The High Acuity Patient

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The High Acuity Patient
MODULE 5
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Coronary Artery Anatomy

• Varies from patient to patient
• General patterns of distribution exist

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Left Coronary Artery
Left Main
Right Coronary Artery
Left Circumflex
Right Ventricle
Lateral Wall
Septal Wall
Anterior Wall
Anterior Descending Artery
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Left Coronary Artery (LCA)

• Left Main (proximal LCA)
• Left Circumflex (LCX)
• Left Anterior Descending (LAD)

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Distribution

• LAD anteroseptal
• LCX lateral
• Proximal LCA extensive anterior

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Practice ECG
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Practice ECG
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Practice ECG
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Extensive Anterior MI

• Evidence in septal, anterior, and lateral leads
• Often from proximal LCA lesion
• Widow Maker
• Complications common

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Definitive Therapy for Extensive AWMI

• Normal blood pressure
• Thrombolysis
• Signs of shock
• PTCA
• CABG

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LCA Occlusions

• Other considerations
• Bundle branches supplied by LCA
• Serious infranodal heart block may occur

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Right Coronary Artery
Left Coronary Artery
Right Coronary Artery
Lateral Wall
Posterior Descending Artery
Left Ventricle
Posterior Wall
Inferior Wall
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Right Coronary Artery (RCA)

• Proximal RCA
• Posterior descending artery (PDA)

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RCA Distribution

• Proximal RCA
• Right ventricle
• Posterior wall
• Inferior wall
• PDA
• Inferior wall

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Practice ECG
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Proximal RCA Occlusion

• Right Ventricular Infarct (RVI)
• 12-lead ECG does not view right ventricle
• Use additional leads
• V3R - V6R
• V4R

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Right Precordial Leads

• On right side of chest
• Same anatomical landmarks as V3 - V6

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Practice ECG
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ECG Evidence of RVI

• Inferior MI (always suspect RVI)
• ST elevation right V leads

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Cardiac Blood Flow
To Lungs
From Lungs
To Body
From Body
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Physical Evidence of RVI

• Dyspnea with clear lungs
• Jugular vein distension
• Hypotension
• Relative or absolute

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Treatment for RVI

• Use caution with vasodilators
• Small incremental doses of MS
• NTG by drip

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Fluid for Hypotension

• One to two liters may be required
• Large bore lines suitable here

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Posterior Wall MI (PWMI)

• Usually an extension of an inferior or lateral MI
• Common with proximal RCA occlusions
• Occurs with LCX occlusions

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PWMI

• Reciprocal changes
• V1 - V4
• Indicative changes
• V7, V8, V9

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Posterior Leads

• V7
• Posterior axillary line
• Level with V6
• V8
• Mid-scapular line
• Level with V6
• V9
• Left para-vertebral
• Level with V6

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Indicative Leads
Infarcted Tissue
Posterior Wall
Ischemic Tissue
Reciprocal Leads
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PWMI

• Best to identify with direct leads
• V7, V8, V9
• ST elevation in posterior leads is evidence of
  posterior MI

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Practice ECG
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PWMI

• Look for PWMI when
• V1 -V4 show ST depression
• The ECG is normal
• The story is convincing

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Left Coronary Dominance

• Approximately 10 of population
• LCX supplies PDA
• Inferolateral MI

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Dominant Left Coronary

• Left circumflex supplies posterior descending
  artery

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Practice ECG
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Lab for Module 5

• Lab manual