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Chapter 11 - Putting It All Together
- 1. ONTARIO BASE HOSPITAL GROUP Chapter 11 for 12 Lead Training - Putting it all together- Ontario Base Hospital Group Education Subcommittee 2008 TIME IS MUSCLE
- 2. Putting it all together REVIEWERS/CONTRIBUTORS Neil Freckleton, AEMCA, ACP Hamilton Base Hospital Jim Scott, AEMCA, PCP Sault Area Hospital Ed Ouston, AEMCA, ACP Ottawa Base Hospital Laura McCleary, AEMCA, ACP SOCPC Tim Dodd, AEMCA, ACP Hamilton Base Hospital Dr. Rick Verbeek, Medical Director OBHG Education Subcommittee AUTHOR Greg Soto, BEd, BA, ACP Niagara Base Hospital 2008 Ontario Base Hospital Group SOCPC
- 3. Chapter 11 - Objectives Describe the importance of using a systematic approach to interpretation of the 12 Lead ECG Use a simple algorithm for a time-saving approach to reading 12 Lead OBHG Education Subcommittee ECGs Practice interpreting 12 Lead ECG
- 4. Systematic Approach In initial assessment of patient acquire at least a 6-second ECG strip for rhythm interpretation Decide if life threatening arrhythmias exist - if so, treat accordingly Could 12 Lead ECG assist in OBHG Education Subcommittee dysrhythmia interpretation? Acquire 12 Lead ECG
- 5. Systematic Approach Look for ST elevation Locate the AMI Look for ST depression, reciprocal OBHG Education Subcommittee changes and Q waves Rapid treatment and transport Rapid triage for reperfusion – ALERT RECEIVING HOSPITAL Acquire 2nd 12 Lead enroute to look for changes
- 6. Junctional rhythm - Inferior STEMI with OBHG Education Subcommittee RCs
- 7. AFib w/ PVCs and RBBB OBHG Education Subcommittee
- 8. Underlying Sinus Rhythm w/ PVCs - OBHG Education Subcommittee Inferolateral ischemia
- 9. NSR - old Septal wall MI OBHG Education Subcommittee
- 10. OBHG Education Subcommittee A Fib w/ RBBB
- 11. NSR - Inferolateral STEMI OBHG Education Subcommittee
- 12. NSR – No STEMI OBHG Education Subcommittee
- 13. NSR – Extensive Anterior AMI OBHG Education Subcommittee
- 14. NSR w/lateral ischemia OBHG Education Subcommittee
- 15. NSR – Anteroseptal STEMI OBHG Education Subcommittee w/RCs
- 16. Junctional – Anteroseptal ischemia OBHG Education Subcommittee
- 17. 1st° Block w/PVCs – Anteroseptal OBHG Education Subcommittee STEMI
- 18. NSR – old Septal MI OBHG Education Subcommittee
- 19. 1st° Block – Lateral wall ischemia OBHG Education Subcommittee
- 20. NSR – Inferior STEMI w/RCs OBHG Education Subcommittee
- 21. OBHG Education Subcommittee NSR w/LBBB
- 22. S Brad – Lateral STEMI w/RCs OBHG Education Subcommittee
- 23. 1st° Block – Inferior STEMI w/RCs OBHG Education Subcommittee
- 24. NSR – no STEMI OBHG Education Subcommittee
- 25. AFib w/PVCs – No STEMI OBHG Education Subcommittee
- 26. 1st° Block w/PVCs – RBBB OBHG Education Subcommittee
- 27. OBHG Education Subcommittee NSR – no STEMI
- 28. STach – Inferior STEMI w/RCs OBHG Education Subcommittee
- 29. NSR – Extensive Ant STEMI OBHG Education Subcommittee
- 30. OBHG Education Subcommittee NSR w/ PAC
- 31. NSR w/ couplets (PVCs) OBHG Education Subcommittee
- 32. 1st degree AV block OBHG Education Subcommittee
- 33. SBrad – inferolateral ischemia OBHG Education Subcommittee
- 34. OBHG Education Subcommittee Paced rhythm
- 35. NSR – Inferior STEMI w/RCs OBHG Education Subcommittee
- 36. S Brad – Inferior STEMI w/RCs OBHG Education Subcommittee
- 37. 2nd° Type I - LBBB OBHG Education Subcommittee
- 38. OBHG Education Subcommittee A Fib – RBBB
- 39. NSR – Inferior STEMI w/RCs OBHG Education Subcommittee
- 40. NSR w/PVC – No STEMI OBHG Education Subcommittee
- 41. S Brad – old Anteroseptal MI OBHG Education Subcommittee
- 42. A Fib – Inferior STEMI w/RCs OBHG Education Subcommittee
- 43. STach – No STEMI OBHG Education Subcommittee
- 44. NSR - Anteroseptal MI OBHG Education Subcommittee
- 45. NSR – old Inferior MI OBHG Education Subcommittee
- 46. RBBB w/sinus exit block OBHG Education Subcommittee
- 47. 3rd° block – broad Ischemia OBHG Education Subcommittee
- 48. S Brad – Anteroseptal & Inferior STEMI OBHG Education Subcommittee
- 49. OBHG Education Subcommittee Normal
- 50. S Brad – old anteroseptal MI OBHG Education Subcommittee
- 51. OBHG Education Subcommittee Anterior (septal)
- 52. NSR – old inferior MI OBHG Education Subcommittee
- 53. NSR lateral ischemia OBHG Education Subcommittee
- 54. OBHG Education Subcommittee Incomplete LBBB
- 55. OBHG Education Subcommittee Anterolateral
- 56. OBHG Education Subcommittee NSR – no STEMI
- 57. OBHG Education Subcommittee SVT w/RBBB
- 58. 1st° block, Anteroseptal AMI OBHG Education Subcommittee
- 59. NSR – ST depressions (subendocardial injury) OBHG Education Subcommittee
- 60. OBHG Education Subcommittee Conclusions This course is intended to introduce the paramedic to the basic concepts and purposes of prehospital 12 Lead ECG interpretation. 12 Lead ECG mastery is achieved only through the application of study and practice. Keep in mind: the main goal of prehospital 12 Lead ECG is to identify patients at risk of acute myocardial infarction for rapid triage and transport for in-hospital STEMI reperfusion.
- 61. Thanks & So Long! OBHG Education Subcommittee
- 62. ONTARIO BASE HOSPITAL GROUP QUESTIONS?
- 63. ONTARIO BASE HOSPITAL GROUP Well Done! Education Subcommittee START QUIT
Editor's Notes
- ASK GROUP: Q: Could 12 Lead ECG assist is rhythm interpretation? A: Often YES! It can be useful in differentiating wide vs. narrow QRS complexes often associated with tachycardias. Also, computer generated impressions and clinical data such as PR intervals and QRS durations can be useful.
- Who should you acquire a PHECG on and when is it not indicated? YES: Any patient with a problem between the belly button and the neck Any patient you suspect may be experiencing an ACS. This can be based on clinical presentation (chest pain/SOB), history of CVD and risk factors for ACS. NO: Any patient in extreme instability for whom resuscitation is required: Examples may be when ABCs compromised, Cardiac Arrest or Prearrest.
- This slide begins the practice exercise component of this CME I recommend that you go around the room asking each participant to read and interpret each ECG as per outlined systematic approach. Do not forget to make sure each participant does not miss any of the non-ST elevation components of interpretation while focussing on MUST know aspect of STEMI recognition. One tool I find useful when newer or older medics are learning 12 Lead for first time is to emphasize must know vs. good to know. STEMI is must know – ST depression, Q-waves and reciprocal changes are good to know. The more exposure participants get to 12 leads the more they begin to see the reason the “good to knows” provide important information on severity and can really assist in interpretation. I have found that repetition with 12 Lead ECG learning is even more important than in other areas. By this I mean that the more opportunities you have to review 12 Lead ECG even if it means covering the basics more that once or as a component of ongoing optional CME.
- (ST depressions/inverted T waves in II, III, aVF, V5, V6)
- Q waves in V1, V2 Possible ischemia in High laterals: I, aVL.
- ST depressions in I, aVL, V1, V2
- Maybe RCs but hard to tell. Ext Ant dx made from ST elevation in aVL, V1-V5.
- ST depression – II, III, aVF; V5, V6.
- Indwelling cardiac pacemakers can present challenges to ST-segment evaluation. Firstly, pacer spikes may not be visible in each lead. Secondly, AV sequential pacemakers often present with two spikes, one preceding the P-wave and one preceding the QRS at times making them confusing to those unfamiliar with pacer spikes. Thirdly, the QRS complexes created by ventricular pacers appears similar to a PVC (wide, biphasic, aberrant with ST-elevations). It is the ST-elevations that can appear as if the patient is infarcting in multiple leads. Point of fact is they mimic ST-elevation. AMI determination, like cases of BBB, should be made on clinical presentation of the patient.
- NO STEMI
- Q waves V1-V4.
- Q waves II, III, aVF – hard to see but they are there.
- Q: Do RCs matter in this case? Not really as both anterior and inferior regions of heart are infarcting.
- Q-waves in V1-V4
- Anterior STEMI: ST segment elevation is evident in leads V1 to V4. The morphology seems obliquely straight. Emergency cardiac catheterization revealed a 90% stenotic lesion in the left anterior descending artery; the patient did well after placement of a coronary stent but showed serum marker evidence of AMI.
- Subendocardial injury defined: Injury to the myocardial cells results when the ischemic process is more severe. Subendocardial injury on a surface ECG is manifested by broad ST segment depression. In patients with coronary artery disease, ischemia, injury and myocardial infarction of different areas frequently coexist, producing mixed and complex ECG patterns.
- Encourage participants to continually review this material as well as sources and websites provided in the References (print handout to be given to participants on conclusion of course).