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TWELVE LEAD EKG

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nathan brooks

on 5 March 2016

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Transcript of TWELVE LEAD EKG

TWELVE LEAD EKG
After this class we will be refreshed with..
Basic Theory
EKG equipment and use of such equipment
Recognition of EKG rhythms and Arrhythmias
How to perform a 12 lead and use information obtained by test.
Protocols to follow when dealing with MI patients.

Lets refresh on our equipment...
LIFEPAK 15
EKG MONITOR/DEFIBRILATIOR W/ AED MODE.
20.1 LBS
8.4" Diagonal window
360 J capacity
NIBP - 20 seconds not including inflation time (>2 min will cancel bp.)
Co2 w/ apnea alarm and RR
10 cable ready for 12 lead
ANATOMY/PHYSIOLOGY
RECOGNIZING CARDIAC RHYTHMS
CONT.
COUPLET, BIGEMINY, TRIGEMINY, RUN!
The Theory
EKG PAPER RECOGNITION

LEAD PLACEMENT
RECOGNIZING CARDIAC RHYTHMS
Normal EKG
0.20sec
<0.12
OUR MOST COMMON RHYTHMS
Normal Sinus Rhythm
Sinus Arrhythmia
Atrial Rhythms
Junctional Rhythms
Idioventricular rhythms
NSR
sinus arrhythmia
Atrial fibrillation
supra-ventricular (SVT)
junctional
IVR
V-TACH
V-FIB
torsades de pointes
Premature Ventricular Contraction
PVCs are usually caused by electrical irritability in the ventricular conduction system or muscle tissue.Conditions that can disrupt electrolyte shifts include:
electrolyte imbalances, such as
hypokalemia, hyperkalemia, hypomagnesemia, and hypocalcemia
metabolic acidosis
hypoxia
myocardial ischemia and infarction
drug intoxication, particularly cocaine, amphetamines, and tri- cyclic antidepressants
enlargement of the ventricular chambers
increased sympathetic stimulation
myocarditis
caffeine or alcohol ingestion
tobacco use.
asystole
PAC
PJC
PVC
HEART BLOCKS
1st Degree AV block
Basic Principle
- in 1790, Luigi Galvani completed a circuit, placing dissimilar metals to the legs of a recently deceased frog, creating an electrical current and causing the frog legs to dance.
- in 1855, Kollicker and Mueller found that when a motor nerve of a frog leg was laid over its isolated beating heart, the leg kicked in sync with the heart beat.
- conclusion? the heart must have an electrical impulse which caused the leg to move.

- 1880, while using a "capillary electrometer", Ludwig and Waller discovered that a heart's rhythmic electrical stimuli could be monitored from a person skin.

Enter Dr. Willem Einthoven
- two skin sensors (electrodes) where placed on a man and were then connected to the ends of the silver wire, which ran between two poles of a magnet. The silvered portion of the wire pulsated with each heart beat.

- Einthoven then projected a tiny light beam through holes in the magnet, across the twitching silvered wire.
- the wires movements were recoreded as waves. P QRS T.
Third degree HB
Second degree HB Mobitz I
Second degree HB Mobitz II
TREATMENT
MOBITS I - Wenkebach; SYMPTOMATIC BRADYCARDIA, it is ok to use Atropine: 0.5mg IV
MOBITS II/ Third Degree HB: SYMPTOMATIC BRADYCARDIA;
TCP
-
NO ATROPINE
EINTHOVEN'S TRIANGLE
12 LEAD (VIEWS)
WHY?
front
front
Left
Left
Left
Left
RIGHT
RIGHT
DIRECTION
RIGHT
ICEMA: Protocol reference # 10100 (OLD PROTOCOL)
-Paramedics will obtain a 12 lead ECG in patients suspected of having acute coronary syndrome and provide treatment in accordance with this policy.
Chest or upper abdominal discomfort suggestive of acute coronary syndrome.
New onset cardiac dysrhythmias (including adult cardiac arrest if return of spontaneous circulation).
Unexplained syncope or near syncope.
Unexplained acute generalized weakness with or without diaphoresis.
Acute onset of dyspnea suggestive of congestive heart failure.
Other signs or symptoms suggestive of acute coronary syndrome.
May be considered in patients with stable tachycardia for diagnostic purposes.
Any atypical presentation of symptoms that may be a suspected anginal equivalent.
ST ELEVATION
ST Depression
T wave inversion












Premature Atrial Contraction
PACs, which commonly occur in a normal heart, can be triggered by alcohol, nicotine, anxiety, fatigue, fever, hypoxia, and infectious diseases.
not normally dangerous

Premature Junctional Contraction
PJCs may be caused by toxic levels of digoxin, excessive caffeine intake,
inferior wall myocardial MI
, rheumatic heart disease, valvular disease, hypoxia, heart failure, or swelling of the AV junction after heart surgery.
not normally dangerous
retrograde P wave may be seen.
Premature Beats
Atrial Flutter
ST Segments





POSTERIOR MI
Bundle Branch Block
AXIS DEVIATION
MISC. WAVE FORMS
Hypercalcemia Hypocalcemia









Early-Repolorization




Left Axis Deviation
Right Axis Deviation
Hemiblocks
PROTOCOLS
FIELD ASSESSMENT/TREATMENT INDICATORS
 Chest pain (typical or atypical).
 Syncopal episode.
 History of previous AMI, Angina, heart disease, or other associated risk factors.
ALS INTERVENTIONS
REFERENCE: 11060 Page 2 of 3
 Aspirin per ICEMA Reference #7040 - Medication - Standard Orders.
 Consider early vascular access.
 For patients with chest pain, signs of inadequate tissue perfusion and clear breath sounds, administer 300 ml NS bolus, may repeat.
12-Lead Technology:
 Obtain 12-lead ECG.
Do not disconnect 12-lead cables until
necessary for transport.
If signs of inadequate tissue perfusion or if inferior wall infarct is suspected,
obtain a right-sided 12-lead (V4R).

If right ventricular infarct (RVI) is suspected with signs of inadequate tissue perfusion,
consider 300 ml NS bolus, may repeat.
Nitrates
are contraindicated in the presence of RVI or hypotension.

With documented ST segment elevation in two (2) or more contiguous leads, contact STEMI base hospital for destination decision while preparing patient for expeditious transport, refer to ICEMA Reference #6070

Repeat 12-lead at regular intervals, but do not delay transport of patient. If patient is placed on a different cardiac monitor for transport, transporting provider should obtain an initial 12-lead on their cardiac monitor and leave 12-lead cables in place throughout transport.

 EMS field personnel shall ensure that a copy of the 12-lead ECG is scanned or attached as a permanent part of the patient’s ePCR or O1A and submit to ICEMA if patient is going to a SRC as a suspected STEMI.

Nitroglycerin per ICEMA Reference #7040 - Medication - Standard Orders. Utilize Fentanyl for pain control when Nitroglycerin is contraindicated.



Fentanyl per ICEMA Reference #7040 - Medication - Standard Orders.
Consider concurrent administration of Nitroglycerin with Fentanyl if there is no pain relief from the initial Nitroglycerin administration.
Contact base hospital for further Fentanyl orders.

Consider establishing a saline lock as a secondary IV site.

Make early STEMI notification to the STEMI Receiving Center.

In Radio Communication Failure (RCF), may administer an additional 100 mcg of Fentanyl in 50 mcg increments with signs of adequate tissue perfusion.
DRUG:
FENTANYL
TRADE NAMES;
Fentinil, Sublimaze,Actiq, Durogesic, Duragesic, Fentora, Matrifen, Haldid, Onsolis, Instanyl,Abstral, Lazanda
MOA:
Opiod Analgesic; 80-100 times more potent then Morphine.

SHORT ACTING



ACUTE PERICARDITIS






REGULAR
P - WAVE UPRIGHT






IRREGULAR WITH RESPIRATIONS
FOUND IN ACTIVE INDIVIDUALS.






FIBRILLATORY WAVES, NOT P WAVES
3:1 RESPONSE
LOW MAGNESIUM - LOW POTASSIUM
QUESTIONS



New Protocol 10190 (standing orders)
prior to medication
Coronary Syndrome
typical or atypical chest pain
syncopal epidode
hx of AMI or heart disease
other (Think of all possibilities)
Full transcript