August 14, 2014

A 52 year old female with a past medical history of type II diabetes mellitus and tobacco abuse presents with a chief complaint of chest pain. According to the patient she had about 2 - 3 months of stuttering, substernal chest pain without any radiation.  She described the pain as pressure-like, with activity, but that it would typically resolve after a few minutes of rest.  Today she awoke with substernal chest pain that never resolved and continued in the emergency department.  She quantifies her pain as 7/10 and not relieved with 2L nasal cannula of oxygen, 325mg PO aspirin, and SL NTG x3. BP 127/89     HR 76     RR 20      O2 sat 100% on 2L NC     Temp 99.3 Awake, A&Ox3, appears uncomfortable Mild JVD on examination RRR w/o m/r/g CTA B 2+ pulses in her extremities, no edema ECG is shown (No prior ECG for comparison).....

June 9, 2014

  89 year old male with PMH of hypertension, stage 3 chronic kidney disease with chief complaint of shortness of breath. Several days ago patient had a laminectomy for radicular pain. He was doing fine post-operatively and began to develop gradual shortness of breath.  He had no complaints of chest pain, nausea/vomiting, fevers, diaphoresis, but did have some weakness.  There were no prior ECGs for comparison. BP: 98/48 HR: 103 RR: 18 O2 on RA: 94% Temp: 38.6 JVD to the angle of the mandible Bibasilar Crackles Sinus Tachycardia Bilateral lower extremity pitting edema Labs: Na 125, K+ 4.2, Creatinine 2, BNP > 2500 ECG from triage is shown...

April 17, 2014

Hyperkalemia is an electrolyte abnormality seen in the emergency department as well as in hospitalized patients and it can be associated with adverse clinical outcomes and death if not treated appropriately. It is important to remember that the electrophysiologic effects of hyperkalemia are directly proportional to both the absolute plasma potassium and its rate of rise. However, neither the ECG nor the plasma potassium alone are an adequate index of the severity of hyperkalemia, and therefore providers should have a low threshold to initiate therapy. Classic teaching of the chronological ECG changes of hyperkalemia include:
  1. Peaked T waves
  2. Prolongation of PR interval
  3. Widening QRS Complex
  4. Loss of P wave
  5. "Sine Wave"
  6. Asystole

February 15, 2014

Electrocardiography is a fundamental part of cardiovascular assessment. It is an essential tool for investigating cardiac arrhythmias and ischemia. Just because electrocardiography is a basic skill in EM doesn't mean that our skills should be basic...we must be the EXPERTS! Below is a summary of some ECG basics including:
  • ECG Measurements
  • ECG Rate
  • ECG Axis

December 12, 2013

The case from this week is from one of the PGY-1 residents at University of Texas Health Science Center at San Antonio (UTHSCSA).  Several of the details of the case have been changed to keep patient information confidential. 53 year old female with a past medical history of hypertension, hyperlipidemia, coronary artery disease, and 3 anterior myocardial infarctions s/p 4-vessel CABG (LIMA-LAD, RIMA-RCA, SVG-D1-OM1 sequentially) 9 months ago who presents with intermittent 10/10 chest pain that radiates to his left arm for the past 6 months. The chest pain is associated with nausea and shortness of breath but denies diaphoresis or syncope. Patient reports that the pain is the same as his index chest pain and is both exertional and non-exertional and will often wake him up from sleep. The pain can last 5-10 minutes and is always relieved by rest. The patient reports good medication compliance (on metoprolol, atorvastatin, enalapril, amlodipine, aspirin). He presented with similar symptoms 3 months ago but left against medical advice before a work-up could be performed. Now he presents with increasing frequency of chest pain. BP 152/105  HR 86 RR 16 O2 sat 99% on RA   Temp 98.0 ECG from triage is shown…
0