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Enhanced 12-Lead ECG Interpretation (Multi-Lead Medics)

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Enhanced 12-Lead ECG Interpretation (Multi-Lead Medics) Enhanced Participant Workbook 1 Multi-Lead Medics" Enhanced 12 Lead ECG Interpretation Course Purpose of This Course The enhanced course is designed to show acute care providers how to get extra information from a 12 or 15 lead ECG allowing greater insight into the pathophysiology behind the patient with cardiac or other problems. The course is designed for those who have a strong working knowledge and high level of comfort with the basic concepts taught in the Multi-Lead Medics" Course. Participants should also be experienced in caring for cardiac patients in an emergency or critical care environment. Objectives: By the end of the course, the participant should be able to: # Demonstrate the ability to rapidly assess a 12 lead ECG for the following information: rhythm, axis and hemiblock bundle branch block, and AMI location. # Using a table, formula and morphology clues, determine which patients with a LBBB could be having and MI. # Describe different criteria for determining the presence of Left and Right Ventricular Hypertrophy and the presence of strain. # Using various criteria, identify cases of LVH and RVH on 12 lead ECG. # Describe the clinical significance in LVH. # Identify criteria suggestive of right and left atrial enlargement. # Describe ECG changes associated with drug and electrolyte disturbances such as the digitalis effect, hyper and Hypokalemia, hyper and hypocalcemia, and the clinical implications of these conditions. # Describe the potential implications of a prolonged QT interval. # Identify ECG changes that could indicate conditions such as pericarditis, acute pulmonary embolism and early repolarization variant. # Identify ECG changes that could indicate acute coronary syndromes such as subendocardial (non-q wave) infarction. REVIEW of BASIC MLM CONCEPTS 1. First name the rhythm; In wide complex tachycardia, use the VT criteria. 2. Once you are certain the rhythm is not ventricular, determine the presence of axis deviation and hemiblock. 3. Next, determine the presence of bundle branch block. 4. Finally, using the ISAL method, determine the infarct location and reciprocal changes. Use the 15 lead to cover the right ventricle and posterior walls. These 4 steps are designed to provide you with important information for the acute management of the cardiac patient. The enhanced segment of this course will present the not-so-acute and not-so-obvious aspects of 12-lead ECG interpretation. !1999 Multi-Lead Medics! Enhanced Participant Workbook 2 LBBB and Acute MI: An Enigma inside a Dilemma In the basic MLM class you learned that an AMI is difficult to diagnose in the setting of a left bundle branch block. This meant that although a person is presenting with the signs and symptoms of an AMI, the ECG evidence is inconclusive. Therefore, treatment may be delayed until enzyme tests or an old 12 lead is found. Facts about a Left Bundle Branch Block: ! Higher mortality than RBBB or no BBB ! Most often seen in large anterior MI’s ! They have lower ejection fractions (< 50% when QRS is >170ms) ! They have higher left ventricular end diastolic pressures (LVEDP) ! They have poorer global LV function ! ISIS II showed AMI with LBBB had higher mortality when not treated with a thrombolytic agent. ! FTT trial showed mortality within 6 hours of symptom onset significantly reduced in patients receiving thrombolytic. Remember How You Found the LBBB? ! Lead V1 (MCL-1) ! QRS is > 120ms ! Circle the J point ! Draw a line into the complex ! Go down with the terminal deflection ! Arrow points down, turn LEFT (LBBB) LBBB had ST elevation as a normal finding because of late repolarization of the left ventricle that did not allow the return to isoelectric. For this reason, the AMI could hide behind the Left Bundle Branch Block. Many researchers have been looking into this “Enigma” Several criteria have been mentioned as an aid in determining the presence of a MI in the presence of a left bundle branch block. It should be noted again that no ECG criterion is foolproof, ECG criteria are not a substitute for clinical assessment and history taking skills. Easiest of Criteria for AMI in LBBB Perhaps the easiest criterion for this condition is a new onset of left bundle branch block along with signs and symptoms of an AMI. This will generally point to the conclusion that it is an AMI. Of course, one would have to have an old 12 lead that demonstrated that there was not a LBBB before this episode. In the hospital, medical records may have the chart available for this. However, in the out of hospital setting, that is not usually the case. At any rate, the prehospital !1999 Multi-Lead Medics! Enhanced Participant Workbook 3 provider should supply the receiving hospital with the information necessary for a rapid search of the records to find the file. In some cases, paramedics have received a return call to the ambulance by an ER physician, who found the records, and diagnosed the MI based on new onset. This heads up action will speed up the time to intervention with aspirin and heparin, and reduce door to drug or door to balloon time. ECG Criteria for AMI in LBBB Changes in QRS configuration: Think: Q-R-S " Q waves seen in at least two lateral leads (I, aVL, V5, V6) I aVL V5 V6 " R wave Regression seen from leads V1-V4: V1 V2 V3 V4 !1999 Multi-Lead Medics! Enhanced Participant Workbook 4 " Late Notching of the S wave in at least 2 of leads V3-V5 Another Way to Determine the Likelihood AMI in LBBB and Chest Pain Sgarbossa, Pinski, Barbagetata, et al developed this simple table: The evidence came about during the GUSTO-1 trial. Basically, The interpreter is to determine 3 things looking at an ECG with a LBBB. 1. Is there ST segment elevation >= 1mm and is concordant with QRS axis? This means that the elevation is in the same direction as the QRS deflection. II III aVF If this criterion is met, it is worth 5 points. This is the most heavily weighted criterion of the three that are listed. !1999 Multi-Lead Medics! Enhanced Participant Workbook 5 2. Is there ST Segment Depression >= 1 mm in V1, V2, or V3? This simple criterion can be seen in either of these leads. Remember to find the J point when looking for the point of ST depression. V1 V2 V3 If this criterion is met, it is worth 3 points. 3. Is there ST Segment elevation >= 5mm discordant from the QRS axis? This means that the ST elevation goes up and the QRS deflection is down. V1 V2 V3 This criterion is worth 2 points if present. There are various combinations that can be present. It is important that you use the chart to help you determine the likelihood of an AMI. Furthermore, the chart has relatively high reliability as ECG goes. As long as the score total is at least 3, the sensitivity is 78%. This means that 22% would be missed or would not meet the criteria, but still be having an AMI. The specificity is 90%. In other words, if the score totals at least 3, then 90 out of 100 would have accuracy that the table suggests. This is a very promising method that is easy to use. In light of current practice that renders an ECG with a LBBB non-diagnostic, this new development brings new hope. !1999 Multi-Lead Medics! Enhanced Participant Workbook 6 Chamber Enlargement Objectives: By the end of this section you will be able to: 1. Identify by criteria, evidence of right and left atrial enlargement. 2. Identify by criteria, evidence of right and left ventricular hypertrophy and the presence of strain pattern. 3. Describe the clinical implications of atrial and ventricular enlargement. Atrial Abnormalities We all learned in basic ECG classes that sinus “p” waves were upright, round and uniform in shape in lead II. In fact, this is the governing criteria for the title “Sinus” rhythm, or “Sinus” tachycardia, etc. However, the more ECG’s we look at, the more we realize that not all “p” waves look nice and rounded, or even “normal” for that matter. What is the meaning of all this? Is there an easy way of determining why a “p” wave is shaped the way it is? This section will present some simple criteria for the determination of Right and Left atrial enlargement. Normal “P” Waves " ECG Recognition: P wave is rounded and less than 3mm in height and less than 120ms wide. It is upright in lead II, III and AVF, and Upright, negative, or biphasic in Lead V1 (MCL-1) Normal P Right Atrial Abnormality (Enlargement) RAE " ECG Recognition: Tall, Pointed “P” waves in the inferior leads II, III, or AVF. The P wave will be more than 2.5mm (.25mV) 2.5mm RAE Since the right side of the heart is the pulmonary side, the 3 P’s have been used to describe RAE: Pointed, Prominent, Pulmonary or “P-Pulmonale”. Causes of RAE: # Congenital heart disease # Tricuspid or pulmonary valve disease # Pulmonary hypertension (any cause) !1999 Multi-Lead Medics! Enhanced Participant Workbook 7 Clinical Implications: # Generally not an acute problem. # Frequently seen with Right Ventricular Hypertrophy # Can been seen with other criteria pointing to other more severe problems, i.e. pulmonary embolism Left Atrial Abnormality (Enlargement) LAE " ECG Recognition: " Lead II: Widened (>120ms or 3mm) P wave with a notched or “m” shaped appearance. " Lead V1 or MCL-1: A broad, terminal negative “p’ deflection of more than 1mm or one small square. Lead II MCL-1 120ms It has been suggested that the criteria demonstrate a conduction abnormality and not necessarily atrial enlargement.
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