the multi-lead ecg: improve your quality of care! … · the multi-lead ecg: improve your quality...
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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!
Standard Limb Electrode Placement
Augmented Limb Leads
Standard Limb Electrode Placement
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
RVI Clinical Presentation
Hypotension
Clear lungs
Distended neck veins
Kussmaul’s sign
Tricuspid insufficiency
Widely split S2
S3 or S4 gallop
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
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.
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
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
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
Posterior Wall MI Complications
Bradycardias
Heart blocks
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