Overview of Revised CMC EMS System CE; 12 Lead EKG’s February 2009 CE Site Code #107200E1209...

Overview of Revised Overview of Revised CMC EMS System CE;CMC EMS System CE;

12 Lead EKG’s12 Lead EKG’s

February 2009 CEFebruary 2009 CESite Code #107200E1209Site Code #107200E1209

Prepared by:Prepared by: Bill Glade, DC Wauconda Fire Department Bill Glade, DC Wauconda Fire Department

Sharon Hopkins, RN, BSNSharon Hopkins, RN, BSN

ObjectivesObjectives

Upon successful completion of this module, the Upon successful completion of this module, the EMS provider will be able to accomplish the EMS provider will be able to accomplish the following:following: Identify changes in the Advocate Condell EMS System Identify changes in the Advocate Condell EMS System

CE program as taught in class.CE program as taught in class. Identify the appropriate components of the cardiac Identify the appropriate components of the cardiac

conduction system with the correct wave form on a conduction system with the correct wave form on a rhythm strip.rhythm strip.

Identify when it is appropriate to obtain an EKGIdentify when it is appropriate to obtain an EKG Identify the criteria for significant ST elevation following Identify the criteria for significant ST elevation following

guidelines reviewed in class.guidelines reviewed in class. Identify EKG leads that view the anterior, inferior, Identify EKG leads that view the anterior, inferior,

lateral walls, and septumlateral walls, and septum


Recognize the patterns of an MI after viewing the Recognize the patterns of an MI after viewing the components of a 12 lead EKGcomponents of a 12 lead EKG

Identify typical and atypical presentations of AMIIdentify typical and atypical presentations of AMI Identify complications associated with an inferior wall MIIdentify complications associated with an inferior wall MI Identify complications associated with an anterior/septal Identify complications associated with an anterior/septal

wall MIwall MI Identify complications associated with a lateral wall MIIdentify complications associated with a lateral wall MI Identify interventions for complications related to heart Identify interventions for complications related to heart

block, pulmonary edema, and cardiogenic shockblock, pulmonary edema, and cardiogenic shock Identify the SOP guidelines for the patient presenting with Identify the SOP guidelines for the patient presenting with

acute coronary syndrome asacute coronary syndrome as written in the Region X written in the Region X SOP’sSOP’s


State dosing and precautions for Aspirin, State dosing and precautions for Aspirin, Nitroglycerin, and MorphineNitroglycerin, and Morphine

Identify ED staff expectations of EMS personnel when Identify ED staff expectations of EMS personnel when calling the hospital to report a patient with ST calling the hospital to report a patient with ST elevation identified on a 12 lead EKGelevation identified on a 12 lead EKG

Identify EMS expectations when delivering a patient Identify EMS expectations when delivering a patient to a hospital after ST elevation has been identified on to a hospital after ST elevation has been identified on a 12 lead EKGa 12 lead EKG

Actively participate in 12 lead EKG scenario practice Actively participate in 12 lead EKG scenario practice and discussionand discussion

Given a picture, correctly trace the order of the Given a picture, correctly trace the order of the cardiac conduction system.cardiac conduction system.

Given a manikin, correctly place electrodes to obtain Given a manikin, correctly place electrodes to obtain a 12 lead EKG.a 12 lead EKG.

CMC EMS CE Process For 2009CMC EMS CE Process For 2009

Educational committee formed to develop a new Educational committee formed to develop a new CE process that will be evolvingCE process that will be evolving

7 CE’s presented by EMS staff7 CE’s presented by EMS staff 2 CE’s presented by department members2 CE’s presented by department members Total of 27 hours of CE per year Total of 27 hours of CE per year Objectives and references for each CE sent to Objectives and references for each CE sent to

departments for previewdepartments for preview Each department will receive a detailed copy of Each department will receive a detailed copy of

the CE material for referencethe CE material for reference CE power points will continue to be posted on CE power points will continue to be posted on

the Condell websitethe Condell website

2009 CE Process2009 CE Process

All CE’s must be completed by year’s endAll CE’s must be completed by year’s end Medical Officer will oversee the completion for Medical Officer will oversee the completion for

those not completing during EMS staff those not completing during EMS staff presentationpresentation

There will no longer be biannual examsThere will no longer be biannual exams Quizzes will be administered at the completion Quizzes will be administered at the completion

of each CEof each CE Successful completion is at 80%Successful completion is at 80% Number of quiz questions may be variable dependent Number of quiz questions may be variable dependent

on topic and will be based on objectiveson topic and will be based on objectives Handouts at class will only be material Handouts at class will only be material

applicable to complete that topic and no longer applicable to complete that topic and no longer the full power points the full power points

Why Are We doing Pre-hospital Why Are We doing Pre-hospital EKG’s?EKG’s?

Early recognition and fast, appropriate Early recognition and fast, appropriate treatment can prevent the extension of an treatment can prevent the extension of an MIMI

Early recognition = early interventionEarly recognition = early intervention

An important diagnostic tool will also be An important diagnostic tool will also be the patient’s general appearancethe patient’s general appearance

Cardiac Conduction SystemCardiac Conduction System

Electrical cells arranged in a systematic Electrical cells arranged in a systematic pathwaypathway

Predominant pacemaker starting the Predominant pacemaker starting the electrical flow comes from the SA nodeelectrical flow comes from the SA node

Electrical cells are part of the conduction Electrical cells are part of the conduction systemsystem

Muscle cells are the mechanical cellsMuscle cells are the mechanical cells

Cardiac Cardiac Conduction Conduction

SystemSystem

Purkinje fibers

EKG WaveformsEKG Waveforms

P wave represents atrial stimulationP wave represents atrial stimulation P wave is rounded and uprightP wave is rounded and upright

PR intervalPR interval Includes the P wave and the isoelectric PR Includes the P wave and the isoelectric PR

segmentsegment PR interval is the time it takes for an impulse PR interval is the time it takes for an impulse

to travel from the SA node through the to travel from the SA node through the internodal pathways toward the ventriclesinternodal pathways toward the ventricles

Includes delay time in the AV nodeIncludes delay time in the AV node Normal PR interval is Normal PR interval is 0.12 – 0.20 seconds0.12 – 0.20 seconds

PR PR IntervalInterval

PR Interval AbnormalitiesPR Interval Abnormalities

PR interval <0.12 secondsPR interval <0.12 seconds Impulse did not begin in the normal Impulse did not begin in the normal

pacemaker site of the SA node but pacemaker site of the SA node but somewhere in the atriasomewhere in the atria

PR interval >0.20 secondsPR interval >0.20 seconds There was a longer than normal delay There was a longer than normal delay

transmitting the impulse through the AV nodetransmitting the impulse through the AV node A change in the PR interval measurement A change in the PR interval measurement

generally will not make the patient symptomaticgenerally will not make the patient symptomatic

EKG Wave Forms cont’dEKG Wave Forms cont’d

QRS complexQRS complex Consists of the Q, R, and S waves collectivelyConsists of the Q, R, and S waves collectively Represents ventricular depolarization or discharge of Represents ventricular depolarization or discharge of

electrical energy throughout ventricular muscleelectrical energy throughout ventricular muscle Larger than the P wave because ventricular Larger than the P wave because ventricular

depolarization involves a larger muscle mass than depolarization involves a larger muscle mass than atrial depolarizationatrial depolarization

Palpation of a pulse is generated by ventricular Palpation of a pulse is generated by ventricular depolarization (seen as the QRS complex)depolarization (seen as the QRS complex)

Normal timing usually considered between 0.06 Normal timing usually considered between 0.06 and 0.11 secondsand 0.11 seconds Normal is less than 0.12 secondsNormal is less than 0.12 seconds

QRS ComplexQRS Complex

QRS Complex MeasurementQRS Complex Measurement

From beginning of Q wave – usually fairly From beginning of Q wave – usually fairly straight forwardstraight forward

Stop measurement at end of S wave; not Stop measurement at end of S wave; not necessarily where QRS intersects baseline necessarily where QRS intersects baseline

On S wave, watch for small notch or other On S wave, watch for small notch or other indicator that electrical flow is changingindicator that electrical flow is changingNot always so easy to determine stop pointNot always so easy to determine stop point

Do not include ST segment or T waveDo not include ST segment or T wave Abnormally wide QRS indicates delay in Abnormally wide QRS indicates delay in

conduction time through the ventriclesconduction time through the ventricles

EKG Wave Forms cont’dEKG Wave Forms cont’d

T waveT wave Represents ventricular repolarizationRepresents ventricular repolarization Repolarization is the phase of electrical activity Repolarization is the phase of electrical activity

where electrical charges (influenced primarily by where electrical charges (influenced primarily by sodium (Na+) and potassium (K+)) return to their sodium (Na+) and potassium (K+)) return to their original state and prepare to respond to the next original state and prepare to respond to the next electrical charge receivedelectrical charge received

Atria repolarize during ventricular depolarization so the Atria repolarize during ventricular depolarization so the small atrial T wave is hidden during the larger QRS small atrial T wave is hidden during the larger QRS complexcomplex

When To Obtain a 12-Lead EKGWhen To Obtain a 12-Lead EKG

Any patient presenting with signs and/or symptoms of Any patient presenting with signs and/or symptoms of an acute coronary syndromean acute coronary syndrome

Consider atypical AMI presentationsConsider atypical AMI presentations ElderlyElderly WomenWomen Patient with long standing history of diabetesPatient with long standing history of diabetes

Any patient presenting with a Second degree Type II Any patient presenting with a Second degree Type II (classical) or 3(classical) or 3rdrd degree heart block degree heart block Consider the origin from an AMI until proven Consider the origin from an AMI until proven

otherwiseotherwise

What Are We Looking For?What Are We Looking For? Abnormalities that indicate interruption in the blood Abnormalities that indicate interruption in the blood

flow to the myocardiumflow to the myocardium Plaque formation diminishes blood flow through the Plaque formation diminishes blood flow through the

coronary arteriescoronary arteriesPatients may be asymptomatic while damage Patients may be asymptomatic while damage

silently developssilently develops Plaque rupture begins a cascade of events that Plaque rupture begins a cascade of events that

further compromises blood flow through the injured further compromises blood flow through the injured vessel(s)vessel(s)

This cascade of events could lead to an acute This cascade of events could lead to an acute coronary syndrome (ie: acute MI)coronary syndrome (ie: acute MI)

Coronary CirculationCoronary Circulation

Coronary arteries and veinsCoronary arteries and veins Myocardium extracts the largest amount of Myocardium extracts the largest amount of

oxygen as blood moves into general oxygen as blood moves into general circulationcirculation

Oxygen uptake by the myocardium can Oxygen uptake by the myocardium can only improve by increasing blood flow only improve by increasing blood flow through the coronary arteriesthrough the coronary arteries

If the coronary arteries are blocked, they If the coronary arteries are blocked, they must be reopened if circulation is going to must be reopened if circulation is going to be restored to that area of tissue suppliedbe restored to that area of tissue supplied

12-Lead Electrodes12-Lead Electrodes

A lead is a tracing of the electrical activity A lead is a tracing of the electrical activity between 2 electrodesbetween 2 electrodes

Leads view the heart from the front of the bodyLeads view the heart from the front of the body Top, bottom, right, and left side of heartTop, bottom, right, and left side of heart

Leads view the heart as if it were sliced in half Leads view the heart as if it were sliced in half horizontallyhorizontally Front, back, right, and left sides of heartFront, back, right, and left sides of heart

Each lead has a positive and a negative Each lead has a positive and a negative electrodeelectrode

Standard 12-Lead EKGStandard 12-Lead EKG

Six limb leadsSix limb leads Leads I, II, III, aVR, aVL, aVFLeads I, II, III, aVR, aVL, aVF

Six chest leads (precordial leads)Six chest leads (precordial leads) V1, V2, V3, V4, V5, V6V1, V2, V3, V4, V5, V6

Information from 12 leads obtained Information from 12 leads obtained from the attachment of only 10 from the attachment of only 10 electrodeselectrodes

View The Leads ProvideView The Leads Provide

II, III, aVF – view inferior wall of heartII, III, aVF – view inferior wall of heart V1 and V2 – view septal wall of heartV1 and V2 – view septal wall of heart V3 and V4 – view anterior wall of V3 and V4 – view anterior wall of

heartheart I, aVL, V5, V6 – view lateral wall of I, aVL, V5, V6 – view lateral wall of

heartheart

Preparation for 12 Lead EKG Preparation for 12 Lead EKG Skin preparationSkin preparation

Hair removalHair removalclip hair if necessary so electrodes adhereclip hair if necessary so electrodes adhere

Clean and dry skin surfaceClean and dry skin surfacegently rub skin area with gauze padgently rub skin area with gauze pad

need to remove skin oils & dead skinneed to remove skin oils & dead skinif diaphoretic patient wipe with if diaphoretic patient wipe with

towel/gauze or use antiperspirant spraytowel/gauze or use antiperspirant spray

Patient positioningPatient positioning Preferably flatPreferably flat

Heart rotates position as the patient Heart rotates position as the patient position changesposition changes

If patient is elevated, note that If patient is elevated, note that information on the EKGinformation on the EKG

Precordial Chest LeadsPrecordial Chest Leads

For For everyevery person, each precordial lead placed in person, each precordial lead placed in the same relative positionthe same relative position

V1 - 4V1 - 4thth intercostal space, R of sternum intercostal space, R of sternumV2 - 4V2 - 4thth intercostal space, L of sternum intercostal space, L of sternumV4 - 5V4 - 5thth intercostal space, midclavicular intercostal space, midclavicularV3 - between V2 and V4, on 5V3 - between V2 and V4, on 5thth rib rib V5 - 5V5 - 5thth intercostal space, anterior axillary line intercostal space, anterior axillary lineV6 - 5V6 - 5thth intercostal space, mid-axillary line intercostal space, mid-axillary line

Precordial Precordial LeadsLeads

2nd ICS

3rd ICS

1st ICS

12 Lead EKG Printout12 Lead EKG Printout

Standard format 8Standard format 811//22 x 11 x 11 paper paper

12 lead format:12 lead format:

II aVR aVR V1 V1 V4 V4

IIII aVL aVL V2 V2 V5 V5

IIIIII aVF aVF V3 V3 V6 V6

Machines can analyze data obtained Machines can analyze data obtained but humans must interpret databut humans must interpret data

Lateral View – I, aVL, V5, V6Lateral View – I, aVL, V5, V6

Inferior View – II, III, aVFInferior View – II, III, aVF

Septal View – V1 & V2Septal View – V1 & V2

Anterior View – V3 & V4Anterior View – V3 & V4

Myocardial InsultMyocardial Insult IschemiaIschemia

lack of oxygenationlack of oxygenation ST depression or T wave inversionST depression or T wave inversion permanent damage avoidablepermanent damage avoidable

InjuryInjury prolonged ischemiaprolonged ischemia ST elevationST elevation permanent damage avoidablepermanent damage avoidable

InfarctInfarct death of myocardial tissue; damage permanent; may have death of myocardial tissue; damage permanent; may have

Q waveQ wave

Why A Pre-hospital EKG?Why A Pre-hospital EKG?

EMS looking for ST segment elevationEMS looking for ST segment elevation Indicates injury that can be reversible if found Indicates injury that can be reversible if found

early and acted upon earlyearly and acted upon early TIME IS MUSCLETIME IS MUSCLE The earlier the discovery of an acute cardiac The earlier the discovery of an acute cardiac

event, the quicker the patient can receive the event, the quicker the patient can receive the most appropriate caremost appropriate care

EKG’s sent to the ED before patient arrival EKG’s sent to the ED before patient arrival allows for the right personnel to be available to allows for the right personnel to be available to properly care for the patientproperly care for the patient in the most time in the most time efficient mannerefficient manner

What Do You Have to Do?What Do You Have to Do?

Obtain a 12 lead EKGObtain a 12 lead EKG Evaluate the leads yourself as you are Evaluate the leads yourself as you are

sending the 12 lead to the EDsending the 12 lead to the ED Identify for the presence or absence of ST Identify for the presence or absence of ST

elevationelevation Report what you see, not just what is Report what you see, not just what is

printed on the machine copy of the EKGprinted on the machine copy of the EKG Upon arrival, hand a copy of your 12 lead Upon arrival, hand a copy of your 12 lead

to the ED staff while you give bedside to the ED staff while you give bedside reportreport

Evaluating for ST Segment Evaluating for ST Segment ElevationElevation

Locate the J-pointLocate the J-point Identify/estimate where the isoelectric line Identify/estimate where the isoelectric line

is noted to beis noted to be Compare the level of the ST segment to Compare the level of the ST segment to

the isoelectric linethe isoelectric line Elevation (or depression) is significant if Elevation (or depression) is significant if

more than 1 mm (one small box) is seen in more than 1 mm (one small box) is seen in 2 or more leads facing the same 2 or more leads facing the same anatomical area of the heart anatomical area of the heart (ie: contiguous leads)(ie: contiguous leads)

J point – where the QRS complex and ST J point – where the QRS complex and ST segment meetsegment meet

ST segment elevation - evaluated 0.04 seconds ST segment elevation - evaluated 0.04 seconds (one small box) after J point (one small box) after J point

The J PointThe J Point

Coved Coved shape shape usually usually indicates indicates acute injuryacute injury

Concave Concave shape is shape is usually usually benign benign especially if especially if patient is patient is asympto-asympto-matic matic

Significant ST ElevationSignificant ST Elevation ST segment elevation measurementST segment elevation measurement

starts 0.04 seconds after J pointstarts 0.04 seconds after J point

ST elevationST elevation > 1mm (1 small box) in 2 or more contiguous chest > 1mm (1 small box) in 2 or more contiguous chest

leads (V1-V6)leads (V1-V6) >1mm (1 small box) in 2 or more anatomically >1mm (1 small box) in 2 or more anatomically

contiguous leadscontiguous leads

Contiguous leadContiguous lead limb leads that “look” at the same area of the heart limb leads that “look” at the same area of the heart

or are numerically consecutive chest leadsor are numerically consecutive chest leads

Contiguous LeadsContiguous Leads

Lateral wall: I, aVL, V5, V6Lateral wall: I, aVL, V5, V6 Inferior wall: II, III, avFInferior wall: II, III, avF Septum: V1 and V2Septum: V1 and V2 Anterior wall: V3 and V4Anterior wall: V3 and V4 Posterior wall: V7-V9 (leads placed Posterior wall: V7-V9 (leads placed

on the patient’s back 5on the patient’s back 5thth intercostal intercostal space creating a 15 lead EKG)space creating a 15 lead EKG)

Evolution of AMIEvolution of AMIA - pre-infarct (normal)A - pre-infarct (normal)

B - Tall T wave (B - Tall T wave (first few first few minutes of infarctminutes of infarct))

C - Tall T wave C - Tall T wave andand ST ST elevation (elevation (injuryinjury))

D - Elevated ST (D - Elevated ST (injuryinjury), ), inverted T wave (inverted T wave (ischemiaischemia), ), Q wave (Q wave (tissue deathtissue death))

E - Inverted T wave E - Inverted T wave ((ischemiaischemia), Q wave (), Q wave (tissue tissue deathdeath))

F - Q wave (F - Q wave (permanent permanent marking) marking)

ST Segment ST Segment ElevationElevation

EKG monitoringEKG monitoring Evaluates electrical activity of the heartEvaluates electrical activity of the heart Can indicate myocardial insult and locationCan indicate myocardial insult and location

ischemiaischemia - initial insult; ST depression seen - initial insult; ST depression seeninjuryinjury - prolonged myocardial hypoxia or - prolonged myocardial hypoxia or

ischemia; ST elevation seenischemia; ST elevation seeninfarctioninfarction - tissue death - tissue death

dead tissue no longer contractsdead tissue no longer contracts amount of dead tissue directly relates to amount of dead tissue directly relates to

degree of muscle impairmentdegree of muscle impairment may show Q waves may show Q waves

Contiguous ECG LeadsContiguous ECG Leads EKG changes are EKG changes are

significant when they significant when they are seen in at least two are seen in at least two contiguouscontiguous leads leads

Two leads are Two leads are contiguous if they look contiguous if they look at the same area of the at the same area of the heart or they are heart or they are numerically consecutive numerically consecutive chest leadschest leads

Groups of EKG LeadsGroups of EKG Leads Inferior wall - II, III, aVFInferior wall - II, III, aVF Septal wall - V1, V2Septal wall - V1, V2 Anterior wall - V3, V4Anterior wall - V3, V4 Lateral wall - I, aVL, V5, V6 Lateral wall - I, aVL, V5, V6

aVR is not evaluated in typical groups aVR is not evaluated in typical groups Standard lead placement does not look at Standard lead placement does not look at

posterior wall or right ventricle of the heart - need posterior wall or right ventricle of the heart - need special lead placement for these viewsspecial lead placement for these views

Basic 12-Lead EKG FormatBasic 12-Lead EKG Format

Lead ILateral wall

aVR not evaluated

V1

Septum

V4

Anterior wall

Lead II Inferior wall

aVLLateral wall

V2

Septum

V5

Lateral wall

Lead III Inferior wall

aVFInferior wall

V3

Anterior

V6

Lateral wall

Lateral Wall MI: I, aVL, V5, V6Lateral Wall MI: I, aVL, V5, V6

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.

Inferior Wall MI II, III, aVFInferior Wall MI II, III, aVF


Septal MI: Leads V1 and V2Septal MI: Leads V1 and V2


Anterior Wall MI V3, V4Anterior Wall MI V3, V4


Posterior MI – Reciprocal Changes Posterior MI – Reciprocal Changes ST Depression V1, V2, V3, poss V4ST Depression V1, V2, V3, poss V4


Complications of Lateral Wall MIComplications of Lateral Wall MI

I, aVL, V5,V6I, aVL, V5,V6 Complications arise due to the conduction Complications arise due to the conduction

components that are in the septumcomponents that are in the septum Conduction dysrhythmias most commonConduction dysrhythmias most common

Second degree Type II – classicalSecond degree Type II – classical 33rdrd degree – complete heart block degree – complete heart block Bundle branch blocksBundle branch blocks

Monitor patient closely for these blocksMonitor patient closely for these blocks 22ndnd degree Type II and 3 degree Type II and 3rdrd degree are serious degree are serious

dysrhythmias that need to be treated aggressively dysrhythmias that need to be treated aggressively with TCPwith TCP

Complications of Inferior Wall MIComplications of Inferior Wall MI

II, III, aVFII, III, aVF 40% of patients with inferior MI’s have right ventricular 40% of patients with inferior MI’s have right ventricular

infarcts infarcts In the presence of a right ventricular infarct, there is a In the presence of a right ventricular infarct, there is a

high likeliness of both ventricles being damagedhigh likeliness of both ventricles being damaged Contraction capabilities will be negatively affected Contraction capabilities will be negatively affected

Patients may present hypotensivePatients may present hypotensive Nitrates and Morphine alone will dilate blood vessels Nitrates and Morphine alone will dilate blood vessels

worsening hypotensionworsening hypotension Under Medical Control direction patients are often Under Medical Control direction patients are often

treated with a fluid challenge with the nitrates treated with a fluid challenge with the nitrates 11stst degree heart block and Second degree Type I degree heart block and Second degree Type I

Wenckebach most common heart blocksWenckebach most common heart blocks

Complications of Septal Wall MIComplications of Septal Wall MI

V1 and V2V1 and V2 Significant amount of conduction components Significant amount of conduction components

are in the septal areaare in the septal area Patient predisposed to dysrhythmiaPatient predisposed to dysrhythmia

Second degree Type II – classicalSecond degree Type II – classical 33rdrd degree heart block degree heart block Bundle branch blockBundle branch block

Lethal heart blocks treated aggressively - TCPLethal heart blocks treated aggressively - TCP Rare to have a septal MI aloneRare to have a septal MI alone

Common to have anterior or lateral involvement along Common to have anterior or lateral involvement along with septal areawith septal area

Complications of Anterior Wall MIComplications of Anterior Wall MI

V3, V4V3, V4 Known as the “widowmaker” due to the potential Known as the “widowmaker” due to the potential

for a massive area of infarction from blockage of for a massive area of infarction from blockage of the large amount of myocardium supplied by the the large amount of myocardium supplied by the LAD (left anterior descending artery)LAD (left anterior descending artery)

Often the septal or lateral walls are also involvedOften the septal or lateral walls are also involved Watch for lethal ventricular dysrhythmias and Watch for lethal ventricular dysrhythmias and

cardiogenic shockcardiogenic shock Second degree Type II and 3Second degree Type II and 3rdrd degree heart degree heart

block are more common than other blocksblock are more common than other blocks

Anterior Wall MI - V3, V4Anterior Wall MI - V3, V4

Early death within a few days often from CHFEarly death within a few days often from CHF Massive area of ventricular tissue infarcted if LAD Massive area of ventricular tissue infarcted if LAD

totally occludedtotally occluded

Important to obtain history of recent MI Important to obtain history of recent MI diagnosis and hospital dischargediagnosis and hospital discharge Increased incidence of ventricular tachycardia Increased incidence of ventricular tachycardia

(VT) and ventricular fibrillation (VF) up to 1 -2 (VT) and ventricular fibrillation (VF) up to 1 -2 weeks post acute anterior MIweeks post acute anterior MI

Additional Complications Additional Complications

Acute pulmonary edemaAcute pulmonary edema Nitroglycerin to dilate blood vessels and Nitroglycerin to dilate blood vessels and

reduce preloadreduce preload Lasix to dilate blood vessels and reduce Lasix to dilate blood vessels and reduce

preload; as a diureticpreload; as a diuretic Morphine to dilate blood vessels and reduce Morphine to dilate blood vessels and reduce

preload; reduce anxietypreload; reduce anxiety

Additional ComplicationsAdditional Complications Cardiogenic shockCardiogenic shock

Ineffective pumping from the damaged heartIneffective pumping from the damaged heart IV fluid challenge if lung sounds are clearIV fluid challenge if lung sounds are clear Dopamine drip titrated to maintain a systolic Dopamine drip titrated to maintain a systolic

blood pressure of blood pressure of >>100 mmHg100 mmHgStart at a low dose (5mcg/kg/min)Start at a low dose (5mcg/kg/min)

Estimate the patient’s pounds (ie: 100 #)Estimate the patient’s pounds (ie: 100 #) Take the 1Take the 1stst 2 numbers dropping the last 2 numbers dropping the last

number (“10”)number (“10”) This is the starting point for This is the starting point for

minidrips/minute (8 minidrips/minute)minidrips/minute (8 minidrips/minute)

Common Terms Patients Common Terms Patients Use To Describe Chest Pain Use To Describe Chest PainHeavinessHeaviness

Pressing Pressing

Suffocating Suffocating

Squeezing Squeezing

StranglingStrangling

Burning Burning

Constricting bandConstricting band

A weight in the A weight in the center of my chest center of my chest

A vise tightening A vise tightening around my chestaround my chest

Additional Patient Complaints or Additional Patient Complaints or PresentationsPresentations

Difficulty breathingDifficulty breathingExcessive sweatingExcessive sweatingUnexplained nausea Unexplained nausea

or vomitingor vomitingGeneralized Generalized

weaknessweaknessDizzinessDizziness

Syncope or near-Syncope or near-syncopesyncope

PalpitationsPalpitationsIsolated arm or jaw Isolated arm or jaw

painpainFatigueFatigueDysrhythmiasDysrhythmias

Typical Injury PatternsTypical Injury Patterns


Atypical PresentationAtypical Presentation in the in the ElderlyElderly Most frequent symptoms of acute MI:Most frequent symptoms of acute MI:

Shortness of breathShortness of breath

Fatigue and weakness (“I just don’t feel well”)Fatigue and weakness (“I just don’t feel well”)

Abdominal or epigastric discomfortAbdominal or epigastric discomfort

Often have preexisting conditions making this an Often have preexisting conditions making this an already vulnerable populationalready vulnerable population

HypertensionHypertension

CHFCHF

Previous AMIPrevious AMI

Likely to delay seeking treatmentLikely to delay seeking treatment

Atypical PresentationAtypical Presentation in in WomenWomen Discomfort described as:Discomfort described as:

AchingAchingTightnessTightnessPressurePressureSharpnessSharpnessBurningBurningFullnessFullnessTingling Tingling

Often have no actual chest pain to offer as a Often have no actual chest pain to offer as a complaint. Often the pain is in the back, complaint. Often the pain is in the back, shoulders, or neckshoulders, or neck

Frequent acute Frequent acute symptoms:symptoms:Shortness of breathShortness of breathWeaknessWeaknessUnusual fatigueUnusual fatigueCold sweatsCold sweatsDizzinessDizzinessNausea/vomitingNausea/vomiting

Atypical PresentationAtypical Presentation in the in the Patient With Patient With DiabetesDiabetes

Atypical presentation due to autonomic Atypical presentation due to autonomic dysfunctiondysfunction

Common signs/symptoms:Common signs/symptoms: Generalized weaknessGeneralized weakness Generalized feeling of not being wellGeneralized feeling of not being well SyncopeSyncope LightheadednessLightheadedness Change in mental statusChange in mental status

Region X SOP – Acute Coronary Region X SOP – Acute Coronary SyndromeSyndrome

A 12 lead EKG is obtained on all patients A 12 lead EKG is obtained on all patients presenting with signs and symptoms of presenting with signs and symptoms of acute MIacute MI

OROR For patients where suspicions are raised For patients where suspicions are raised

that the patient may be experiencing an that the patient may be experiencing an acute MI (ie: heart block)acute MI (ie: heart block)

12-Lead Electrode Placement12-Lead Electrode Placement

Region X SOP – Acute Coronary Region X SOP – Acute Coronary SyndromeSyndrome

Determine if the patient is stable or Determine if the patient is stable or unstable to proceed with interventionsunstable to proceed with interventions

Easiest way to determine stability is to Easiest way to determine stability is to evaluate blood flow evaluate blood flow What is the level of consciousness?What is the level of consciousness? What is the blood pressure / is there a radial What is the blood pressure / is there a radial

pulse?pulse? Remember: A B/P reading of 100/systolic Remember: A B/P reading of 100/systolic

does not necessarily indicate the presence does not necessarily indicate the presence or absence of symptomsor absence of symptoms

OxygenOxygen

In the presence of an acute MI, the In the presence of an acute MI, the myocardium is being deprived of blood myocardium is being deprived of blood flow and therefore adequate oxygen levelsflow and therefore adequate oxygen levels

Provide what the patient needsProvide what the patient needs Evaluate each individual clinical Evaluate each individual clinical

presentationpresentation All patients deserve some form of oxygen All patients deserve some form of oxygen

in this early period of myocardial starvation in this early period of myocardial starvation for itfor it

AspirinAspirin

Used to prevent platelet aggregationUsed to prevent platelet aggregation When a plague ruptures, chemicals are released. When a plague ruptures, chemicals are released.

Platelets congregate to the area to seal the rupture. Platelets congregate to the area to seal the rupture. Platelet aggregation further increases the degree of Platelet aggregation further increases the degree of vessel blockage.vessel blockage.

Dosage is 4 – 81 mg (324 mg total) baby aspirin Dosage is 4 – 81 mg (324 mg total) baby aspirin chewedchewed Chewing breaks down the aspirin and allows for faster Chewing breaks down the aspirin and allows for faster

absorptionabsorption Give dose if patient not reliable about taking Give dose if patient not reliable about taking

their own dose or has not taken any aspirintheir own dose or has not taken any aspirin

NitroglycerinNitroglycerin VenodilatorVenodilator

Improves coronary blood flowImproves coronary blood flow By dilating blood vessels, pools blood away By dilating blood vessels, pools blood away

from the heart which decreases preload. This from the heart which decreases preload. This decreases the work load of a stressed heart.decreases the work load of a stressed heart.

Carefully monitor blood pressure before and Carefully monitor blood pressure before and after dosagesafter dosages

Dosage is 0.4 mg tablet slDosage is 0.4 mg tablet sl Dosage can be repeated in 5 minutes if blood Dosage can be repeated in 5 minutes if blood

pressure remains stablepressure remains stable FYI: Pain level will not drop to “0” until the clot FYI: Pain level will not drop to “0” until the clot

is removedis removed

For CMC EMS System ParticipantsFor CMC EMS System Participants

If the patient is <35 years of ageIf the patient is <35 years of age Follow Acute coronary Syndrome SOP by Follow Acute coronary Syndrome SOP by

administering aspirinadministering aspirin Contact Medical control prior to administration of Contact Medical control prior to administration of

nitroglycerin or morphinenitroglycerin or morphine

There should be no delay in obtaining a 12 lead There should be no delay in obtaining a 12 lead EKG in the field and transmitting it to the EDEKG in the field and transmitting it to the ED

Your visual interpretation is to be given during Your visual interpretation is to be given during report to the receiving hospital report to the receiving hospital

MorphineMorphine CNS depressant to reduce anxietyCNS depressant to reduce anxiety Venodilates blood vessels to reduce the Venodilates blood vessels to reduce the

volume of blood returning to the heart to volume of blood returning to the heart to decrease the heart’s workloaddecrease the heart’s workload

Dosage is 2 mg slow IVPDosage is 2 mg slow IVP Dosage started when the 2Dosage started when the 2ndnd dose of dose of

nitroglycerin proves ineffectivenitroglycerin proves ineffective Dosage may be repeated every 2 minutes as Dosage may be repeated every 2 minutes as

neededneeded Maximum dosage is 10 mgMaximum dosage is 10 mg

Watch for hypotension Watch for hypotension

Receiving Hospital ReportReceiving Hospital Report

When sending a 12 lead EKG, inform the When sending a 12 lead EKG, inform the receiving hospital what identifiers have receiving hospital what identifiers have been usedbeen used Department ID numberDepartment ID number Patient sex (M / F)Patient sex (M / F) Patient agePatient age Any other identifierAny other identifier

Always give your visual interpretation of Always give your visual interpretation of what you have observed for ST elevationwhat you have observed for ST elevation

Activating a Cardiac AlertActivating a Cardiac Alert The ED activates a cardiac alert to prepare the The ED activates a cardiac alert to prepare the

cardiac team to provide optimal care for the cardiac team to provide optimal care for the patientpatient

Typical cardiac alert team membersTypical cardiac alert team members ED staff – MD, RN, tech, secretaryED staff – MD, RN, tech, secretary CardiologistCardiologist Cath lab personnelCath lab personnel EKG tech (may be an ED staff member)EKG tech (may be an ED staff member) Lab techLab tech X-ray techX-ray tech

Not all hospitals use all members in a formalized Not all hospitals use all members in a formalized team but all of these members are somehow team but all of these members are somehow integrated into the care of the patientintegrated into the care of the patient

When Does a Cardiac Alert Get When Does a Cardiac Alert Get Called?Called?

When you send a 12 lead EKG with ST When you send a 12 lead EKG with ST elevation, the team gets activatedelevation, the team gets activated

When you confirm what you see on the 12 When you confirm what you see on the 12 lead, whether the EKG is sent or not, may lead, whether the EKG is sent or not, may trigger a cardiac alerttrigger a cardiac alert

There is a direct link in your accuracy, There is a direct link in your accuracy, completeness in patient report, and EKG completeness in patient report, and EKG interpretation with pre-hospital activation interpretation with pre-hospital activation of the cardiac alert teamof the cardiac alert team

Transferring Care of The Patient to Transferring Care of The Patient to The EDThe ED

Bedside report is restated to the ED Bedside report is restated to the ED personnel in the roompersonnel in the room The main report must be to an RN or MDThe main report must be to an RN or MD

Rhythm strips and 12 lead EKG are Rhythm strips and 12 lead EKG are presentedpresented

Important to note positive and negative Important to note positive and negative changes in the patient conditionchanges in the patient condition Pain level has decreasedPain level has decreased Blood pressure has droppedBlood pressure has dropped

DocumentationDocumentation

Follow OPQRST guidelinesFollow OPQRST guidelines Some of this information is added into a check Some of this information is added into a check

box or other prompt; otherwise the information is box or other prompt; otherwise the information is written into the narrativewritten into the narrative

OOnset – what was the patient doing when the nset – what was the patient doing when the problem/pain began? Any contributing factors? problem/pain began? Any contributing factors?

Add this information to the narrative.Add this information to the narrative. PProvocation/palliation – what makes the pain rovocation/palliation – what makes the pain

worse/makes it better; added to narrative worse/makes it better; added to narrative QQuality- in the patient’s own words; added to uality- in the patient’s own words; added to

narrativenarrative

RRegion/egion/RRadiation – where is the problem/pain; adiation – where is the problem/pain; radiation is typically to the jaw, down an arm, felt radiation is typically to the jaw, down an arm, felt in the back; added to narrativein the back; added to narrative

SSeverity – on a scale of 0-10, 0 being no pain everity – on a scale of 0-10, 0 being no pain and 10 being the worse pain the patient has and 10 being the worse pain the patient has experienced; use the “pain scale” boxexperienced; use the “pain scale” box

TTime – when did the problem/pain begin and ime – when did the problem/pain begin and how long has it lasted? Use the “time of onset” how long has it lasted? Use the “time of onset” box.box.

Include associated symptoms like dyspnea or Include associated symptoms like dyspnea or nauseanausea

EKG PracticeEKG Practice

Practice reviewing the following 12 lead Practice reviewing the following 12 lead EKG’s for ST segment elevationEKG’s for ST segment elevation

Evaluate the ST segment at the J pointEvaluate the ST segment at the J point Note: A peaked T wave is Note: A peaked T wave is notnot equivalent equivalent

with ST elevationwith ST elevation Consider potential complications to Consider potential complications to

monitor for based on the location of the monitor for based on the location of the acute MIacute MI

Practice Identifying ST Segment Practice Identifying ST Segment ElevationElevation

> 1mm (1 small box) above the baseline in 2 leads > 1mm (1 small box) above the baseline in 2 leads from any group or 2 or more contiguous leadsfrom any group or 2 or more contiguous leads

(>2 mm (2 small boxes) in limb leads considered (>2 mm (2 small boxes) in limb leads considered alternative elevation by some) measured 0.04 alternative elevation by some) measured 0.04 seconds after J pointseconds after J point

Case #1Case #1

Case #1Case #1 52 year-old patient complains of 52 year-old patient complains of

indigestion after pizza & beer dinner.indigestion after pizza & beer dinner. VS: 124/82; P – 108; R - 18VS: 124/82; P – 108; R - 18 Is there ST elevation:Is there ST elevation:

I, aVL, V5, V6?I, aVL, V5, V6? II, III, aVF?II, III, aVF? V1, V2?V1, V2? V3, V4?V3, V4?

What are you going to do for this patient?What are you going to do for this patient?

Case #2Case #2

Case #2Case #2

62 year-old female developed chest & jaw 62 year-old female developed chest & jaw pain while in the showerpain while in the shower

VS: 110/62; P – 66; R – 20VS: 110/62; P – 66; R – 20 Is there ST elevation:Is there ST elevation:



Case #3Case #3

Case #3Case #3

45 year-old patient who complains of chest 45 year-old patient who complains of chest heaviness & lightheadednessheaviness & lightheadedness

VS: 90/56; P – 86; R - 22VS: 90/56; P – 86; R - 22 Is there ST elevation:Is there ST elevation:



Case #4Case #4

Case #4Case #4

87 year-old female patient complains of 87 year-old female patient complains of dizziness and being extremely tireddizziness and being extremely tired




Case #5Case #5

Case #5Case #5

58 year-old male patient who complains of chest 58 year-old male patient who complains of chest pain radiating down the left arm after working out pain radiating down the left arm after working out in the gymin the gym




Case #6Case #6

Case #6Case #6

92 year-old patient complaining of 92 year-old patient complaining of pounding in her chest for one hourpounding in her chest for one hour

VS: 98/66; P – 110; R- 16VS: 98/66; P – 110; R- 16 Is there ST elevation:Is there ST elevation:



Case #7Case #7

Case #7Case #7

66 year-old patient with history of diabetes 66 year-old patient with history of diabetes for 25 years complains of being for 25 years complains of being lightheaded and is sweatylightheaded and is sweaty

Is there ST elevation:Is there ST elevation: I, aVL, V5, V6?I, aVL, V5, V6? II, III, aVF?II, III, aVF? V1, V2?V1, V2? V3, V4?V3, V4?


Case #8Case #8

Case #8Case #8

70 year-old patient had a syncopal episode 70 year-old patient had a syncopal episode when they stood up from the couchwhen they stood up from the couch




Case #9Case #9

Case #9Case #9

82 year-old patient complains of sudden onset of 82 year-old patient complains of sudden onset of slurred speech, inability to grasp a coffee cup, slurred speech, inability to grasp a coffee cup, and inability to follow simple commandsand inability to follow simple commands




Case #10Case #10

Case #10Case #10

36 year-old patient who passed out 36 year-old patient who passed out standing in line at a bankstanding in line at a bank




BibliographyBibliography Aehlert, B. EKG’s Made Easy third Edition. Aehlert, B. EKG’s Made Easy third Edition.

Elsevier Mosby. 2006.Elsevier Mosby. 2006. Beasley, B. Understanding EKG’s A Beasley, B. Understanding EKG’s A

Practical Approach. Brady. 2003.Practical Approach. Brady. 2003. Bledsoe, B., Porter, R., Cherry, R. Bledsoe, B., Porter, R., Cherry, R.

Paramedic Care Principles and Practices. Paramedic Care Principles and Practices. Third Edition. Brady. 2009.Third Edition. Brady. 2009.

Ellis, K. EKG Plain and Simple. Prentice Ellis, K. EKG Plain and Simple. Prentice Hall. 2002.Hall. 2002.

Page, B. 12 Lead EKG for Acute and Page, B. 12 Lead EKG for Acute and Critical Care Providers. Brady. 2005.Critical Care Providers. Brady. 2005.

Phalen, T., Aehlert, B. The 12 Lead EKG in Phalen, T., Aehlert, B. The 12 Lead EKG in Acute Coronary Syndromes. Second Edition, Acute Coronary Syndromes. Second Edition, Elsevier Mosby. 2006.Elsevier Mosby. 2006.

Region X SOP’s. March 2007, Amended Region X SOP’s. March 2007, Amended January 1, 2008.January 1, 2008.

freemd.com (Acute Coronary Syndrome 9/2008)freemd.com (Acute Coronary Syndrome 9/2008) www.anaesthetist.com/icu/organs/heart/ecg/www.anaesthetist.com/icu/organs/heart/ecg/

Findex.htmFindex.htm www.ecglibrary.com/www.ecglibrary.com/ www.gwc.maricopa.edu/class/bio202/cyberheartwww.gwc.maricopa.edu/class/bio202/cyberheart

/ekgqzr.htm/ekgqzr.htm www.madsci.com/manu/ekg_mi.htmwww.madsci.com/manu/ekg_mi.htm

Overview of Revised CMC EMS System CE; 12 Lead EKG’s February 2009 CE Site Code #107200E1209...

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