tag:blogger.com,1999:blog-549949223388475481.post3292685471333395942..comments2024-03-26T22:42:04.176-05:00Comments on Dr. Smith's ECG Blog: A man in his 50s with 2 hours of chest pressureUnknownnoreply@blogger.comBlogger15125tag:blogger.com,1999:blog-549949223388475481.post-63238969629665605832020-09-15T21:08:15.271-05:002020-09-15T21:08:15.271-05:00Thank you Jerry! — :)Thank you Jerry! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-15632697290356605912020-09-15T20:40:44.676-05:002020-09-15T20:40:44.676-05:00Ken and Pendell...
A very, very sad case. Fortuna...Ken and Pendell...<br /><br />A very, very sad case. Fortunately, the outcome wasn't as bad as it might have been.<br /><br />Personally, I thought the initial ECG was obvious. The T waves were too large, too wide and too symmetrical to be normal T waves. They were literally screaming "HYPERACUTE!"<br /><br />I always teach my students that it is just as important to recognize normal as abnormal - especially when "abnormal" is a bit subtle. A practice tip I give is to take two leads - Lead II and V3, for instance - and for the next twenty or thirty ECGs that you see, study the T waves in those two leads (after assessing all the others, of course). Learn what normal looks like - check the height and width, check for asymmetry, compare inferior T waves to lateral T waves. Learn to recognize all the shades of normal. Once done, the T waves in this ECG will immediately grab your attention.<br /><br />Jerry W. Jones, MD FACEP FAAEM<br />https://medicusofhouston.comDouble Downhttps://www.blogger.com/profile/09589348333176062815noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-2833284436210826562020-09-14T15:09:58.126-05:002020-09-14T15:09:58.126-05:00I’m afraid I do not understand all of your questio...I’m afraid I do not understand all of your question — but YES, if the ONLY thing we saw that was abnormal on ECG #1 was that shape and that amount of ST depression in leads V2,V3 and V4 — this alone is enough to call it an “OMI” ( = Occlusion-based acute MI). We get into semantics as to whether this is a “STEMI” — since technically there isn’t ST “elevation” — but practically speaking NONE of that matters. What counts is whether or not there is acute occlusion of a major coronary artery — and maximal ST depression of the shape we see in V2-V4 in ECG #1 in a patient with new chest pain IS diagnostic of acute OMI (This is the 5th bullet in my Figure-1). I hope that addresses your concerns — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-76783301527592419352020-09-14T08:28:53.369-05:002020-09-14T08:28:53.369-05:00I'm curious when there is close to a net isoel...I'm curious when there is close to a net isoelectric complex whether we should V2 and V3 to be contiguous concordant STE. In the end the clinical picture and enzymes along with many atypical leads trumps any nitpicking about millimeters or concordant vs discordant but I might even have called it STEMI positive based on V2-4.DrMusicManhttps://www.blogger.com/profile/06719029236216127407noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-86697820547254052452020-09-14T06:48:17.845-05:002020-09-14T06:48:17.845-05:00Our pleasure! — :)Our pleasure! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-30890576775781003402020-09-14T06:48:01.252-05:002020-09-14T06:48:01.252-05:00Yes. Cath confirmed OMI with total (100%) occlusio...Yes. Cath confirmed OMI with total (100%) occlusion of the 1st obtuse marginal branch of the LCx (including other narrowings) and localized hypokinesis.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-50056217561400612042020-09-14T05:16:47.816-05:002020-09-14T05:16:47.816-05:00OMI????OMI????Anonymoushttps://www.blogger.com/profile/12763144526877242310noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-57037031090549065222020-09-14T02:27:42.022-05:002020-09-14T02:27:42.022-05:00Thank you for the updateThank you for the updateAnonymoushttps://www.blogger.com/profile/08486946739538041819noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-73021842035739026402020-09-13T19:33:48.429-05:002020-09-13T19:33:48.429-05:00@ jpmishra — TOUGH issues you raise. These are dis...@ jpmishra — TOUGH issues you raise. These are discussed all the time by us on Dr. Smith’s ECG Blog — as when emergency providers recognize acute OMI but cardiology consultants are not convinced. As illustrated in many of our cases — additional testing (ie, serial troponins, frequent repeat ECGs looking for dynamic changes, comparison with prior tracings, and ideally a stat Echo at the bedside during chest pain looking for localized wall motion abnormalities) + frequent discussion with cardiology are effective measures in many cases to get agreement on the need for prompt cath. Hopefully, with time — your consulting cardiology team will get to know emergency providers better (and will hopefully value and respect their opinion on ECG interpretation). That said, as some of our cases show — sometimes nothing works to convince the Cardiology team … Sometimes cardiology refusal to cath the patient is done from afar, or by a junior member of the team (resident or fellow). All I can suggest under such circumstances is to insist that the Cardiology Attending come in to DIRECTLY see and examine the patient — and that they then take over care (with the ED physician documenting it all on the chart).ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3733240287989811272020-09-13T19:22:28.742-05:002020-09-13T19:22:28.742-05:00@ PB — Posterior leads are NOT needed to make the ...@ PB — Posterior leads are NOT needed to make the diagnosis of acute posterior involvement. I explain and illustrate this with my Mirror Test in My Comment above. Please realize that the size of changes with posterior leads tends to be much less obvious that what can plainly be seen by mirror-image of the anterior leads — so it is RARE indeed (if it ever happens ... ) that posterior leads will tell you something that can't be seen by the standard 12 leads (using the mirror-image technique). Send us a case if you have one of a posterior MI not apparent on standard 12-lead ECG but diagnosed only by posterior leads — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-34233408119922207202020-09-13T15:13:06.619-05:002020-09-13T15:13:06.619-05:00A great case!
1. As a matter of fact, the ECG chan...A great case!<br />1. As a matter of fact, the ECG changes in ER are more than subtle. When there is a disagreement between ER docs and Cardiology team, how do we reconcile it?: next level of testing: Echo right away and of course, cath would have been real helpful (in hindsight). There should have been an insistence by ER docs to pursue the diagnosis further sooner. You know why for the #2 reason, at least.<br />2. Suppose that patient coded on the floor/ICU with VT/VF and died, the case went to the court and ER docs were also implicated, what would they say, "Not my problem!" Likely wont work.<br />Great explanation as always. Thank you for sharing.jpmishrahttps://www.blogger.com/profile/09660893171129684275noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-57235386369662653502020-09-13T11:36:11.803-05:002020-09-13T11:36:11.803-05:00Not posterior leads was obtained?Not posterior leads was obtained?PBhttps://www.blogger.com/profile/12874095324244698091noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-62182156780551350872020-09-13T11:06:58.349-05:002020-09-13T11:06:58.349-05:00I also don't understand ...I also don't understand ...ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-45302234245359938142020-09-13T09:29:47.494-05:002020-09-13T09:29:47.494-05:00I don't understand why with continued pain (I ...I don't understand why with continued pain (I assume?) And actively rising enzymes why not immediate cath. Also I would think a point of care echocardiogram or formal stat echo would go a long way herePMhttps://www.blogger.com/profile/02137437568582174388noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-72348977086276537122020-09-13T08:45:06.055-05:002020-09-13T08:45:06.055-05:00What a shame...What a shame...Nadav shouahttps://www.blogger.com/profile/17330808847744006766noreply@blogger.com