Unraveling the

Mysteries of the
12 Lead EKG

Developed by the
 Objectives
• Identify the correct lead placement for
performing a 12 lead EKG
• Identify and interpret heart rhythm and
differing blocks
• Identify extreme axis deviations
• Identify and interpret bundle branch blocks
• Interpret MI location based on ST elevation

2
ECG Pre-test

3
• Is this ECG normal?
A. True
B. False

4
• Is this ECG normal?
A. True
B. False - Wenkebach

5
• Would you call a STEMI alert?
A. Yes
B. No

6
• Would you call a STEMI alert?
A. Yes
B. No - RBBB

7
• Does this person need anticoagulation?
A. Yes
B. No

8
• Does this person need anticoagulation?
A. Yes – Atrial fibrillation
B. No

9
• The initial treatment of choice for this rhythm is
cardioversion.
A. True
B. False

10
• The initial treatment of choice for this rhythm is
cardioversion.
A. True
B. False – SVT (try adenosine first)

11
• This ECG explains the patient’s complaints of
dizziness.
A. True
B. False

12
• This ECG explains the patient’s complaints of
dizziness.
A. True – sinus bradycardia with heart rate of 37 bpm
B. False

13
How did you do?

OK – let’s get started!!

14
 Monitoring vs Assessing
• Monitoring – EKG leads can be placed
anywhere
– Allows for identification of VF and Asystole
• Assessing – EKG leads MUST be placed in
specific locations
– Allows for interpretation of changes in the
electrical conduction (depolarization and
repolarization changes) i.e., ischemia.

16
 Patient Preparation
• Provide a level of privacy
• Remove the patient’s shirt
• Shave the chest
• Prep the skin
– Remove the dead epithelials
• Electrically non-conductive
• Place the patient in a
hospital gown
 YES! – Women Too
• Remove the bra
• Use a sheet to drape the patient
• Diaphoresis
– Dry the chest
– Use alcohol
– Use benzene
 Patient Position
• Place the patient in the correct position to
acquire the EKG
– Supine Recommended
– Sitting up is fine
• Ask the patient to hold still
• Keep their hands down by their side
– May need to hold the patient’s hands

19
Lead Placement

• 12 Lead ECG’s use 10 Electrodes

– one electrode on each limb
– 6 electrodes on the left chest

20
 Lead Placement
• Limb Lead go on the LIMBS!
– LA Left ARM
– RA Right ARM
– LL Left LEG
– RL Right LEG

21
 Left Chest Lead Placement
• Precordial Leads (V leads or MCL leads)
– V1 4th intercostal space, right of sternum
– V2 4th intercostal space, left of the sternum
– V3 between V4 and V2
– V4 5th intercostal space, left of sternum
– V5 5th intercostal space, left of sternum
– V6 5th intercostal space, left of sternum

22
Left Chest EKG

23
The Normal Conduction System

24
Normal ECG

25
Limb Lead Reversal

26
Limb Lead Reversal

27
Waveforms

28
 QRS Labeling

Q Waves
First negative deflection after the
P waves in any lead

Q wave
 QRS Labeling

R Waves

"R"

First positive deflection after the

P waves in any lead
 QRS Labeling

S Wave

s s

QS

Negative deflection below the

baseline after an "R" or "Q" wave
 QRS Labeling

The "J" Point

Also called the" juncture" point.

Where the qrs complex ends
and the ST segment begins

32
 QRS Labeling

QRS Morphologies
Can you label these complexes?
R R

q s
QS
R
r R’
r

S q S

33
 Now YOU Do It!
• Video of proper ECG lead placement

34
 Interpretation
• Develop a systematic approach to reading
EKGs and use it every time
• The system recommended is:
– Rate
– Rhythm (including intervals and blocks)
– Axis
– Ischemia

35
 Rate
• Rule of 300- Divide 300 by the number of
boxes between each QRS = rate

Number of Rate
big boxes
1 300
2 150
3 100
4 75
5 60
6 50

36
Estimate of Heart Rate

37
What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm

38
 Rate
• HR of 60-100 per minute is normal
• HR > 100 = tachycardia
• HR < 60 = bradycardia

39
 Differential Diagnosis of Tachycardia

Tachycardia Narrow Complex Wide Complex

Regular ST ST w/ BBB
SVT SVT w/ BBB
Atrial flutter VT
Irregular A-fib A-fib w/ BBB
A-flutter w/ A-fib w/ WPW
variable conduction VT
MAT

40
 Rhythm

• Sinus
– Originating from SA
node
– P wave before
every QRS
– P wave in same
direction as QRS

41
What is this rhythm?

42
 Normal Intervals

• PR
– 0.20 sec (less than one
large box)
• QRS
– 0.08 – 0.10 sec (1-2 small
boxes)
• QT
– 450 ms in men, 460 ms in
women
– Based on sex / heart rate
– Half the R-R interval with
normal HR

43
 Causes of Prolonged QT
• Causes
– Drugs
– Hypocalcemia,
hypomagnesemia,
hypokalemia
– Hypothermia
– AMI
– Congenital
– Increased ICP

44
Consequences of Prolonged QT

45
 Blocks
• AV blocks
– First degree block
• PR interval fixed and > 0.2 sec
– Second degree block, Mobitz type 1
• PR gradually lengthened, then drop QRS
– Second degree block, Mobitz type 2
• PR fixed, but drop QRS randomly
– Type 3 block
• PR and QRS dissociated

46
What is this rhythm?

47
 What is this rhythm?
First degree AV block
PR is fixed and longer than 0.2 sec

48
What is this rhythm?

49
 What is this rhythm?

Type 1 second degree block (Wenckebach)

50
What is this rhythm?

51
What is this rhythm?

52
What is this rhythm?

53
 What is this rhythm?
3rd degree heart block (complete)

54
Section Two

55
 Axis

• Axis: predominant
flow of electricity
through the heart

• We look at the QRS

complexes for
ventricular axis
 I

NORMAL AXIS

III II
57
 Hexaxial Reference System
• Divided into 6 part grid
– Based on the leads
• I
• II
• III
• aVR
• aVF
• aVL
• Degrees of electrical flow
– 0 to +180
– 0 to -180

58
ECG with Normal Axis

59
Extreme Right Axis
-90 to -180 degrees

60
ECG with Extreme Right Axis

61
Differential Diagnosis of Extreme Right
Axis
• Ventricular tachycardia
• Hyperkalemia (acute renal failure)
• Apical MI
• Right Ventricular Hypertrophy

62
Limb Lead Reversal

63
 Hemiblocks
• A hemiblock is a block
of one of the fascicles
of the left bundle Left Bundle Branch
branch.
Posterior Hemifascicle

• Hemiblock is an ECG
diagnosis Anterior Hemifascicle
 Hemiblocks

• Anterior Hemiblock
Left Bundle Branch
– pathological left axis
– negative deflection in
leads II and III
– small q in lead I, small
r in lead III
– common block
– 4x higher mortality
rate in AMI Anterior Hemifascicle
Anterior Hemiblock

66
 Hemiblocks

• Posterior Hemiblock
– right axis deviation Left Bundle Branch

– small r in lead I, small Posterior Hemifascicl

q in lead III
– high mortality rate
when with an AMI
– two coronary arteries
involved
 Posterior Hemiblock

• Very rare and much more dangerous.

• Posterior hemifascicle has redundant
blood supply from two separate
coronary arteries.
• In setting of an acute MI, two coronary
arteries would have to be occluded
proximally in order to create this
condition.
Posterior Hemiblock
69
 Rapid Axis
• Rapid Axis and Hemiblock Chart

Axis Lead I Lead II Lead III Comments

Normal Axis
0 - 90
Physiologic
Left Axis
0 to -40
Pathological Anterior
Left Axis Hemiblock
-40 to -90
Right Axis Posterior
90 - 180 Hemiblock
Extreme Right Ventricular in
Axis
no man's land origin
70
Test Your Knowledge!

71
 Leftward Axis
(normal)

Left Posterior Hemiblock

Normal Axis

Extreme Right Axis

Left Anterior Hemiblock 72

 Ventricular Tachycardia

• 12 Lead ECG and VT:

• You may be the only one
to see the rhythm
• A 12 lead ECG of VT is
very helpful to the
cardiologist looking for
the cause
• More benefit and less risk
in knowing for sure
 Ventricular Tachycardia
• Rate 110 -250 bpm
• Wide complex (>0.12 – 3 small blocks)
• Regular
• AV dissociation
• Extreme Right Axis Deviation + Upright MCL-1

I II III

MCL-1
EXTREME RIGHT AXIS
ERAD

V1

III II 75
VT

76
 Bundle Branch Blocks
• A Bundle Branch Block is a block of one of the
two bundle branches, left or right
• A Bundle Branch is a fascicle of electrical
conduction system cells designed to carry
impulses to the ventricles
• Bundle Branches facilitate “syncytium” or
both ventricles contracting in sync.

77
 Bundle Branch Blocks
• Turn Signal Theory
– easy way to
determine left or right
BBB
– use lead V1
– QRS complex must be
at least .12sec (120
ms) or wider (or 3
little squares)
 Bundle Branch Blocks

• Turn Signal Theory

– Use lead V1 or MCL-1 IF QRS > 120 ms (.12 sec)
– Circle the J point
– Draw line back into the complex, then up or down
with the terminal deflection
– shade in the triangle made by this line
– Arrow points up - turn signal up - Right BBB
– Arrow points down - turn signal down - Left BBB
79
 Bundle Branch Blocks
• Turn Signal Theory

1 2 3

LBBB

RBBB
 QRS Labeling
Can You Identify These
QRS Morphologies
Can youBundle Branch
label these Blocks?
complexes?
RBBB

LBBB LBBB

RBBB RBBB

LBBB

81
 Right Bundle Branch Block and
Hemiblocks can occur together!
RBBB + Anterior Hemiblock (most commonly seen)

Left Bundle Branch

Right Bundle Branch

Anterior Hemifascicle
RBBB + LAHB

83
Section Three

84
Myocardial Blood Supply

85
 AMI
Myocardial Blood Supply
• Right Coronary Artery
• Inferior Wall (LV)
• Posterior Wall (LV)
• Right Ventricle
• SA and AV Node
• Posterior fascicle of LBB
 Myocardial Blood Supply

• Left Anterior Descending

• Anterior Wall of LV
• Septal Wall
• Bundle of His and BB
 Myocardial Blood Supply

• Circumflex

• Lateral Wall of LV
• Rarely SA and AV nodes
• Posterior Wall of LV
 Clinical Manifestations of
Arterial Thrombosis
UA/NSTEMI: ST  MI:
Partially-occlusive thrombus Occlusive thrombus (platelets,
(primarily platelets) red blood cells, and fibrin)

Intra-plaque Plaque core

Intra-plaque Plaque core thrombus (platelet
thrombus (platelet dominated)
dominated)

SUDDEN DEATH
Adapted from Davies MJ. Circulation. 1990; 82 (supl II): 30-46.
 ECG Signs of Ischemia
• Usually indicated by ST changes
– Elevation = Acute infarction
– Depression = Ischemia
• Can manifest as T wave changes
• Remote infarction can be shown by q waves

90
 ECG Progression
in Infarct

• ECG pattern in AMI =

continuum that extends
from normal to full infarct.
• First: T wave flips in early
ischemia.
• Then: ST elevation either
flat or tombstoning
(flipped T wave may
disappear).
• Finally: We see Q waves.

91
 12 Lead ECG and AMI
• Benefits of 12 Lead ECG’s
– Highly specific (90% + confidence)
– If it shows an MI, there probably is an MI
– Rapid identification of MI in early stages
– Can commit to treat with ECG, history and
physical exam
– Complications can be identified

92
 12 Lead ECG and AMI
• Limitations
– Only 46 - 50 % sensitive (may miss 50%)
• Increase sensitivity by looking at the whole heart
– Diagnostic quality necessary
– Training needed to read the 12 leads
– ECG evidence is only one piece of the puzzle
– Some non-MI conditions look like MI’s

93
 12 Lead ECG and AMI

A NORMAL 12 LEAD ECG DOES NOT

RULE OUT A MYOCARDIAL
INFARCTION
If there is suspicion for MI, repeat the
ECG

94
 Acute Ischemia

• Area of ischemia is more negative than surrounding normal tissue

• Causes ST depression; T wave is flipped
• Causes repolarization to occur along abnormal pathway

95
 Acute Injury
• Zone of injury does not repolarize completely
• Remains more positive than surrounding tissue, leading to ST
elevation
• T remains flipped (abnormal repolarization paths along
injured/ischemic areas of myocardium)

96
Cardiac Location of Event

97
 Posterior MI
Is there a lead for that?
• You only find what you’re looking for!
– Move V4, V5, V6
– 5th intercostal space

98
 Posterior MI
• Look for anterior reciprocal changes

99
 What about the right side?
RV infacts
Occur in conjunction with inferior MIs

• Move V4 to the
right side same
location
– 5th intercostal
space anterior
axillary

100
Acute MI with RV involvement

101
Where/What is It?

102
Where/What is It?

103
Where/What is It?

104
Where/What is It?

105
106
 Scorecard
• The guidelines call for a 90 minute medical
contact to balloon time.
• Very important to perform immediate or in-
field ECG to make earlier diagnosis to start the
STEMI alert.

107
 Interventional Plan for EMS

• Out of hospital 12 lead

• Early notification of
hospital
• O2, NTG, pain control
• ASA, Heparin
• Thrombolytic prescreen
• Transport to PCI Center
 Definitive AMI Treatment
Percutaneous Coronary Intervention
When to Consider Thrombolytics
• Acute MI patients in whom first medical
contact to balloon time is like to exceed
2 hours.
• Cath lab is not available.

110
 How do thrombolytics or more
appropriately fibrinolytics work?
t-PA
• A naturally occurring blood protein
Plasminogen activates the production of
plasmin – a digestive enzyme
• Presence of a clot causes the endothelia cells
to secrete tissue plasminogen activator which
starts the breakdown of the clot

111
 How do fibrinolytics work?
• Fibrinolytics
– Destroy the clot
at the level of the fibrin.

– Activate the production

of plasmin to cause the
digestion of the clot

112
 EMS and the AMI:
Making a difference
• Early recognition and treatment
• Early activation of cath lab
• Once infarction begins 500
myocardial cells die each second
• Salvage myocardium
• Decreased incidence of CHF
• Maintain active lifestyles
 Infarct Caveats

• Anterior Wall MI
– most lethal (highest mortality)
– can suddenly develop, CHB, VF or VT
– if seen with hemiblocks or BBB, place quick
combo pads on the patient and prepare for
the worst
– can extend to septum (anteroseptal) or lateral
(anterolateral)
– nitrates are great, fluids are spared
114
 Infarct Caveats

• Inferior MI
– Most common seen. Can be fatal
– 50% have posterior and right ventricle involved
– Patients may have bradycardia and hypotension
– Could also have 1st degree or Mobitz 1 blocks
– Nausea is common, phenergan or compazine
– Use nitrates with caution, may need fluids

115
 Infarct Imitators

• Left Bundle Branch Block

– late depolarization makes ST
elevation difficult to distinguish
– LBBB considered a non-diagnostic
ECG
• Left Ventricular Hypertrophy
– won’t have reciprocal changes

• Early Repolarization
Benign early repolarization

(…but is it really benign?)

 Who gets it?
• 2-5% of the general population (Wellens,
2008)
• Usually the young and physically fit
• More prominent in African-Americans
• Generally disappears with advancing age

118
What does it look like?

Red arrows: concave up ST-segment elevation anteriorly

119
Blue arrows: hyperdynamic, symmetrical, concordant T-waves
Classic findings

1. J-point “notching”

2. Concave-up ST segment
(smiley face)

3. ST segment elevation
from baseline in V2-V5,
typically <3mm

4. Large, symmetrically
concordant T-waves in
leads with STE

120
 Can we tease it out?
• The degree of ST segment elevation is thought to
be indirectly proportional to the degree of
sympathetic tone

• In other words, the more relaxed the patient, the

more pronounced the ST segment elevation (and
vice versa)

• If you truly want to test your patient, get their

heart rate up and look at the ST segment

121
14yo M w/ palpitations

HR: 64
122
1. Notched J-point
2. Concave down ST
elevation in
precordial leads

123
Same patient after asking him to do 2min of jumping jacks in the room to try and
get his heart rate up…

HR 83 (up 20bpm from previous) 124

 HR 64 HR 83

The ST segment is NOT fixed in pts w/ BER and changes from EKG to EKG and with the
degree of sympathetic strain

On the right, note the complete resolution of the ST elevation but maintenance of the
J-point notching in V4

125
 Early Repolarization

• Should be a diagnosis of exclusion and should ALWAYS be

placed in clinical context!!!
• The above was taken in a patient with difficulty breathing and
chest pain…and is an Myocardial Infarction -- NOT Early
Repolarization!!! 126
 Pericarditis
• Pericarditis is an inflammation of the
pericardium (sac that surrounds the heart).
• This often occurs as a result of a viral
infection.
• However, this can cause severe chest pain and
can lead to ST elevation in all leads.
• Therefore, it is important to distinguish acute
pericarditis from acute myocardial infarction.

127
 Pericarditis
• Diffuse ST elevation

128
 Pericarditis
• PR segment depression, usually in lead II

129
 Pericarditis Treatment
• NSAIDs
• Colchicine
• Occasionally steroids

• Anticoagulation could cause a hemorrhagic

pericardial effusion – life threatening.

130
 Section 4
• ECG Tests are next!

131
ECG Quiz
 EKG #1

1. What is the rhythm?

a. V-Tach
b. A-Fib
c. A-flutter
d. normal 133
 EKG #2

1. What does this EKG represent?

a. pericarditis
b. myocarditis
c. digitalis effect
134
d. inferior wall ST-elevation MI
 EKG #3

1. What is the rhythm?

a. V-Tach
b. A-Fib
c. A-flutter
d. normal 135
 EKG #4

1. What does this EKG represent?

a. sius bradycardia
b. sinus tachycardia
c. 2nd degree AV block
136
d. complete heart block
 EKG #5

1. What does this EKG represent?

a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal 137
 EKG #6

1. What does this EKG represent?

a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
138
 EKG #7

1. What does this EKG represent?

a. V-fib
b. A-fib
c. Supraventricular tachycardia
d. normal
139
 EKG #8

1. What does this EKG represent?

a. V-fib
b. A-fib
c. A-flutter
d. V- tach
140
 EKG #9

1. What does this EKG represent?

a. V-fib
b. sinus bradycardia
c. complete heart block
d. sinus tachycardia 141
 EKG #10

1. What does this EKG represent?

a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
142
 EKG #11

1. What diagnostic test would be the best to order next?

a. Echo
b. CTA
c. Cath 143
 EKG #12

1. What therapy would be the best to order next?

a. Thrombolytic therapy
b. Emergent cath and PCI
c. Toradol IV 144
STEMI Alerts
Would You Activate the STEMI
Alert Team?

146
 YES!

• This is an large anteroseptal, anterior,

and anterolateral MI

147
Would You Activate the STEMI
Alert Team?

148
 NO!

• This is Pericarditis – inflammation of the

sac around the heart.
– Diffuse ST elevation
– PR segment depression
– Younger
– Recent viral syndrome
– Hurts worse with deep breaths or lying
down

149
Would You Activate the STEMI
Alert Team?

150
 YES!

• This is new-onset Left Bundle Branch

Block
• Also note the lateral ST elevation

151
Would You Activate the STEMI
Alert Team?

152
Previous ECG (from 2011)

153
 NO!

• This is a chronic Left Bundle Branch

Block
• Marker of CAD, heart valve disease, as
well as hypertension.

154
Would You Activate the STEMI
Alert Team?

155
 NO!

• This is a PACED rhythm!

• No interpretation of the ECG is possible.

156
Would You Activate the STEMI
Alert Team?

157
 NO!

• This is Early Repolarization.

– Early repolarization is a common ECG variant,
characterized by either terminal QRS slurring
(the transition from the QRS segment to the ST
segment) or notching (a positive deflection
inscribed on terminal QRS complex) associated
with concave upward ST-segment elevation
and prominent T waves in at least two
contiguous leads.

158
 NO!

• This is Early Repolarization.

– This benign ECG phenomenon is noted in 1%
to 2% of the adult population and generally
occurs in the absence of myocardial disease.
– People with this mostly consist of men, young
adults, athletes, and people of African American
heritage

159
160
161
Would You Activate the STEMI
Alert Team?

162
 YES!

• This is an inferior – posterior – lateral MI

163
Would You Activate the STEMI
Alert Team?

164
 YES!

• This is Ventricular Tachycardia – and

likely is related to MI

165
Would You Activate the STEMI
Alert Team?

166
 YES!

• This is an acute Anterior Wall MI with

Ventricular Bigeminy

167
Would You First Activate the
STEMI Alert Team?

168
 NO!

• Shock that!
• While MI may be the reason for Vfib, other
reasons also need to be excluded.
• Consider Hypothermia Therapy in route

169
Section 5

170
 Review of MHCA Protocols
• STEMI
• Stroke

171
 Goals for STEMI
• First Medical Contact (FMC) to PCI < 90 minutes
• Door to ECG time < 10 minutes
• Door In / Door Out Time < 30 minutes
• FMC to Non-PCI hospital to PCI < 120 minutes
EMS specific
• Ideal for all chest pain patients to have in-field
ECG
• Pre-hospital Activation of STEMI network
• Diversion to STEMI hospital
172
EMS Requirements

Equip all ambulances in state with ECG machines by 2012

Ambulance services should obtain EKG within 15 minutes for
 typical chest pain in anyone > 30 years, and
 atypical chest pain in all patients 50 and older
 EMS should interpret and transfer ECG to affiliated ED
 EMS personnel need training / certification in ECG interpretation
of STEMI

173
 ECG + Symptoms
• Chest pain,fullness, or
pressure
• Radiation to jaw, teeth,
shoulder, arm, or back
• Shortness of breath
• Epigastric discomfort
• Sweating
• Dizziness
• Cognitive impairment
174
EMS Requirements

 + EKG patients directly to PCI hospital if 90 minutes window

obtainable from first med contact to PCI AND patient is
hemodynamically stable
 + EKG patients directly to PCI hospital if 90 minutes window
obtainable from first med contact to PCI BUT patient is
hemodynamically UNSTABLE
 Go to nearest ED
 Activate Air Transport immediately for transfer to PCI center

175
EMS Requirements

 If no pre-hospital ECG available for a chest pain patient who

arrives at a non-PCI hospital
 Keep the patient on the EMS stretcher until ECG performed
 If EKG results + transfer to PCI hospital with SAME ambulance if
patient hemodynamically stable

176
STEMI Network (24/7) PCI Centers
Jackson South Haven
Baptist Memorial Hospital Desoto
St. Dominic
Corinth
MBHS Magnolia Regional Health Center
UMMC Vicksburg
CMMC River Region Hospital
Hattiesburg Greenville
Forrest General Hospital Delta Regional Medical Center
Wesley Columbus
Meridian Baptist Memorial Hospital Golden
Triangle
Jeff Anderson Hospital
Pascagoula
Rush Hospital Singing River Health Systems
Tupelo Gulfport
North Mississippi Medical Center Gulfport Memorial Hospital
Oxford McComb
Baptist Memorial Hospital North South West Regional Medical
Mississippi Center

177
 EMS Territorial Boundaries Broken

 It is imperative for EMS to be able to cross county lines

when necessary for reperfusion.
 EMS services should cross-cover for adjacent EMS in
another county.
 A “Heart Attack” should take priority over many non-
life threatening medical conditions.

178
179
 Goals for STEMI
• First Medical Contact (FMC) to PCI < 90 minutes
• Door to ECG time < 10 minutes
• Door In / Door Out Time < 30 minutes
• FMC to Non-PCI hospital to PCI < 120 minutes
EMS specific
• Ideal for all chest pain patients to have in-field
ECG
• Pre-hospital Activation of STEMI network
• Diversion to STEMI hospital
180
 Phases of EMS Management
of the Stroke Patient
• Activation of 911 system
• EMS response
• On scene assessment and stabilization
• Selection of appropriate destination
• Transport
• Pre-arrival stroke alert to receiving emergency
department (as early as possible)
• Delivery of patient and information
• PI feedback
181
 Scene Assessment
• General assessment
– Consider alternative causes of neurologic deficit
• Focused neurologic assessment to include FAST
– Face
– Arm
– Speech
– Time
• Sensitivity 80%/specificity 30%
• Time of onset - may not be available at hospital

182
183
 Treatment
• Stabilization
– Standard protocols (check vital signs, ECG,
glucose, hydration and treat as needed)
– Scene time should be minimized but prehospital
care should not be sacrificed for less scene time

184
 Select Appropriate Destination
• Transport to the nearest hospital with an
appropriate level of stroke care
– Level may vary as resources change
– Utilize knowledge of local facilities
• Window of opportunity – 4 ½ hours to
completion of fibrinolytic treatment (earlier
more effective than later)
• Useful time – 3 ½ hours until time of arrival at
stroke capable hospital

185
EMS Goals for Stroke

186
1) Initial assessment, transport ASAP:
ABCs ; Obtain time of symptom onset (Last time known well) _______; Source of information
________; Contact information _________.
2) Administer high concentration oxygen, as needed, to maintain O2 Sat >94 percent.
3) Position patient with head/shoulders elevated to 15-30 degrees (unless contraindicated).
4) Maintain NPO.
5) Blood glucose < 60, treat per protocol.
6) Do not treat high blood pressure without physician approval.
7) Perform Stroke Scale – Cincinnati Stroke Scale.
8) Transport patient to the appropriate facility:
a. Transport patient to the closest hospital capable of treating the patient with IV Alteplase
(Stroke Capable or Primary/Comprehensive Stroke Center). Hospitals not able to diagnose
and treat stroke patients (Level 4 hospitals) may be by-passed. EMS may use discretion based
on transport time or other unforeseen factors.
b. Consider transport of the stroke patient with severe symptoms (hemiplegia, aphasia, neglect,
stably intubated) to a Comprehensive Stroke Center if symptom onset to hospital arrival time
is greater than 3 hours and less than 6 hours.
c. Transport patient to the closest appropriate facility if unstable (e.g., cardiac arrest, unstable
airway).
9) IV NS KVO once en route.
10) EKG once en route.
11) Notify receiving facility of estimated arrival time of acute stroke patient, Stroke Scale finding, and
time of onset. 187
Section 6

188
 EMS Cardiac
Pharmacology

189
 Oxygen
• Indications
– Any suspected cardiopulmonary emergency
– Saturate hemoglobin with oxygen
– Reduce anxiety & further damage
– Note: Pulse oximetry should be monitored

190
 Oxygen
• Precautions
– Pulse oximetry inaccurate in:
• Low cardiac output
• Vasoconstriction
• Hypothermia
– NEVER rely on pulse oximetry!
– Too much oxygen can make some patients with
emphysema quit breathing

191
 Aspirin
• Indications
– Administer to all patients with ACS, particularly
reperfusion candidates
• Give 325 mg as soon as possible, non-coated preferred
– Blocks formation of thromboxane A2, which
causes platelets to aggregate

192
Anti-Platelet Actions

193
 Aspirin
• Precautions
– Many patients are allergic to aspirin – be sure to
ask!
– Does not provide blood thinning effects in all
people (aspirin resistance)
– Relatively contraindicated in patients with active
bleeding

194
 Thienopyridines
(Brilinta, Effient,Plavix)
• Indications
– Use as a second anti-platelet agent in patients
with ACS, particularly reperfusion candidates
– Blocks ADP activation of platelets
– Usually given as a bolus dose
• Brilinta – 180 mg (MHCA preferred agent)
• Plavix (clopidogrel) – 600 mg
• Effient – 60 mg

195
Anti-Platelet Actions

196
 Thienopyridine
• Precautions
– Plavix does not provide blood thinning effects in
all people (plavix resistance)
– Effient should not be given to patients with
previous stroke or TIA
– Relatively contraindicated in patients with active
bleeding

197
 Glycoprotein IIb/IIIa Inhibitors
• Indications
– Inhibit the glycoprotein IIb/IIIa receptor in the
membrane of platelets, inhibiting platelet
aggregation
– Can be used as an early second anti-platelet agent
rather than thienopyridines, especially in those
who can’t swallow or have nausea and vomiting.

198
Anti-Platelet Actions

199
 Glycoprotein IIb/IIIa Inhibitors
• Eptifibatide (integrilin)
– Within 10 minutes after bolus, > 90% of platelets
are inhibited
– Platelet function recovers within 4 to 8 hours after
discontinuation
– Dose
• 180 mcg/kg IV bolus, then 2 mcg/kg/min infusion

200
 Glycoprotein IIb/IIIa Inhibitors
• Precautions
– Integrilin (eptifibatide) is a derivative of snake
venom
– Use in precaution in those patients with previous
snake bites

201
 Heparin
• Indications
– Inhibits thrombin generation by factor Xa
inhibition and also inhibit thrombin indirectly by
formation of a complex with antithrombin III
– Exists in two forms
• Unfractionated
• Low molecular weight

202
 Unfractionated Heparin
• Dosing
– Initial bolus 60 IU/kg
• Maximum bolus: 4000 IU
• Check efficacy of dose with ACT
• Not always effective
– Continuous infusion at 800-1200 units/hour

203
 Low Molecular Weight Heparin
Lovenox (enoxaparin)
• Dosing in ACS in those proceeding to PCI or to
receive thrombolytics
– 30 mg IV
• Bolus is active for 3 hours

• Initial dosing in medically treated patients

– 1 mg/kg SQ
• Dose is active for 12 hours

204
 Heparins
• Precautions
– Contraindications: active bleeding; recent
intracranial, intraspinal or eye surgery; severe
hypertension; bleeding disorders;
gastroinintestinal bleeding
– DO NOT use if platelet count is below 100 000

205
 Nitroglycerin
• Indications
– Chest pain of suspected cardiac origin
– Unstable angina
– Complications of AMI, including congestive heart
failure, left ventricular failure
– Hypertensive crisis or urgency with chest pain

206
 Nitroglycerin
• What it does…
– Decreases pain of ischemia
– Increases venous dilation
– Decreases venous blood return to heart
– Decreases preload and cardiac
oxygen consumption
– Dilates coronary arteries
– Increases cardiac collateral flow

207
 Nitroglycerin
• What it does NOT do…
– Prevent heart attacks
– Save lives
– Limit infarct size

208
 Nitroglycerin
• Dosing
– Sublingual Route
• 0.3 to 0.4 mg; repeat every 5 minutes
– Aerosol Spray
• Spray for 0.5 to 1.0 second at 5 minute intervals
– IV Infusion
• Infuse at 10 to 20 µg/min
• Route of choice for emergencies
• Titrate to effect

209
 Nitroglycerin
• Precautions
– Use extreme caution if systolic BP <90 mm Hg
– Use extreme caution in Inferior and/or RV infarctions
– Suspect RV infarction with inferior ST changes
– Limit BP drop to 10% if patient is normotensive
– Limit BP drop to 30% if patient is hypertensive
– Watch for headache, drop in BP, syncope, tachycardia
– Tell patient to sit or lie down during administration

210
 Morphine Sulfate
• Indications
– Chest pain and anxiety associated with AMI or
cardiac ischemia
– Acute cardiogenic pulmonary edema (if blood
pressure is adequate)

211
 Morphine Sulfate
• Dosing
– 1 to 4 mg IV (over 1 to 5 minutes) every 5 to 10
minutes as needed

212
 Morphine Sulfate
• Precautions
– Administer slowly and titrate to effect
– May compromise respiration; therefore use with
caution in acute pulmonary edema
– Causes hypotension in volume-depleted patients

213
 Fibrinolytics
• Indications
– For AMI in adults
• ST elevation or new or presumably new LBBB; strongly
suspicious for injury
• Time of onset of symptoms < 12 hours
– For strokes in adelts
• Time of onset of symptoms< 4.5 hours

214
 Fibrinolytics
• Dosing
– For fibrinolytic use, all patients should have 2
peripheral IV lines
• 1 line exclusively for fibrinolytic administration

215
 Fibrinolytics
• Dosing for AMI Patients
– Tenecteplase (TNKase)
• Bolus 30 to 50 mg
– Alteplase, recombinant (tPA)
• Accelerated Infusion
– 15 mg IV bolus
– Then 0.75 mg/kg over the next 30 minutes
» Not to exceed 50 mg
– Then 0.5 mg/kg over the next 60 minutes
» Not to exceed 35 mg

216
 Fibrinolytics
• Dosing for Acute Ischemic Stroke
– Alteplase, recombinant (tPA)
• Give 0.9 mg/kg (maximum 90 mg) infused over 60
minutes
– Give 10% of total dose as an initial IV bolus over 1 minute
– Give the remaining 90% over the next 60 minutes
– Alteplase is the only agent approved for use in
Ischemic Stroke patients

217
 Fibrinolytics
• Precautions
– Specific Exclusion Criteria
• Active internal bleeding (except mensus) within 21 days
• History of CVA, intracranial, or intraspinal within 3
months
• Major trauma or serious injury within 14 days
• Aortic dissection
• Severe uncontrolled hypertension

218
 Fibrinolytics
• Precautions
– Specific Exclusion Criteria
• Known bleeding disorders
• Prolonged CPR with evidence of thoracic trauma
• Lumbar puncture within 7 days
• Recent arterial puncture at noncompressible site
• During the first 24 hours of fibrinolytic therapy for
ischemic stroke, do not give aspirin or heparin

219
 Amiodarone
• Indications
– Powerful anti-arrhythmic with activity in both
atria and ventricles; so that, this drug can be used
for atrial fibrillation and VT
– Can be used to prevent recurrent VF

220
 Amiodarone
• Dosing
– 150 mg bolus dose
• May repeat x 1
– Can also use continual IV infusion
• 1 mg/min x 6 hours, then
• 0.5 mg/min

221
 Amiodarone
• Precautions
– May produce vasodilation & hypotension
– May have negative inotropic effects
– Terminal elimination
• IV half-life lasts hours
• Oral half-life lasts up to 40 days

222
 Lidocaine
• Indications
– VT
– Vfib
– Frequent PVCs

223
 Lidocaine
• Bolus Dosing
– Initial dose: 1.0 to 1.5 mg/kg bolus IV
– May repeat bolus x 1 for refractory VF
– May also be given down ET tube

• Maintenance Infusion
– 2 to 4 mg/min IV continuous infusion

224
 Lidocaine
• Precautions
– Reduce maintenance dose (not loading dose) in
presence of impaired liver function or left
ventricular dysfunction
– Discontinue infusion immediately if signs of
toxicity (seizures, confusion) develop

225
 Atropine Sulfate
• Indications
– Should only be used for bradycardia
• Relative or Absolute
– Used to increase heart rate

226
 Atropine Sulfate
• Dosing
– 1 mg IV push
– Repeat every 3 to 5 minutes
– May give via ET tube (2 to 2.5 mg) diluted in 10
mL of NS

227
 Atropine Sulfate
• Precautions
– Increases myocardial oxygen demand
– May result in unwanted tachycardia or
dysrhythmia
– When given in low doses (<0.4 mg), can cause a
paradoxical bradycardia

228
 Dopamine
• Indications
– Second drug for symptomatic bradycardia (after
atropine)
– Use for hypotension (systolic BP 70 to 100 mm Hg)
with S/S of shock

229
 Dopamine
• Dosing
– IV Infusions (Titrate to Effect)
• Low Dose “Renal Dose"
– 1 to 5 µg/kg per minute
• Moderate Dose “Cardiac Dose"
– 5 to 10 µg/kg per minute
• High Dose “Vasopressor Dose"
– 10 to 20 µg/kg per minute

230
 Dopamine
• Precautions
– May use in patients with hypovolemia but only after
volume replacement
– May cause tachyarrhythmias, excessive vasoconstriction
– DO NOT mix with sodium bicarbonate

231
 Epinephrine
• Indications
– Increases:
• Heart rate
• Force of contraction
• Conduction velocity
– Peripheral vasoconstriction (raises blood pressure)
– Bronchial dilation

232
 Epinephrine
• Dosing
– 1 mg IV push; may repeat every 3 to 5 minutes
– May use higher doses (0.2 mg/kg) if lower dose is
not effective
– Endotracheal Route
• 2.0 to 2.5 mg diluted in 10 mL normal saline
– Profound Bradycardia
• 2 to 10 µg/min infusion (add 1 mg of 1:1000 to 500 mL
normal saline; infuse at 1 to 5 mL/min)

233
 Epinephrine
• Precautions
– Raising blood pressure and increasing heart rate
may cause myocardial ischemia, angina, and
increased myocardial oxygen demand
– Do not mix or give with alkaline solutions
– Higher doses have not improved outcome & may
cause myocardial dysfunction

234
 Diltiazem
• Indications
– To control ventricular rate in atrial fibrillation and
atrial flutter
– Use after adenosine to treat refractory PSVT in
patients with narrow QRS complex and adequate
blood pressure

235
 Diltiazem
• Dosing
– Acute Rate Control
• 10 to 20 mg (0.25 mg/kg) IV over 2 minutes
• May repeat in 15 minutes at 20 to 25 mg (0.35 mg/kg)
over 2 minutes
– Maintenance Infusion
• 5 to 15 mg/hour, titrated to heart rate

236
 Diltiazem
• Precautions
– Do not use calcium channel blockers for tachycardias of
uncertain origin
– Avoid calcium channel blockers in patients with Wolff-
Parkinson-White syndrome, in patients with sick sinus
syndrome, or in patients with AV block without a
pacemaker
– Expect blood pressure drop resulting from peripheral
vasodilation
– Concurrent IV administration with IV ß-blockers can cause
severe hypotension or heart block

237
 Question 1
• Which of the following is an adverse reaction
to nitroglycerin?
A) Hypertension
B) Hypotension
C) Lacrimation
D) Arrhythmias

238
 Question 1
• Which of the following is an adverse reaction
to nitroglycerin?
A) Hypertension
B) Hypotension
C) Lacrimation
D) Arrhythmias

239
 Question 2
• Which of the following must be given within
4.5 hours of the beginning of a stroke?
A. Thrombolytics
B. Anti-platelets
C. Heparin

240
 Question 2
• Which of the following must be given within
4.5 hours of the beginning of a stroke?
A. Thrombolytics
B. Anti-platelets
C. Heparin

241
 Question 3
• Which of the following agents is most
efficacious in the conversion of acute AF into
sinus rhythm?
a. Metoprolol
b. Digoxin
c. Amiodarone
d. Diltiazem
e. Esmolol
242
 Question 3
• Which of the following agents is most
efficacious in the conversion of acute AF into
sinus rhythm?
a. Metoprolol
b. Digoxin
c. Amiodarone
d. Diltiazem
e. Esmolol
243
 Question 4
• The following are true for aspirin, except:
a. Aspirin is indicated in combination with
warfarin in patients at high risk for mechanical
valve thrombosis
b. Clopidogrel should be administered to aspirin-
intolerant patients acutely with an STEMI
c. Aspirin is indicated in acute thrombotic stroke
d. Aspirin is FDA approved for primary
prevention of MI.
244
 Question 4
• The following are true for aspirin, except:
a. Aspirin is indicated in combination with
warfarin in patients at high risk for mechanical
valve thrombosis
b. Clopidogrel should be administered to aspirin-
intolerant patients acutely with an STEMI
c. Aspirin is indicated in acute thrombotic stroke
d. Aspirin is FDA approved for primary
prevention of MI.
245
 Question 5
• Appropriate upfront medical therapy in a
previously healthy 51 year old man having a
STEMI includes all of the following except:
a. Aspirin
b. Heparin
c. Lipitor
d. Brilinta

246
 Question 5
• Appropriate upfront medical therapy in a
previously healthy 51 year old man having a
STEMI includes all of the following except:
a. Aspirin
b. Heparin
c. Lipitor
d. Brilinta

247
 CONCLUSIONS
• Be constantly alert—patients can change in
seconds
• Know your drugs---use resources
• Remember that every drug, even OTC drugs,
have the potential to result in a serious
adverse reaction
 CONCLUSIONS

• Never leave the sending facility unless you feel

thoroughly comfortable with your patient and
with the medications you are being asked to
administer or monitor
 CONCLUSIONS

• Make sure that you are thoroughly prepared

for any complication
• Know where possible diversion hospitals are
located
• Use your EMS medical director whenever
necessary
Questions?
 The End
• Thank you for your time today in learning the
interpretation of ECGs.
• With your new knowledge and proficiencies,
patients of Mississippi are in better hands.

252