Cardiac Module- Part I:

EKG Rhythms, Interpretation, Patient

Presentation, & Intervention
March 2017, EMS CE
Condell Medical Center EMS System
Site Code #107200E-1217
Prepared By: Teresa Boron BSN, RN, TNS
 Objectives
•Upon successful completion of this module, the EMS provider will be able to:
•State the steps used in the process of rhythm interpretation
•Review the correct placement of the electrodes for obtaining a 12-lead ECG
•Differentiate the groupings of ECG leads that view the same area of the heart
•Analyze a variety of 12-lead ECG, identifying abnormalities, including ST segment elevation.
•Review your department’s procedure for transmission of the 12-lead ECG to the destination
hospital.
•Describe patient assessment and presentation to determine the presence of complications
related to the heart.
•Choose the correct intervention (pharmacological or electrical) for a variety of patient
presentations.
•Identify ROSC.
•Review Region X SOP manual relating to cardiac events.
•Complete the post-quiz with a score of 80% or better. 2
 EKG Rhythm Interpretation
• Adopt a systematic process to gather data- approach each ECG the same way.
• Sometimes you need to stop looking at the picture and review all of your data –
not all sinus rhythms look the same but they meet the same criteria!!!

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 EKG Wave Form & Interval

• Why is it important to know wave forms?

• If you can relate the wave form to the appropriate part of the EKG, you can
predict where the issue originates in the conduction system (ie: P wave, PR
interval, QRS complex)

• This can help anticipate the way your patient will present.
• This allows for more accurate interpretation of data and application of
appropriate interventions.

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 ACS General Presentation - Men
Men will usually present with typical signs and symptoms

üChest pressure; elephant sitting on their chest; squeezing/pressure sensation

üNausea
üDiaphoresis
üAnxiety
üChange in skin color – usually pale

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 ACS General Impression – Women, Elderly
• Women usually present with atypical complaints
üNausea
üPain between their shoulder blades
ü“I just don’t feel right”
• Elderly and long standing diabetics with atypical complaints
üFeel very tired
üHave never felt this way before
• Maintain a high index of suspicion.
• Obtain baseline 12-lead EKG to help avoid delay in appropriate treatment.

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 Process For Rhythm Analysis-Systematic
Approach
• Regularity – can be off 3 small boxes and still be regular
• Rate – multiply number of complexes in 6 second strip by 10
• P wave – presence, morphology (upright? inverted? rounded?)
• PR interval – normal 0.12 – 0.20 seconds
• QRS complex – narrow or wide?
• Interpretation – what is the name of the rhythm
• What does the patient look like???
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 Rule of Fours
• Four Initial Features
• History/Clinical picture- MOST IMPORTANT
• Rate
• Rhythm
• Axis- don’t get hung up on this one- more for physician use.

• Four Waves
• P-wave
• QRS- Complexes
• T-wave
• U-wave- Follows the t-wave closely, thought to be the repolarization of the Purkinje Fibers.

• Four Intervals
• PR Interval
• QRS Width
• ST Segment
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• QT interval- time of depolarization and repolarization of the ventricles
 Electrode Use and Placement
• Proper site preparation allows for good contact è easier interpretation with good
tracing and it’s more accurate
• Electrodes should be stored in sealed bag
• Conductive gel in the center needs to stay moist to conduct
• Gel will dry out over time
• Monitoring leads
• Typically monitor in Lead II (current moving RA to LL)

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 Electrode Placement

• Typical use is 4 lead system

• RA, LA, RL, LL
• 3 views can be appreciated just by changing your
dial selector to the lead required
üLead I – RA to LA
üLead II – RA to LL
üLead III – LA to LL

üAdditional lead placed on the Right

functions as a neutral lead.
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 12-Lead Electrode Placement
• Consistency is important
• 12-lead EKG’s are frequently repeated
• Results compared to previous reports
• Improper lead placement could cause inaccurate interpretation
• V1 – 4th ICS right sternal border
• V2 – 4th ICS left sternal border
• V4 – 5th ICS mid-clavicular
• V3 – between V2 and V4 on 5th rib
• V5 – 5th ICS anterior axillary line
• V6 – 5th ICS mid-axillary line

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 Obtaining 12 Lead EKG
• Attach leads with careful attention to placement
• Lay patient as flat as possible/tolerated
• If head elevated, note elevation on 12 lead EKG (ie: 450
elevation, 900 elevation)
• Ask patient to breath easy, and not talk
• Obtain tracing
• Interpret tracing
• Transmit tracing
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 Transmitting 12-Lead EKG’s
• Once you review the 12-lead EKG, report your findings
• The presence or absence of ST Elevation
• If ST elevation present: which leads
• Do you notice any other abnormalities
• Then read word for word the computer interpretation on the 12-lead EKG
• Remember to also report the patient’s underlying rhythm (i.e. Sinus rhythm with 1st
degree AV block.)

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 ST Elevation

• Definition
• >1 mm elevation of ST segment in limb leads
• > 2mm elevation in precordial (chest) leads (V1 – V6)
• Point of measurement
• 0.04 seconds after J point
Point where QRS meets ST segment
• Point of reference
• Compared to isoelectric baseline

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 Tombstone Effect
• Elevation of ST segment mimics the head-on appearance of a tombstone

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 Anticipating Complications of Acute MI
• Based on leads affected, you can state which area of heart is affected
• Based on leads affected, you can predict which vessel is blocked
• With this information, you can anticipate specific complications that may occur
• If you are watching/monitoring for specific responses, you can be prepared for the
correct intervention
• These patients are UNSTABLE. Their rhythm may
change unexpectedly!!!
• NEW PRACTICE: When ST Elevation noted in 2 or more
contiguous leads, place DEFIB PADS!!!

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 Views of The Heart
• View of heart based on placement of electrodes
üAnterior (V3 and V4)
üSeptal (V1 and V2)
üInferior (II, III, aVF)
üLateral (I, aVL, V5, V6)
• Coronary arteries feed specific areas
üLAD
üCircumflex
üRCA

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 Infarct Locations
* Reciprocal changes noted as ST depression in opposite leads

Location MI EKG Changes & Reciprocal Leads Coronary Artery

Anterior V1 –V4 LAD
*Reciprocal changes: II, III, aVF
Inferior II, III, aVF RCA
*Reciprocal changes: I, aVL, V leads
Lateral I, aVL, V5, V6 Circumflex
*Reciprocal changes: II, III, aVF
Posterior No indication – no leads “look” at posterior wall RCA or
*Reciprocal changes: V1, V2 (large R wave, upright T wave, circumflex
poss ST depression (mirror image anterior MI)
Extensive anterior I, aVL. V1 - V6 LAD or main
(also called *Reciprocal changes: II, III,aVF
anterior-lateral)
Anteroseptal V1, V2 LAD
Reciprocal changes: usually none 18
 Mimics of ST Elevation AMI – Acute
Pericarditis
• Inflammation of pericardium
• Widespread, not limited to one
portion of myocardium
• Does not involve blockage of
coronary artery
• ST elevation is concave, not convex
like MI
• Referred to “smiley face” vs
“frowny face” appearance
• No reciprocal changes 19
 Mimics of ST Elevation AMI - LBBB
• New onset often indicates presence of cardiac disease
• Concern is presence of heart disease and possibility of development of heart blocks
• The T wave changes mimic ST elevation
• Evaluate V1: think of using turn signals
• Evaluate last 0.04 seconds of QRS from J point
• If terminal portion QRS is negative in V1, LBBB is present
• If terminal portion QRS is positive in V1, RBBB is present
• “turn signal theory”
• When turning to the left, you depress turn signal (QRS negative in V1)
• When turning to the right, you lift up turn signal (QRS positive in V1)

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 Mimics of ST Elevation MI – Paced
Rhythm

• Pacemaker wire often lies in right ventricle

• Right ventricle depolarized and then the left ventricle
• This will create widened QRS complex
• Initially, cardiologist will take patient to cath-lab based on presentation and
history as EKG is non-diagnostic for MI in these patients.
• Time is ALWAYS muscle!
VIDEO
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 12-Lead EKG Interpretation
• What do you think?

• In LBBB cannot determine pathological ST elevation

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 Cardiac Complications: Right Ventricular Infarct
(RVI)
• When you notice ST elevation in inferior leads (II, III, aVF), consider right ventricular infarct
Ø In the hospital, we may obtain a right sided 12 lead EKG for evaluation
• Clinical evidence of right ventricular infarct (RVI)
ü JVD
ü Clear lungs sounds
ü Hypotension
• With Medical Control orders, cautious administration of fluids could help improve preload and blood
volume return to right heart è improved patient condition.
• Monitor patient carefully for fluid overload – pulmonary edema could develop!!!

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 Cardiac Complications - Hypotension

• Can be caused by hypovolemia or poor cardiac function

ØProblem – not enough volume being circulated to adequately perfuse
tissues
ØFix – Add volume to the system or improve cardiac function
ØSolution – Fluid challenges (200 ml increments titrated; can repeat)
• Dopamine drip beginning at 5 mcg/kg/min to maintain B/P >90 mmHg
systolic-use if not responsive to fluid challenge.

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 Complications: Hypotension
IV Fluid Challenge
• Fluid administered into vascular space (normal saline)
• Isotonic solution (ie: NS) used
ØWill immediately expand circulating volume (vascular fluid)
ØDoes not cause immediate shift of fluid or electrolytes
• Within one hour, fluid levels replaced do start to shift
Ø 1 part will stay in vascular space
Ø 2 parts will move out of vascular space

• Watch for onset of heart failure- Listen closely to breath sounds

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 Complications: Hypotension
Dopamine
• Stimulates heart to increase strength of
contractions (positive inotropic properties)
• Always infused as piggyback
• Onset 5 minutes; duration <10 minutes
• Avoid changing dose too frequently; give drug a chance to work
• Carefully monitor IV site for infiltration
• Infiltration could cause tissue sloughing if
site not properly cared for
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 Complications: Hypotension
Dopamine- What Would You Do?
• What would you do if the Dopamine infusion infiltrated?
üStop the infusion
üReport to RN/MD during bedside hand-off
üDocument: site, site appearance, action taken, who you handed off to.

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 Complications With Acute MI - Blocks

• AV blocks develop due to issues in the AV junction – the conduction tissue

• AV blocks can occur at level of AV node, level of bundle branches, or sites in
between (ie: bundle of His)
• Clue:
üBlocks at AV node generally have narrow QRS
üBlocks in bundle branches generally have wide QRS

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 AV Node
• Job: to delay conduction to the ventricles
• Allows impulses to regroup after being
transmitted from the SA node through the
atria- allows simultaneous conduction
through to the ventricles via the right and left
bundle branches .
• Development of heart block by location
of problem
üAV junction
üBundle of His
üBundle branches 29
 Complications With Acute MI - Blocks
• Second degree Type II heart block
• Usual cause is disease of left coronary artery presenting as anterior wall MI (V3, V4)
• Patient often symptomatic
• Commonly progresses to third degree (complete)
• Narrow QRS blocks generally respond to Atropine
• Wide QRS blocks generally do not respond to Atropine

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 Complications With Acute MI: Blocks
• Third degree heart block – complete
• Due to inferior wall MI (II, III, aVF)

• Block usually above bundle of His

• Often preceded by 1st degree or second degree type I
• Rhythm usually stable, QRS narrow, ventricular rate over 40
• Due to anterior wall MI (V3, V4)

• Block usually low in conduction system with ventricular pacemaker site

• Often preceded by Second degree Type II heart block
• Rhythm usually unstable, QRS wide, ventricular rate less than 40
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 Complications With Acute MI
• Lethal dysrhythmias most common in first hour of infarct
• If you know to watch for lethal rhythms, you are prepared to provide appropriate
intervention in timely fashion

• What is the immediate action to take when first seeing VF?

• Do not delay - prepare for immediate defibrillation!
• If extra hands available, can begin chest compressions

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Identification and Interventions for Complications

• Frequent monitoring essential to watch for changes in condition

• If a change is noted:
ØDetermine what the problem is/what is causing signs and
symptoms
ØConsider what you have to do to fix the problem and monitor effectiveness
of intervention

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 Region X Interventions for ACS

• Evaluate patient stability

üHold patient’s wrist (actually feel for pulse) as you say “hello” watching for response back
• Evaluate level of consciousness
• 1st indicator to change with change in perfusion

• Quality of peripheral pulse gives insight to quality of blood pressure

• Blood pressure last indicator to fall when decompensating
üIf patient is unstable (altered level of consciousness, falling blood pressure), interventions
more limited

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 Interventions for Unstable ACS
• Administer aspirin
• As anti-platelet, stops platelet aggregation at sight of plague which would further reduce
coronary blood flow
• Dose of 324 mg allows blood levels to be therapeutic
• If patient on a daily dose of aspirin, levels already therapeutic
• Will not hurt giving additional dose
• IV/IO fluid challenge
• Evaluate for clear breath sounds first to monitor for heart failure
• Administer fluid in 200 ml increments with frequent reassessment
• General formula for total fluid challenge volume calculation is 20 ml/kg

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 Interventions for Stable ACS
• Aspirin 324 mg chewed
• Chewing breaks med down for faster absorption
• Nitroglycerin 0.4 mg sl (1/150 gr)
• May repeat every 5 minutes to 3 doses
• On order of Medical Control could be requested to continue dosing every 5 minutes
• Screening prior to administration is VERY IMPORTANT!
N Blood pressure >90 systolic (NTG acts as venodilator)
N Allergies (to nitrates)
N Phosphodiesterase inhibitors (ie: Viagra, Levitra, Cialis) within 24-48 hours
N Inferior wall MI (leads II, III, aVF)

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 Return of Spontaneous Circulation - ROSC
• How do you know ROSC is achieved???
• Clues:
• Waveform capnography suddenly spikes–often initially high due to
retained CO2 being excreted from a now-perfusing heart
During <10 second pause in compressions observe organized rhythm
on monitor confirmed with presence of pulse

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 ROSC
• Very next assessment follows ABC approach
üEvaluate oxygenation and ventilation
• Is the patient breathing or do you still need to support them?
• BVM – 1 breath every 5-6 seconds (10-12 breaths per minute)
• Advanced airway – 1 breath every 6 seconds (10 breaths per minute)
• AFTER airway and breathing assessed, then evaluate perfusion status
• Blood pressure
• Expect it to be low initially and give it some time to increase as patient
condition continues to improve

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 Complications During ROSC -
• Heart is very irritable at this point
• If you anticipate an unstable patient, you will be prepared
üDysrhythmias – most common in the first hour of acute process
üHeart blocks related to location of acute MI and coronary artery
affected
• Inferior wall (RCA) – Third degree
• Anterior wall (LAD) – Second degree type II and 3rd degree
üSustained hypotension – inferior wall MI (RCA)
üSeizure activity
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 Documentation Pearls
?Application of monitor
?Interpretation of patient’s rhythm
?Acquisition of 12-lead EKG
?Presence/absence of ST elevation
?ALL leads where ST-elevation is present
?Transmission of 12-lead EKG to receiving facility

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 Documentation Pearls cont’d
• If complications are present

ü Signs and symptoms assessed

ü Interventions performed
ü Response to interventions
• On-going reassessment very important in this critical, unstable population

• REMEMBER: If it wasn’t documented, it wasn’t done!!!

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 “Stay N Play” or “Load N Go”???
• AHA supports remaining stationary while delivering chest compressions
üLess effective when moving a patient on a cot
üLess effective when performed in a moving ambulance
• AHA recommends to stay at the scene, if possible, to work the arrest
• Moving a patient with an auto pulse is acceptable
• Auto pulse effectiveness not interrupted with patient movement

• Region X Medical Directors support staying on the scene

CNo specific time frame has been established by the Region as of yet
CRecommend a case-by-case common sense approach to decision making
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 Highlight Reel
üPatients presenting in the face of acute MI process have
irritable hearts
üThe one rhythm you currently see may not be the only
one observed

Constantly monitor for changing rhythms

üWaveform capnography measures effectiveness of CPR,
advanced airway placement, ROSC
üPatients achieving ROSC can and often re-arrest
Keep a close eye on pt pulse to monitor peripheral
perfusion!
üBe alert to unusual stories or presence of Type II or 3rd
degree heart block – may be in the face of an acute MI
üPlace defib pads on every patient with ST-Elevation in 2 or more contiguous leads
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Rhythm Identification
Practice

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 STEMI- A Closer Look
The following are REAL ECG’s obtained by Condell ED

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 DATE: 01-14-17 TIME: 2236

Pt. is a 56y/o Filipino male who arrived to Condell’s ED via Buffalo Grove Fire/Rescue c/o sub-
sternal CP for 2 hours PTA. Pt. has a medical history of HTN and gout and a remote history of
smoking. Pt. has a strong family history of CAD, as his brother had CABG in his 50s. Initial ECG
in the ED revealed ST elevation in the inferior leads (II, III, and AVF) confirming an inferior wall
MI. A cardiac alert was called and the pt. was emergently transferred to cath lab. A coronary
angiogram revealed a blockage in the distal RCA involving the posterior lateral branch.
Successful ballooning and stenting performed. Additionally the pt. was found to have a 90%
blockage in the proximal LAD, which will be addressed later on an elective basis. The pt.
remained hemodynamically stable and was sent to the ICU to recover. 60

D2B time: 60 mins

 DATE: 01-26-17 TIME: 843

Pt. is an 85y/o Caucasian female who arrived to Condell’s ED via Lincolnshire-Riverwoods
Fire/Rescue c/o dizziness and SOB approximately one hour PTA. Pt. has a medical history of
HTN, hyperlipidemia and renal insufficiency. Initial ECG by EMS revealed ST elevation in the
inferior leads (II III and AVF), as well as ST elevation in the lateral V leads (V4-V6), EMS relayed
info and a cardiac alert was called pre hospital. Pt. was emergently transported to the cath lab.
Coronary angiogram revealed a 99% mid RCA occlusion. Flow was restored to the myocardium
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by coronary ballooning and stenting. The pt. remained hemodynamically stable. Pt. was
transported to ICU to recover.

D2B time: 48 mins

DATE: 02-10-17 TIME: 1930

Pt. is an 65y/o Caucasian male who arrived to Condell’s ED via private vehicle c/o CP, SOB, and
nausea. Pt. has no known medical history. Initial ECG in ED revealed ST elevation in the
anterior leads (V2-V4) with lateral wall involvement (V5-V6). Reciprocal changes noted in the
inferior leads. A cardiac alert was initiated. Pt. was emergently transported to the cath lab.
Coronary angiogram revealed a 100% proximal LAD occlusion. Flow was restored to the
myocardium by coronary ballooning and stenting. The pt. remained hemodynamically stable. 62
Pt. was transported to ICU to recover. Pt. was D/C home on 2-13-17.

D2B time: 66 mins

DATE: 12-11-16 TIME: 1047

Pt. is a 67y/o male who presented to Advocate Condell’s ED via private vehicle c/o bilateral shoulder
pain which started approximately two hours prior to arrival. Initial 12 lead ECG performed, as seen
above, clearly shows ST elevation in all V leads as well as leads I and AVL, signifying an anterolateral wall
MI. Pt. has a medical history of GERD, panic attacks , and HTN. A cardiac alert was initiated by the ED
physician and the pt. was transported to the cath lab. Subsequent coronary angiogram revealed a
significant mid LAD blockage, requiring coronary ballooning and placement of a coronary stent. Pt.
tolerated the procedure well, and remained hemodynamically stable. Pt. was transferred to the ICU.

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D2B time : 79 min

DATE: 12-13-16 TIME: 2130

Pt. is a 36y/o male who arrived to Advocate Condell’s ER via Lincolnshire Riverwoods Fire/Rescue c/o
CP and diaphoresis. Pt. has significant family history of CAD and is a smoker. Initial EKG in ER revealed,
as seen above, ST elevation in inferior leads (II, III, and AVF) and arguably ST elevation in V6. Pt. was
clearly symptomatic with CP 10/10 and diaphoresis. Cardiac Alert was initiated. Pt. was transported to
the Cath Lab emergently. Cardiac cath revealed triple vessel CAD. Pt. remained hemodynamically
stable. Pt. will require CABG to revascularize his coronary arteries . Pt. was transported to ICU.

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D2B time : N/A

 DATE: 12-17-16 TIME: 0952

Pt. is a 53 y/o male who presented to Advocate Condell’s ED via private vehicle c/o chest pain which
started approximately 0330 this a.m. while shoveling snow. Initial 12 lead ECG performed, as seen above
shows ST elevation in inferior leads II, III, and AVF and reciprocal changes in the anterior V leads. Pt. was
diagnosed with an inferior wall MI, cardiac alert was called. Pt. has a medical history of HTN and
smoking. Of note, his fasting blood glucose was noted to be over 400mg/dl. The pt. was transported to
the cath lab. Subsequent coronary angiogram revealed a proximal RCA blockage, heavily thrombosed,
requiring coronary thrombectomy, ballooning, and placement of a coronary stent. Pt. tolerated the
procedure well, and remained hemodynamically stable. Pt. was transferred to the ICU.
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D2B time: 83 min

 DATE: 12-18-16 TIME: 1331

Pt. is a 55 y/o male who presented to Advocate Condell’s ED via private vehicle c/o chest pain which
started one hour PTA after snow blowing. Initial 12 lead ECG performed, as seen above shows ST
elevation in inferior leads II, III, and AVF as well as in the lateral leads I, AVL, and V6. Pt. was diagnosed
with an inferolateral wall MI, cardiac alert was called. Pt. has a medical history of HTN, CAD with stent
placement 5 years ago. The pt. was transported to the cath lab. Subsequent coronary angiogram
revealed a proximal obtuse marginal branch off the left circumflex, requiring, coronary ballooning and
placement of a coronary stent. Pt. tolerated the procedure well, and remained hemodynamically stable.
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D2B time: 78 min

 DATE: 12-22-16 TIME: 2140

Patient is a 76 year old male who arrived to Advocate Condell’s ED, via
Grayslake Fire /Rescue, c/o chest pain with the pain radiating to shoulders
bilaterally, for one day PTA .Patient has a medical history of HTN, CAD with
previous placed stent in the LAD and is a former smoker. 12 lead ECG in ED, as
seen above, showed ST elevation in the inferior leads (II , III, and AVF). A
Cardiac Alert was called, and the patient was transported emergently to the
cath lab. Coronary angiogram revealed totally occluded obtuse marginal branch
off the left circumflex coronary artery. A coronary stent was successfully
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placed, the patient remained hemodynamically stable and is recovering in the
ICU.
D2B time: 68 min
DATE: 12-27-16 TIME: 0525

Patient is a 51 year old male who arrived to Advocate Condell’s ED, via Gurnee
Fire /Rescue, c/o chest pain, which started at midnight and worsened near
dawn. Patient has a medical history of HTN, hypercholesteremia, NIDDM, CAD
with previous placed stent in the LCX and is a smoker of both cigarettes and
marijuana. 12 lead ECG in ED, as seen above, showed ST elevation in the
inferior leads (V1 –V3) with reciprocal changes in leads I, AVL, and V6. A
Cardiac Alert was called, and the patient was transported emergently to the
cath lab. Coronary angiogram revealed a 80-90% blockage of the left coronary
artery, also involving the first diagonal branch. Two coronary stents were
successfully placed, the patient remained hemodynamically stable and is 68
recovering on W3, intermediate unit.
D2B time: 87 min
DATE: 12-30-16 TIME: 0930

Pt. is a 64y/o Caucasian male who arrived to Condell’s ED via Libertyville Fire/Rescue c/o sub-
sternal CP s/p working out. Pt. has a medical history of CAD with stent placement in 2007, HTN,
hyperlipidemia and paroxysmal atrial fibrillation. Initial ECG by EMS revealed ST elevation in
leads II, III, and AVF (inferior leads), Libertyville Rescue relayed info and a cardiac alert was
called pre hospital. ECG in the ER, as seen above, confirmed ST elevation in the inferior leads.
Pt. was emergently transported to the cath lab. Coronary angiogram revealed a distal RCA total
occlusion, in stent re stenosis from a previously placed stent in 2007. Flow was restored to the
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myocardium by coronary ballooning and the pt. remained hemodynamically stable. Pt. was
transported to an intermediate telemetry unit for recovery.

D2B time: 56mins

DATE: 11-28-16 TIME: 1430

Patient is a 70y/o Black male, with a medical hx of CAD, HTN, hyperlipidemia, and HIV, came to
Advocate Condell’s ER via Libertyville Fire/ Rescue with signs and symptoms of an acute MI. The pt. was
at his primary care physician’s office with onset of chest pain. 12 lead ECG performed there, revealed ST
segment elevation in leads V2 and V3. ECG in ER confirmed an anterior wall MI( as seen with the EMS
12 lead ECG above). A cardiac alert was initiated. Of note, this patient was in our facility 9 days prior
with an acute MI and a stent was placed in his LAD coronary artery. Pt. sent to cath lab emergently and 70
discovered the previously placed stent was occluded. Coronary thrombectomy , ballooning and
additional stent was placed in the LAD. Pt. remained hemodynamically stable and was transferred post
procedure to the ICU.
 Bibliography
• Aehlert, B. ECGs Made Easy 4th Edition. MosbyJems. 2011.
• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.
• Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010.
• Phalen, T., Aehlert, B. 12-Lead ECG in Acute Coronary Syndromes. 2nd Edition. MosbyJems. 2006.
• Region X SOP’s; IDPH Approved April 10, 2014.
• Walraven, G. Basic Arrhythmias 7th Edition. Brady. 2011.
• https://en.wikipedia.org/wiki/Electrocardiography_in_myocardial_infarction
• http://www.aliem.com/the-importance-of-reciprocal-changes-in-lead-avl/
• http://www.lakeems.org/wp-content/uploads/QD-Capnography-in-EMS.pdf
• https://eccguidelines.heart.org/index.php/american-heart-association/
• http://circ.ahajournals.org/content/132/18_suppl_2.toc
• Thank you to James Russo- Condell Cath Lab RN, for the real STEMI ECG’s!!!

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