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Mod I-12 Lead Ekgs
Mod I-12 Lead Ekgs
ECRN CE
12 Lead EKG’s
Mod I 2009 CE
Prepared by:
Sharon Hopkins, RN, BSN
Objectives
Upon successful completion of this module,
the ECRN will be able to accomplish the
following:
Identify the appropriate components of the
cardiac conduction system with the correct
wave form on a rhythm strip.
Identify when it is appropriate to obtain an EKG
Identify the criteria for significant ST elevation.
Identify EKG leads that view the anterior,
inferior, lateral walls, and septum
Objectives
Recognize the patterns of an MI after viewing the
components of a 12 lead EKG
Identify typical and atypical presentations of AMI
Identify complications associated with an inferior wall MI
Identify complications associated with an anterior/septal
wall MI
Identify complications associated with a lateral wall MI
Identify interventions for complications related to heart
block, pulmonary edema, and cardiogenic shock
Identify the SOP guidelines for the patient presenting with
acute coronary syndrome as written in the Region X
SOP’s
Objectives
State dosing and precautions for Aspirin,
Nitroglycerin, and Morphine in the Region X SOP’s.
Identify ED staff expectations of EMS personnel when
calling the hospital to report a patient with ST
elevation identified on a 12 lead EKG
Identify EMS expectations when delivering a patient
to a hospital after ST elevation has been identified on
a 12 lead EKG
Given a picture, correctly trace the order of the
cardiac conduction system.
Given a picture, correctly identify electrode placement
to obtain a 12 lead EKG.
Why Are We doing Pre-hospital
EKG’s?
Early recognition and fast, appropriate
treatment can prevent the extension of an
MI
5
Purkinje
fibers
EKG Waveforms
P wave represents atrial stimulation
P wave is rounded and upright
PR interval
Includes the P wave and the isoelectric PR
segment
PR interval is the time it takes for an impulse
to travel from the SA node through the
internodal pathways toward the ventricles
Includes delay time in the AV node
Normal PR interval is 0.12 – 0.20 seconds
PR
Interval
Normal
0.12 –
0.20
seconds
PR Interval Abnormalities
PR interval <0.12 seconds
Impulse did not begin in the normal
pacemaker site of the SA node but
somewhere in the atria
PR interval >0.20 seconds
There was a longer than normal delay
transmitting the impulse through the AV node
A change in the PR interval measurement
generally will not make the patient symptomatic
EKG Wave Forms cont’d
QRS complex
Consists of the Q, R, and S waves collectively
Represents ventricular depolarization or discharge of
electrical energy throughout ventricular muscle
Larger than the P wave because ventricular
depolarization involves a larger muscle mass than
atrial depolarization
Palpation of a pulse is generated by ventricular
depolarization (seen as the QRS complex)
Normal timing usually considered between 0.06
and 0.11 seconds
Normal is less than 0.12 seconds
QRS Complex
QRS
QRS Complex Measurement
From beginning of Q wave – usually fairly
straight forward
Stop measurement at end of S wave; not
necessarily where QRS intersects baseline
On S wave, watch for small notch or other
indicator that electrical flow is changing
Not always so easy to determine stop point
Do not include ST segment or T wave
Abnormally wide QRS indicates delay in
conduction time through the ventricles
EKG Wave Forms cont’d
T wave
Represents ventricular repolarization
Repolarization is the phase of electrical activity
where electrical charges (influenced primarily by
sodium (Na+) and potassium (K+)) return to their
original state and prepare to respond to the next
electrical charge received
2nd ICS
3rd ICS
Precordial
leads
12 Lead EKG Printout
Standard format 81/2 x 11 paper
12 lead format:
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II aVL V2 V5
V3 V6
III aVF
Lateral View – I, aVL, V5, V6
V5
aVL
V6
Inferior View – II, III, aVF
II
III aVF
Septal View – V1 & V2
V1
V2
Anterior View – V3 & V4
V4
V3
Myocardial Insult
Ischemia
lack of oxygenation
ST depression or T wave inversion
permanent damage avoidable
Injury
prolonged ischemia
ST elevation
permanent damage avoidable
Infarct
death of myocardial tissue; damage permanent; may have
Q wave
Why A Pre-hospital EKG?
EMS looking for ST segment elevation
Indicates injury that can be reversible if found
early and acted upon early
TIME IS MUSCLE
The earlier the discovery of an acute cardiac
event, the quicker the patient can receive the
most appropriate care
EKG’s sent to the ED before patient arrival
allows for the right personnel to be available to
properly care for the patient in the most time
efficient manner
What Does EMS Have to Do?
Obtain a 12 lead EKG
EMS to evaluate the leads as they are
sending the 12 lead to the ED
Identify for the presence or absence of ST
elevation
EMS to report what they see, not just what
is printed on the machine copy of the EKG
Upon arrival, EMS to hand a copy of their
12 lead to the ED staff while they give
bedside report
Evaluating for ST Segment
Elevation
Locate the J-point
Identify/estimate where the isoelectric line
is noted to be
Compare the level of the ST segment to
the isoelectric line
Elevation (or depression) is significant if
more than 1 mm (one small box) is seen in
2 or more leads facing the same
anatomical area of the heart
(ie: contiguous leads-see slide #41, #42)
The J Point
Concave
shape is
usually
benign
especially if
patient is
asympto-
matic
Significant ST Elevation
ST segment elevation measurement
starts 0.04 seconds after J point
ST elevation
> 1mm (1 small box) in 2 or more contiguous chest
leads (V1-V6)
>1mm (1 small box) in 2 or more anatomically
contiguous leads (ie: II, III, aVF; I, aVL, V5, V6)
Contiguous lead
limb leads that “look” at the same area of the heart or
are numerically consecutive chest leads (ie: V1 – V6)
Contiguous Leads
Lateral wall: I, aVL, V5, V6
Inferior wall: II, III, avF
Septum: V1 and V2
Anterior wall: V3 and V4
Posterior wall: V7-V9 (leads placed
on the patient’s back 5th intercostal
space creating a 15 lead EKG)
Evolution of AMI
A - pre-infarct (normal)
B - Tall T wave (first few
minutes of infarct)
C - Tall T wave and ST
elevation (injury)
D - Elevated ST (injury),
inverted T wave (ischemia),
Q wave (tissue death)
E - Inverted T wave
(ischemia), Q wave (tissue
death)
F - Q wave (permanent
marking)
ST Segment
Elevation
EKG monitoring
Evaluates electrical activity of the heart
Can indicate myocardial insult and location
ischemia - initial insult; ST depression seen
injury - prolonged myocardial hypoxia or
ischemia; ST elevation seen
infarction - tissue death
dead tissue no longer contracts
amount of dead tissue directly relates to
degree of muscle impairment
may show Q waves
Contiguous ECG Leads
EKG changes are
significant when they
are seen in at least two
contiguous leads
Lead II aVL V2 V5
Inferior wall Lateral wall Septum Lateral wall
Common signs/symptoms:
Generalized weakness
Generalized feeling of not being well
Syncope
Lightheadedness
Change in mental status
Region X SOP – Acute Coronary
Syndrome
A 12 lead EKG is obtained on all patients
presenting with signs and symptoms of
acute MI
OR
For patients where suspicions are raised
that the patient may be experiencing an
acute MI (ie: heart block)
12-Lead Electrode Placement
Region X SOP – Acute Coronary
Syndrome
Determine if the patient is stable or
unstable to proceed with interventions
Easiest way to determine stability is to
evaluate blood flow
What is the level of consciousness?
What is the blood pressure / is there a radial
pulse?
Remember: A B/P reading of 100/systolic
does not necessarily indicate the presence
or absence of symptoms
Oxygen
In the presence of an acute MI, the
myocardium is being deprived of blood
flow and therefore adequate oxygen levels
Provide what the patient needs
Evaluate each individual clinical
presentation
All patients deserve some form of oxygen
in this early period of myocardial starvation
for it
Aspirin
Used to prevent platelet aggregation
When a plague ruptures, chemicals are released.
Platelets congregate to the area to seal the rupture.
Platelet aggregation further increases the degree of
vessel blockage.
Field dosage is 4 – 81 mg (324 mg total) baby
aspirin chewed
Chewing breaks down the aspirin and allows for faster
absorption
Give dose if patient not reliable about taking
their own dose or has not taken any aspirin
Nitroglycerin
Venodilator
Improves coronary blood flow
By dilating blood vessels, pools blood away
from the heart which decreases preload. This
decreases the work load of a stressed heart.
Carefully monitor blood pressure before and
after dosages
Field dosage is 0.4 mg tablet sl
Dosage can be repeated in 5 minutes if blood
pressure remains stable
FYI: Pain level will not drop to “0” until the clot
is removed
For CMC EMS System Participants
If the patient is <35 years of age
Follow Acute coronary Syndrome SOP by
administering aspirin
Medical Control contacted prior to
administration of nitroglycerin or morphine
There should be no delay in obtaining a 12 lead
EKG in the field and transmitting it to the ED
A visual interpretation is to be given during
report to the receiving hospital even when the 12
lead EKG is faxed in
Morphine
CNS depressant to reduce anxiety
Venodilates blood vessels to reduce the
volume of blood returning to the heart to
decrease the heart’s workload
Field dosage is 2 mg slow IVP
Dosage started when the 2nd dose of
nitroglycerin proves ineffective
Dosage may be repeated every 2 minutes as
needed
Maximum dosage is 10 mg
Watch for hypotension
Receiving Hospital Report
When sending a 12 lead EKG, EMS to
inform the receiving hospital what
identifiers have been used
Department ID number
Patient sex (M / F)
Patient age
Any other identifier
EMS should always give their visual
interpretation of what they have observed
for ST elevation
Activating a Cardiac Alert
The ED activates a cardiac alert to prepare the
cardiac team to provide optimal care for the
patient
Typical cardiac alert team members
ED staff – MD, RN, tech, secretary
Cardiologist
Cath lab personnel
EKG tech (may be an ED staff member)
Lab tech
X-ray tech
Not all hospitals use all members in a formalized
team but all of these members are somehow
integrated into the care of the patient
When Does a Cardiac Alert Get
Called?
When EMS sends a 12 lead EKG with ST
elevation, the team gets activated
When EMS confirms what they see on the
12 lead, whether the EKG is sent or not,
may trigger a cardiac alert
There is a direct link in EMS accuracy,
completeness in patient report, and EKG
interpretation with pre-hospital activation
of the cardiac alert team
Transferring Care of The Patient to
The ED
Bedside report is restated to the ED
personnel in the room
The main report must be to an RN or MD
Rhythm strips and 12 lead EKG are
presented
Important to note positive and negative
changes in the patient condition
Pain level has decreased
Blood pressure has dropped
EKG Practice
Practice reviewing the following 12 lead
EKG’s for ST segment elevation
Evaluate the ST segment at the J point
Note: A peaked T wave is not equivalent
with ST elevation
Consider potential complications to
monitor for based on the location of the
acute MI
Vignette follows the 12 lead EKG picture
Practice Identifying ST Segment
Elevation