CMC EMS System ECRN CE 12 Lead EKG

1
CMC EMS System ECRN CE12 Lead EKGs

• Mod I 2009 CE
• Prepared by
• Sharon Hopkins, RN, BSN

2
Objectives

• Upon successful completion of this module, the
  ECRN will be able to accomplish the following
• Identify the appropriate components of the
  cardiac conduction system with the correct wave
  form on a rhythm strip.
• Identify when it is appropriate to obtain an EKG
• Identify the criteria for significant ST
  elevation.
• Identify EKG leads that view the anterior,
  inferior, lateral walls, and septum

3
Objectives

• Recognize the patterns of an MI after viewing the
  components of a 12 lead EKG
• Identify typical and atypical presentations of
  AMI
• Identify complications associated with an
  inferior wall MI
• Identify complications associated with an
  anterior/septal wall MI
• Identify complications associated with a lateral
  wall MI
• Identify interventions for complications related
  to heart block, pulmonary edema, and cardiogenic
  shock
• Identify the SOP guidelines for the patient
  presenting with acute coronary syndrome as
  written in the Region X SOPs

4
Objectives

• State dosing and precautions for Aspirin,
  Nitroglycerin, and Morphine in the Region X
  SOPs.
• Identify ED staff expectations of EMS personnel
  when calling the hospital to report a patient
  with ST elevation identified on a 12 lead EKG
• Identify EMS expectations when delivering a
  patient to a hospital after ST elevation has been
  identified on a 12 lead EKG
• Given a picture, correctly trace the order of the
  cardiac conduction system.
• Given a picture, correctly identify electrode
  placement to obtain a 12 lead EKG.

5
Why Are We doing Pre-hospital EKGs?

• Early recognition and fast, appropriate treatment
  can prevent the extension of an MI
• Early recognition early intervention
• An important diagnostic tool will also be the
  patients general appearance

6
Cardiac Conduction System

• Electrical cells arranged in a systematic pathway
• Predominant pacemaker starting the electrical
  flow comes from the SA node
• Electrical cells are part of the conduction
  system
• Muscle cells are the mechanical cells

7
Cardiac Conduction System
1
3
2
4
4
5
Purkinje fibers
8
EKG Waveforms

• P wave represents atrial stimulation
• P wave is rounded and upright
• PR interval
• Includes the P wave and the isoelectric PR
  segment
• PR interval is the time it takes for an impulse
  to travel from the SA node through the internodal
  pathways toward the ventricles
• Includes delay time in the AV node
• Normal PR interval is 0.12 0.20 seconds

9

• PR
• Interval
• Normal
• 0.12
• 0.20
• seconds

10
PR Interval Abnormalities

• PR interval lt0.12 seconds
• Impulse did not begin in the normal pacemaker
  site of the SA node but somewhere in the atria
• PR interval gt0.20 seconds
• There was a longer than normal delay transmitting
  the impulse through the AV node
• A change in the PR interval measurement generally
  will not make the patient symptomatic

11
EKG Wave Forms contd

• QRS complex
• Consists of the Q, R, and S waves collectively
• Represents ventricular depolarization or
  discharge of electrical energy throughout
  ventricular muscle
• Larger than the P wave because ventricular
  depolarization involves a larger muscle mass than
  atrial depolarization
• Palpation of a pulse is generated by ventricular
  depolarization (seen as the QRS complex)
• Normal timing usually considered between 0.06 and
  0.11 seconds
• Normal is less than 0.12 seconds

12
QRS Complex
QRS
13
QRS Complex Measurement

• From beginning of Q wave usually fairly
  straight forward
• Stop measurement at end of S wave not
  necessarily where QRS intersects baseline
• On S wave, watch for small notch or other
  indicator that electrical flow is changing
• Not always so easy to determine stop point
• Do not include ST segment or T wave
• Abnormally wide QRS indicates delay in conduction
  time through the ventricles

14
(No Transcript)
15
EKG Wave Forms contd

• T wave
• Represents ventricular repolarization
• Repolarization is the phase of electrical
  activity where electrical charges (influenced
  primarily by sodium (Na) and potassium (K))
  return to their original state and prepare to
  respond to the next electrical charge received
• Atria repolarize during ventricular
  depolarization so the small atrial T wave is
  hidden during the larger QRS complex

16
When To Obtain a 12-Lead EKG

• Any patient presenting with signs and/or symptoms
  of an acute coronary syndrome
• Consider atypical AMI presentations
• Elderly
• Women
• Patient with long standing history of diabetes
• Any patient presenting with a Second degree Type
  II (classical) or 3rd degree heart block
• Consider the origin of heart block from an AMI
  until proven otherwise

17
What Are We Looking For?

• Abnormalities that indicate interruption in the
  blood flow to the myocardium
• Plaque formation diminishes blood flow through
  the coronary arteries
• Patients may be asymptomatic while damage
  silently develops
• Plaque rupture begins a cascade of events that
  further compromises blood flow through the
  injured vessel(s)
• This cascade of events could lead to an acute
  coronary syndrome (ie acute MI)

18
Coronary Circulation

• Coronary arteries and veins
• Myocardium extracts the largest amount of oxygen
  as blood moves into general circulation
• Oxygen uptake by the myocardium can only improve
  by increasing blood flow through the coronary
  arteries
• If the coronary arteries are blocked, they must
  be reopened if circulation is going to be
  restored to that area of tissue supplied

19
(No Transcript)
20
12-Lead Electrodes

• A lead is a tracing of the electrical activity
  between 2 electrodes
• Leads view the heart from the front of the body
• Top, bottom, right, and left side of heart
• Leads view the heart as if it were sliced in half
  horizontally
• Front, back, right, and left sides of heart
• Each lead has a positive and a negative electrode

21
Standard 12-Lead EKG

• Six limb leads
• Leads I, II, III, aVR, aVL, aVF
• Six chest leads (precordial leads)
• V1, V2, V3, V4, V5, V6
• Information from 12 leads obtained from the
  attachment of only 10 electrodes

22
View The Leads Provide

• II, III, aVF view inferior wall of heart
• V1 and V2 view septal wall of heart
• V3 and V4 view anterior wall of heart
• I, aVL, V5, V6 view lateral wall of heart

23
Preparation for 12 Lead EKG

• Skin preparation
• Hair removal
• clip hair if necessary so electrodes adhere
• Clean and dry skin surface
• gently rub skin area with gauze pad
• need to remove skin oils dead skin
• if diaphoretic patient wipe with towel/gauze or
  use antiperspirant spray

24

• Patient positioning
• Preferably flat
• Heart rotates position as the patient position
  changes
• If patient is elevated, note that information on
  the EKG

25
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
• V5 - 5th intercostal space, anterior axillary
  line
• V6 - 5th intercostal space, mid-axillary line

26
1st ICS
2nd ICS
3rd ICS

• Precordial leads

27
(No Transcript)
28
12 Lead EKG Printout

• Standard format 81/2? x 11? paper
• 12 lead format
• I aVR V1 V4
• II aVL V2 V5
• III aVF V3 V6
• Machines can analyze data obtained but humans
  must interpret data

29
I
V4
aVR
V1
II
V2
V5
aVL
V3
V6
III
aVF
30
(No Transcript)
31
Lateral View I, aVL, V5, V6
I
V5
aVL
V6
32
Inferior View II, III, aVF
II
III
aVF
33
Septal View V1 V2
V1
V2
34
Anterior View V3 V4
V4
V3
35
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 damage permanent may
  have Q wave

36
Why A Pre-hospital EKG?

• EMS looking for ST segment elevation
• Indicates injury that can be reversible if found
  early and acted upon early
• TIME IS MUSCLE
• The earlier the discovery of an acute cardiac
  event, the quicker the patient can receive the
  most appropriate care
• EKGs sent to the ED before patient arrival
  allows for the right personnel to be available to
  properly care for the patient in the most time
  efficient manner

37
What Does EMS Have to Do?

• Obtain a 12 lead EKG
• EMS to evaluate the leads as they are sending the
  12 lead to the ED
• Identify for the presence or absence of ST
  elevation
• EMS to report what they see, not just what is
  printed on the machine copy of the EKG
• Upon arrival, EMS to hand a copy of their 12 lead
  to the ED staff while they give bedside report

38
Evaluating for ST Segment Elevation

• Locate the J-point
• Identify/estimate where the isoelectric line is
  noted to be
• Compare the level of the ST segment to the
  isoelectric line
• Elevation (or depression) is significant if more
  than 1 mm (one small box) is seen in 2 or more
  leads facing the same anatomical area of the
  heart (ie contiguous leads-see
  slide 41, 42)

39
The J Point

• J point where the QRS complex and ST segment
  meet
• ST segment elevation - evaluated 0.04 seconds
  (one small box) after J point

40

• Coved shape usually indicates acute injury
• Concave shape is usually benign especially if
  patient is asympto-matic

41
Significant ST Elevation

• ST segment elevation measurement
• starts 0.04 seconds after J point
• ST elevation
• gt 1mm (1 small box) in 2 or more contiguous chest
  leads (V1-V6)
• gt1mm (1 small box) in 2 or more anatomically
  contiguous leads (ie II, III, aVF I, aVL, V5,
  V6)
• Contiguous lead
• limb leads that look at the same area of the
  heart or are numerically consecutive chest leads
  (ie V1 V6)

42
Contiguous Leads

• Lateral wall I, aVL, V5, V6
• Inferior wall II, III, avF
• 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)

43

• Evolution of AMI
• A - pre-infarct (normal)
• B - Tall T wave (first few minutes of infarct)
• C - Tall T wave and ST elevation (injury)
• D - Elevated ST (injury), inverted T wave
  (ischemia), Q wave (tissue death)
• E - Inverted T wave (ischemia), Q wave (tissue
  death)
• F - Q wave (permanent marking)

44
ST Segment Elevation
45

• EKG monitoring
• Evaluates electrical activity of the heart
• Can indicate myocardial insult and location
• ischemia - initial insult ST depression seen
• injury - prolonged myocardial hypoxia or
  ischemia ST elevation seen
• infarction - tissue death
• dead tissue no longer contracts
• amount of dead tissue directly relates to degree
  of muscle impairment
• may show Q waves

46
Contiguous ECG Leads

• EKG changes are significant when they are seen in
  at least two contiguous leads
• Two leads are contiguous if they look at the same
  area of the heart or they are numerically
  consecutive chest leads

47
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

48
Basic 12-Lead EKG Format
Lead I Lateral wall aVR not evaluated V1 Septum V4 Anterior wall
Lead II Inferior wall aVL Lateral wall V2 Septum V5 Lateral wall
Lead III Inferior wall aVF Inferior wall V3 Anterior V6 Lateral wall
49
Lateral Wall MI I, aVL, V5, V6
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
50
Inferior Wall MI II, III, aVF
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
51
Septal MI Leads V1 and V2
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
52
Anterior Wall MI V3, V4
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
53
Posterior MI Reciprocal Changes ST Depression
V1, V2, V3, poss V4
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
54
Complications of Lateral Wall MI

• I, aVL, V5,V6
• Complications arise due to the conduction
  components that are in the septum
• Conduction dysrhythmias most common
• Second degree Type II classical
• 3rd degree complete heart block
• Bundle branch blocks
• Monitor patient closely for these blocks
• 2nd degree Type II and 3rd degree are serious
  dysrhythmias that need to be treated aggressively
  with TCP

55
Complications of Inferior Wall MI

• II, III, aVF
• 40 of patients with inferior MIs have right
  ventricular infarcts
• In the presence of a right ventricular infarct,
  there is a high likeliness of both ventricles
  being damaged
• Contraction capabilities will be negatively
  affected
• Patients may present hypotensive
• Nitrates and Morphine alone will dilate blood
  vessels worsening hypotension
• Under Medical Control direction patients are
  often treated with a fluid challenge with the
  nitrates
• 1st degree heart block and Second degree Type I
  Wenckebach most common heart blocks

56
Complications of Septal Wall MI

• V1 and V2
• Significant amount of conduction components are
  in the septal area
• Patient predisposed to dysrhythmia
• Second degree Type II classical
• 3rd degree heart block
• Bundle branch block
• Lethal heart blocks treated aggressively - TCP
• Rare to have a septal MI alone
• Common to have anterior or lateral involvement
  along with septal area

57
Complications of Anterior Wall MI

• V3, V4
• Known as the widowmaker due to the potential
  for a massive area of infarction from blockage of
  the large amount of myocardium supplied by the
  LAD (left anterior descending artery)
• Often the septal or lateral walls are also
  involved
• Watch for lethal ventricular dysrhythmias and
  cardiogenic shock
• Second degree Type II and 3rd degree heart block
  are more common than other blocks

58
Anterior Wall MI - V3, V4

• Early death within a few days often from CHF
• Massive area of ventricular tissue infarcted if
  LAD totally occluded
• Important to obtain history of recent MI
  diagnosis and hospital discharge
• Increased incidence of ventricular tachycardia
  (VT) and ventricular fibrillation (VF) up to 1 -2
  weeks post acute anterior MI

59
Additional Complications

• Acute pulmonary edema
• Nitroglycerin given to dilate blood vessels and
  reduce preload
• Lasix given to dilate blood vessels and reduce
  preload as a diuretic
• Morphine given to dilate blood vessels and reduce
  preload reduce anxiety
• All medications and interventions (ie CPAP) can
  drop the B/P monitor carefully

60
Additional Complications

• Cardiogenic shock
• Ineffective pumping from the damaged heart
• IV fluid challenge if lung sounds are clear
• Dopamine drip titrated to maintain a systolic
  blood pressure of gt100 mmHg
• Start at a low dose (5mcg/kg/min)
• Estimate the patients pounds (ie 100 )
• Take the 1st 2 numbers dropping the last number
  (10)
• Minus 2 from the 1st 2 numbers
• This is the starting point for minidrips/minute
  (10 2 8 minidrips/minute)

61
Common Terms Patients Use To Describe Chest Pain

• Burning
• Constricting band
• A weight in the center of my chest
• A vise tightening around my chest

• Heaviness
• Pressing
• Suffocating
• Squeezing
• Strangling

62
Additional Patient Complaints or Presentations

• Difficulty breathing
• Excessive sweating
• Unexplained nausea or vomiting
• Generalized weakness
• Dizziness

• Syncope or near-syncope
• Palpitations
• Isolated arm or jaw pain
• Fatigue
• Dysrhythmias

63
Typical Injury Patterns
Source The 12-Lead ECG in Acute Coronary
Syndromes, MosbyJems, 2006.
64
Atypical Presentation in the Elderly

• Most frequent symptoms of acute MI
• Shortness of breath
• Fatigue and weakness (I just dont feel well)
• Abdominal or epigastric discomfort
• Often have preexisting conditions making this an
  already vulnerable population
• Hypertension
• CHF
• Previous AMI
• Likely to delay seeking treatment

65
Atypical Presentation in Women

• Discomfort described as
• Aching
• Tightness
• Pressure
• Sharpness
• Burning
• Fullness
• Tingling
• Often have no actual chest pain to offer as a
  complaint. Often the pain is in the back,
  shoulders, or neck

• Frequent acute symptoms
• Shortness of breath
• Weakness
• Unusual fatigue
• Cold sweats
• Dizziness
• Nausea/vomiting

66
Atypical Presentation in the Patient With Diabetes

• Atypical presentation due to autonomic
  dysfunction
• Common signs/symptoms
• Generalized weakness
• Generalized feeling of not being well
• Syncope
• Lightheadedness
• Change in mental status

67
Region X SOP Acute Coronary Syndrome

• A 12 lead EKG is obtained on all patients
  presenting with signs and symptoms of acute MI
• OR
• For patients where suspicions are raised that the
  patient may be experiencing an acute MI (ie
  heart block)

68
12-Lead Electrode Placement
69
Region X SOP Acute Coronary Syndrome

• Determine if the patient is stable or unstable to
  proceed with interventions
• Easiest way to determine stability is to evaluate
  blood flow
• What is the level of consciousness?
• What is the blood pressure / is there a radial
  pulse?
• Remember A B/P reading of 100/systolic does not
  necessarily indicate the presence or absence of
  symptoms

70
Oxygen

• In the presence of an acute MI, the myocardium is
  being deprived of blood flow and therefore
  adequate oxygen levels
• Provide what the patient needs
• Evaluate each individual clinical presentation
• All patients deserve some form of oxygen in this
  early period of myocardial starvation for it

71
Aspirin

• Used to prevent platelet aggregation
• When a plague ruptures, chemicals are released.
  Platelets congregate to the area to seal the
  rupture. Platelet aggregation further increases
  the degree of vessel blockage.
• Field dosage is 4 81 mg (324 mg total) baby
  aspirin chewed
• Chewing breaks down the aspirin and allows for
  faster absorption
• Give dose if patient not reliable about taking
  their own dose or has not taken any aspirin

72
Nitroglycerin

• Venodilator
• Improves coronary blood flow
• By dilating blood vessels, pools blood away from
  the heart which decreases preload. This decreases
  the work load of a stressed heart.
• Carefully monitor blood pressure before and after
  dosages
• Field dosage is 0.4 mg tablet sl
• Dosage can be repeated in 5 minutes if blood
  pressure remains stable
• FYI Pain level will not drop to 0 until the
  clot is removed

73
For CMC EMS System Participants

• If the patient is lt35 years of age
• Follow Acute coronary Syndrome SOP by
  administering aspirin
• Medical Control contacted prior to administration
  of nitroglycerin or morphine
• There should be no delay in obtaining a 12 lead
  EKG in the field and transmitting it to the ED
• A visual interpretation is to be given during
  report to the receiving hospital even when the 12
  lead EKG is faxed in

74
Morphine

• CNS depressant to reduce anxiety
• Venodilates blood vessels to reduce the volume of
  blood returning to the heart to decrease the
  hearts workload
• Field dosage is 2 mg slow IVP
• Dosage started when the 2nd dose of nitroglycerin
  proves ineffective
• Dosage may be repeated every 2 minutes as needed
• Maximum dosage is 10 mg
• Watch for hypotension

75
Receiving Hospital Report

• When sending a 12 lead EKG, EMS to inform the
  receiving hospital what identifiers have been
  used
• Department ID number
• Patient sex (M / F)
• Patient age
• Any other identifier
• EMS should always give their visual
  interpretation of what they have observed for ST
  elevation

76
Activating a Cardiac Alert

• The ED activates a cardiac alert to prepare the
  cardiac team to provide optimal care for the
  patient
• Typical cardiac alert team members
• ED staff MD, RN, tech, secretary
• Cardiologist
• Cath lab personnel
• EKG tech (may be an ED staff member)
• Lab tech
• X-ray tech
• Not all hospitals use all members in a formalized
  team but all of these members are somehow
  integrated into the care of the patient

77
When Does a Cardiac Alert Get Called?

• When EMS sends a 12 lead EKG with ST elevation,
  the team gets activated
• When EMS confirms what they see on the 12 lead,
  whether the EKG is sent or not, may trigger a
  cardiac alert
• There is a direct link in EMS accuracy,
  completeness in patient report, and EKG
  interpretation with pre-hospital activation of
  the cardiac alert team

78
Transferring Care of The Patient to The ED

• Bedside report is restated to the ED personnel in
  the room
• The main report must be to an RN or MD
• Rhythm strips and 12 lead EKG are presented
• Important to note positive and negative changes
  in the patient condition
• Pain level has decreased
• Blood pressure has dropped

79
EKG Practice

• Practice reviewing the following 12 lead EKGs
  for ST segment elevation
• Evaluate the ST segment at the J point
• Note A peaked T wave is not equivalent with ST
  elevation
• Consider potential complications to monitor for
  based on the location of the acute MI
• Vignette follows the 12 lead EKG picture

80
Practice Identifying ST Segment Elevation

• gt 1mm (1 small box) above the baseline in 2
  leads from any group or 2 or more contiguous
  leads
• (gt2 mm (2 small boxes) in limb leads considered
  alternative elevation by some) measured 0.04
  seconds after J point

81
(No Transcript)
82
Case 1
83
Case 1

• 52 year-old patient complains of indigestion
  after pizza beer dinner.
• VS 124/82 P 108 R - 18
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (There is no ST elevation)

84
Case 2
85
Case 2

• 62 year-old female developed chest jaw pain
  while in the shower
• VS 110/62 P 66 R 20
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (ST elevation II, III, aVF Inferior wall MI)

86
Case 3
87
Case 3

• 45 year-old patient who complains of chest
  heaviness lightheadedness
• VS 90/56 P 86 R - 22
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (ST elevation V2-V5 anterior infarction)

88
Case 4
89
Case 4

• 87 year-old female patient complains of dizziness
  and being extremely tired
• VS 88/52 P 30 R - 16
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (ST elevation II, III, aVF, V2-V4)

90
Case 5
91
Case 5

• 58 year-old male patient who complains of chest
  pain radiating down the left arm after working
  out in the gym
• VS 110/72 P 100 R - 18
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (ST elevation II, III, aVF)

92
Case 6
93
Case 6

• 92 year-old patient complaining of pounding in
  her chest for one hour
• VS 98/66 P 110 R- 16
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (ST elevation V1-V4 anterioseptal MI)

94
Case 7
95
Case 7

• 66 year-old patient with history of diabetes for
  25 years complains of being lightheaded and is
  sweaty
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (Normal EKG sinus bradycardia)

96
Case 8
97
Case 8

• 70 year-old patient had a syncopal episode when
  they stood up from the couch
• VS 156/98 P 76 R - 16
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (ST elevation V2, V3, slightly in V1, V4)

98
Case 9
99
Case 9

• 82 year-old patient complains of sudden onset of
  slurred speech, inability to grasp a coffee cup,
  and inability to follow simple commands
• VS 122/84 P 110 R - 18
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (No ST elevation, atrial fibrillation rhythm)

100
Case 10
101
Case 10

• 36 year-old patient who passed out standing in
  line at a bank
• VS 128/78 P 80 R - 20
• Is there ST elevation
• I, aVL, V5, V6?
• II, III, aVF?
• V1, V2?
• V3, V4?
• What are you going to do for this patient?
• (ST elevation II, III, aVF)

102
Bibliography

• Aehlert, B. EKGs Made Easy third Edition.
  Elsevier Mosby. 2006.
• Beasley, B. Understanding EKGs A Practical
  Approach. Brady. 2003.
• Bledsoe, B., Porter, R., Cherry, R. Paramedic
  Care Principles and Practices. Third Edition.
  Brady. 2009.
• Ellis, K. EKG Plain and Simple. Prentice Hall.
  2002.
• Page, B. 12 Lead EKG for Acute and Critical Care
  Providers. Brady. 2005.

103

• Phalen, T., Aehlert, B. The 12 Lead EKG in Acute
  Coronary Syndromes. Second Edition, Elsevier
  Mosby. 2006.
• Region X SOPs. March 2007, Amended January 1,
  2008.
• freemd.com (Acute Coronary Syndrome 9/2008)
• www.anaesthetist.com/icu/organs/heart/ecg/Findex.h
  tm
• www.ecglibrary.com/
• www.gwc.maricopa.edu/class/bio202/cyberheart/ekgqz
  r.htm
• www.madsci.com/manu/ekg_mi.htm