Ken Grauer, MD

JULY 15, 2023

By the P s, Q s, 3 R Approach ( as reviewed in ECG Blog #185 ): The Q RS complex is obviously wide. Given the rapid rate of the tachycardia and the amorphous shape of the QRS — the decision was made to sedate the patient and cardiovert. ECG Blog #185 — Systematic P s, Q s, 3 R Approach to Rhythm Interpretation.

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Blog Coronary Angiogram Cardiomyopathy Ischemia 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

SEPTEMBER 27, 2023

This was written by Magnus Nossen, from Norway, with comments and additions by Smith A 50 something smoker with no previous medical hx contacted EMS due to acute onset chest pain. Upon EMS arrival the patient appeared acutely ill and complained of chest pain. An ECG was recorded immediately and is shown below.

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Tachycardia Chest Pain Academic Arrhythmia 123

Dr. Smith's ECG Blog

JANUARY 27, 2024

Written by Jesse McLaren, comments by Smith A 55 year old with a history of NSTEMI presented with two hours of exertional chest pain, with normal vitals. See these posts: Chest Pain, ST Elevation, and an Elevated Troponin: Should we Activate the Cath Lab? What do you think?

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Chest Pain STEMI Aneurysm Stent 96

Ken Grauer, MD

FEBRUARY 13, 2023

The ECG in Figure-1 was obtained from an older woman — who presented with chest pain and palpitations over the previous hour. Contrast today's rhythm with true ventricular bigeminy — that was seen in ECG Blog #343 ). Contrast today's rhythm with true alternating bundle branch block — that was seen in ECG Blog #306 ).

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Blog Arrhythmia Exercise Chest Pain 78

Dr. Smith's ECG Blog

JUNE 17, 2018

A middle-aged patient with lung cancer had presented to clinic complaining of generalized malaise, cough, and chest pain. There is sinus tachycardia. Symptoms other than chest pain (malaise, cough in a cancer patient) 2. Sinus tachycardia, which exaggerates ST segments and implies that there is another pathology.

Chest Pain 52

Chest Pain Pericarditis Tachycardia Myocardial Infarction 52

Ken Grauer, MD

JUNE 2, 2023

PEARL # 6: As I discuss in my review of SSS ( See ECG Blog #342 for details ) — establishing a diagnosis that sinus bradycardia indicates SSS — will depend on the following: Finding out the age of the patient ( ie, SSS is most common in older individuals ) — and learning whether the patient has been symptomatic? ( No pause beyond 2.0

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Blog Bradycardia Arrhythmia Tachycardia 78

Dr. Smith's ECG Blog

MARCH 26, 2024

Here is his ECG: Original image, suboptimal quality Quality improved with PM Cardio digitization The ECG is highly suggestive of acute right heart strain, with sinus tachycardia, S1Q3T3, and T wave inversions in anterior and inferior with morphology consistent with acute right heart strain. Moreover, there is tachycardia.

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Chest Pain Embolism Pulmonary Ischemia 71

Dr. Smith's ECG Blog

SEPTEMBER 19, 2023

He had concurrent sharp substernal chest pain that resolved, but palpitations continued. Over past 3 months, he has had similar intermittent episodes of sharp chest pain while running, but none at rest. Read this post: Idiopathic Ventricular Tachycardias for the EM Physician 2. Ken notes AV dissociation.

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Tachycardia Cardiogenic Shock Angina Coronary Angiogram 132

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

Sinus tachycardia has many potential causes. This is especially true for the elderly patient with sinus tachycardia. What is the cause of the sudden tachycardia? She had a very elevated troponin T at 12,335 ng/L at the time of presentation. The patient in today’s case suddenly became tachycardic while sleeping.

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Cardiogenic Shock Pericarditis Chest Pain Myocardial Infarction 97

Ken Grauer, MD

SEPTEMBER 21, 2024

For example, considering whatever symptoms that the patient may have had ( ie, chest pain, palpitations, shortness of breath, etc. ) — what this might mean in view of the ECG we are looking at. The sinus tachycardia is a definite concern that something acute may be ongoing. Does the patient's age infuence your interpretation?

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Chest Pain Blog Thrombosis Risk Factors 132

Dr. Smith's ECG Blog

JUNE 17, 2024

Written by Bobby Nicholson, MD 67 year old male with history of hypertension and hyperlipidemia presented to the Emergency Department via ambulance with midsternal nonradiating chest pain and dyspnea on exertion. Pain improved to 1/10 after EMS administers 324 mg aspirin and the following EKG is obtained at triage.

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Chest Pain Embolism Pulmonary Tachycardia 134

Dr. Smith's ECG Blog

FEBRUARY 16, 2024

He had no chest pain or shortness of breath. But it is not disorganized enough to be polymorphic ventricular tachycardia. Learning Points: Wide complex irregularly irregular tachycardias include PMVT, AF with WPW, and AF with aberrancy. See our other cases of AF with WPW: A young man with another episode of tachycardia.

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Tachycardia Atrial Fibrillation Chest Pain Blood Pressure 122

Dr. Smith's ECG Blog

JUNE 11, 2023

Written by Bobby Nicholson MD and Pendell Meyers A man in his 30s presented to the ED for evaluation of chest pain and palpitations. The ECGs show a wide complex, irregularly irregular tachycardia. At this point, the patient had been symptomatic for almost 5 hours, appeared unwell with chest pain and diaphoresis.

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Tachycardia Atrial Fibrillation Chest Pain Blood Pressure 80

Dr. Smith's ECG Blog

MARCH 1, 2024

The tachycardia was gone by the time paramedics arrived. But syncope or seizure alone, without chest pain, is not enough to call it Wellens syndrome. Without chest pain, the pretest probability is not very high. With the chest pain history, this is now Wellens' syndrome. There was tongue biting.

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Chest Pain Myocardial Infarction Tachycardia Stenosis 90

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Case written and submitted by Ryan Barnicle MD, with edits by Pendell Meyers While vacationing on one of the islands off the northeast coast, a healthy 70ish year old male presented to the island health center for an evaluation of chest pain. The chest pain started about one hour prior to arrival while bike riding.

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Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

JULY 25, 2024

Just as important is pretest probability: did the patient report chest pain prior to collapse? Confirmation of sinus tachycardia should be easy to verify when the heart rate slows a little bit ( as the patient's condition improves ) — allowing clearer definition between the T and P waves. Then assume there is ACS.

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Cardiac Arrest Ischemia Tachycardia Defibrillator 105

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

On the second morning of his admission, he developed 10/10 chest pain and some diaphoresis after breakfast. The patient was given opiates which improved his chest pain to 7/10. The consulting cardiologist wrote in their note: “Could be cardiac chest pain. She is usually incredibly good at recognizing them!

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Chest Pain Blog Hospital Tachycardia 102

Dr. Smith's ECG Blog

MARCH 7, 2024

CT of chest showed the bullet path through his right lung but nowhere near his heart. There were times when it would be usurped by sinus tachycardia, then return to this rhythm. But he did get an EKG: What is this? There is a wide complex. It is irregular. It is not fast (cannot be VT).

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Hemorrhage Chest Pain AFIB Article 109

Dr. Smith's ECG Blog

JULY 16, 2024

This is the prehospital ECG from an 81 year old man with acute chest pain. I favor the P s, Q s, 3 R Approach — as a simple acronym to facilitate recall of the 5 KEY Parameters for rhythm interpretation ( See My Comment in the October 25, 2022 post in Dr. Smith’s ECG Blog ). The medics did NOT activate the cath lab. Arrhythmia?

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Atrial Flutter Chest Pain Tachycardia Arrhythmia 60

Dr. Smith's ECG Blog

SEPTEMBER 18, 2024

This strip was obtained: Apparent Wide Complex Tachycardia at a rate of 280 What do you think? Troponins 34>33>43, likely secondary to myocardial injury from tachycardia. Sinus tachycardia does not go this fast. A 60-something ow healthy male had syncope while on treadmill. What do you want to do?

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Atrial Flutter Exercise AFIB Tachycardia 66

Dr. Smith's ECG Blog

DECEMBER 14, 2016

A middle aged male presented at midnight after 14 hours of constant, severe substernal chest pain, radiating to his throat and to bilateral jaws, and associated with diaphoresis. The pain was not positional, pleuritic, or reproducible. It was not relieved by anything. He had no previous medical history. Is it STEMI or NonSTEMI?

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Chest Pain STEMI Aortic Myocardial Infarction 52

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 Very Wide Complex Tachycardia. EMS reportedly gave 4 grams of calcium (unknown whether CaCl or gluconate) and 50 mEq of sodium bicarbonate. What is the Rhythm? Use Lewis Leads!! What is it?

Cardiac Arrest 131

Cardiac Arrest Bradycardia Tachycardia Chest Pain 131

Dr. Smith's ECG Blog

JUNE 14, 2024

Written by Willy Frick A 57 year old man with was admitted to the hospital with chest pain. The team immediately paged cardiology, concerned for polymorphic ventricular tachycardia. Since sinus conducted QRS complexes cannot co-exist together with ventricular tachycardia, this must all be artifact.

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Atrial Fibrillation Tachycardia Chest Pain Blog 73

Dr. Smith's ECG Blog

OCTOBER 15, 2024

He arrived to the ED by helicopter at 1507, about three hours after the start of his chest pain while chopping wood around noon. He arrived to the ED by ambulance at 1529, only a half hour after the start of his chest pain around 1500 while eating. Patient 1 remained in the hospital overnight. It was stented.

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Chest Pain STEMI Echocardiogram Stent 100

Dr. Smith's ECG Blog

FEBRUARY 8, 2015

They had already cardioverted at 120 J, then 200 J, which resulted in the following: Ventricular Tachycardia They then cardioverted at 200 J which r esulted in the same narrow complex rhythm shown above, at 185 beats per minute. This would treat both SVT or sinus tachycardia. I suggested esmolol if the heart rate did not improve.

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Tachycardia Chest Pain Pharmacology Myocardial Infarction 52

Ken Grauer, MD

MAY 28, 2024

Easy LINKS — tinyurl.com/KG-ECG-Podcasts — [link] — Other ECG Audio PEARLS I previously made for my ECG Blog can be found in the right column of each page on this blog just below this icon — under, "ECG Audio PEARLS". Get a post -conversion 12-lead ECG — and compare this to the initial 12-lead ECG obtained during the tachycardia!

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Blog Arrhythmia Tachycardia CME 122