Cardiac Concepts: Review of the Lost Chapters

Blaze Amodei FP-C, CCP-C, TP-C Objectives

• Basics review of cardiology and electrophysiology for the prehospital clinician • The “false paradigm of a STEMI/NSTEMI dichotomy” • 30,000 ft view of OMI/NOMI pattern presentation • HAVE FUN

“In every situation, do what is right for the patient.” -Dr. John L. McDonald Review the Basics

• Anatomy of the Heart • Chambers, vessels, and valves • Conduction system

• Basic ECG • Einthoven’s Triangle, calibrations, Hexaxial reference plain • Vectors and Axis (Why does it mater) • P wave, QRS, w/ intervals durations

Einthoven’s Triangle & Hexaxial reference plain

• Lets math it out and look at the camera angles Calibration

Standard calibration: 10mm/mV @ 25mm/sec ECG tracing

STEMI vs. NSTEMI

Only STEMI needs emergent cathertization right?

OMI or NOMI, that is the Question….

Location, location, location… Sensitivity & Specificity

• Classic Criteria • LBBB/Paced Rhythms (SMSC) • New RBBB w/ LAFB • RV Infarction • Posterior Wall MI • High Lateral MI • D-Winter • aVR (Who knew….?) • Hyper Acute T Waves • Wellens Phenomenon • Transient STEMI and/or Unrelieved pain w/NSTEMI RBBB and LBBB RBBB -The heart rhythm must originate above the ventricles (i.e. sinoatrial node, atria or atrioventricular node) to activate the conduction system at the correct point. -The QRS duration must be more than 100 ms (incomplete block) or more than 120 ms (complete block) -There should be a terminal R wave in lead V1 (e.g. R, rR', rsR', rSR' or qR) -There should be a slurred S wave in leads I and V6

LBBB -The heart rhythm must be supraventricular in origin -The QRS duration must be ≥ 120 ms[2] -There should be a QS or rS complex in lead V1 -There should be a notched ('M'-shaped) R wave in lead V6.

Fasicular blocks

LAFB: LPFB: LAD RAD q1 r3 r1 q3 I up I down II down II biphasic/up III down III up

Pacemakers • Indications: • : Symptomatic sinus , sick sinus syndrome • Conduction disturbances: 2nd type II or 3rd degree heart blocks • Tachyarrhythmias: A-fib and VT

• Types: • Permanent (Implanted) • Temporary: Transcutaneus, transvenous, Transthoracic

Chambers paced: Chambers sensed: Mode of response: A: Atria O: None O: None V: Ventricles A: Atria I: Inhibited D: Dual V: Ventricles T: Triggered D: Dual D: Dual

Wellens’ Syndrome: A look at a widow maker

Indicates LAD and coronary artery stenosis Don’t let BTWI fool you! 1. There is a relatively short QT interval (QTc < 425ms) 2 Types: 2. The leads with T-wave inversion often have very Symmetric deeply inverted T waves in V2 and V3 distinct J-waves. Biphasic T waves in V2 and V3 (less common) 3. The T-wave inversion is usually in leads V3-V6 (in contrast to Wellens' syndrome, in which they are V2-V4) 4. The T-wave inversion does not evolve and is Either of the 2 T wave abnormalities described. generally stable over time (in contrast to Wellens', History of chest pain. which always evolves). Normal / minimally elevated cardiac enzymes. 5. The leads with T-wave inversion (left precordial) No pathological Praecordial Q waves. usually have some ST elevation Minimal / no ST elevation. 6. Right precordial leads often have ST elevation typical of classic early repolarization No loss of precordial R waves. 7. The T-wave inversion in leads V4-V6 is preceded by minimal S-waves 8. The T-wave inversion in leads V4-V6 is preceded by high R-wave amplitude 9. II, III, and aVF also frequently have T-wave inversion.

Winter is coming…. De Winter T waves

Anterior STEMI equilvant without obvious ST elevation changes KEY: ST depression and peaked T waves in the precordial leads.

Diagnostic Criteria

-Tall, prominent, symmetric T waves in the precordial leads -Upsloping ST segment depression >1mm at the J-point in the precordial leads -Absence of ST elevation in the precordial leads -ST segment elevation (0.5mm- 1mm) in aVR -“Normal” STEMI morphology may precede or follow the deWinter pattern

Hyper Acute T waves

T waves should not exceed 10mm in precordial leads and 5 mm in hexaxial leads but the ratio is what counts.

Immediately after coronary artery occlusion (and reperfusion) T wave amplitude increases as the first significant finding (If any one lead has a QRS to T wave ratio greater than 0.36, it is acute STEMI with equal accuracy. False negatives had a long time between symptom onset and ECG, so that the T-wave was no longer tall.) aVR: What is it good for?

Previously thought elevation in aVR with diffuse depression = LM occlusion When data in not communicated appropriately…. 1) in patients with recognized STEMI (due to coronary occlusion, usually of the LAD) and is associated with higher mortality than in patients without STE in aVR and 2) in patients without ischemic ST elevation, in which case there is always diffuse ST depression of subendocardial (which can be due to supply-demand mismatch or due to ACS).

If due to ACS, this STE in aVR is associated not only with acute LM insufficiency, but alternatively with 3 vessel disease, or with LAD insufficiency. Smith Modified Sgarbossa criteria

- Concordant ST-segment elevation ≥ 1 mm in any lead (other than V1-V3)

- Concordant ST-segment depression ≥ 1 mm in lead V1 – V3

- Discordant ST/S Ratio > 0.25

Misdirections • BER: Benign Early Repolarization • LVH: Left (Sick Gains Bro!) • • LV anuerysm • Electrolyte Abnormalities (Goldilocks was just right) • SVT with aberrancy • Artifact or wandering baseline • WPW and conduction abnormalities • • Neurocritical care BER: Benign Early Repolarization

-Widespread concave ST elevation, most prominent in the mid- to left precordial leads (V2-5). -Notching or slurring at the J-point “Fish Hook”. -Prominent, slightly asymmetrical T-waves that are concordant with the QRS complexes (pointing in the same direction). -The degree of ST elevation is modest in comparison to the T-wave amplitude (less than 25% of the T wave height in V6) -ST elevation is usually < 2mm in the precordial leads and < 0.5mm in the limb leads, although precordial STE may be up to 5mm in some instances. -No reciprocal ST depression to suggest STEMI (except in aVR). -ST changes are relatively stable over time (no progression on serial ECG tracings).

Questions? Thank YOU! If you would like references or additional resources I can link up with you offline References • Pendell Meyers. EMCrit Podcast 250 – The OMI Manifesto Lecture by Pendell Meyers. EMCrit Blog. Published on June 27, 2019. Accessed on July 18th 2019. Available at [https://emcrit.org/emcrit/emcrit-podcast-250-the-omi-manifesto-lecture- by-pendell-meyers/ ]. • Scott Weingart. EMCrit Podcast 147 – Who Needs an Acute PCI with Steve Smith (Part II). EMCrit Blog. Published on April 12, 2015. Accessed on July 18th 2019. Available at [https://emcrit.org/emcrit/who-needs-an-acute-pci-ii/ ]. • Smith, S. (2012, January 5th). ECG Diagnosis of Acute STEMI-Equivalent in the Presence of Left . Retrieved from https://vimeo.com/34634434. • Smith, S. (2016, August 8th). Lecture: Acute Coronary Syndromes, Part (Overview and Non-STE-ACS) and Part 2 (STEMI) Retrieved from http://hqmeded-ecg.blogspot.com/2016/08/lecture-acute-coronary-syndromes-part.html. • Mehta et al. Early versus delayed invasive intervention in acute coronary syndromes. The New England journal of medicine 2009;360:2165-75. The TIMACS (Timing of Intervention in ACS) Trial. • Amsterdam et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;130:e344-426. • Macfarlane et al. Age, sex, and the ST amplitude in health and disease. J Electrocardiol. 2001;34 Suppl:235-41. (PMID:11781962) • Smith et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation . Ann Emerg Med. 2012;60:45-56. • Schmitt et al. Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel: limitations of ST-segment elevation in standard and extended ECG leads. Chest. 2001 Nov;120(5):1540-6. (PMID: 11713132) Ventilation Management

Casey Brown, FP-C REACH Air Medical Services Objectives

• Learn the basic functions of the ventilator

• Explain why this is a powerful tool in the critical care arsenal

• Give a hands-on demonstration and comparison between an Ambu-bag and ventilator. Ventilator ZOLL 731 Series Zoll 731 - Functions

• https://www.zoll.com/medical-products/ventilators/emv-plus

• Compressor driven

• SpO2 and EtCO2 pleth wave

• CPAP or BIPAP functions in NIPPV mode Zoll 731 – Functions; continued

• O2 Source – Used with high or low flow oxygen – Increases tank usage time

• Can deliver up to 100% FiO2 with each breath

• Approximately 10 hour run time – 2-hour charge for a 90% battery recharge Why Use a Ventilator? Ventilator Use

• Extra set of hands • Allows for critical care – Medication administration – Titration – Compressions – OG/NG tube placement – Tracheal suction – Etc. • Precise and volume-controlled breath Ventilator Use, continued

• Deliver prescribed FiO2%

• Respiratory rate

• Airway compliance monitoring – PIP measurements Ventilator Use, continued

• Ventilate 5kg - >160kg • NIPPV or CPAP/BIPAP • Ventilate special patients – ARDS – Sepsis – Facial Trauma – Barotrauma – ALL KINDS OF PATIENTS!! • So we ask ourselves, “why not use a ventilator?” Can Your AMBU Bag Do That? • Ambu bag • Zoll 731 Basics of the Zoll 731 Basics of Zoll 731, continued

• SpO2 pleth wave with HR

• EtCO2 pleth wave with FiO2, PIP and PEEP

• Vt (set) and RR

• Mode What do the Abbreviations Mean?

• SpO2 • Vt • EtCO2 • Vte • FiO2 • RR • PIP • Vm • PEEP • SIMV Putting It All Together

• Effective Ventilation needs adequate – PIP – Vte – PEEP – FiO2 – RR • Without a good RR • Without PEEP and FiO2 – No ventilation • No oxygenation • Without Vt • No air movement References:

• https://www.zoll.com/-/media/public- site/products/ventilators/ems_emv_specsheetep_00 95.ashx?la=es- es&hash=DD95835C9EB0743CC1A07C173D41C4A49 318078A • https://api.zoll.com/-/media/public- site/products/ventilators/9650-002360-01-sf_a.ashx • http://www.rcjournal.com/guidelines_for_authors/s ymbols.pdf It is Time to Practice!