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Dr. R. Irabagon Myocardial Infarction Permanent destruction of the myocardium. Usually caused:
by reduced blood flow in a coronary artery due to rupture of an atherosclerotic plaque subsequent occlusion of the artery by a thrombus. Acute MI – Clinical Features
Effects of Ischemia, Injury, and Infarction on ECG Clinical Manifestations and Diagnosis
Chest pain, other symptoms ECG Laboratory tests--biomarkers CK-MB
Myoglobin Troponin T or I
DX: ECG, Cardiac enzymes/proteins, Echo, HX & PE Cardiac enzymes: a.
CKMB: increases 4-8 hours after MI, peaks after 24-36 H, returns to normal after 3 days AST; increases 12-16 H, peaks after 24 hours, returns to normal after 3 days LDH: peaks 3 days post MI, & persists for 4-7 days Troponin I: Increases 2-4 H post MI, peaks 4-24 H post MI, Returns to normal after 1-3 weeks
CVS: chest pain or discomfort, palpitations. Heart sounds may include S3, S4 & new onset of a murmur. Jugular vein distention, decreased/increased BP, ST segment changes RS: Dyspnea, tachypnea, crackles GIT: n/v GUT: decreased UO SKIN: cold, clammy, diaphoretic, pale Neurologic: Anxious, restless, HA, visual disturbance Psychological: fear of impending death
Treatment of Acute MI
Obtain diagnostic tests including ECG within 10 minutes of admission to the ED.
As indicated. beta-blockers Angiotensin-converting enzyme inhibitor within 24 hours Evaluate for percutaneous coronary intervention or thrombolytic therapy. Percutaneous Coronary Intervention Coronary Artery Bypass Grafts Greater and lesser saphenous veins are commonly used for bypass graft procedures.Oxygen Aspirin. absence of respiratory dysfunction. nitroglycerin. glycoprotein IIb/IIIa inhibitor Bed rest Nursing Process: The Care of the Patient with ACS: Diagnosis Ineffective cardiac tissue perfusion Risk for fluid imbalance Risk for ineffective peripheral tissue perfusion Death anxiety Deficient knowledge Collaborative Problems Acute pulmonary edema Heart failure Cardiogenic shock Dysrhythmias and cardiac arrest Pericardial effusion and cardiac tamponade Nursing Process: The Care of the Patient with ACS: Planning Goals include the relief of pain or ischemic signs and symptoms. adherence to the self-care program. IV heparin or LMWH. morphine. reduced anxiety. prevention of further myocardial damage. absence or early recognition of complications. clopidogrel or ticlopidine. Postoperative Care of the Cardiac Surgical Patient . maintenance of or attainment of adequate tissue perfusion.
lead II = left leg-right arm. and Electrical Impulse ECG Electrode Placement The 12 conventional ECG leads record the difference in potential between electrodes placed on the surface of the body. The signals are detected by means of metal electrodes attached to the extremities & chest wall & are then amplified and recorded by electrocardiograph. myocarditis. and aVF). and the chest leads record potentials transmitted onto the horizontal plane. Lead System. II. The extremity leads record potentials transmitted onto the frontal plane. These leads are divided into two groups: six extremity (limb) leads and six chest (precordial) leads. and III) and three unipolar leads (aVR. The unipolar leads measure the voltage (V) at one locus relative to an electrode (called the central terminal or indifferent electrode) that has approximately zero potential. Each lead can be likened to a different camera angle "looking" at the same events¾atrial and ventricular depolarization and repolarization¾from different spatial orientations . pericarditis. Thus. and lead III = left leg-left arm. aVL = left arm. The six extremity leads are further subdivided into three bipolar leads (I. Each bipolar lead measures the difference in potential between electrodes at two extremities: lead I = left arm-right arm voltages. the frontal and horizontal plane electrodes provide a three-dimensional representation of cardiac electrical activity. aVL. Indication: To determine cardiac rate To accurately define cardiac rhythm To diagnose old or new myocardial infarction To identify intra-cardiac conduction disturbances To aid in the diagnosis of ischemic heart disease.Complications: arrhythmia: most common cause of death in the first several hours following MI myocardial rupture: a catastrophic complication within the 1st 4-7 days & may result in death from cardiac tamponade Mural thrombosis Ventricular aneurysm: w/in 3. electrolyte abnormalities & pacemaker malfunction Relationship of ECG Complex.6 months after MI Electrocardiogram (ECG or EKG) A graphic recording of electric potential generated by the heart. and aVF = left leg (foot) Together. aVR = right arm.
Since the ECG paper speed is generally 25 mm/s.The electrocardiogram is ordinarily recorded on special graph paper which is divided into 1-mm2 gridlike boxes . Heart Rate 3 Possibilities Bradycardia : <60 beats per minute Normal Rate : 60-100 beats per minute Tachycardia : > 100 beats per minute Rate Analysis Formula Heart Rate= 1500/ #of small boxes Or = 300/ # of big boxes Short cut If R to R interval > 5 big square: Bradycardia If R to R interval between 3-5 big square: Normal Rate If R to R interval < 3 big square: Tachycardia Mnemonic Heart Rate Determination Normal Sinus Rhythm Sinus Bradycardia Sinus Tachycardia Rhythm Common Rhythm Interpretations: . and U wave) represents ventricular repolarization J point is the junction between the end of the QRS complex and the beginning of the ST segment. Atrial repolarization is usually too low in amplitude to be detected. but it may become apparent in such conditions as acute pericarditis or atrial infarction. the ECG graph measures the amplitude of a given wave or deflection (1 mV = 10 mm with standard calibration.20 s (200 ms). with heavier lines at intervals of 0. Vertically.04 s (40 ms). T wave. which represents atrial depolarization QRS complex represents ventricular depolarization ST-T-U complex (ST segment. the smallest (1 mm) horizontal divisions correspond to 0. the voltage criteria for hypertrophy mentioned below are given in millimeters) The ECG waveforms are labeled alphabetically P wave.
12-020 sec) Short PR (WPW syndrome) Normal PR Prolonged PR (1st degree or 2nd degree AV block) Normal Sinus Rhythm Check QRS duration (Normal QRS duration <0. Check the relation of P wave to QRS P wave is before QRS (Normal) P wave is buried or after QRS (ex. (-) QRS deflection: Average QRS vector below the baseline in lead I or AVF . SVT.Sinus rhythm Common supraventricular arrythmias: Atrial fibrillation Atrial flutter Supraventricular tachycardia Ventricular Arrhythmias Premature Ventricular Contraction Ventricular tachycardia Ventricular fibrillation Heart Blocks First degree AV block Second degree AV block Mobitz type 1 (wenckebach) Second degree AV block mobitz type II 3rd degree AV block Left or rigth bundle branch block( complete & incomplete) Rhythm Analysis Identify the P wave Determine frm the configuration if this is a sinus P.10 sec) Normal QRS Wide QRS (bundle branch blocks Check the relation of R-P & PP interval Equal R-R & P-P interval (normal) P-P interval shorter than R-R interval (complete heart block) P-P interval longer than R-R interval (AV dissociation) Normal Sinus Rhythm Axis Interpretation Normal axis Left axis deviation (LAD) Right axis deviation (RAD) Indeterminate axis Analysis (+) QRS deflection: Average QRS vector above the baseline in lead I or AVF. complete HB) Check PR interval (Normal PR interval: 0.
Q wave ≥ 0. scooping of ST segment.5 mEq/L Hyperkalemia Chest leads: T wave> 10mm in most leads. short QT interval Hypocalcemia Prolonged QT interval Hypercalcemia Shortened QT interval . 100% specific RVH Right axis deviation Lead V1: Rwave >Swave Deep S wave in leads V5 & V6 ST depression & T wave inversion in V1 – V3 Myocardial Infarction: correspondence of specific ECG lead ECG criteria for MI ST elevation≥ 2mm in 2 or more chest lead (chest lead) Or ≥1mm in 2 or more limb leads.04 sec (1 ml square) Miscellaneous Hypokalemia U wave as tall or taller than the T wave at leads V2 & V3 Normal serum Potassium: 3.6-5. in limb leads.Differential Dx Hypertrophy No hypertrophy LVH RVH Left atrial enlargement Right atrial enlargement combination LVH S wave in V1 + Rwave in V5 or V6: >35mm Commonly used 43% sensitive.T wave > 5mm in most leads Digitalis effect Prolonged PR interval. 97% specific R in AVL > 11mm 11% sensitive.
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