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stemi on ekg

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kathy okinaga

on 16 January 2016

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Transcript of stemi on ekg

And one more thing...
12 lead EKG
ST elevation
II,III,AVF
inferior
STEP 3
STEP 1
STEMI

in 2 or more contiguous leads
>2 inV2-V3 (>1.5 in women)
>1mm in others

V2-V4
anterior
Common Terminologies

RCA
right coronary artery
LM
left main
left coronary artery
LAD
-left anterior descending
Cx-
circumflex
Cath report
for answer

st elevated myocardial infarction
Activity
I,AVL,V5,6
lateral
STEP 2
associate region & vessel
anterior-LAD
inferior-RCA
lateral-Cx
http://www.ecglibrary.com/ami.html
http://www.ecglibrary.com/infmi.html
http://www.ecglibrary.com/highk.html
http://www.ecglibrary.com/postlat.html
reciprocal changes
70% inferior
30% anterior
when present rules out early repolarization
when absent does not rule out STEMI
General EKG Changes suggestive of Ischemia

Electrocardiogram may be completely normal
ST Elevation or ST depression
Over 1 mm ST changes that are transient with symptoms
Summed ST deviation (sum of affected leads) >2.5 mm
Holmvang (2003) J Am Coll Cardiol 41:905-15
Deep symmetric T-wave inversion
Occurs in multiple precordial leads
Left main Coronary Artery stenosis marker
aVR ST segment elevation > V1 ST segment elevation
Gaitonde (2003) Am J Cardiol 92:846-8
GHS critical value policy
THE BIG ONE!
practice with cheat sheet
precath
postcath
ALWAYS!
compare
any ecg
with st elevation.................
nstemi
chest pain
changes
anatomical
relationship
V1V2
septal MI-LAD branch
posterior MI-RCA/Cx
RV infarct
prox RCA
40% of all inf mi
higher mortality rate
BP, JVD, clear lungs
50% MORTALITY
How is bp treated in an acute MI?
V1,V2
septal
posterior (depression)
MI & = !
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122768/
references
http://www.ecglibrary.com/infmi.html
case study
On a 12 lead ecg...
what's the difference between an inferior mi with reciprical changes & an inferior/posterior mi?
http://www.aafp.org/afp/1999/1015/p1727.html
STEMI s/p stent LAD,
plan 'work on RCA' next week
pt has cont increasing ache 2/10-3/10 when awake,
not like the heart attack
when asleep bp 85/60 hr 45
RV (only 40%)
relative V2-V3 depression
LV-inferior/posterior (other 60%)
V2 depression > 1/2 amp AVF
TABLE 3*
Effects of Right Ventricular Ischemia

Systolic RV dysfunction ⇒
↓ RV CO ⇒ ↓ LV CO
RV dilatation
↑ RV volume ⇒ septal shift

Diastolic RV dysfunction ⇒ ↓ compliance ⇒
↑ RVDP ⇒ septal shift ⇒ ↓ LVDP ⇒ ↓ LV CO
↑ RAP ⇒ ↓ septal shift ⇒ ↓ LAP ⇒ ↓ LV CO
PDA-determines dominance
http://www.ecglibrary.com/infmi.html
70% RCA
20% codominace
10% Cx
An acute inferior wall transmural myocardial infarction presents with the changes in leads 2, 3, and aVF (show ECG 6).
Reciprocal ECG changes occasionally are observed during the initial period of the acute infarction, presenting with ST segment depressions in leads V1 to V3, 1, or aVL.
The ST segment changes in the precordial leads are not reciprocal in some cases, but represent true posterior wall involvement (which may be diagnosed by ST elevation in leads V7 to V9) [1] or involvement of the right ventricle (which may be diagnosed by ST elevations in right precordial chest leads). (See "Right ventricular myocardial infarction").

limb leads


precordial
I AVR
V1 V4
II AVL
V2 V5
III AVF
V3 V6
precath post cath
STUNNED RV
decreased preload
What's the best lead to use
for monitoring st elevation?

FRONTAL

HORIZONTAL


CHB
2nd degree HB type II
LV dysfunction
Pulmonary edema
Cardiogenic shock-10%


brady arrythmias
2nd degree HB type I
nausea/vomiting
hypotension
bipolar unipolar
hypotension
decreased urine output
AMS.....
SOB
crackles
decreased urine output
increased oxygen requirements
Is it ok to give NTG with an inferior MI?

Describe the GHS critical values policy as it relates to the ‘Acute MI’ result and the responsibilities of the RN related to this policy.

1. Recognize ecg changes of an acute myocardial infarction as well as the expected evolution of these changes

2. Associate the contiguous ecg leads with the anatomical region of injury, in order to differentiate symptoms and appropriate treatment for the different types of MI

3.Correlate the ekg findings with the cardiac cath lab results and apply these to individual patients
Early inferior STEMI:

Hyperacute (peaked) T waves in II, III and aVF with relative loss of R wave height.
Early ST elevation and Q-wave formation in lead III.
Reciprocal ST depression and T wave inversion in aVL.
ST elevation in lead III > lead II suggests an RCA occlusion; the subtle ST elevation in V4R would be consistent with this.

Note how the ST segment morphology in aVL is an exact mirror image of lead III. This reciprocal change occurs because these two leads are approximately opposite to one another (150 degrees apart).

The concept of reciprocal change can be further highlighted by taking lead aVL and inverting it… see how the ST morphology now looks identical to lead III.
20% Inferior MI develope bradycardia
RCA occlusion
sa nodal artery
av nodal artery
Increased vagal tone
what do you look for?
why do we need to know this?
how to use cath lab report?
How can you estimate
the extent of damage ?
Lesions in the proximal part of a vessel can result in more damage than lesions in the very distal portion
Major vs minor vessel
Location of the lesion
Left ventriculogram

Hypokinesia- decreased but not absent motion of a ventricular segment
Dyskinesia- paradoxical expansion or wall motion usually due to tethering from the adjacent segments
Akinesia - complete absence of wall motion
Left Ventricular function
EF
50-70%
EDP
-end diastolic function
direct measurement of preload
PCW indirect measurement
Cheat sheet
1
2
4
5
6
7
8
9
11
12
10
13
14
15
16
16
17
18
19
inferior
anterior
lateral
3
J-point elevation
Early Repolarization
Injury
1. 2. 3. ?
1.2.3.?
1. 2. 3. ?
1.2.3.?
1.2.3.?
ECG is a 3D picture of the heart
street view only


http://www.ecglibrary.com/postlat.html
OBJECTIVES
http://emedicine.medscape.com/article/157961-overview#a0104
Bezold-Jarisch reflex
VS decreases infarct size and inflammatory markers during ischemia/reperfusion independent of the heart rate.

WALL FUNCTION
Extra stuff...just for fun!!
Applying ECG & cath result
to the patient
ACC 2014
Treatment depends on the type of MI
INFERIOR
ANTERIOR
where do we look ?
http://www.fpnotebook.com/cv/CAD/ElctrcrdgrmInMycrdlInfrctn.htm
concave
convex
Lanza, 2001 CCN
Full transcript