Cardiovascular Emergencies and 12 Lead EKGs

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Cardiovascular Emergencies and 12 Lead EKGs

• Condell Medical Center
• EMS System
• ECRN Packet
• Module III 2007

Prepared by Sharon Hopkins, RN, BSN, EMT-P
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Objectives

• Upon successful completion of this program, the
  ECRN should be able to
• understand the normal anatomy physiology of the
  cardiovascular system
• describe anatomical changes to the heart during
  ischemic episodes
• differentiate presentations of patients with
  cardiorespiratory complaints

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• recognize ST elevation on
• the 12 lead EKG
• identify and appropriately state interventions
  for a variety of dysrhythmias
• review discussion of case presentations
• successfully complete the quiz with a score of
  80 or better

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Cardiovascular System

• This system is composed of the heart and blood
  vessels
• Delivers oxygenated blood to all cells
• Transports hormones throughout the body
• Transports waste products for waste disposal
• The heart is a pump
• right pump is under low pressure
• left pump is under high pressure

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3 Components of The Circulatory System

• Functioning heart
• Sufficient blood volume
• Intact blood vessels
• If any one of the above 3 are not working
  properly, the patient may be symptomatic and
  could be in need of intervention

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Aorta
Superior vena cava
Left atrium
Right atrium
Left ventricle
Right ventricle
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Myocardial Blood Flow

• The heart is a muscle (myocardium)
• 3 layers
• epicardium - smooth outer surface
• myocardium - thick middle layer, responsible for
  cardiac contraction activity
• endocardium - innermost layer of thin connective
  tissue
• Myocardial blood flow
• via coronary arteries immediately off aorta
• heart is the 1st structure to receive oxygenated
  blood - its that important!

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Coronary Arteries

• Left main coronary artery
• left anterior descending coronary artery (LAD)
• supplies left ventricle, septum
• circumflex coronary artery
• supplies left atrium, left ventricle, septum,
  part of right ventricle
• Right coronary artery (RCA)
• supplies right atrium ventricle and part of
  left ventricle

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Coronary Blood Flow
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Collateral Circulation

• Development of new blood vessels to reroute blood
  flow around blockage in a coronary artery
• New arteries may not be able to supply enough
  oxygenated blood to heart muscle in time of
  increased demand
• Ischemia occurs when blood supply to the heart is
  inadequate to meet the demands

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Influences of Heart Function

• Preload
• pressure under which a ventricle fills volume of
  blood returning to fill the heart
• Afterload
• the resistance the ventricle has to pump against
  to eject blood out of the heart
• the higher the afterload the harder the ventricle
  has to work
• Ejection fraction (EF)
• percentage of blood pumped by the ventricle with
  each contraction (healthy 55)
• damage to heart muscle decreases EF

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Influences On Preload Afterload

• Afterload
• arteriosclerosis induced high B/P can cause left
  ventricle to become exhausted stop working
  efficiently

• Preload
• increased oxygen demand increases volume of blood
  returning to heart
• temporarily not a problem
• heart enlarges when preload remains increased
  (Frank-Starling law)

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Problems That Decrease Ejection Fraction (EF)

• Myocardial infarction (MI)
• Congestive heart failure (CHF)
• Coronary artery disease (CAD)
• Atrial fibrillation
• Cardiomyopathy
• Anemia
• Excess body weight
• Poorly controlled blood pressure

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Coronary Artery Disease (CAD)

• Leading cause of death in USA
• Narrowing or blockage in coronary artery
  decreasing blood flow
• Atherosclerosis - thickening hardening of the
  arteries due to fatty deposits in vessels
• Plaque deposits build up in arteries
• arteries narrow
• arteries become blocked
• blood clots form
• Overtime, CAD can contribute to heart failure
  dysrhythmias

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Coronary Artery Disease (CAD)

• Plaque in a coronary artery breaks apart causing
  blood clot to form and blocks artery

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Symptoms of Cardiovascular Problems

• Breathing problems
• Shortness of breath (SOB)
• Paroxysmal nocturnal dyspnea (PND)
• suddenly awakens with shortness of breath
• Orthopnea
• dyspnea when lying down
• Breath sounds
• are they clear or not clear?

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• Peripheral edema
• excess fluid found in tissues of the most
  dependent part of the body
• presacral area in bedridden person
• feet and ankles in someone up and about
• Syncope
• fainting when cardiac output falls
• fainting while lying down is considered cardiac
  in nature until proven otherwise
• Palpitations
• sensation of fast or irregular heartbeat
• Pain

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Initial Impression

• Not necessarily important to know exactly what to
  name the patients problem (diagnosis)
• Important to identify signs and symptoms that
  need to be treated
• think whats the worse case scenario?
• Important to recognize the possible medical
  condition the signs and symptoms may be
  representing
• Important to determine the right treatment
  approach

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Patient AssessmentOPQRST of Pain Symptoms

• Onset
• Sudden or gradual?
• Anything like this before?
• Provocation or palliation
• What makes it better/worse?
• What was the patient doing at the time?
• Quality
• What does it feel like (in patients own words)?

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• Radiation
• From where to where?
• Severity
• How bad is it on a scale of 0-10?
• Timing
• When did it start
• How long did it last?
• Continuous or intermittent?

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Vital Signs Tools for Pt Assessment

• Heart rate
• too fast
• ventricle does not stay open long enough to
  adequately fill
• too slow
• rate too slow to pump often enough to maintain an
  adequate volume output
• Blood pressure
• could be elevated in anxiety and pain
• low in shock
• serial readings (trending) tell much

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• Respirations
• Abnormally fast, slow, labored, noisy?
• Clear - hear breath sounds enter exit
• normal
• Crackles - pop, snap, click, crackle
• fluid in lower airways
• Rhonchi - rattling sounds resembles snoring
• mucus in the airways
• Wheezes - whistling sound initially heard on
  exhalation
• narrowing airways (ie asthma)
• Absence of sound - not good!!!

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• Pulse oximetry (SaO2)
• Measures percent of saturated hemoglobin in
  arterial blood
• Need to evaluate reading with patients clinical
  presentation -
• do they match?

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Inaccurate SaO2 Readings

• Hypotensive or cold patient (falsely low)
• Carbon monoxide poisoning (falsely high)
• Abnormal hemoglobin (sickle-cell disease)
  (falsely low)
• Incorrect probe placement (falsely low)
• Dark nail polish (falsely low)
• Anemia (falsely high - whatever hemoglobin
  patient has is saturated)

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• EKG monitoring
• Indicates electrical activity of the heart
• Evaluate mechanical activity by measuring pulse,
  heart rate and blood pressure
• Can indicate myocardial insult and location
• ischemia - initial insult ST depression
• injury - prolonged myocardial hypoxia or
  ischemia ST elevation injury reversible
• infarction - tissue death
• dead tissue no longer contracts
• amount of dead tissue directly relates to degree
  of muscle impairment
• may show Q waves

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ST depression
ST elevation
Q wave
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Acute Coronary Syndrome

• Variety of events that represent acute
  myocardial ischemic pain (plaque rupture)
• Unstable angina
• Intermediate severity of disease between stable
  angina and acute MI tissue ischemia
• Non-Q wave infarct (NSTEMI)
• No ST elevation but MI is present with tissue
  necrosis (death)
• Q wave infarct (STEMI)
• ST elevation MI with tissue necrosis (death)
• Usually a large/significant infarct

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Acute Myocardial Infarction

• Coronary blood flow deprived so that portion of
  muscle dies
• occlusion by a thrombus (blood clot superimposed
  on ruptured plaque)
• spasm of coronary artery
• reduction in blood flow (shock, arrhythmias,
  pulmonary embolism)
• Location and size of infarct depends on which
  coronary artery is blocked where
• left ventricle most common

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AMI Signs Symptoms

• Chest pain - most common especially in men
• lasts 15 minutes
• does not go away with rest
• typically felt beneath sternum
• typically described as heavy, squeezing,
  crushing, tight
• can radiate down the arm (usually left), fingers,
  jaw,upper back, epigastrium
• Pain not influenced by coughing, deep breathing,
  movement

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Atypical AMI Signs Symptoms

• Persons with diabetes, elderly, women, and heart
  transplant patients
• Atypical presentation - from drop in cardiac
  output (CO)
• sudden dyspnea
• sudden lose of consciousness (syncope) or
  near-syncope
• unexplained drop in blood pressure
• apparent stroke
• confusion
• generalized weakness

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Atypical AMI Signs Symptoms

• Women at greater risk
• symptoms ignored (by patient MD)
• under-recognized
• under-treated
• Typical presentation in women
• nausea
• lightheadedness
• epigastric burning
• sudden onset weakness
• unexplained tiredness/weakness

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Region X SOP Initial Treatment Acute Coronary
Syndrome

• Regardless of the end diagnosis, all patients
  treated initially the same
• IV-O2-monitor-vital signs-history
• aspirin
• nitroglycerin
• morphine if necessary
• 12 lead EKG obtained (transmitted to ED by EMS)
• Treatment fine-tuned as more diagnostic
  information is obtained

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Congestive Heart Failure

• Heart unable to pump efficiently
• Blood backs up into systemic system, pulmonary
  system or both
• Right heart failure
• most often occurs due to left heart failure
• can occur from pulmonary embolism
• can occur from long-standing COPD (esp chronic
  bronchitis)
• Left heart failure
• most commonly from acute MI
• also occurs due to chronic hypertension

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Right Heart Failure

• Blood backs up into systemic circulation
• gradual onset over days to weeks
• jugular vein distension (JVD)
• edema (most visible in dependent parts of the
  body) from fluids pushed out of veins
• engorged, swollen liver due to edema
• right sided failure alone seldom a life
  threatening situation
• Pre-hospital treatment most often symptomatic
• More aggressive treatment needed when accompanied
  with left heart failure

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Left Sided Heart Failure

• Heart unable to effectively pump blood from
  pulmonary veins
• Blood backs up behind left ventricle
• Pulmonary veins engorged with blood
• Serum forced out of pulmonary capillaries and
  into alveoli (air sacs)
• Serum mixes with air to produce foam (pulmonary
  edema)

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Progression Left Heart Failure

• Think left - lungs
• Impaired oxygenation
• compensates by ? respiratory rate
• Fluid leaks into interstitial spaces
• auscultate crackles
• ? interstitial pressure narrows bronchioles
• auscultate wheezing
• Dyspnea hypoxemia?panic?release of
  adrenaline?increased work load on heart

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Left Heart Failure

• Sympathetic nervous system response
• Peripheral vasoconstriction
• peripheral resistance (afterload) increases
• weakened heart has to pump harder to eject blood
  out through narrowed vessels
• blood pressure initially elevated to keep up with
  the demands and to pump harder against increased
  vessel resistance
• diaphoretic, pale, cold skin

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Asthma or Heart Failure?

• Asthma
• younger patient
• hx of asthma
• unproductive cough
• meds for asthma
• wheezing
• accessory muscles being used

• Left heart failure
• older patient
• poss hx heart problems
• orthopnea
• recent rapid weight gain
• cough with watery or foamy fluid
• meds for heart problems
• wheezing
• JVD
• Pedal or sacral edema

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Which Came First - CHF or AMI?

• Not unusual to see the AMI patient in pulmonary
  edema - watch for it!
• Often hard to determine which came first and
  triggered the development of the other problem
• Heart failure?poor perfusion hypoxemia?
  myocardium suffers from inadequate blood oxygen
  supply?acute myocardial ischemia?acute coronary
  syndrome
• AMI?poor pumping performance of heart?acute
  failure of left heart pump?left heart failure

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Cardiogenic Shock

• Heart extensively damaged it can no longer
  function as a pump
• 25 of heart damage causes left heart failure
• if 40 of the left ventricle is infarcted,
  cardiogenic shock occurs
• High mortality rate

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Signs Symptoms Cardiogenic Shock

• Altered level of consciousness
• confusion to unconsciousness
• Restless, anxious
• Massive peripheral vasoconstriction
• pale, cold skin, poor renal perfusion
• Pulse rapid and thready
• Respirations rapid and shallow
• Falling blood pressure

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Treatment Goals Acute Coronary Syndrome

• Goals
• early recognition of a possible cardiac problem
• minimize size of infarction
• reduce myocardial oxygen demand
• decrease patients fear pain (minimizes
  sympathetic discharge)
• salvage ischemic myocardium
• prevent development of dysrhythmias
• improve chances of survival

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Region X SOP - Acute Coronary Syndrome

• Oxygen
• may limit ischemic injury
• Aspirin - 324 mg chewed
• blocks platelet aggregation (clumping) to keep
  clot from getting bigger
• chewing breaks medication down faster allows
  for quicker absorption
• hold if patient allergic or for a reliable
  patient that states they have taken aspirin
  within last 24 hours

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• Nitroglycerin 0.4 mg sl every 5 minutes
• dilates coronary vessels to relieve vasospams
• increases collateral blood flow
• dilates veins to reduce preload to reduce
  workload of heart
• if pain persists after 2 doses, Morphine to be
  started
• Morphine - 2 mg slow IVP
• decreases pain apprehension
• mild venodilator arterial dilator
• reduces preload and afterload
• 2mg slow IVP repeated every 2 minutes as needed,
  max total dose 10 mg

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Treatment GoalsCongestive Heart Failure

• Goals
• improve oxygenation
• decrease workload of the heart (ie
  decrease preload afterload)

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Region X SOPTreatment Stable Acute Pulmonary
Edema (B/P100)

• Nitroglycerin - 0.4 mg sl
• Vasodilator to create venous pooling
• Reduces preload afterload
• Maximum 3 doses (repeated every 5 minutes if
  blood pressure remains 100)
• Consider CPAP - use if indicated

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Region X SOP contd

• Lasix - 40 mg IVP
• Diuretic - excess fluid excreted via kidneys
• Venodilating effect to pool venous blood
• Dose ? to 80 mg IVP if patient on Lasix at home

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• Morphine - 2 mg slow IVP
• Venodilator to increase pooling of blood
• Anxiolytic to calm anxious patient
• May repeat 2mg dose every 2 minutes
• Maximum total dose 10 mg
• Albuterol - 2.5 mg/3ml nebulizer
• Wheezing may indicate bronchoconstriction from
  excessive fluid
• Bronchodilator could be helpful

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Region X SOP contd

• Hypotensive side effects from treatments used for
  stable pulmonary edema
• Treatment used (NTG, Lasix, Morphine, CPAP) can
  all cause venodilation ? ?B/P
• Blood pressure needs to be carefully monitored

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Region x SOP Treatment Unstable Acute Pulmonary
Edema (B/P

Contact Medical Control

CPAP on orders of Medical Control

Consider Cardiogenic Shock Protocol

If wheezing (indicating bronchoconstriction),
contact Medical Control for Albuterol order

if patient needs to be intubated, Albuterol to be
delivered via in-line

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Treatment GoalsCardiogenic Shock

• Goals
• Improve oxygenation
• Improve peripheral perfusion
• Avoid adding any workload to the heart

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Region X SOPTreatment Cardiogenic Shock

• Oxygen via nonrebreather mask
• BVM if respirations ineffective
• Intubation may become necessary
• Positioning
• Supine if lungs are clear
• Head somewhat elevated if pulmonary edema is
  present (semi-fowlers)
• IV/IO fluid challenge in 200ml increments if lung
  sounds are clear
• The shock may include a hypovolemic component

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Treatment Cardiogenic Shock

• Cardiac monitor
• Arrhythmias are likely
• May cause hypotension decreasing cardiac output
• Dopamine Infusion - maintain B/P 100
• Effects dose related dependent on clinical
  condition of patient
• 5 - 20 ?g/kg/min has beta influence on the heart
• Increases contractility strength of heart
• To a lesser degree increases heart rate

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• Dopamine contd
• Doses 20?g/kg/min
• Alpha stimulation predominate vasoconstriction
  my negatively affect circulation
• Extravasation - leaking out of vessels
• Can cause tissue necrosis
• IV infiltration reported to ED staff document
• Dosing - start at 5 ?g/kg/min
• Refer to table in SOP page 13 OR
• Take patients weight in pounds, take 1st 2
  numbers, subtract 2 (ie 185 pounds 18 -
  2 16 ?gtts/min to start drip)

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EKG Monitoring 12 Lead EKGs

• Goal EKG monitoring
• Identify a disturbance in the normal cardiac
  rhythm
• Arrhythmias caused by
• Ischemia
• Electrolyte imbalances
• Disturbances or damage in electrical conduction
  system
• Goal of obtaining 12 lead EKG
• Early recognition Acute Coronary Syndrome
• Treat clinical condition, not the monitor!

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12 Lead EKGs

• EMS to transmit EKG to Medical control when
  following the Acute Coronary Syndrome SOP
• Many patients can be monitored by a Lead II but
  not all patients need a 12 lead.
• Some patients experiencing angina or an acute MI
  will not yet have any EKG changes indicated on
  the 12 lead.

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12 Lead Transmitted From The Field

• ECRN to complete the radio report
• ECRN immediately after radio report to retrieve
  faxed copy of the field 12 lead EKG
• 12 lead EKG to be immediately presented to the ED
  physician
• 12 lead EKG from EMS is to be placed on the
  patients chart after MD review

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• A normal EKG DOES NOT necessarily mean there is
  nothing acute going on!

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Cardiac Conduction System

• SA node - dominant pacemaker
• upper right atrium
• blood supply from RCA
• Internodal pathways
• to spread electrical impulse thru-out atria
• AV node in region of AV junction
• in 85-90 of people, blood supplied by RCA to AV
  node
• in 10-15 of people, blood supplied by left
  circumflex

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Conduction System contd

• bundle of His
• Right and left bundle branches
• Purkinje fibers - through ventricular muscle
• Changes in electrolyte concentrations influence
  depolarization and repolarization
• sodium (Na), ?potassium (K), ?calcium
  (Ca), ?Magnesium (Mg)

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Conduction System
L l
Left bundle branches
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EKG Wave Forms

• P wave
• depolarization of atria
• PR interval
• depolarization of atria delay at AV junction
• normal PR interval 0.12 - 0.20 seconds
• QRS complex
• depolarization of ventricles
• normal QRS complex
• T waves
• repolarization of ventricles (and atria)

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The J Point

• J point - end of QRS complex beginning of ST
  segment
• ST segment elevation - evaluated 0.04 seconds
  after J point

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Precordial Chest Leads

• For every person, each precordial lead placed in
  the same relative position
• V1 - 4th intercostal space, R of sternum
• V2 - 4th intercostal space, L of sternum
• V4 - 5th intercostal space, midclavicular
• V3 - between V2 and V4, on 5th rib or in
• 5th intercostal space
• V5 - 5th intercostal space, anterior
• axillary line
• V6 - 5th intercostal space, mid-axillary

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Precordial Leads
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Lead Placement

• The more accurate the lead placement, the more
  accurate the 12-lead interpretation when
  interpreted from all other EKGs taken on this
  patient
• 12-leads are often evaluated on a sequential
  basis, each interpretation made trying to
  consider the previous one
• V4-6 should be in a straight line

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12 Lead Printout

• Standard format 81/2? x 11? paper
• 12 lead views printed on top half
• I aVR V1 V4
• II aVL V2 V5
• III aVF V3 V6
• Additional single view of rhythm strips usually
  printed on bottom of report
• Machines can analyze data obtained but humans
  must interpret data

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Limb Leads (Bipolar)
I

• Lead I - views the left (lateral) side of heart
• Lead II - views the bottom (inferior) side of
  heart
• Lead III - another inferior view of the heart

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Limb Leads (Unipolar)

• aVR - view from right arm
• aVL - lateral view from left arm
• aVF - inferior view from left leg

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Precordial (Chest) Leads

• Views the septal, anterior, lateral portions of
  the heart

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Heart in the Thoracic Cavity
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Myocardial Insult

• Ischemia
• lack of oxygenation
• ST depression or T wave inversion
• permanent damage avoidable
• Injury
• prolonged ischemia
• ST elevation
• permanent damage avoidable
• Infarct
• death of myocardial tissue
• may have Q wave

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• Evolution of AMI
• A - pre-infarct
• B - Tall T wave
• C - Tall T wave ST elevation
• D - Elevated ST, inverted T wave,
  Q wave
• E - Inverted T wave, Q wave
• F - Q wave

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ST Depression

• Can indicate
• ischemia
• electrolyte abnormality
• rapid heart rate
• digitalis influence
• reciprocal changes to ST elevation
• ST depression measurement
• 1 mm (1 small box) below baseline measured 2 mm
  (2 small boxes) after end of QRS

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ST elevation is more significant so should be
looked for in opposite leads when depression noted
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T Wave Inversion

• T wave represents ventricular repolarization
• Normally upright in all leads except V1 and aVR
• Inverted T waves tend to represent ischemia
• Note
• T wave
• inversion
• aVL,
• V4 -6

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ST Segment Elevation

• Myocardium exposed to prolonged hypoxia or
  ischemia
• Finding indicates injury or damage
• Injury probably due to occluded coronary artery
• Muscle can still be salvaged
• If corrective intervention not taken in timely
  manner, tissue necrosis/death is likely
  (infarction)
• TIME IS MUSCLE!

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Significant ST Elevation

• ST segment elevation measurement
• 0.04 seconds after J point
• ST elevation
• 1mm (1 small box) in 2 or more contiguous chest
  leads (V1-V6)
• 1mm (1 small box) in 2 or more anatomically
  contiguous leads
• Contiguous lead
• limb leads that look at the same area of the
  heart or are numerically consecutive chest leads

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Contiguous Leads

• Inferior wall II, III, avF
• Lateral wall I, aVL, V5, V6
• Septum V1 and V2
• Anterior wall V3 and V4
• Posterior wall V7-V9 (leads
  placed on the patients back 5th intercostal
  space creating a 15 lead EKG)

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ST Segment Elevation
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• Coved shape usually indicates acute injury
• Concave shape is usually benign if patient is
  asympto-matic

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Groups of EKG Leads

• Inferior wall - II, III, aVF
• Septal wall - V1, V2
• Anterior wall - V3, V4
• Lateral wall - I, aVL, V5, V6
• aVR is not evaluated in typical groups
• Standard lead placement does not look at
  posterior wall or right ventricle of the heart -
  need special lead placement for these views

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Pathological Q Waves - Infarction

• Death of tissue
• Pathological Q wave
• 0.04 seconds wide or
• 1/3 of R wave height
• when seen with ST elevation indicates ongoing
  myocardial infarction
• Remember ST segment probably single most
  important element on EKG when looking for
  evidence of AMI

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Pathological Q Wave
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Reciprocal Changes

• Changes seen in the wall of the heart opposite
  the location of the infarction
• Observe ST segment depression
• Usually observed at the onset of infarction
• Usually a short lived change
• Lead Reciprocal changes
• II, III, aVF I, aVL
• I, aVL, V5, V6 II, III, aVF
• V1-V4 V7-V9

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Acute MI Locator Table
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Acute Myocardial Infarction

• Acute myocardial infarction (AMI) is part of a
  spectrum of disease known as acute coronary
  syndrome (ACS)
• ACS
• Larger term to cover a group of clinical
  syndromes compatible with acute myocardial
  ischemia
• Chest pain is due to insufficient blood supply to
  the heart muscle that results from coronary
  artery disease (CAD)
• Clinical conditions include unstable angina to
  non-Q wave MI and Q wave MI

89
Common Complications of AMI

• V1-2 septal wall - infranodal heartblock, BBB
• V3-4 anterior wall - LV dysfunction, CHF, BBB,
  3rd degree HB, PVCs
• I, aVL, V5-6 lateral wall -LV dysfunction, AV
  nodal block in some
• II, III, aVF inferior posterior wall LV -
  hypotension, sensitivity to Nitroglycerin
  Morphine

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Practice Identifying ST Segment Elevation

• 1mm (1 small box) in 2 leads from any group
  or 2 or more contiguous leads
• (2 mm (2 small boxes) in limb leads considered
  alternative elevation by some) measured 0.04
  seconds after J point

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Think Pattern RecognitionInferior Wall MI
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Think Pattern RecognitionLateral Wall MI
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Think Pattern RecognitionAnterior Wall MI
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Think Pattern RecognitionSeptal Wall MI
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Test Yourself -What pattern would indicate an
anterior/septal wall MI?
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• Practice Identifying
• Leads Showing ST Elevation
• Evaluate the top 3 rows of the 12-lead EKG
• Answers follow the 12 lead

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ST Elevation II, III, aVF Inferior Wall
Involvement
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ST Elevation V5, V6, aVL - Lateral
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ST Elevation V1-V4 - Ant/Septal
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ST Elevation II, III, aVF, V6Inferior Lateral
Wall
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ST Elevation I, aVL, V2-6
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ST Elevation II, III, aVF
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Case Discussion 1

• 66 year-old male presents with indigestion for
  past 2 hours, frequent belching, nausea,
  paleness, diaphoresis, left arm discomfort
• Vital signs
• 102/76 HR 98 RR 20 SaO2 98
• What is your impression and what initial
  treatment is indicated in the prehospital setting?

110
Case 1

• Impression possible AMI (assume and treat for
  the worse)
• SOP Acute Coronary Syndrome
• Prehospital treatment
• IV-O2-monitor-pulse ox
• Vitals stable
• History unremarkable
• Aspirin chewed (any contraindications?)
• Nitroglycerin sl (ask about Viagra use)
• Morphine if pain unrelieved after 2 NTG
• 12 lead transmitted to ED for interpretation

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Case 1 12-Lead
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Case 1

• Impression of 12 lead?
• no ST segment elevation noted
• Does lack of ST segment elevation change field
  treatment for this patient?
• Normal EKG does not preclude that acute
  myocardial event is occurring
• Acute Coronary Syndrome SOP to be followed

113
Case Discussion 2

• 77 year-old female with history of CABG,
  hypertension, ? cholesterol, and long standing
  diabetes
• Presents with vague complaints of not feeling
  well, very tired no energy over the last day
• Meds
• Aspirin, Isoptin, Toprol, Hydrochlorothiazide,
  Lipitor, Glucophage

114
Case 2

• Vitals 110/72 HR-72 RR-18 SaO2 97
• Monitor (lead II rhythm strip)

115
Case 2

• What is your initial impression?
• Need to at least consider possible MI
• Remember
• women, elderly, and long standing diabetics
  report the most atypical complaints
• Remember
• a lead II only looks at one view of the heart
• a normal EKG does not rule out AMI

116
Case 2

• Prehospital treatment
• IV-O2-monitor (SR with PVCs)-vitals
• Aspirin appropriate?
• Nitroglycerin indicated?
• 12 lead EKG necessary?
• What about antidysrhythmic for the PVCs?
• call Medical Control for guidance
• oxygen is often enough to suppress PVC activity

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Case 2

• Aspirin
• if patient reliable and took own dose within last
  24 hours, can omit, document why omitted and when
  taken
• Nitroglycerin
• patient not having chest pain. Defer to Medical
  Control for orders
• no contraindications noted (B/P 100 no viagra
  type drug used within past 24 hours - ask, dont
  assume!)
• 12 lead should be obtained on high index of
  suspicion

118
Case 3

• 81 year-old female complaining of shortness of
  breath for past 2 days. Unable to tolerate lying
  flat JVD noted
• History of CHF, angina, arthritis, and mild COPD
• Vitals126/92 HR-170 RR-24 SaO2 97
• Medications nitroglycerin PRN,
• Lasix 40 mg daily
• Potassium
• Aspirin, one daily
• Proventil inhaler PRN

119
Case 3 - What is this rhythm?
Check the rhythm strip on the bottom
120
Case 3

• Rhythm
• Rapid atrial fibrillation
• Initial impression?
• Rapid atrial fibrillation
• ? heart rate ? ineffective pumping ?
  ? cardiac output
• Prehospital treatment initiated
• IV-O2-monitor-vitals-history
• Goal of therapy - slow down heart rate
• Is patient stable or unstable?
• Stable - B/P 100, alert cooperative

121
Case 3

• Prehospital ALS treatment
• If Diltiazem not available, then what?
• Verapamil
• 5 mg IVP slowly over 2 minutes
• If no response after 15 minutes and B/P remains
  100, repeat 5mg slow IVP
• Carefully monitor patient for development of
  further deterioration and increased difficulty
  breathing
• Position of comfort - usually sitting up

122
Verapamil / Isoptin

• Action
• Calcium channel blocker
• Slows conduction thru AV node to control
  ventricular rate
• Relaxes vascular smooth muscle
• Dilates coronary arteries

123
Region X SOP - Verapamil

• Indications
• Alternative to Diltiazem/cardizem
• SVT not responsive to 2 doses of Adenosine - to
  terminate rhythm
• Stable rapid atrial flutter/fibrillation - to
  control heart rate
• Dosing
• 5 mg IVP slowly over 2 minutes
• If no response after 15 minutes and B/P 100, may
  repeat Verapamil 5 mg IVP slowly over 2 minutes

124
Verapamil

• Side Effects
• Headache, dizziness
• ? B/P from vasodilation
• nausea vomiting
• Contraindications
• ? B/P
• Wide complex tachycardias of uncertain origin
• Heart block without implanted pacemaker
• WPW, short PR sick sinus syndromes

125
Case 4

• 32 year-old male patient with complaints of chest
  tightness, shortness of breath, and just not
  feeling well for past 2 days. Also states sore
  throat and ear pain. Very anxious scared.
• No history, no meds
• Jogs 2-3 miles 5 times per week
• Vitals 110/70 HR-68 RR-20 SaO2 98
• Lungs clear skin warm, dry pink

126
Case 4

• Initial impression
• Cardiac?
• Musculoskeletal (what has patient
• been doing)?
• Viral illness (sore throat ear pain)?
• What treatment would EMS begin?
• Cardiac - can give Aspirin but call
• Medical Control for NTG or Morphine
• Normal EKG cannot rule out ACS
• process

127
Case 5

• 68 year-old male called 911 due to non-radiating
  chest discomfort (not relieved with 3 of the
  patients own nitroglycerin) with some minor
  shortness of breath
• History
• stable angina
• GERD
• hypertension (controlled with medications)
• Type II diabetic (recently diagnosed)

128
Case 5

• Allergies - aspirin
• Medications
• nitroglycerin PRN
• isordil
• nexium
• verapamil
• glucophage
• Vital signs
• 136/78 HR-78 RR-18 SaO2 99
• What is the initial impression what prehospital
  treatment is initiated?

129
Case 5

• Initial impression acute coronary syndrome
• IV-O2-monitor-SaO2-vitals history
• Lead II EKG strip

130

• The patient in case 5 was just hooked up for a
  12-lead EKG when they grabbed their chest and
  became unresponsive

131
Case 5

• What is this rhythm strip?
• What action needs to be taken by EMS?

132
Case 5 - VF

• Confirm no breathing, no pulse
• Begin CPR until the defibrillator is ready and is
  charged to maximum joules
• Clear the patient deliver 1 shock
• Immediately resume CPR for 2 minutes (5 cycles of
  302)
• Check rhythm, defibrillate
• Meds vasopressor (Epinephrine)
• antidysrhythmic (choose 1)
• 1 shock in between meds 2 min CPR

133
VF/Pulseless VT SOP Meds

• Epinephrine 1mg every 3-5 minutes IV/IO for
  duration of arrest
• Antidysrhythmic
• Amiodarone 300 mg IV/IO 1st dose
• OR
• Lidocaine 1.5 mg/kg IV/IO 1st dose
• Repeat dose antidysrhythmic x1 in 5 min
• If Amiodarone given, then 150 mg IV/IO
  
• OR
• If Lidocaine given, then 0.75 mg/kg IV/IO

134
Antidysrhythmics in VF/VT

• Amiodarone needs to be diluted (irritable to the
  vein)
• total of 20 ml syringe (med mixed with saline)
• rapid push in VF/VT (slow if pt has pulse!)
• Lidocaine -
• if unsuccessful defibrillation
• contact Medical Control for 3rd dose order
• if defib successful bolus given drip 2mg/min (30 mcgtts)
• if defib successful bolus given 10 min, give
  Lido 0.75 mg/kg IV/IO start drip

135
Case 5

• The patient was defibrillated twice and received
  1 dose of epinephrine
• After the 3rd shock, 2 minutes of immediate CPR
  resumed
• After 2 min of CPR, what is the rhythm?

136
Case 5

• Rhythm sinus rhythm
• EMS action?
• Determine if there is a pulse (yes!!!)
• Reevaluate airway, breathing, circulation-B/P
• Medications
• because no antidysrhythmic were given, need to
  call Medical Control for direction
• if Lidocaine, usually 0.75 mg/kg IV/IO
• if Amiodarone, 150 mg diluted into 100 ml bag
  D5W run thru mini-drip tubing run piggyback at
  rapid drip over 10 minutes
• May not want any antidysrhythmic given

137
ETT Route

• Endotracheal tube route is discouraged, not
  eliminated.
• Absorption found to be unpredictable
• ETT drugs if this route is used
• L - Lidocaine
• E- Epinephrine
• A- Atropine
• N - Narcan
• Double the calculated amount for the IV/IO route

138
Bibliography

• American Heart Association Guidelines CPR ECC
  2005
• Beasley, B., West, M. Understanding 12-Lead EKG.
  Pearson Ed, 2001.
• Caroline, Nancy. Emergency Care in The Streets,
  Jones Bartlett, 2008.
• Page, B. 12-Lead EKG, Pearson, 2005.
• Phalen, T, Aehlert, B. The 12-Lead EKG in Acute
  Coronary Syndromes, 2006.
• www.clevelandclinic.org
• www.nhlbi.nih.gov/health/dci/Diseases