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Cardiovascular Emergencies and 12 Lead EKGs


Congestive heart failure (CHF) Coronary artery disease (CAD) Atrial fibrillation. Cardiomyopathy ... Congestive Heart Failure. Goals. improve oxygenation ... – PowerPoint PPT presentation

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Title: Cardiovascular Emergencies and 12 Lead EKGs

Cardiovascular Emergencies and 12 Lead EKGs
  • Condell Medical Center
  • EMS System
  • ECRN Packet
  • Module III 2007

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

  • 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

Cardiovascular System
  • This system is composed of the heart and blood
  • 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

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

Superior vena cava
Left atrium
Right atrium
Left ventricle
Right ventricle
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
  • Myocardial blood flow
  • via coronary arteries immediately off aorta
  • heart is the 1st structure to receive oxygenated
    blood - its that important!

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

Coronary Blood Flow
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

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

Influences On Preload Afterload
  • Afterload
  • arteriosclerosis induced high B/P can cause left
    ventricle to become exhausted stop working
  • Preload
  • increased oxygen demand increases volume of blood
    returning to heart
  • temporarily not a problem
  • heart enlarges when preload remains increased
    (Frank-Starling law)

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

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

Coronary Artery Disease (CAD)
  • Plaque in a coronary artery breaks apart causing
    blood clot to form and blocks artery

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?

  • 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

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
  • Important to determine the right treatment

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)?

  • 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?

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

  • 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
  • narrowing airways (ie asthma)
  • Absence of sound - not good!!!

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

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)

  • 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

ST depression
ST elevation
Q wave
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

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

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,

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
  • unexplained drop in blood pressure
  • apparent stroke
  • confusion
  • generalized weakness

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

Region X SOP Initial Treatment Acute Coronary
  • 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

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
  • Left heart failure
  • most commonly from acute MI
  • also occurs due to chronic hypertension

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

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

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

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

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

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
  • AMI?poor pumping performance of heart?acute
    failure of left heart pump?left heart failure

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

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

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

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

  • 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
  • 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

Treatment GoalsCongestive Heart Failure
  • Goals
  • improve oxygenation
  • decrease workload of the heart (ie
    decrease preload afterload)

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

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

  • 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

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

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

  • 51
    Treatment GoalsCardiogenic Shock
    • Goals
    • Improve oxygenation
    • Improve peripheral perfusion
    • Avoid adding any workload to the heart

    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

    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

    • 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)

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

    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.

    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
    • 12 lead EKG from EMS is to be placed on the
      patients chart after MD review

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

    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
    • in 10-15 of people, blood supplied by left

    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)

    Conduction System
    L l
    Left bundle branches
    (No Transcript)
    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)

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

    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

    Precordial Leads
    Lead Placement
    • The more accurate the lead placement, the more
      accurate the 12-lead interpretation when
      interpreted from all other EKGs taken on this
    • 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

    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

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

    Limb Leads (Unipolar)
    • aVR - view from right arm
    • aVL - lateral view from left arm
    • aVF - inferior view from left leg

    Precordial (Chest) Leads
    • Views the septal, anterior, lateral portions of
      the heart

    Heart in the Thoracic Cavity
    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

    • 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

    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

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

    ST Segment Elevation
    • Myocardium exposed to prolonged hypoxia or
    • 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

    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

    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)

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

    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

    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

    Pathological Q Wave
    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

    Acute MI Locator Table
    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
    • 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

    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

    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

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

    (No Transcript)
    ST Elevation II, III, aVF Inferior Wall
    (No Transcript)
    ST Elevation V5, V6, aVL - Lateral
    (No Transcript)
    ST Elevation V1-V4 - Ant/Septal
    (No Transcript)
    ST Elevation II, III, aVF, V6Inferior Lateral
    (No Transcript)
    ST Elevation I, aVL, V2-6
    (No Transcript)
    ST Elevation II, III, aVF
    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?

    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

    Case 1 12-Lead
    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

    Case Discussion 2
    • 77 year-old female with history of CABG,
      hypertension, ? cholesterol, and long standing
    • Presents with vague complaints of not feeling
      well, very tired no energy over the last day
    • Meds
    • Aspirin, Isoptin, Toprol, Hydrochlorothiazide,
      Lipitor, Glucophage

    Case 2
    • Vitals 110/72 HR-72 RR-18 SaO2 97
    • Monitor (lead II rhythm strip)

    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

    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

    Case 2
    • Aspirin
    • if patient reliable and took own dose within last
      24 hours, can omit, document why omitted and when
    • 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
    • 12 lead should be obtained on high index of

    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

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

    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
    • Position of comfort - usually sitting up

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

    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

    • 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

    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

    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

    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)

    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?

    Case 5
    • Initial impression acute coronary syndrome
    • IV-O2-monitor-SaO2-vitals history
    • Lead II EKG strip

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

    Case 5
    • What is this rhythm strip?
    • What action needs to be taken by EMS?

    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
    • Check rhythm, defibrillate
    • Meds vasopressor (Epinephrine)
    • antidysrhythmic (choose 1)
    • 1 shock in between meds 2 min CPR

    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

    Antidysrhythmics in VF/VT
    • Amiodarone needs to be diluted (irritable to the
    • 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

    Case 5
    • The patient was defibrillated twice and received
      1 dose of epinephrine
    • After the 3rd shock, 2 minutes of immediate CPR
    • After 2 min of CPR, what is the rhythm?

    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

    ETT Route
    • Endotracheal tube route is discouraged, not
    • 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

    • American Heart Association Guidelines CPR ECC
    • 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.
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