Category: Dr. Smith’s ECG Blog

Pre-existing Left Bundle Branch Block and Atrial Fib: what is alarming on this routine pre-procedure ECG?

An elderly patient had a pre-procedure ECG (ECG-1).  She was asymptomatic.  The patient had known Left Bundle Branch Block (LBBB) and atrial fibrillation (see ECG-2 below), and was rate controlled on metoprolol.  ECG-1 What is the problem? ECG-2 (previous for comparison): There are enormous U-waves, best seen in V1-V3, but also in V4 and V5. 

The Interventionalist Refuses Angiography, and even to speak to the Emergency Physician

A recent residency graduate, let’s call her “The Graduate” or “TG,” texted me these ECGs from somewhere far away across the country, in real time, in the hopes of being able to persuade the interventionalist to take the patient to the cath lab. Case An otherwise healthy middle-aged patient presented with chest pain of uncertain

One of the Great Books of Emergency Medicine Just Published: Extraordinary Cases in Emergency Medicine

Doug Brunette is one of the finest Emergency Physicians, if not the finest, whom I have ever known.  He was one of the early Hennepin greats, and one of my first and best teachers.  He has always been passionate about teaching and practicing Emergency Medicine. Doug’s landmark article in JAMA 1989 was my inspiration to


Written by Pendell Meyers, with edits by Steve Smith The VERDICT trial was recently published. This is yet another study looking at the optimal timing of cardiac catheterization in the setting of NSTEMI. Here are the key summary points of this RCT: Reference: Kofoed et al. Early Versus Standard Care Invasive Examination and Treatment of Patients

What is the diagnosis?

I was reading a stack of ECGs when I came across this one: What do you think? I immediately saw that this ECG is DIAGNOSTIC of hyperkalemia.  There are very flat ST segments with a sharp upturn to the T-wave.  The base of the T-wave is very abnormally narrow, which is what creates the peaked