Wayne Ruppert and Dr. James Irwin, St Joseph s Hospital, Tampa, FL 2006
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1 The EMS 12 Lead 101 Wayne W Ruppert, CVT, CCCC, NREMT-P Interventional Cardiovascular Technologist Cardiovascular Coordinator Bayfront Health Seven Rivers
2 Welcome!
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4 Wayne Ruppert and Dr. James Irwin, St Joseph s Hospital, Tampa, FL 2006
5 Cardiac Cath Lab
6 Electrophysiology Lab EP Catheters within the heart used for obtaining the Electrogram (the internal ECG ) Tracing and for Pace-mapping, an integral component of an EP study Author Wayne Ruppert conducting Pacemapping during EP study at the St Joseph s Hospital Heart Institute, Pediatric Electrophysiology Program, Tampa, FL in 2004
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8 Wayne Ruppert bio: Cardiovascular Coordinator 2012-present (coordinated 5 successful accreditations) Interventional Cardiovascular / Electrophysiology Technologist, 1995-Present. Author of: 12 Lead ECG Interpretation in Acute Coronary Syndrome with Case Studies from the Cardiac Cath Lab, 2010, TriGen publishing / Ingram Books Author of: STEMI Assistant, 2014, TriGen publishing / Ingram Books Florida Nursing CE Provider # Lead ECG Instructor, 1994-present (multiple hospitals, USF College of Medicine 1994) Website:
9 BarnesandNoble.com Amazon.com
10 BarnesandNoble.com Amazon.com
11 STEMI Assistant: an Emergency Crash Cart Interactive Reference Manual - free Download STEMI Assistant Information Video
12 STEMI Assistant Editorial Board: Barbra Backus, MD, PhD Inventor of The HEART Score, University Medical Center, Utrech, Netherlands Michael R. Gunderson, National Director, Clinical and Health IT, American Heart Association Anna Ek, AACC, BSN, RN Accreditation Review Specialist, The American College of Cardiology William Parker, PharmD, CGP, Director of Pharmacy, Bayfront Dade City Printed and Marketed Worldwide by The Ingram Book Company Current
13 Copyright 2010, 2011, 2015, 2019 All cardiovascular subject-related images, graphics and diagrams were created by the author, Wayne Ruppert, and have been taken from his two published textbooks, STEMI Assistant and 12 Lead ECG Interpretation in ACS with Case Studies from the Cardiac Cath Lab, are Copyright protected, and may not be removed from this PowerPoint presentation. This presentation may not be used as part of a profitgenerating program without prior written consent from the author. Wayneruppert@aol.com
14 American College of Cardiology 20 th Congress 2017 Red Rock Resort, Las Vegas October 25 & 26, 2017 Advanced Telemetry & 12 Lead ECG Workshop Part 1 Observation Medicine Tract By: Wayne W Ruppert, CVT, CCCC, NREMT-P
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16 Download Today s Presentation To go: from the MENU BAR at left side of screen, select Downloads PDF, and then select: EMS 12 Lead 101
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18 Single Lead ECG vs 12 Leads Single lead rhythm strips are obtained to see what rhythm the patient is currently in (e.g.: NSR, atrial fibrillation, heart blocks, etc). 12 Lead ECG is used to see if any part of the heart is not getting adequate blood supply (i.e.: ischemia, infarction). Plus, it aids in the diagnosis of many other conditions...
19 .Other 12 Lead ECG Diagnoses: Bundle Branch Blocks* and Fascicular Blocks Necrosis (old MI, evolving MI*) V-Tach vs SVT with aberrancy Hypertrophy (enlargement of 1 or more chambers) Electrolyte imbalances Sudden Arrhythmia Death Syndromes: Brugada, Long QT*, ARVD, CPVT, HCM, Wolff-Parkinson-White Syndrome Acute Myocarditis / Pericarditis And many more * Covered in this course
20 EMS 12 Lead ECG
21 OBTAINING THE 12 LEAD ECG
22 10 wires... 4 limb leads 6 chest ( V ) leads
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28 Obtaining the 12 Lead ECG
29 Obtaining the 12 Lead ECG Limb leads should be on the limbs.
30 Obtaining the 12 Lead ECG Recent AHA/ACC/HRS literature indicates QRS AMPLITUDE, Q WAVE DURATION, AXIS and WAVEFORM DEFLECTION can be altered when limb leads are placed on the patient's torso (Mason-Likar lead placement). Therefore every effort should be made to place limb leads on the limbs.
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33 Obtaining the 12 Lead ECG Limb leads should be on the limbs. When emergency circumstances dictate that limb leads be placed on patient's torso, the words "LIMB LEADS ON PATIENT'S TORSO" should be noted on the ECG.
34 Obtaining the 12 Lead ECG Limb leads should be on the limbs. When emergency circumstances dictate that limb leads be placed on patient's torso, the words "LIMB LEADS ON PATIENT'S TORSO" should be noted on the ECG. However in the field, it may not be possible or practical to put limb leads on limbs!
35 Limb leads field ECG
36 Remember this... White to the Right Smoke over Fire Green Grass below the White Clouds
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42 Leads V1 & V2 on 12 Lead ECG: Proper lead placement of precordial Leads V1 and V2 are 4th intercostal space on opposite sides of the sternum. Incorrect placement of Leads V1 and V2 will result in: reduction of R wave amplitude (resulting in poor R wave progression) leading to misdiagnosis of previous anterior / septal infarction.
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44 Obtaining the 12 Lead ECG, etc Patient should lay as flat as possible If you see too much artifact on the ECG, you may have to coach patient to relax all of your muscles... Arms Legs Chest Abdomen, etc.
45 To help you understand what part of the heart each lead of a 12 Lead ECG sees....
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48 What each of the 12 Leads sees, in more detail....
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56 A 12 Lead ECG sees MOST of the Heart, but it has some BLIND SPOTS!!....
57 THE 12 LEAD ECG HAS TWO MAJOR BLIND SPOTS..
58 Regarding the POSTERIOR WALL, the Standard 12 Lead will give you some good clues that there s a PROBLEM by displaying what we call RECIPROCAL CHANGES.kind of like seeing reflected changes in a mirror
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62 ST DEPRESSION can be from any other these conditions:
63 THE 12 LEAD ECG HAS TWO MAJOR BLIND SPOTS..
64 THE 18 LEAD ECG COVERS THE ENTIRE HEART..
65 To do 18 Lead ECG with 12 Lead machine after you obtain 12 Lead, reposition CHEST LEADS to this configuration, then print!
66 RIGHT SIDED ECG is indicated whenever you see INFERIOR WALL STEMI!!
67 POSTERIOR ECG is indicated whenever you see ST DEPRESSION In Leads V1-V4
68 ST Depression in V1 V4....
69 INDICATIONS for 18 Lead ECG include: - INFERIOR WALL MI F Right sided ECG - ST Depression V1-V4 F Posterior ECG
70 Practical application of 18 Lead ECGs is presented in the CASE STUDIES section of this curriculum.
71 Before we go any farther, you should know...
72 Sometimes, ECGs LIE to us!
73 ECGs and USED CAR SALESMEN often have MUCH in common!
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75 PROBLEMS WITH SENSITIVITY... NORMAL ECG. But..... LETHAL TRIPLE VESSEL DISEASE
76 PROBLEMS WITH SPECIFICITY...
77 PROBLEMS WITH SPECIFICITY...
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79 Patient: Asymptomatic Troponin normal Cardiac Cath angiography = no obstructive CAD. Discharge diagnosis: EARLY REPOLARIZATION. This degree of ST Elevation in early repolarization is VERY RARE: The only such ECG I have seen in approximately 13,000 cardiac catheterizations.
80 Despite the ECG s problematic issues with Lack of Sensitivity & Lack of Specificity, The 12 Lead ECG remains one of our QUICKEST, most costefficient front-line Triage Tools that we have today.
81 So how do we know when the ECG is telling us the truth???
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83 In the hospital we utilize ACS Risk Stratification tools such as The HEART Score. We also have Troponins, Echo, CT and Cardiac Cath. In the field, you have far fewer resources!!
84 What do you have in the field? Symptoms Risk Factors ECG Physical Exam
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86 You arrive at a patient s residence. The scene is safe, and you re led into the living room by the patient s daughter... The instant you see the patient, you assess for: CAB (pulse, breathing) the patient is awake, to you know he has a pulse and you see him breathing Shock Assessment....
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89 FAIL the SHOCK SURVEY? F RAPIDLY FIND AND TREAT THE ROOT CAUSE... WORK TO RAPIDLY IDENTIFY THE CAUSE OF SHOCK.
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92 CHIEF COMPLAINT KEY WORDS: CHEST: PAIN / HEAVINESS / PRESSURE/ FUNNY FEELING IN, etc. SHORTNESS BREATH DIZZINESS / LIGHTHEADEDNESS ETC. ETC. ETC.
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95 BEWARE of the patient with INTERMITTENT CHEST PAIN.... M
96 ATYPICAL SYMPTOMS of ACS???
97 BOOK PAGE: 70
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100 Physical Exam Clues of MI: Skin may be PALE, CLAMMY SWEATING! (Diaphoresis) Clutching /Rubbing chest BP can be high, normal or low Anxiety / look of impending doom.
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102 3 or more major RISK FACTORS gets you a checkmark in the RISK FACTOR box!
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104 Here is the HEART Score! Let s see what the score is for our patient with the NORMAL ECG.who had Critical Triple Vessel Disease and needed STAT Bypass Surgery!...
105 PROBLEMS WITH SENSITIVITY... NORMAL ECG. But..... LETHAL TRIPLE VESSEL DISEASE
106 H = chest pain = 2 E = ECG normal = 0 A = 63 = 1 R = 3 risk factors = 2 T = Trop. NL = 0 HEART Score: = 5
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109 Some Basic Vocabulary: Ischemia = Inadequate blood supply to cells, but cells are still getting blood. Cellular Oxygen Demand is HIGHER than the Oxygen Supply. Infarction = blood supply to cells has been cut off. Cells are no longer receiving oxygen or glucose. Cells survive by consuming available glycogen reserves, convert to ANAEROBIC metabolism. Unless blood supply is restored, cells die when glycogen reserves are depleted.
110 Some Basic Vocabulary: Acute Coronary Syndrome (ACS) is made up of the following cardiac conditions: Unstable Angina Non-ST Segment Elevation Myocardial Infarction (NSTEMI) ST Segment Elevation Myocardial Infarction (STEMI) Low Risk Chest Pain
111 Unstable Angina
112 Non-STEMI (NSTEMI) Non-ST Segment Elevation Myocardial Infarction. sub-endocardial MI... partial wall thickness
113 Non-STEMI (NSTEMI) Non-ST Segment Elevation Myocardial Infarction. sub-endocardial MI... partial wall thickness The 12 Lead ECG may show: - ST Depression - Other ST Segment changes - Inverted T wave - THE ECG MAY BE TOTALLY NORMAL.
114 Non-STEMI (NSTEMI) Non-ST Segment Elevation Myocardial Infarction. sub-endocardial MI... partial wall thickness This is a Partial Wall Thickness MI, heart cells are dying, and the Troponin becomes detectable in the patient s bloodstream. Usually less severe than a STEMI, patient needs blood thinners and to get to the cath lab in hours.
115 STEMI ST Segment Elevation Myocardial Infarction.
116 Non-STEMI (NSTEMI) ST Segment Elevation Myocardial Infarction. ( full-wall thickness, Transmural event) This is a life-threatening emergency. Part of the patient s heart is dying. Blood flow must be restored within 90 minutes or less in order to preserve heart muscle. Based on the region of the heart affected, critical and often lethal complications may rapidly develop.
117 A quick review of some very basic ECG concepts: When you turn on the ECG machine, it defaults to normal values.. Records at 25mm/ second (horizontal axis) Amplitude (vertical axis) is set so 1 mv = 10 small (1mm) boxes.
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120 P WAVE = ATRIAL DEPOLARIZATION QRS COMPLEX = VENTRICULAR DEPOLARIZATION (contracting) T WAVE = VENTRICULAR REPOLARIZATION (recharging)
121 Q: To evaluate the patient for ischemia or infarction, what part of the ECG do we look at?
122 Q: To evaluate the patient for ischemia or infarction, what part of the ECG do we look at? A: We evaluate the J Points ST Segments & T Waves.. in each lead!
123 Evaluating the ECG for ACS:
124 Evaluating the ECG for ACS: Patients with Normal Width QRS (QRSd < 120ms)
125 Q: Why is QRS width an issue when we look at J Points, ST Segments and T Waves??
126 Q: Why is QRS width an issue when we look at J Points, ST Segments and T Waves?? A: When the QRS is abnormally wide (> 120ms), it ALTERS the J Points, ST Segements and T Waves.
127 Defining NORMAL QRS <120ms:
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132 ...the flat line between ECG complexes, when there is no detectable electrical activity...
133 The Isoelectric Line - it s not always isoelectric!
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135 Use the P-Q junction as a reference point for measuring the J Point and ST-Segment when iso-electric line is not isoelectric!
136 Defining NORMAL:
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144 Normal Variants: T Wave Inversion
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146 The next slide shows an ECG waveform with normal J Points, ST Segments and T waves THINK OF THIS AS YOUR MEASURING STICK of what NORMAL is!!!
147 Patients with normal QRS duration ( QRS < 120 ms ) :
148 Q: If the previous slide showed what normal J Points, ST Segments and T waves look like, what is ABNORMAL?
149 Q: If the previous slide showed what normal J Points, ST Segments and T waves look like, what is ABNORMAL? A: EVERYTHING ELSE!!!
150 Up Next: ECG Indicators of ABNORMAL PERFUSION (possible ischemia / infarction) in Patients with Normal Width QRS Complexes (QRS duration < 120 ms)
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153 Some less common, less reliable possible indicators of ACS:
154 LET S START HERE....
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158 WHEN EVALUATING for ST SEGMENT ELEVATION From: AMERICAN HEART ASSOCIATION ACLS 2005 REVISIONS
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162 ECG COMPUTER DOES NOT NOTICE THE CONVEX J-T APEX SEGMENTS!
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166 ECG Patterns associated with EARLY PHASE MI: J-T Apex abnormalities Dynamic ST-T Wave Changes on Serial ECGs
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168 3. Dynmamic ST-T Wave Changes in Serial ECGs. Recorded at SRRMC 1 st ECG 2 nd ECG 1 st ECG 2 nd ECG
169 Acute In-Stent Thrombus Proximal LAD
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171 T waves should not be HYPERACUTE
172 HYPERACUTE T Waves may indicate: Early phase Acute MI Transmural ischemia (usually seen in one region of the ECG) Hyperkalemia (seen globally across ECG) Hypertrophy
173 HYPERACUTE T WAVES ECG waveforms obtained just before (hyperacute) and just after (normal) the critical blockage was stented in this patient s Proximal Left Anterior Descending (LAD) artery.
174 Helpful Clue: Hyper-Acute T Waves GLOBAL Hyper-acute T Waves (in leads viewing multiple myocardial regions / arterial distributions) favors HYPERKALEMIA
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176 Helpful Clue: Hyper-Acute T Waves GLOBAL Hyper-acute T Waves (in leads viewing multiple myocardial regions / arterial distributions) favors HYPERKALEMIA Hyper-acute T Wave noted in ONE ARTERIAL DISTRIBUTION ( Anterior / Lateral / Inferior ) favors TRANSMURAL ISCHEMIA / Early Phase Acute MI
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180 Cath Lab findings:
181 Dynamic ST-T Wave Changes: Other than HEART RATE related variations (which affect intervals), J Points, ST- Segments and T Waves SHOULD NOT CHANGE.
182 Dynamic ST-T Wave Changes: Other than HEART RATE related variations (which affect intervals), J Points, ST- Segments and T Waves SHOULD NOT CHANGE. When changes to J Points, ST-Segments and/or T waves are NOTED, consider EVOLVING MYOCARDIAL ISCHEMIA and/or EARLY PHASE MI, until proven otherwise.
183 46 year old male Exertional dyspnea X several weeks Intermittent chest pressure X last 3 hours. Currently pain free.
184 46 year old male: ECG 1 Chest pressure has returned, 5 on 1-10 scale. 2 nd ECG obtained due to change in symptoms :
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187 ST-Segment Depression 7:59 am 8:08 am
188 Cath Lab Angiography:
189 NOWHERE, NEW MEXICO, 1994
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191 ECG CRITERIA for DIAGNOSIS of STEMI: (ST J POINT) *LEADS V2 and V3: MALES AGE 40 and up mm (MALES LESS THAN mm) FEMALES mm ALL OTHER LEADS: 1.0 mm or more, in TWO or more CONTIGUOUS LEADS * P. Rautaharju et al, Standardization and Interpretation of the ECG, JACC 2009;(53)No.11:
192 ST SEGMENT ELEVATION: 3 COMMON PATTERNS of ST SEGMENT ELEVATION From ACUTE MI:
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194 Reciprocal S-T Segment Depression may or may not be present during AMI. The presence of S-T Depression on an EKG which exhibits significant S-T elevation is a fairly reliable indicator that AMI is the diagnosis. However the lack of Reciprocal S-T Depression DOES NOT rule out AMI.
195 STEMI CASE STUDIES
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197 INVALUABLE ASSET for ALL MEDICAL PROFESSIONALS who provide direct care to STEMI patients!
198 The 12 Lead ECG becomes your crystal ball!!
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200 STEMI CASE STUDIES
201 STEMI Case Studies, excerpts from 12 Lead ECG Interpretation in ACS with Case Studies from the Cardiac Cath Lab.
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205 Note: There is NO Reciprocal ST Depression on this STEMI ECG!
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212 ANTICIPATED COMPLICATIONS of ANTERIOR-SEPTAL WALL STEMI & POSSIBLE INDICATED INTERVENTIONS: - CARDIAC ARREST BCLS / ACLS - CARDIAC DYSRHYTHMIAS (VT / VF) ACLS (antiarrhythmics) - PUMP FAILURE with INOTROPE THERAPY: CARDIOGENIC SHOCK -DOPAMINE / DOBUTAMINE / LEVOPHED - INTRA-AORTIC BALLOON PUMP (use caution with fluid challenges due to PULMONARY EDEMA) - PULMONARY EDEMA - CPAP - ET INTUBATION (use caution with dieuretics due to pump failure and hypotension) - 3rd DEGREE HEART BLOCK - NOT RESPONSIVE TO ATROPINE TRANSCUTANEOUS or TRANSVENOUS PACING
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219 CASE PROGRESSION: As the patient was being prepared for transport to the Cardiac Cath Lab, she experienced an episode of Ventricular Fibrillation.
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224 - Reciprocal ST Depression is NOW PRESENT - Additional ST Elevation is present in Leads I, AVL
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230 ANTICIPATED COMPLICATIONS of ANTERIOR-SEPTAL WALL STEMI & POSSIBLE INDICATED INTERVENTIONS: - CARDIAC ARREST BCLS / ACLS - CARDIAC DYSRHYTHMIAS (VT / VF) ACLS (antiarrhythmics) - PUMP FAILURE with INOTROPE THERAPY: CARDIOGENIC SHOCK -DOPAMINE / DOBUTAMINE / LEVOPHED - INTRA-AORTIC BALLOON PUMP (use caution with fluid challenges due to PULMONARY EDEMA) - PULMONARY EDEMA - CPAP - ET INTUBATION (use caution with dieuretics due to pump failure and hypotension) - 3rd DEGREE HEART BLOCK - NOT RESPONSIVE TO ATROPINE TRANSCUTANEOUS or TRANSVENOUS PACING
231 WHILE AWAITING THE CATH TEAM, THE PATIENT BEGAN VOMITING. SKIN BECAME ASHEN & DIAPHORETIC. REPEAT BP = 50/30. -WHAT THERAPEUTIC INTERVENTIONS SHOULD BE IMPLMENTED AT THIS POINT?
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234 WHO SHOULD GO TO THE CATH LAB FIRST? And.... WHAT WOULD YOU DO WITH THE PATIENT WHO DID NOT GO TO THE CATH LAB?
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236 PATIENT A: PATIENT B:
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240 Despite the dismal mortality rate associated with STEMI from total LMCA occlusion, this patient survived and was later discharged. His EF is estimated at approximately 30%. He received an ICD, and is currently stable.
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249 ANTICIPATED COMPLICATIONS of INFERIOR WALL STEMI secondary to RCA Occlusion & POSSIBLE INDICATED INTERVENTIONS: - CARDIAC ARREST BCLS / ACLS - CARDIAC DYSRHYTHMIAS (VT / VF) ACLS (antiarrhythmics) - SINUS BRADYCARDIA ATROPINE 0.5mg, REPEAT as needed UP TO 3mg. (follow ACLS and/or UNIT protocols) - HEART BLOCKS (1st, 2nd & 3rd Degree HB) ATROPINE 0.5mg, REPEAT as needed UP TO 3mg, Transcutaneous Pacing, (follow ACLS and/or UNIT - RIGHT VENTRICULAR MYOCARDIAL INFARCTION protocols) - The standard 12 Lead ECG does NOT view the Right Ventricle. - You must do a RIGHT-SIDED ECG to see if RV MI is present. - Do NOT give any Inferior Wall STEMI patient NITRATES or DIURETICS until RV MI has been RULED OUT. - POSTERIOR WALL INFARCTION - POSTERIOR WALL MI presents on the 12 Lead ECG as ST DEPRESSION in Leads V1 - V3. - POSTERIOR WALL MI is NOT PRESENT
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255 IN EVERY CASE of INFERIOR WALL STEMI You must first RULE OUT RIGHT VENTRICULAR MI BEFORE giving any: - NITROGLYCERIN - Diuretics
256 Nitroglycerin & Diuretics are CLASS III CONTRINDICATED in RIGHT VENTRICULAR MI!!* They precipitate SEVERE HYPOTENSION * A.H.A. ACLS 2010 / 2015
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258 ANTICIPATED COMPLICATIONS of INFERIOR - RIGHT VENRICULAR WALL STEMI secondary to PROXIMAL RCA Occlusion & POSSIBLE INDICATED INTERVENTIONS: - CARDIAC ARREST BCLS / ACLS - CARDIAC DYSRHYTHMIAS (VT / VF) ACLS (antiarrhythmics) - SINUS BRADYCARDIA ATROPINE 0.5mg, REPEAT as needed UP TO 3mg. (follow ACLS and/or UNIT protocols) - HEART BLOCKS (1st, 2nd & 3rd Degree HB) ATROPINE 0.5mg, REPEAT as needed UP TO 3mg, Transcutaneous Pacing, (follow ACLS and/or UNIT protocols) - RIGHT VENTRICULAR MYOCARDIAL INFARCTION - NITRATES and DIURETICS are CONTRA- INDICATED. - TREAT HYPOTENSION WITH FLUIDS. (It is Not uncommon to give ml of NORMAL SALINE to stabilize BP. - POSTERIOR WALL INFARCTION - POSTERIOR WALL MI presents on the 12 Lead ECG as ST DEPRESSION in Leads V1 - V3. - POSTERIOR WALL MI is NOT PRESENT ON THIS ECG.
259 If this patient becomes HYPOTENSIVE.....
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270 Case Study- January y/o female complaining of L arm pain, and minimal chest pain EMS 12 Lead ECGs show ST Depression in Anterior Leads V1-V4. There is NO ST Elevation
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272 Initial Exam in ED Upon arrival in ED, 12 Lead ECG confirmed EMS findings: ST Depression in Leads V1-V4.
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274 Causes of ST Depression V1-V4 Anterior Wall ischemia Anterior Wall NSTEMI (partial wall thickness myocardial infarction) Posterior Wall STEMI
275 Posterior Wall STEMI. Does not show ST elevation on standard 12 lead ECG because NONE of the 12 leads view the Posterior Wall directly.
276 Posterior Wall STEMI. Often shows NO ST Elevation on the standard 12 Lead ECG. Will show up on standard 12 Lead ECG as ST Depression (Reciprocal) in Leads V1-V3 (sometimes V4-V6, too).
277 V1-V3 see the Posterior Wall ONLY through RECIPROCAL changes (ST Depression)
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279 Posterior Wall STEMI. To see ST Elevation from a Posterior Wall STEMI, you must place ECG leads on the patient s back
280 Continued Exam in the ED. Upon noting ST Depression in Anterior Leads V1-V4, ED Paramedic Gary Polizzi place three leads on the patient s back. Gary used the lead wires for V4, V5 and V6, with placement as shown here: The Posterior Lead ECG is seen on the next slide
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282 STEMI Alert! Upon seeing Significant ST Elevation in TWO or more CONTIGUOUS LEADS, the ED physician diagnosed Posterior Wall STEMI, a STEMI Alert was issued, and the patient was taken immediately to the cardiac cath lab, where the following images were obtained.
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286 SUMMARY Whenever ST Depression is noted in Anterior Leads (V1-V4), it could indicate that Acute Posterior Wall STEMI is present. To rule-out Posterior Wall STEMI, a posterior lead ECG (V7 V9) must be obtained. In THIS CASE, Posterior Wall STEMI was diagnosed via Posterior Lead ECG. STEMI Alert was issued, with a Door-to-PCI time of 53 minutes!
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288 Evaluating the ECG for ACS:
289 Wide QRS present: QRSd > 120ms Determine RIGHT vs. LEFT Bundle Branch Block Pattern
290 Simple Turn Signal Method...
291 Terminal Phase of QRS Method...
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294 From: Rapid Interpretation of ECGs by Dale Dubin, MD
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299 Wide QRS present: (QRSd > 120ms) When RIGHT Bundle Branch Block pattern is present: Precordial Leads typically demonstrate ST Depression and T wave Inversion
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301 Wide QRS present: (QRSd > 120ms) When RIGHT Bundle Branch Block pattern is present: Precordial Leads typically demonstrate ST Depression and T wave Inversion DOES NOT MASK STEMI; when ST Elevation is noted, CONSIDER STEMI!!
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305 Wide QRS present: (QRSd > 120ms) When LBBB QRS pattern is present:
306 Wide QRS present: (QRSd > 120ms) When LBBB QRS pattern is present: ST-Segment Elevation is typically noted in Precordial Leads
307 Wide QRS present: (QRSd > 120ms) When LBBB QRS pattern is present: ST-Segment Elevation is typically noted in Precordial Leads Can cause up to 5mm of J Point Elevation in normally calibrated ECG (1mm=10mv)
308 Wide QRS present: (QRSd > 120ms) When LBBB QRS pattern is present: ST-Segment Elevation is typically noted in Precordial Leads Can cause up to 5mm of J Point Elevation in normally calibrated ECG (1mm=10mv) Does NOT typically cause ST elevation in INFERIOR Leads (II, III and AVF).
309 Diagnosis of STEMI with LBBB pattern: 2013 ACC/AHA Guideline for Management of STEMI ST Elevation of 0.1mv (1mm) or more in leads with Positive Deflection QRS complexes
310 Diagnosis of STEMI with LBBB pattern: 2013 ACC/AHA Guideline for Management of STEMI ST Elevation of 0.1mv (1mm) or more in leads with Positive Deflection QRS complexes ST Elevation of 0.5mv (5mm) or more in leads with Negative Deflection QRS complexes
311 Diagnosis of STEMI with LBBB pattern: 2013 ACC/AHA Guideline for Management of STEMI ST Elevation of 0.1mv (1mm) or more in leads with Positive Deflection QRS complexes ST Elevation of 0.5mv (5mm) or more in leads with Negative Deflection QRS complexes ST Segment Changes as compared with those of older ECGs with LBBB
312 Diagnosis of STEMI with LBBB pattern: 2013 ACC/AHA Guideline for Management of STEMI ST Elevation of 0.1mv (1mm) or more in leads with Positive Deflection QRS complexes ST Elevation of 0.5mv (5mm) or more in leads with Negative Deflection QRS complexes ST Segment Changes as compared with those of older ECGs with LBBB Convex ST Segment
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316 Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block Birnbaum et al, N Engl J Med 1996; 334:
317 Be advised that in patients with Left Bundle Branch Block Combined with Ventricular Hypertrophy, The J Point elevation can exceed 0.5 mv (5mm) above the iso-electric line in patients without ACS.
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321 STEMI Assistant: an Emergency Crash Cart Interactive Reference Manual - free Download STEMI Assistant Information Video
322 Helpful STEMI ECG Resources [1] Use of the Electrocardiogram in Acute Myocardial Infarction, Zimetbaum, et al, NEJM 348: Abnormal ST Elevation Criteria: ACC/AHA 2009 Standardization and Interpretation of the ECG, Part VI Acute Ischemia and Infarction, Galen Wagner, et al ECG in STEMI excellent powerpoint quick reference, in-depth material
323 Helpful STEMI ECG Resources Download Non-ED STEMI Protocol - example Download STEMI Alert ED Physicians Order Set
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329 Classic Wellen s Syndrome: Characteristic T wave changes Biphasic T waves Inverted T waves History of anginal chest pain Normal or minimally elevated cardiac markers ECG without Q waves, without significant ST-segment elevation, and with normal precordial R-wave progression
330 Wellen s Syndrome ETIOLOGY: Critical Lesion, Proximal LAD Coronary Artery Vasospasm Cocaine use (vasospasm) Increased myocardial oxygen demand Generalized Hypoxia / anemia / low H&H
331 Wellen s Syndrome EPIDEMIOLOGY & PROGNOSIS: Present in 14-18% of patients admitted with unstable angina 75% patients not treated developed extensive Anterior MI within 3 weeks. Median Average time from presentation to Acute Myocardial Infarction 8 days Sources: H Wellens et. Al, Am Heart J 1982; v103(4)
332 Wellen s Syndrome Case Study 33 y/o male Chief complaint sharp, pleuritic quality chest pain, intermittent, recent history lower respiratory infection with productive cough. ED physician attributed the ST elevation in precordial leads to early repolarization, due to patient age, gender, race (African American) and concave nature of ST-segments.
333 Wellen s Syndrome Case Study
334 Wellen s Syndrome Case Study
335 DYNAMIC ST-T Wave Changes ARE PRESENT!! NOW is the time for the STAT CALL to the CARDIOLOGIST!!!!
336 Wellen s Syndrome Case Study
337 Wellen s Syndrome Case Study
338 Wellen s Syndrome Case Study
339 Wellen s Syndrome Case Study
340 Additional Resources: Wellen s Syndrome, NEJM case study
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343 Some less common, less reliable possible indicators of ACS:
344 Long QT Syndrome
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347 Determining the QTc Manual calculation: QT CORRECTION FORMULAS: Bazett s Fredericia Framingham Rautaharju QTc=QT/ RR QTc=QT/(RR)1/3 QTc=QT+0.154(1-RR) QTp=656/(1+HR/100)
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351 Determining the QT / QTc Method 1 12 Lead ECG Report:
352 Determining the QTc Method 4, Use a Smartphone App: iphone Android m.medsam.qtccalculator&hl=en
353 There s an APP for that!
354 Determining the QTc Method 3, Use a Web-based App:
355 SOURCE: ACC/AHA/HRS Recommendations for Standardization and Interpretation of the ECG, Part IV: The ST Segment, T and U Waves, and the QT Interval Rautaharju et al 2009
356 WHEN THE QUICK PEEK METHOD for QT INTERAL EVALUATION IS APPLIED TO THE ABOVE ECG, WHAT IS THE RESULT?
357 Dysrhythmia Associated with Mortality, Triggered by LQTS: Torsades de Pointes Torsades de Pointes (TdP) HEMODYNAMICS: Decreased to NO Cardiac Output Often patient PULSELESS during episode Patients often report SYNCOPE when TdP self-terminates. May DETERIORATE into VENTRICULAR FIBRILLATION and CARDIAC ARREST. ( Sudden Death )
358 ECG Characteristics of TdP: The QRS Pattern of Torsades de Pointes resembles..... a piece of Twisted Ribbon!
359 Evolving MI & Old MI
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367 The NORMAL ECG R wave amplitude (size) gradually increases from V1 through V6....
368 The NORMAL ECG In V3 or V4, the QRS complex becomes Biphasic.
369 Poor R Wave Progression.... Anterior Wall necrosis ( old MI ) is a common cause of Poor R Wave Progression.
370 EVOLVING STEMI: -ST SEGMENTS DROP -Q WAVES FORM -R WAVE PROGRESSION CHANGES IN PRECORDIAL LEADS.
371 EVOLVING STEMI: -ST SEGMENTS DROP -Q WAVES FORM -R WAVE PROGRESSION CHANGES IN PRECORDIAL LEADS.
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373 ACUTE ANTERIOR WALL STEMI
374 EVOLVING ANTERIOR WALL STEMI
375 FULLY EVOLVED ANTERIOR WALL MI
376 Additional Materials:
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392 ACUTE MITRAL VALVE RUPTURE USUALLY OCCURS 7-10 DAYS POST EXTENSIVE MI (e.g.: INFERIOR POSTERIOR LATERAL MI).
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398 Practice ECGs...
399 Let s review ECG abnormality(ies)? 2. Possible diagnosis? 3. Action / Intervention?
400 1. ECG abnormality(ies)? ST Elevation Leads I, AVR AVL, V1, V2, V3, V4, V5 & V6. ST Depression II, III and AVF 2. Possible diagnosis? Acute Anterolateral Wall STEMI secondary to Left Main Coronary Artery occlusion (widowmaker MI). 3. Action / Intervention? STAT CATH LAB vs STAT Thrombolytics. Prepare for Cardiac Arrest
401 1. ECG abnormality(ies)? 2. Possible diagnosis? 3. Action / Intervention?
402 1. ECG abnormality(ies)? ST Depression V1-V4 2. Possible diagnosis? Anterior ischemia vs. Posterior wall STEMI 3. Action / Intervention? Posterior ECG (V7-V9)
403 1. ECG abnormality(ies)? 2. Possible diagnosis? 3. Action / Intervention?
404 1. ECG abnormality(ies)? ST Elevation, Leads II,III & AVF 2. Possible diagnosis? Inferior Wall STEMI 3. Action / Intervention? 1. Do R-sided ECG, prepare for Atropine administration, external pacing, cardiac arrest, STAT cath lab visit!
405 What leads show signs of possible ACS?
406 12 Lead ECG shows ISCHEMIC CHANGES Lateral Wall:
407 1. ECG abnormality(ies)? 2. Possible diagnosis? 3. Action / Intervention?
408 1. ECG abnormality(ies)? ST Elevation Lead AVR, Global ST Depression (I, II, III, AVL, AVF, V2, V3, V4, V5, V6) 2. Possible diagnosis? possible LMCA or 3x vessel disease. 3. Action / Intervention? Troponins, Continuous ST monitoring, cath lab visit STAT or ASAP (based on sympt.)
409 1. ECG abnormality(ies)? 2. Possible diagnosis? 3. Action / Intervention?
410 1. ECG abnormality(ies)? Inferior (II, III, AVF) ST Depr (ischemia?), I & AVL T wave inversion, V5 ST Depr 2. Possible diagnosis? Inferior / Lateral ischemia 3. Action / Intervention? Serial ECGs / Troponins, additional diagnostic testing, cath lab
411 Your thoughts, ideas, comments and feedback are welcome...
412 Author s correspondence information: Wayne W Ruppert Wayneruppert@bayfronthealth.com Office: Cell:
413 My top two reasons for giving everything in life the best I have to offer.
STAT 12 Lead ECG Workshop: Basics & ACS
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