tag:blogger.com,1999:blog-549949223388475481.post7903799126905458514..comments2024-03-26T22:42:04.176-05:00Comments on Dr. Smith's ECG Blog: Extreme shock and cardiac arrest in COVID patientUnknownnoreply@blogger.comBlogger11125tag:blogger.com,1999:blog-549949223388475481.post-7118699861498237442020-11-23T16:48:50.737-06:002020-11-23T16:48:50.737-06:00Thank you for the clarification! Always appreciate...Thank you for the clarification! Always appreciate the insight on this blog. Jeffreyhttps://www.blogger.com/profile/03274951595275194559noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-85609768436695539612020-11-18T07:54:42.724-06:002020-11-18T07:54:42.724-06:00ThanksThanksJJhttps://www.blogger.com/profile/17519255052010474217noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-2005540939052104302020-11-14T19:58:04.851-06:002020-11-14T19:58:04.851-06:00I'm not sure what you are trying to say. Ther...I'm not sure what you are trying to say. There is no "normal" use of troponin. The most frequent use is for ruling in or ruling out MI. But it has myriad uses in risk stratification of all cardiac disorders.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-43601386375968550802020-11-14T19:56:31.815-06:002020-11-14T19:56:31.815-06:00I see what you mean, but the spiked helmet sign ha...I see what you mean, but the spiked helmet sign has "raised shoulders" on BOTH sides of the QRS, not just one. This is ST Elevation. See this example: https://hqmeded-ecg.blogspot.com/2015/09/central-nervous-system-t-waves.htmlSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-75273204853891458662020-11-14T12:58:22.118-06:002020-11-14T12:58:22.118-06:00@ Jeffrey — Excellent thought (re the QRST in lead...@ Jeffrey — Excellent thought (re the QRST in leads V4,5,6 in ECG #2 of today’s case)! We discuss (and illustrate) the Spiked Helmet Sign in the June 28, 2020 post of Dr. Smith’s ECG Blog (Please scroll down the page to My Comment for illustrated discussion of this phenomenon — at — http://hqmeded-ecg.blogspot.com/2020/06/repost-63-minutes-of-ventricular.html ).<br /><br />As I discuss in this June 28, 2020 post — the QRS-ST segment with the Spiked Helmet Sign typically shows 3 specific components; i) Some elevation of the isoelectric line that begins before the QRS complex (ie, making up the first half of the helmet); ii) Then sharp ascent of the R wave (ie, the “spike” in the helmet); and finally; iii) Coved ST elevation of varying degree, that may mimic an acute ST elevation MI (ie, the second half of the helmet). <br /><br />In contrast, in today’s case — ECG #2 DOES indeed show the 2nd & 3rd components of the sign = a bit of a spike in the R wave (that wasn’t present in ECG #1 in leads V5 and V6) - PLUS - the coved, unusually-shaped ST elevation that mimics an infarct (which wasn’t present in ECG #1) — but it LACKS the 1st component (ie, I do not see any elevation in the isoelectric line that begins before the QRS complex (as I illustrate in the June 28, 2020 post). Whether what we see in ECG #2 represents an early = “evolving” Spiked Helmet Sign, that would have developed that 3rd component had ECMO not been started I think is unknown.<br /><br />Thanks for suggesting this interesting consideration! ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-33885620869770177172020-11-14T10:42:10.729-06:002020-11-14T10:42:10.729-06:00Although it was only present in V4-V6, the ST segm...Although it was only present in V4-V6, the ST segment elevations reminded me of the spiked-helmet sign seen in other critically ill patients. To my knowledge though, the spiked-helmet sign is typically diffuse?Jeffreyhttps://www.blogger.com/profile/03274951595275194559noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-25682804835838315542020-11-14T05:27:46.615-06:002020-11-14T05:27:46.615-06:00Obviously, Cardiac Troponin (cTn) is a nonspecific...Obviously, Cardiac Troponin (cTn) is a nonspecific marker of Myocardial injury,in the normal clinical situation, the use of (cTni) is for diagnosing or to rule out acute Myocardial infarction.ALBERT NWANNEhttps://www.blogger.com/profile/14889061802420399204noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-55170165408715204162020-11-13T02:49:32.108-06:002020-11-13T02:49:32.108-06:00@ Unknown — I also considered lead reversal. Reaso...@ Unknown — I also considered lead reversal. Reasons why I did not think there was lead reversal in ECG #1 were: i) the P wave was upright, and of maximal size (compared to other limb leads) in lead II, as it should be; ii) the P wave and T wave in lead I are both upright (as they should be); iii) the P wave and T wave are both negative in lead aVR (as they should be) — and there ARE times with normal lead placement when you can see a predominant R in lead aVR; iv) I thought the tiny QRS amplitude and pathologic process (ie, Covid myocarditis) were sufficient explanations for the limb lead appearance we see in ECG #1; and v) significant S waves (relative to the tiny R wave size) were also seen in the 2nd and 3rd tracings in lead I in this case.<br />ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-19857252305527947512020-11-13T02:43:02.397-06:002020-11-13T02:43:02.397-06:00Thanks for your comment Tom. Simplistically, my un...Thanks for your comment Tom. Simplistically, my understanding is as you say — that with processes such as large MI, myocardial “stunning”, and myocarditis — that injured myocytes are unable to produce sufficient organization for effective cardiac contraction — leading to low voltage. The effect of COVID appears to add another contributing factor.ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-62986298879798329232020-11-13T01:25:32.904-06:002020-11-13T01:25:32.904-06:00very interesting, and not a little bit depressing,...very interesting, and not a little bit depressing, especially in light of the fact that we had more than 160,000 new cases on thursday, and averaging over 1000 deaths a day.<br /> it seems (am i correct?) that the damaged involved myocytes (myocarditis)simply cannot generate the voltage for healthy QRS complexes, and thus the low voltage we see. Amal Mattu just gave a 16 hour ecg course for EMCases (our toronto friends), and devoted the last 60 minutes to covid related cardiac issues.<br />and it looks that the need for our awareness in this pandemic is not going away any time soon.<br />thank you both, Steve and Ken. tfierohttps://www.blogger.com/profile/15955268501222734373noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-65853132770819295852020-11-13T00:43:14.380-06:002020-11-13T00:43:14.380-06:00is there limb lead reversal in ECG#1? tall R in aV...is there limb lead reversal in ECG#1? tall R in aVR and indeterminated axisAnonymoushttps://www.blogger.com/profile/13466255494068844206noreply@blogger.com