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In this ECG Cases blog, Jesse McLaren and Rajiv Thavanathan explore how ECG and POCUS complement each other for patients presenting to the emergency department with shortness of breath or chestpain. The post ECG Cases 49 – ECG and POCUS for Dyspnea and ChestPain appeared first on Emergency Medicine Cases.
This was sent by anonymous The patient is a 55-year-old male who presented to the emergency department after approximately 3 to 4 days of intermittent central boring chestpain initially responsive to nitroglycerin, but is now more constant and not responsive to nitroglycerin. It is unknown when this pain recurred and became constant.
2 middle aged males presented with chestpain. Which had the more severe chestpain at the time of the ECG? Patient 2 at the bottom with a very subtle OMI complained of 10/10 chestpain at the time the ECG was recorded. 414 patients were included in the analysis.
For example, considering whatever symptoms that the patient may have had ( ie, chestpain, palpitations, shortness of breath, etc. ) — what this might mean in view of the ECG we are looking at. STEP #2 = Clinical Impression — in which we correlate our assessment that we made in Step #1 to the clinical situation at hand.
A man in his mid-50s presented with chestpain lasting 30 minutes. The initial electrocardiogram showed type A preexcitation syndrome, with obvious ST-segment depression in leads V3 through V5 and positive delta wave. What would you do next?
Written by Jesse McLaren, with a very few edits by Smith A 60-year-old presented with chestpain. Inferior hyperacute T waves, which have been added to the 2022 ACC consensus on chestpain as a “STEMI equivalent”[3] 3. But are there any other signs of Occlusion MI? Conduction disorders in the setting of acute STEMI.
Of course he said: "Yes, it was a 60 year old diabetic with Chestpain." K en G rauer gives a thorough explanation here: A 60 year old with chestpain == MY Comment , by K EN G RAUER, MD ( 9/15 /2023 ): == The 1st time that I saw APTA ( A rterial P ulse T ap A rtifact ) — I did not know what it was. That is not a STEMI.
Written by Jesse McLaren A 45-year-old presented with 24 hours of intermittent chestpain. On it’s own this is nonspecific, but in the right context this could be diagonal occlusion (if active chestpain) or infero-posterior reperfusion (if resolved chestpain). #2 Can you guess the sequence?
A 50-something male had onset of chestpain 1 hour prior to ED arrival. Endorses some associated SOB, but denies back pain, fever, cough, chills, leg swelling, or other new symptoms. Always get serial ECGs in a patient with acute chestpain. It is constant, 9/10, left-sided CP that radiates into left arm and jaw.
I assumed it was a patient with acute chestpain. It was a man in his 30s with chestpain. This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. What do you think, Steve? Real or just fake?" What do YOU think? It has some inferior ST elevation with some reciprocal ST depression and inverted T in aVL.
Written by Pendell Meyers Two patients with acute chestpain. Patient 1: Patient 2: Patient 1: A man in his 40s with minimal medical history presented with acute chestpain radiating to his R shoulder. Two patients with chestpain. Do either, neither, or both have OMI and need reperfusion?
A young woman presented with acute chestpain. This case came from a friend whose sister was the patient. She knew I was interested in ECGs, so she took a photo of this one. This was her presenting ECG: What do you think? This is clearly Brugada phenotype. There is downsloping ST Elevation in V1 and V2.
Written by Willy Frick A 67 year old man with a history of hypertension presented with three days of chestpain radiating to his back. Due to the chestpain radiating into the patient's back, the ER physician ordered CTA chest to rule out aortic dissection. He had associated nausea, vomiting, and dyspnea.
The patient was a middle-aged female who had acute chestpain of approximately 6 hours duration. The pain was still active at the time of evaluation. See some relevant cases below: Chestpain with anterior ST depression: look what happens if you use posterior leads.
Written by Jesse McLaren A 65 year old with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented with 3 days of fluctuating chestpain, which was ongoing at triage. So a patient with high pretest probability (prior CABG with new chestpain), had new ECG changes showing posterior OMI.
Written by Pendell Meyers A man in his 40s called EMS for acute chestpain that awoke him from sleep, along with nausea and shortness of breath. His history included known heart failure with prior EF 18%, insulin dependent diabetes, and polysubstance abuse. Vitals were within normal limits except for tachypnea.
Sent by Magnus Nossen MD, written by Pendell Meyers A man in his 50s, previously healthy, developed acute chestpain. The primary care physician there evaluated this patient and deemed the chestpain to be due to gastrointestinal causes. The ECG was also interpreted as normal by the primary care physician.
A 50 year old presented to the emergency department of a remote rural community (where the nearest cath lab is a plane ride away) with one hour of mild chestpain radiating to the back and jaw, and an ECG labeled ‘normal’ by the computer interpretation. What do you think, and how would you manage the patient?
(MedPage Today) -- For lower-risk patients with acute myocardial injury already ruled out for their chestpain, an increase in referrals for noninvasive cardiac testing (NICT) was not associated with improved outcomes, a retrospective cohort study.
Future heart attacks could be better prevented in people visiting their GP with unexplained chestpain, after Keele researchers developed the clearest picture yet of the factors that put them at higher risk. The research is published in the European Journal of Preventive Cardiology.
A 41-year-old male who presents to the emergency department with chestpain. Patient reports approximately 2 hours prior to arrival he developed a sharp chestpain that radiates into his left arm and left lower leg. Describes the radiating pain as numbness/tingling. No shortness of breath. No recent travel.
Written by Willy Frick A man in his early 40s with BMI 36, hypertension, and a 30 pack-year smoking history presented with three days of chestpain. He described it as a mild intensity, nagging pain on the right side of his chest with nausea and dyspnea. It started while he was at rest after finishing a workout.
A 50-something male with hypertension and 20- to 40-year smoking history presented with 1 week of stuttering chestpain that is worse with exertion, which takes many minutes to resolve after resting and never occurs at rest. At times the pain does go to his left neck. It is a ssociated with mild dyspnea on exertion.
A 56 year old male with PMHx significant for hypertension had chestpain for several hours, then presented to the ED in the middle of the night. He reported chestpain that developed several hours prior to arrival and was 5/10 in intensity. The pain was located in the mid to left chest and developed after riding his bike.
Written by Willy Frick A man in his 50s with history of hypertension, hyperlipidemia, and a 30 pack-year smoking history presented to the ER with 1 hour of acute onset, severe chestpain and diaphoresis. His ECG is shown: What do you think? What do you think?
By Magnus Nossen This ECG is from a young man with no risk factors for CAD, he presented with chestpain. The patient is a young adult male with chestpain. The chestpain was described as pressure like and radiation to both arms and the jaw. How would you assess this ECG? What is your next step?
Written by Pendell Meyers A man in his 60s presented with acute chestpain and normal vital signs. Here is his triage ECG: What do you think? The ECG shows massively hyperacute T waves of LAD OMI, plus WPW. V3-V5 also have the depressed HATW takeoff which qualifies them as the rare de Winter subtype of HATWs.
Sent by anonymous, written by Pendell Meyers, reviewed by Smith and Grauer A man in his 40s presented to the ED with HTN, DM, and smoking history for evaluation of acute chestpain. He was eating lunch when he had sudden onset chest pressure, 9/10, radiating to his back, with sweating and numbness in both hands.
This was sent by Sam Ghali @EM_RESUS A 44 year old man presented with chestpain The tech came running with the ECG as the computer called "STEMI!" What do you think? Sam sent this to me and asked: "What do you think, Steve?" My answer: --Tough one! --But
Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chestpain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. The pain radiated down both arms, 10/10 in severity.
Written by Jesse McLaren A 45 year old presented with two weeks of recurring non-exertional chestpain, now constant for an hour. Because of the ECG changes in a patient with chestpain, and with inferolateral hypokinesis on POCUS, the cath lab was activated. Below is old and then new ECG (old on top; new below).
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 chestpain and nausea. The patient continued having chestpain. These diagnoses were not found in his medical records nor even a baseline ECG.
Written by Jesse McLaren Four patients presented with chestpain. All initial ECGs were labeled ‘normal’ or ‘otherwise normal’ by the computer interpretation, and below are the ECGs with the final cardiology interpretation.
No ChestPain, but somnolent. The fact that this is syncope makes give it a far lower pretest probability than chestpain, but it was really more than syncope, as the patient actually underwent CPR and had hypotension on arrival of EMS. Here is the ED ECG (a photo of the paper printout) What do you think?
Click here to sign up for Queen of Hearts Access Case A 58-year-old woman presented to the ED with burning chestpain that started 2-3 hours earlier while sitting on a porch swing. In any case, it is diagnostic of OMI in a chestpain patient. But there is also perhaps some STD in inferior leads -- this would support LAD.
I was working at triage when the medics brought this patient who is 65 yo and has had chestpain for 12 hours. They recorded a prehospital ECG at 2112 and said that it was “normal”. It had already been crumpled up and put in the waste basket. So I uncrumpled it: What do you think?
The patient presented to an outside hospital An 80yo female per triage “patient presents with chestpain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB. HPI: Abrupt onset of substernal chestpain associated with nausea/vomiting 30 min PTA.
Written by Jesse McLaren A healthy 75 year old developed 7/10 chestpain associated with diaphoresis and nausea, which began on exertion but persisted. Below is the first ECG recorded by paramedics after 2 hours of chestpain, interpreted by the machine as “possible inferior ischemia”. What do you think?
Written by Jesse McLaren Two patients in their 70s presented to the ED with chestpain and RBBB. Patient 1 : a 75 year old called paramedics with one day of left shoulder pain which migrated to the central chest, which was worse with deep breaths. Do either, both, or neither have occlusion MI? Vitals were normal.
Written by Willy Frick with edits by Ken Grauer An older man with a history of non-ischemic HFrEF s/p CRT and mild coronary artery disease presented with chestpain. He said he had had three episodes of chestpain that day while urinating. ECG 1 What do you think? There is a lot going on in this ECG.
(MedPage Today) -- PARIS -- Whether a person had chestpains resolved by angioplasty hinged on the nature, not the severity, of their presenting symptoms, an ORBITA-2 analysis showed. Investigators found two groups more likely to benefit from.
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