When the heart rate blasts past 150, our reflex is often to grab a syringe—diltiazem, metoprolol, something to slow things down.

But here’s the hard truth: if the patient is in sick-tachy—tachycardia as a secondary compensation—slamming them with rate control can be catastrophic.

That racing heart rate may be the only thing keeping them alive.

Pausing to ask “sick-tachy or tachy-sick?” is what separates the new learner from the confident emergency clinician.

This episode is all about STOP-ping before you treat the number.

STOP is your mnemonic for the must-consider secondary compensations that drive tachycardia in the ED.

Each of these can mimic or mask primary arrhythmias, and missing them can lead to disaster:

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🛑 STOP Mnemonic

S – Sepsis

• Tachycardia is often the earliest sign of infection.

• Always check a lactate—“Lactic Acid” should be etched in your mind.

• Bundle: fluids + source control.

• Be cautious in elderly or vague abdominal presentations; tachycardia may be your only clue.

T – Thyroid Storm

• Look for agitation, fever, tremor, weight loss history.

• Order TSH/T3/T4.

• Treatment anchor: Beta-blockers (BB) are first-line for rate control here—unique compared to other scenarios.

• Missing thyroid storm means missing a reversible cause of near-fatal tachycardia.

O – HypOvolemia

• Think bleeding (low H/H), dehydration, or anemia.

• Visual: half water / half blood glass—“Fill the Tank.”

• Don’t just reach for meds—give fluids, transfuse, and stabilize volume first.

• Remember also anxiety/pain can amplify sympathetic tone.

P – Pulm/Cards (Cardiopulmonary)

• Pneumonia – fever, infiltrate, hypoxia.

• Pneumothorax – sudden pleuritic chest pain, absent breath sounds.

• PE – unexplained hypoxia, pleuritic pain, risk factors.

• CHF (low EF) – the most dangerous one to miss before you push AV nodal blockers.

• Workup tools: ABG, BNP, CTPA, CXR, POCUS.

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🧠 Why This Matters

• Sinus tachycardia is often appropriate—but it can mask life-threatening systemic illness.

• Medicating away compensation without treating the cause can pull the plug on the patient’s only survival mechanism.

• STOP first before flipping to tachyarrhythmia algorithms (SVT, AFib w/ RVR, VT, Torsades, VF).

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⚡ Clinical Pearls

• Always ask: Stable or unstable? Unstable → Shock immediately per ACLS.

• If stable → STOP. Consider secondary compensations before rhythm drugs.

• POCUS is your left-hand tool—look for low EF before you dare to push AV nodal blockers.

• Gradual vs sudden onset helps distinguish sick-tachy (gradual, compensatory) from tachy-sick (primary arrhythmia, often sudden).

• Repetition is your friend—STOP, STOP, STOP until it becomes second nature.

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🎧 In this episode, you’ll learn how to build a jetpack framework for HR >150 that keeps you calm under pressure, helps you avoid rookie mistakes, and makes sure you never miss the underlying killer hiding beneath “just a fast heart rate.”

STOP first. Then treat.

Chest pain is one of the most common—and highest risk—complaints in the ED. Missing acute coronary syndrome can be catastrophic, but keeping every patient in the hospital isn’t realistic either. That’s why the HEART score has become the standard of care: a simple, validated tool to help you decide who is safe for early discharge and who needs further workup or cardiology assessment.

In this episode, I’ll show you how to remember and apply the HEART score effortlessly by flipping it into the 6 S’s and 6 H’s framework—a diamond-shaped way to risk-stratify chest pain that you can run through in real time, right at the bedside. This method blends the Diamond classification of angina with the HEART score, anchoring it to recall cues you’ll never forget. Once you master the S’s and H’s, you’ll be able to calculate HEART quickly, communicate clearly, and avoid missing high-risk patients.

Of course, always follow your local protocols—but for every chest pain encounter, remember: ALWAYS calculate the HEART score.

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💎 6 S’s & 6 H’s: The Framework

S’s — Symptoms, ECG, Risk factors, Age

Suspicious Symptoms (Diamond criteria)

1 . Substernal

1. ​ Stress-related (worse with exertion)
2. ​ Stops with rest

• ​ Bonus: Sweating

→ Typical angina = 3/3

→ Atypical angina = 2/3

→ Non-anginal = 0–1

1. ​ ST Changes on ECG

• ​ Normal → 0
• ​ Non-specific (LVH, digoxin, etc.) → +1
• ​ Significant ST depression/elevation → +2

1. ​ Smoking (or Vaping)

• ​ Still a major ASCVD risk factor
• ​ Ask specifically in younger patients

1. ​ Sixty-Five (Age ≥65)

• ​ <45 → 0
• ​ 45–64 → +1
• ​ ≥65 → +2

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H’s — The Highs & History

1. ​ High Cholesterol (Hyperlipidemia / LDL)
2. ​ High Sugar (Diabetes)
3. ​ High BP (Hypertension)
4. ​ Heavy (Obesity, BMI >30)
5. ​ History (Family hx <65, personal hx MI/CAD/PCI/CVA/PAD)
6. ​ High Troponin

• ​ 1–3× normal → +1
• ​ >3× normal → +2

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⚠️ Pearls & Pitfalls

• ​ MACE = Major Adverse Cardiac Events.
• ​ HEART pathway randomized trial (Mahler, 2015) → validated early discharge.
• ​ The HEART score is not universal—there are exceptions; know when it doesn’t apply.
• ​ Enough S’s & H’s → They Stay in the Hospital.

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👉 Whether you’re on shift, teaching, or reviewing for boards, this episode makes the HEART score second nature. Save time, reduce misses, and risk stratify chest pain with confidence.

In a cardiac emergency, pattern recognition saves lives. The ability to rapidly identify ST-elevation myocardial infarctions (STEMIs) — and recognize their reciprocal changes — is one of the most high-yield clinical skills you can master. But memorizing lead groupings, artery territories, and reciprocal zones can feel abstract… until now.

This podcast brings EKGs to life inside a colorful, stadium-themed world where each ECG lead is a character in the crowd — making it dramatically easier to remember the key patterns of ischemia and their reciprocals. Whether you’re a student, clinician, or educator, this episode transforms clinical EKG interpretation into vivid, unforgettable storytelling.

🧠 Characters You’ll Meet:

• Inferior Peasants (II, III, aVF) — Dirty, disheveled townsfolk crowd-surfing with broken RC cars (Right Coronary Artery), holding crossed-out nitro packs to remind us: No nitro in RCA infarcts!

• Royal Ladder Holders (I, aVL, V5, V6) — Crowned kings and queens dropping through trapdoors as reciprocal ST depression hits the lateral leads, each holding golden ladders labeled Left Circumflex.

• Cavemen with Septal Bones (V1–V2) — Giant-nosed, primitive figures gripping a huge bone marked SEPTAL, standing just in front of…

• Shirtless Musclemen (V3–V4) — Tattooed with the word Anterior, these strongmen are chained to a floating AC unit labeled Left Ventricle — representing the LAD (Widowmaker).

• Posterior Posts (V7–V9) — Hydraulic pylons rising behind the wall, symbolizing posterior MI that’s often missed without reciprocal signs.

🎯 Quick Reference Patterns Covered in the Episode:

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✅ Inferior MI (II, III, aVF)

• ST elevation: Inferior leads

• Reciprocal depression: I, aVL (high lateral)

→ “When the peasants rise, the royals fall.”

✅ High Lateral MI (I, aVL)

• ST elevation: High lateral leads

• Reciprocal depression: III, aVF

→ Works both ways: “The balcony royals rise, the peasants fall.”

✅ Posterior MI (V7–V9)

• ST elevation: Posterior wall (not on standard 12-lead!)

• Reciprocal depression: V1–V3

→ “When posterior posts rise, septal cavemen drop.”

✅ Anterior MI (V2–V4)

• ST elevation: Anterior leads

• Possible reciprocal depression: II, III, aVF

→ Sometimes: “When the chest heroes rise, peasants tremble.”

✅ Low Lateral MI (V5–V6)

• ST elevation: Low lateral leads

• Reciprocal depression: V1–V2 (septal)

→ “Kings and queens rise, cavemen fall.”

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🔥 Bonus Insights:

• Why reciprocal changes matter: They can confirm a true STEMI, suggest a larger infarct area, and sometimes reveal hidden infarctions (like posterior MIs).

• LBBB & Reciprocal Thinking: LBBB distorts ST segments, but understanding the mirror logic behind “William” (LBBB) and “Marrow” (RBBB) helps clarify expected patterns. ST depression in V1–V2? May just be part of LBBB — unless it’s concordant…

📌 Use this episode as your visual and verbal anchor. Once you’ve seen the peasants, the royalty, the cavemen, and the Left Vent AC unit, you’ll never look at a 12-lead the same way again.