ECG Webinar Series We… · STEMI Criteria | 01895 730020 | [email protected]...

ECG Webinar SeriesEpisode 4: Acute Coronary Syndromes

1st June 2020 at 19:00

Presented by:

Mr Innes Eaton

Paramedic Practitioner

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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes

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Session Plan

• Pathophysiology of ACS

• Refresher on views and ECG layout

• STEMI criteria

• Alternate lead views

• Refresher on Sgarbossa’s Criteria

• Management of ACS

• Q&A Session



Case Study 1



Interactive Quiz



Pathophysiology



Definitions

• Stable vs Unstable Angina• Stable Angina = predictable chest pain +/- ST +/- TWI on exertion

• Diagnosis made clinically +/- stress ECG (chest pain + >1mm ST)

• May be candidates for PCI or CABG

• Unstable Angina = chest pain +/- ST +/- TWI at rest/random onset• Diagnosis made clinically + normal biomarkers

• The 3 Acute Coronary Syndromes• Unstable Angina

• Normal biomarkers and no ST

• Non-ST-elevation myocardial infarction (NSTEMI)• Abnormal biomarkers and no ST

• ST-elevation myocardial infarction (STEMI)• Abnormal biomarkers and ST



Refresher on Lead Views



Refresher on ECG Layout



Reciprocal Changes



Case Study 2

• 999 call: 57 y/o male, chest pain

• HPC: sudden onset after dinner, 30 minutes ago

• Feels like he is going to faint, vomited x3

• Poorly perfused, diaphoretic++, anxious++

• PMH: HTN, pre-diabetes, cholesterol, BMI

• RR 24, SpO2 NT, HR 56 (Reg), BP 72/40, T36.2°C, BGL 9.8, GCS 4/4/6 (14)



Case Study 2



Interactive Quiz



Locating the Culprit Lesion



ST-Depression & ST-Elevation



ST-Elevation or High Take-Off?

• Benign Early Repolarisation (BER) is a relatively common finding of widespread ST in young, healthy patients <50 y/o• May mimic MI or pericarditis• Uncommon in >50s - ST more likely to be ischaemic changes• Rare in >70s

• Diagnostic Criteria:• Widespread concave ST, most prominent in V2-V5

• Notched/slurred J-point• Prominent, asymmetric, concordant T-waves• ST <25% of T-wave height in all leads

• No reciprocal changes suggestive of ischaemia • No changes in serial ECGs



Benign Early Repolarisation (BER)



STEMI Criteria



Inferior MI:

>1mm ST in 2 consecutive leads

Anterior MI:

Men: >2mm ST in 2 consecutive leads

Women: >1.5mm ST in 2 consecutive leads

Lateral MI:

>1mm ST in 2 consecutive leads

Inferior STEMI



Interactive Quiz



Anterior STEMI



Interactive Quiz



Classification of Anterior STEMI



• Septal• V1 – V2

• Anterior• V2 – V5

• Anteroseptal • V1 – V4

• Anterolateral• V3 – V6 plus I & aVL

• Extensive Anterior/Anterolateral• V1 – V6 plus I & aVL

Lateral STEMI



Interactive Quiz



What about the Posterior?



What to look for:

• V1 – V3

• Horizontal ST

• Positive T-Waves

• Tall R-Waves

Alternate Views



Suspected Posterior STEMI

• V7, V8, V9 – to confirm diagnosis

• >0.5mm ST in any lead is diagnostic

Inferior STEMI

• V4(R) – to look for Right Ventricular Infarction (RVI)

• >0.5mm ST is diagnostic

Posterior STEMI



Interactive Quiz



Inferior STEMI with RVI



• Likely to be haemodynamically unstable

• Careful use of GTN

• Careful use of fluids

Sgarbossa’s Criteria in LBBB



A:

Concordant ST↑ ≥1mm in any one lead with

a positive QRS complex (5 points)

B:

Concordant ST↓ ≥1mm in any one of leads

V1-V3 (3 points)

C:

Excessive discordance (>5mm) in any one lead with a

negative QRS complex (2 points)

Modified C:

Discordance of ≥25% of preceding S-wave

in any one lead with a negative QRS

complex

Sgarbossa’s Criteria in LBBB



Sgarbossa A Postive



Sgarbossa B Postive



The Eaton Triage Tool?



Interactive Quiz



The ACS Care Bundle



• Emergency access to PPCI (+/- via ED)

• Dual anti-platelet therapy• 300mg PO Aspirin (chewed)• 300mg/600mg PO Clopidogrel (only in diagnosed MI)

• Glyceryl Trinitrate (GTN)• 800mcg SL stat dose (if not hypotensive)• 400-800mcg repeated every 5-10 minutes (monitor BP)

• Analgesia• Nitrous oxide (Entonox)• Morphine Sulphate 5-10mg IV then titrated PRN <20mg (+/- antiemetic)

• Consider fluid challenge if hypotensive• Increased risk of APO

• Consider atropine if bradycardic• Be cautious with increasing myocardial oxygen demand

• Consider applying defibrillator pads• High risk of ventricular arrhythmias

Always refer to

local guidelines

Interactive Quiz



No PPCI: What then?



• Thrombolysis• Within 6 hours of symptom onset

• No PPCI available or extended delay in access

• Tecteneplase• 30-50mg IV by rapid injection, dose dependant on weight

• Multiple side effects

• Multiple cautions & contraindications

• Limit clopidogrel to 300mg PO

• Transfer patient to nearest ED

Always refer to

local guidelines

Thank You!



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ECG Webinar Series We… · STEMI Criteria | 01895 730020 | [email protected]...

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