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

Dr. Smith's ECG Blog

He was rushed by residents into our critical care room with a diagnosis of STEMI, and they handed me this ECG: There is sinus tachycardia with ST elevation in II, III, and aVF, as well as V4-V6. At first glance, it seems the patient is having a STEMI. Then ACS (STEMI) might be primary; this might be cardiogenic shock.

STEMI 52
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A 40-Something male with a "Seizure," Hypotension, and Bradycardia

Dr. Smith's ECG Blog

There is an obvious inferior STEMI, but what else? Besides the obvious inferior STEMI, there is across the precordial leads also, especially in V1. This STE is diagnostic of Right Ventricular STEMI (RV MI). In fact, the STE is widespread, mimicking an anterior STEMI. EKG is pictured below: What do you think?

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Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

Dr. Smith's ECG Blog

This EKG was recorded as part of a standing order for critical care. 2 days later This is a typical LVH pattern, without ischemia Patient underwent 4 vessel CABG. He had been smoking an opiate and suddenly collapsed. He was ventilated with BVM on arrival. He awoke with naloxone. He denied any CP or SOB.

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A "normal ECG" on a busy night

Dr. Smith's ECG Blog

We brought the patient into one of our critical care rooms and immediately got more history while recording this repeat ECG: The STE in I has greatly diminished or entirely disappeared. He wrote in his note that "The EKG showed early repolarization in I, V2-V3 but no clear STEMI pattern." We activated the cath lab.

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Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?

Dr. Smith's ECG Blog

Despite the clinical context, Cardiology was consulted due to concerns for a "STEMI". It is critically important for all EM and critical care providers to have an intimate understanding of hyperkalemia and its ECG findings. From Ken Grauer ( See below ) — with this Figure adapted from LITFL.