Chest Pain, Tachycardia and Ultrasound

46 year old with chest pain develops a wide complex rhythm -- see many examples

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. These diagnoses were not found in his medical records nor even a baseline ECG.

Chest Pain

Chest Pain Arrhythmia Myocardial Infarction STEMI

Young Man with Very Fast Regular Wide Complex Tachycardia

Dr. Smith's ECG Blog

JUNE 28, 2023

A prehospital 12-lead was recorded: There is a regular wide complex tachycardia. The computer diagnosed this as Ventricular Tachycardia. He arrived in the ED and had an immediate bedside cardiac ultrasound while this ECG was being recorded. There is a wide complex regular tachycardia at a rate of 226. Pulse is 169.

Tachycardia

Tachycardia Ultrasound Heart Disease Atrial Fibrillation

Two patients with chest pain and RBBB: do either have occlusion MI?

Dr. Smith's ECG Blog

OCTOBER 17, 2024

Written by Jesse McLaren Two patients in their 70s presented to the ED with chest pain 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. There is sinus tachycardia at ~100/minute. Vitals were normal.

Chest Pain

Chest Pain STEMI Pulmonary Embolism

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Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

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.

Chest Pain

Chest Pain Embolism Pulmonary Tachycardia

Chest Pain and Inferior ST Elevation.

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

Chest Pain Pericarditis Tachycardia Myocardial Infarction

A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?

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. Pads were placed with ultrasound guidance, so they were in the correct position. Ken notes AV dissociation.

Tachycardia

Tachycardia Cardiogenic Shock Angina Coronary Angiogram

Noisy, low amplitude ECG in a patient with chest pain

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.

Chest Pain

Chest Pain Blog Arrhythmia Critical Care

A Middle-Aged Man with Chest pain, Hypotension and Tachycardia

Dr. Smith's ECG Blog

AUGUST 3, 2018

In the evening, a middle-aged man complained of chest pain at the nursing home. His chest pain was vague. He mentioned "cancer" and "chest". Here was his prehospital ECG, which I viewed immediately while the resident performed cardiac ultrasound: What do you think? Fluids were started. Is is sinus?

Chest Pain

Chest Pain Tachycardia Atrial Flutter Ultrasound

Acute artery occlusion -- which one?

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

It shows sinus tachycardia with right bundle branch block. Taking a step back , remember that sinus tachycardia is less commonly seen in OMI (except in cases of impending cardiogenic shock). Answer : Bedside ultrasound! Smith : RV infarct may also have this appearance on ultrasound. Both were wrong.

Cardiogenic Shock

Cardiogenic Shock Ultrasound Tachycardia Pulmonary

A man in his 50s with shortness of breath

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.

Chest Pain

Chest Pain Embolism Pulmonary Ischemia

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

Dr. Smith's ECG Blog

OCTOBER 26, 2010

This 54 year old patient with a history of kidney transplant with poor transplant function had been vomiting all day when at 10 PM he developed severe substernal crushing chest pain. ACS and STEMI generally do not cause tachycardia unless there is cardiogenic shock. He had this ECG recorded. Are the lungs clear?

STEMI

STEMI Cardiogenic Shock Tachycardia Aneurysm

A young lady with wide complex tachycardia. My first time actually making this diagnosis de novo in real life in the ED!

Dr. Smith's ECG Blog

JUNE 2, 2023

She denied chest pain and denied feeling any palpitations, even during her triage ECG: What do you think? She was awake, alert, well perfused, with normal mental status and overall unremarkable physical exam except for a regular tachycardia, possible rales at both bases, some mild RUQ abdominal tenderness. What is the Diagnosis?

Tachycardia

Tachycardia Cardiomyopathy Electrocardiogram Article

Acute Dyspnea and Right Bundle Branch Block

Dr. Smith's ECG Blog

NOVEMBER 17, 2023

What I had not told him before he made that judgement is that the patient also had ultrasound B-lines of pulmonary edema. Finally, the presentation is dyspnea, not chest pain. A Closer LOOK at the ECG in Figure-1: The ECG in Figure-1 shows sinus tachycardia — with QRS widening due to complete RBBB. What do you think?

Aneurysm

Aneurysm Stent Stents Chest Pain

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

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. Chest pain, SOB, Precordial T-wave inversions, and positive troponin. Now another, with ultrasound. This is a quiz.

Cardiac Arrest

Cardiac Arrest Chest Pain Embolism Pulmonary

Pulmonary Edema, Hypertension, and ST Elevation 2 Days After Stenting for Inferior STEMI

Dr. Smith's ECG Blog

APRIL 12, 2013

He had no chest pain. The computer read is: **Acute MI ** The protocol for prehospital activation in the EMS system that this patient presented to requires 2 elements: 1) Chest pain 2) A computer read of **Acute MI ** Only 1 of 2 was present, so there was no prehospital activation. The patient was transported to the ED.

STEMI

STEMI Pulmonary Stents Stent

"Pericarditis" strikes again

Dr. Smith's ECG Blog

DECEMBER 13, 2019

Written by Pendell Meyers A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain. Several hours prior to presentation, while driving his truck, he started experiencing new central chest pain, without radiation, aggravating/alleviating factors, or other associated symptoms.

Pericarditis

Pericarditis Chest Pain Aortic Blog

What are treatment options for this rhythm, when all else fails?

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.

Arrhythmia

Arrhythmia Cardiogenic Shock Bradycardia Defibrillator

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Dr. Smith's ECG Blog

NOVEMBER 4, 2022

The best course is to wait until the anatomy is defined by angio, then if proceeding to PCI, add Cangrelor (an IV P2Y12 inhibitor) I sent the ECG and clinical information of a 90-year old with chest pain to Dr. McLaren. A slightly prolonged QTc ( although this is difficult to assess given the tachycardia ).

Ischemia

Ischemia STEMI Stenosis Chest Pain

Continuous prolonged generalized weakness, lightheadedness, and presyncope. What might you suspect from the ECG?

Dr. Smith's ECG Blog

OCTOBER 28, 2023

There was some dyspnea but no chest pain. Further ultrasound showed no B-lines (no pulmonary edema). A young man presented with continuous prolonged generalized weakness, lightheadedness, and presyncope. Here is his ECG. This shows LVH, with high voltage. There is very little filling, and thus very poor stroke volume.

Preserved Ejection Fraction

Preserved Ejection Fraction Sudden Cardiac Death Heart Failure Chest Pain

A woman in her 20s with syncope

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Given her reported chest pain, shortness of breath, and syncope, an ECG was quickly obtained: What do you think? A bedside cardiac ultrasound was performed with a parasternal long axis view demonstrated below: There is a large pericardial effusion with collapse of the right ventricle during systole. She has already had syncope.

Tachycardia

Tachycardia Pericarditis Ultrasound Blood Pressure

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

Dr. Smith's ECG Blog

NOVEMBER 19, 2016

It was edited by Smith CASE : A 52-year-old male with a past medical history of hypertension and COPD summoned EMS with complaints of chest pain, weakness and nausea. Smith comment: This patient did not have a bedside ultrasound. In fact, bedside ultrasound might even find severe aortic stenosis. What should be done?

Ischemia

Ischemia Cardiogenic Shock Aortic Stenosis

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

Dr. Smith's ECG Blog

APRIL 8, 2016

A late middle-aged man presented with one hour of chest pain. Bedside ultrasound showed no effusion and moderately decreased LV function, with B-lines of pulmonary edema. See here for management of Polymorphic Ventricular Tachycardia , which includes Torsades. Most recent echo showed EF of 60%. He appeared to be in shock.

STEMI

STEMI Myocardial Infarction Cardiac Arrest Arrhythmia

Cardiac Arrest, hypotension, tachycardia

Dr. Smith's ECG Blog

DECEMBER 22, 2010

Patients who present with chest pain or cardiac arrest and have an ECG diagnostic of STEMI could have myocardial rupture. 5 of 6 presented with chest pain and an ECG indicating reperfusion therapy, but were detected by bedside ultrasound. Obviously, administration of heparin and/or lytics is hazardous.

Cardiac Arrest

Cardiac Arrest Tachycardia STEMI Chest Pain

New Onset Heart Failure and Frequent Prolonged SVT. What is it? Management?

Dr. Smith's ECG Blog

MARCH 6, 2020

This middle-aged man with no cardiac history but with significant history of methamphetamin and alcohol use presented with chest pain and SOB, worsening over days, with orthopnea. Here was his ED ECG: There is sinus tachycardia (rate about 114) with nonspecific ST-T abnormalities. BP:143/99, Pulse 109, Temp 37.2 °C

Heart Failure

Heart Failure Tachycardia Atrial Flutter Cardiomyopathy

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

Dr. Smith's ECG Blog

APRIL 8, 2015

Check : [vitals, SOB, Chest Pain, Ultrasound] If the patient has Abdominal Pain, Chest Pain, Dyspnea or Hypoxemia, Headache, Hypotension , then these should be considered the primary chief complaint (not syncope). Most physicians will automatically be worried about these symptoms. orthostatic vitals b.

Arrhythmia

Arrhythmia Outcomes Risk Factors Chest Pain

A young F is hyperthermic, delirious, and dry: Fever-induced Brugada? Diphenhydramine toxicity? Tricyclic?

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.

Sudden Cardiac Death

Sudden Cardiac Death Heart Rhythm Article Tachycardia

A woman in her 40s with acute chest pain and shortness of breath

Dr. Smith's ECG Blog

NOVEMBER 21, 2024

Written by Pendell Meyers A woman in her 40s presented with acute chest pain and shortness of breath. A 30-something woman with chest pain and h/o pulmonary hypertension due to chronic pulmonary emboli A 30-something with 8 hours of chest pain and an elevated troponin Syncope, Shock, AV block, Large RV, "Anterior" ST Elevation.

Chest Pain

Chest Pain Embolism Pulmonary Tachycardia

Which patient needs a CT scan?

Dr. Smith's ECG Blog

DECEMBER 16, 2024

Case 1: 20-something woman with chest pain Case 2: 50-something man with chest pain Case 1 A 20-something yo woman presented in the middle of the night with severe crushing chest pain. And almost all of them could be detected by bedside ultrasound. Not all chest discomfort is the same.

Chest Pain

Chest Pain Aortic STEMI Ultrasound

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

Dr. Smith's ECG Blog

MARCH 3, 2025

A 69 year old woman with a history of hypertension presented to the emergency department by EMS for evaluation of chest pain and shortness of breath. She awoke in the morning with sharp chest pain which worsened throughout the morning. As her pain worsened, so did her dyspnea. This was written by Hans Helseth.

Tachycardia

Tachycardia Pulmonary Chest Pain Stenosis

Cardiovascular Update

46 year old with chest pain develops a wide complex rhythm -- see many examples

Young Man with Very Fast Regular Wide Complex Tachycardia

Two patients with chest pain and RBBB: do either have occlusion MI?

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Another deadly triage ECG missed, and the waiting patient leaves before being seen. What is this nearly pathognomonic ECG?

Chest Pain and Inferior ST Elevation.

A 50-something with Regular Wide Complex Tachycardia: What to do if electrical cardioversion does not work?

Noisy, low amplitude ECG in a patient with chest pain

A Middle-Aged Man with Chest pain, Hypotension and Tachycardia

Acute artery occlusion -- which one?

A man in his 50s with shortness of breath

Tachycardia must make you doubt an ACS or STEMI diagnosis; put it all in clinical context

A young lady with wide complex tachycardia. My first time actually making this diagnosis de novo in real life in the ED!

Acute Dyspnea and Right Bundle Branch Block

A man in his 30s with cardiac arrest and STE on the post-ROSC ECG

Pulmonary Edema, Hypertension, and ST Elevation 2 Days After Stenting for Inferior STEMI

"Pericarditis" strikes again

What are treatment options for this rhythm, when all else fails?

90 year old with acute chest and epigastric pain, and diffuse ST depression with reciprocal STE in aVR: activate the cath lab?

Continuous prolonged generalized weakness, lightheadedness, and presyncope. What might you suspect from the ECG?

A woman in her 20s with syncope

Diffuse Subendocardial Ischemia on the ECG. Left main? 3-vessel disease? No!

STEMI with Life-Threatening Hypokalemia and Incessant Torsades de Pointes

Cardiac Arrest, hypotension, tachycardia

New Onset Heart Failure and Frequent Prolonged SVT. What is it? Management?

Emergency Department Syncope Workup: After H and P, ECG is the Only Test Required for Every Patient.

A young F is hyperthermic, delirious, and dry: Fever-induced Brugada? Diphenhydramine toxicity? Tricyclic?

A woman in her 40s with acute chest pain and shortness of breath

Which patient needs a CT scan?

Pulmonary edema, with tachycardia and OMI on the ECG -- what is going on?

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