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The Multi-Lead ECG: Improve Your Quality of Care! Class Code 144A Presented By: Barbara Furry, RN-BC, MS, CCRN, FAHA Director The Center of Excellence in Education Director of HERO Follow me on Twitter! CEE Med Updates@BarbaraFurryRN Like me on Facebook!

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The Multi-Lead ECG:

Improve Your Quality of Care!

Class Code 144A

Presented By:

Barbara Furry, RN-BC, MS, CCRN, FAHA

Director The Center of Excellence in Education

Director of HERO

Follow me on Twitter! CEE Med Updates@BarbaraFurryRN Like me on Facebook!

A quick trip down memory

lane……………………

12 Lead ECG Interpretation:

Precordial Leads

V1 - V6

V1 and V2

V3 and V4

V5 and V6

From Huszar, RJ. (2001). Basic Dysrhythmias. Interpretation and Management, pg.250

AMI Locations on the ECG

From: Garcia, et.al. (2001). 12 Lead ECG: The art of interpretation, pg. 410. Used by permission.

What does the 12 lead EKG tell us?

What does the 12 lead EKG NOT tell us?

So the 12 lead EKG only takes us so

far……………..

Historical Perspective

RVI first identified 1940’s

RVI occurs in up to 50% of Inferior Wall

Myocardial Infarction

50% of RVI have hemodynamic compromise

RVI increases mortality from 5% to 31%

RVI increases in-hospital complications from

28% to 64%

Cohn, Guiha, Broder, Lima. Am J Card. 1974; 33:209-214

Zehender, Kasper, Kauder, et al. NEJM. 1993;328:981-987

Pathophysiology of RVI

Primarily occurs with an IWMI or posterior LV

infarct

Blood supply to RV concomitantly lost

(usually RCA)

Occurs 13% in AWMI (LAD occlusion)

RVI Pathophysiology RCA Occlusion Site

Determines Extent of RV Involvement

Occlusion proximal to

all free wall branches

RVI involved

Occlusion distal to RV free

wall branches

RVI probably not involved

Pathophysiology

RVI Clinical Presentation

Hypotension

Clear lungs

Distended neck veins

Kussmaul’s sign

Tricuspid insufficiency

Widely split S2

S3 or S4 gallop

RVI Diagnostic Procedures

2 –D Echo

Technetium Scan

MUGA scan

PA catheter

Making the Diagnosis

Adapted from: Robiolio, PA. Emergency Medicine 1996;28:16-17, 21-24.

Hemodynamic wave forms

Normal RVI

Time

Y-descent

25

20

15

10

5

0

RV Pressure

RA Pressure

4 Chamber Echo

Oh JK, et al. The Echo Manual. 2009. Used by Permission.

Making the Diagnosis

Echo Info

Right ventricular dilation

Right ventricular wall akinesis or dyskinesis

Severe right atrial enlargement.

Tricuspid regurgitation

Ventricular septal defect

Premature opening of the pulmonic valve

indicating a non-compliant ventricle

RVI Diagnosis

Right sided ST segment elevation of > 1mm

in lead V4R

Right ventricular asynergy

Mean right arterial pressure > 10 mm Hg

Non-compliant right atrial pressure

waveform pattern

Horan LG, Flower NC. American Family Physician. 2009;60:1727-1734.

Right-Sided Chest Leads

From Huszar, RJ. (2001). Basic dysrhythmias. Interpretation and management, pg. 251. Used by permission.

Sgarbossa, E.B., Birnbaum, Y., Parrillo, J.E. (2001). American Heart Journal, (141)4, 507-516.

Case Study: TP

MR C ECG

I aVR V1 V4 V4R

Case Study: LD

AC ECG

Goals in RVI Treatment

Increase Ventricular Filling

volume loading

Increase Cardiac Output (Augment RV Performance)

volume loading

avoid NTG or anything that will reduce volume

inotropic agents: dopamine or dobutamine

Increase Peripheral Perfusion

inotropic agents: dopamine or dobutamine

RVI Complications

Conduction Disturbances

accelerated junctional complete heart block

RVI Complications

Low Output State

Severely dysfunctional RV

↓ RV output

↓ LV filling

↓ CO

=

Cardiogenic Shock

RVI Nursing Implications

High index of suspicion in IWMI or PWMI

Routine right sided EKG

Assessment can facilitate early detection and

timely treatment

RVI Case Study

67 year old female presents to ED

Chief complaint: epigastric distress, tired, and

SOB

Medical History: HTN, diabetic, smoker

Physical Exam: alert, BP 140/72, HR 128

Lungs clear, no murmurs

Case Study

Immediate Treatment

ABCD

VOMIT

V – Vitals

O – O2

M – Monitor

I – IV

T - Treatment

O – O2

A – ASA

N – NTG

M - Morphine or narcotic

equivalent

12 Lead ECG

Patient’s 12 Lead ECG

Right Ventricular Leads

Patient’s 15 Lead ECG

Case Study

Pt complains of dizziness

BP: 80/40

What do you do now?

Case Study

Turn off the NTG

Fluid bolus

What kind of fluid and how much?

Patient position?

What remains a priority?

Case Study

Pt’s BP is now 102/64

Pharmacological management may include:

heparin

beta blocker

clopidogrel

GP IIb IIIa inhibitor

And the Patient Buys a Ticket to The Cath Lab!

So Remember……………

Volume load

Avoid preload reduction

Adjunctive agents

Reperfusion is your goal

Posterior Wall MI

And now the rest of the story!

Pathophysiology Posterior MI

In conjunction with IWMI 50%

Artery occluded: RCA or CX

Extending the Horizontal Plane With V7, V8, and V9

V7 V8 V9

6.6

Posterior Wall AMI Treatment

Temporary pacing

Pharmacological therapy

Reperfusion strategies

Rationale for Use of the Multilead EKG

The 12 lead EKG is not diagnostic in 50% of

AMI cases

Localizing the area of infarction for RVI &

posterior MI is difficult and overlooked on the

12 lead EKG

RV precordial leads and direct posterior leads

will facilitate recognition

Conclusions

Multi-lead ECG in all ACS patients

Monitor vital signs closely

Monitor arrhythmias

Pharmacologic management

Thank you for attending!

Class Code 144A