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Learning Station 1 Cardiovascular Emergencies Case 2

©1999 American Heart Association
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St Louis. MD. developed the early drafts of these materials. of Auburn. and Richard O. some of the creative illustrations from the excellent book by Tim Phalen The 12-Lead ECG in Acute Myocardial Infarction. MD. revised the material. MD.Acknowledgments Steve Anderson. They have generously donated these works to the American Heart Association. We have adopted. MSN. Mary Fran Hazinski. WA. RN. Cummins. 2 . John Field. 1996. with permission. MO: Mosby Lifeline.

Learning Objectives After completing this learning station you should be able to describe     Critical actions for treatment of ST-segment elevation in inferior leads ―Infarct localization‖ concept — using 12-lead ECG to locate involved cardiac area and coronary artery Critical actions to avoid (contraindicated) Treatment for inferior and right ventricular injury 3 .

HR = 80 bpm. marked JVD How would you approach this patient? 4 . BP = 80/60 mm Hg Physical exam: distressed. 60-Year-Old Professor: Severe Chest Pain Time = 8:55 AM       60-year-old professor arrives at ED via private car History: CAD. substernal chest pain Pain: lasting >20 min Vital signs: T = 96. RR = 30/min.7°F. clear chest.Case 2. multiple coronary bypass grafts Complaint: severe.

low BP continues  Differential diagnosis: check 12-lead ECG Combine with Ischemic Chest Pain Algorithm 5 . watch level of distress • JVD suggests CHF but lungs surprisingly clear  Circulation: rapid heart rate. noise of breaths  Breathing: listen to lungs.Approach to ACS Patients (Acute Coronary Syndromes) Follow the Secondary ABCD Survey:  Airway: observe air movement.

Approach to ACS Patients   Follow Ischemic Chest Pain Algorithm • Box 2: Immediate assessment (<10 min) • Box 3: Immediate general treatment (―MONA‖) • Box 4: Assess initial 12-lead ECG 12-lead ECG • In efficient ED: technician records 12-lead ECG per protocol whenever a ―chest pain‖ patient arrives 6 .

60-Year-Old Professor: Severe Chest Pain Time = 9:01 AM What is your interpretation of this 1st ECG? 7 .Case 2.

60-Year-Old Professor: Severe Chest Pain ST-segment elevation Interpretation: significant ST elevation in II. III.Case 2. and aVF What area of the heart is injured? 8 .

Associations Between Changes on 12-Lead ECG and Cardiac Anatomy I lateral aVR V1 septal V4 anterior II inferior aVL lateral V2 septal V3 anterior V5 lateral V6 lateral III inferior aVF inferior Now what are the associations between cardiac anatomy and specific coronary arteries? 9 .

V5-V6 10 Septal wall V1-V2 .Cardiac Anatomy in Relation to Coronary Artery Anterior wall V3-V4 Left main coronary artery Right coronary artery Circumflex artery Left anterior descending artery Lateral wall I. aVL.

aVF artery Posterior descending artery HOW TO GET RIGHT-SIDED ECG? 11 . NOTE 2: If there is acute injury in inferior leads (II. III. III.Posterior View of the Heart Circumflex artery (from left coronary artery) Posterior wall NOTE 1: Inferior wall supplied by either the right (85% to 90% of people) or left coronary artery. NOTE 3: KEY — you must obtain a RIGHTRight coronary SIDED ECG at once. unknown whether left or right coronary artery is blocked. aVF). Lateral wall Inferior wall Leads II.

Lead Placement for a Right-sided ECG V1 V2 V3R V6R V5R V4R 12 .

In the meantime do NOT give nitroglycerin or morphine.” Why? What do you look for in a right-sided ECG? 13 .ST-Segment Elevations in Inferior Leads You should ALWAYS respond with  “Must get RIGHT-SIDED ECG.

Right-sided 12-Lead ECG: Patient With Inferior ST-Segment Changes How do you interpret this ECG? 14 .

Right-sided 12-Lead ECG: Patient With Inferior ST-Segment Changes Lead V4R = diagnostic ST-segment elevation 15 .

Inferior MI vs Right Ventricular MI   Initial ECG: injury occurring in inferior heart • Distal left CA occlusion vs • Proximal right CA occlusion Right-sided ECG <4 minutes of 1st ECG: • >1 mm ST-segment elevation in leads over RV (V4R) • Diagnostic of right ventricular MI What is treatment intervention of choice now? What medications are contraindicated? What is best immediate treatment for low BP? 16 .

nitroglycerin) • RV exquisitely sensitive to RV filling: vasodilators cause profound drops in blood pressure.Summary: Treatment of RV MI   Therapeutic intervention of choice • Immediate catheterization: PTCA or stent placement • Thrombolytics not effective in R coronary occlusion What medications are contraindicated? • Avoid medications that vasodilate (morphine. even arrest 17 .

Summary: Treatment of RV MI  What is the best immediate treatment for low BP? • Rapid infusion of normal saline – Increases RV preload (stretch). recruits more Starling forces – Do not be timid: give volume quickly – Evaluate response frequently! – Remember: 1 can of Coke = 335 mL. Rapid infusion of 500 mL will not produce pulmonary edema 18 .