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South Cook County EMSApril, 2020
ACS and
EKG’s
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Objectives
Cognitive
1. Describe the following , STEMI and NSTEMI
2. Explain the assessment for a STEMI patient, including the key indicating factors in diagnosing a STEMI patient in the field.
3. Describe the proper treatment for a STEMI patient, including appropriate transport.
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Incidence
Three types of ACS (Acute Coronary Syndromes)
– Unstable Angina (40% of total)
– NSTEMI - non-ST Elevation Myocardial Infarction (25% of total)
– STEMI - ST Elevation Myocardial Infarction - Accounts for (35% of total)
• 1,500,000 myocardial infarction patients in the US diagnosed per year (per AHA)
• ~ 500,000 deaths due to ACS (per AHA)
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Acute Coronary Syndrome
Caused by an obstructed or partially obstructed coronary artery
– Can result in cardiac tissue becoming injured, ischemic, or infarcted, which causes abnormalities in cardiac conduction
– Electrical abnormalities can be detected with an electrocardiogram (usually a 12 lead EKG)
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Risk Factors
• High cholesterol• Hypertension• Hyperlipidemia• Stress• Drug use • Family history• Diabetes • Smoking• Angina• Stroke• Known coronary artery disease• Increased age• Increased weight• Inactive lifestyle
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STEMI
A clinical syndrome defined by:– characteristic symptoms of myocardial ischemia,
– in association with persistent electrocardiographic (EKG) ST elevation,
– and subsequent release of biomarkers of myocardial necrosis (biomarkers are serial hospital lab values)
– Time is muscle, and therefore performance, when it comes to the heart
– Half of the patients who will die of AMI, die before reaching the hospital.
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Signs & Symptoms
• Substernal chest pain that radiates
• Shortness of breath• Chest pain/pressure
tightness/heaviness squeezing
• Sensation of indigestion/ heartburn
• Pain that worsens with activity
• Pain that persists at rest• Abnormal vital signs
• Anxiety/feeling of doom • Denial of severity• Diaphoresis• Pale skin• Altered mental status• Nausea• Lightheaded /dizzy
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Atypical Signs & Symptoms
• Vague, diffuse pain
• Slight shortness of breath
• Nausea
• Weakness
• Lightheadedness
• Fatigue
• Syncope
Note: consider “atypical” presentations with the elderly, women, and diabetic patients.
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Protocol 16Adult suspected cardiac patient
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Nitroglycerin
• From a group of drugs called nitrates
• Vascular smooth muscle relaxant
• Actions:– Dilates both arteries and veins
– Venous dilation predominates at normal therapeutic levels
– Reduces venous pressure
– Reduces ventricular preload
– Systemic arterial dilation reduces afterload
Dosage: 0.4mg SL tab or spray. May repeat every 5 minutes x 2
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Nitroglycerin (cont’d)
Contraindications:• Hypotension• Erectile dysfunction meds
Side Effects:• Headache• Hypotension• Nausea/vomiting• Flushing• Orthostatic hypotension/syncope
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Fentanyl
• Fentanyl is an opioid analgesic. The onset of pain relief is 1-2 min when given IV and the duration is 30 min to one hour. It decreases the workload of the heart.
Indication:
Pain control
Contraindication:
• Respiratory depression
• Hypotension
• Head injury
• Cardiac dysrhythmias (brady rhythms)
• Myasthenia gravis
• Hypersensitivity to opiates
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Fentanyl (cont’d)
Adverse reactions:• Respiratory depression
• Bradycardia
• Hypotension or hypertension
• Nausea and vomiting
Dosage and Administration:50 mcg IV/IO/IM/IN. May repeat every 10 min as needed until improvement. Max total dose 200 mcg
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Vital Signs and EKG
Vital signs are most useful as a trend over time, one set does not give a most accurate picture.Document: • Pulse• Respirations• BP• Skin• Mental Status• O2 Sat.Reassess every 15 min, (if not sooner), after any intervention, or after any change in patient condition.
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12 lead
Consider 12 lead EKG for complaints of the following:• Chest pain/discomfort/pressure• Arm and/or jaw pain• Upper back pain• Unexplained diaphoresis• Vomiting without fever or diarrhea• SOB, dizziness, syncope, weakness,
fatigue• Epigastric pain• Unexplained fall (in the elderly)• Unexplained brady or tachycardia
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12 Lead ST changes
Non – STEMIOccurs as microemboli from the clot become lodged in the coronary arteries. This produces minimal damage to the myocardium. However, these pts are at a high risk for progression to MI
Non-STEMIs are evident with ST-segment depression or T-wave abnormalities.
STEMIOccurs when the thrombus occludes the coronary vessel for a prolonged period.
STEMI’s are evident by ST-elevation in two or more contiguous (adjacent) leads.
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Transport
Contact hospital as soon as patient’s condition permits. If no radio contact can be established or patient’s condition requires immediate tx, begin interventions immediately.
Transport to closest hospital.
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Electrical Events of the Cardiac Cycle
• Sinoatrial (SA) node is the normal pacemaker of heart and is located in right atrium.
• Depolarization spreads from SA node across atria and results in the P wave.
• Three tracts within atria conduct depolarization to atrioventricular (AV) node.
• Conduction slows in AV node to allow atria to empty blood into ventricles before vent. systole.
• Bundle of His connects AV to bundle branches.
• Purkinje fibers are terminal bundle branches.
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Basic Electrographic Complexes
• P wave represents depolarization of atria which causes atrial contraction
• Repolarization of atria not normally detectable on an ECG
• Excitation of bundle of His and bundle branches occur in middle of PR interval
• QRS complex reflects depolarization of ventricles
• T wave reflects repolarization of muscle fibers in ventricles
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Interpretation of ECG:Rate
First measurement to calculate is heart rate. PQRST waves represent one complete cardiac cycle.
1. At standard paper speed, divide 1500 by distance between R to R waves.
2. Find R wave on heavy line. Count off 300, 150, 100, 75, 60 for each following line. Where next R lands is quick estimate.
3. Multiply number of cycles in 6 second marks by 10.
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Interpretation of ECG: Rate
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Interpretation of ECG: RhythmNormal Sinus
Rhythm• Rate: 60-100 b/min
• Rhythm: regular
• P waves: upright in leads I, II, aVF
• PR interval: < .20 s
• QRS: < .10 s
Sinus Bradycardia• Rate: < 60 bpm
• Rhythm: regular
Sinus Tachycardia• Rate: > 100 bpm
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Sinus Bradycardia
• HR less than 60 bpm
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Sinus Tachycardia
• HR > 100 bpm
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Atrial Flutter
• Sawtooth; F waves (easiest seen in II, III, & aVF)
• Atrial rate of about 300 bpm
• Ventricular rate150, 100 or 75 beats/min
• 2:1, 3:1 and 4:1
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Atrial Fibrillation
• No organized depolarization in atria.
• Irregular “f waves” can range from looking almost like P waves to a flat line.
• Atrial rate is about 600 bpm
• Normal QRS w/ ventricular rate ~110-180 but random & irregular
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Junctional Rhythm
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Accelerated Junctional Rhythm
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WPW(Wolf Parkinson White)
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First Degree AV Block
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2nd Degree AV Block, Type 1
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3rd Degree AV Block
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Premature Ventricular Contractions
• Characteristics
1.Premature and occur before the next normal beat
2.Wide (> 0.12) and the T wave is usually opposite of the QRS
3.Bizarre looking
• PVCs usually precede a P wave.
• A nonsinus P wave may follow the PVC
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PVC
• Unifocal (monomorphic) PVCs
– same appearance in the same lead
– small focus
– normal and diseased hearts
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PVC• Polymorphic (multifocal and multiform) PVCs
– different appearance in the same lead
– multiform = different coupling intervals
– multifocal = same coupling intervals
– usually diseased hearts
Multiform
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Idioventricular Rhythm
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Couplet
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Triplet
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Bigeminy and Trigeminy
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Ventricular Tachycardia
...more than three PVCs
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Ventricular Fibrillation
Note the course and fine waves
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Summary and Key points
Key Points
IMC
• Monitor and support CAB’s
• Prepare for CPR/defib
• Position of comfort/O2
Administer ASA and consider NTG (contraindications, etc)
Obtain 12 Lead
Consider Fentanyl
Medical Control contact.
Summary
• STEMI is one of 3 coronary syndromes
• EMS needs to quickly recognize s/s and well as know the treatment/transport protocols
• Reading/interpreting EKG’s takes practice in order to accurately identify arrhythmias
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12 Lead EKG - STEMI