1. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 3 Medical Emergencies

2. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 2 Cardiology

3. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 2, Part 3 12-Lead ECG Monitoring and Interpretation

4. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Cardiac Conductive System ECG Recording ECG Leads Mean QRS Axis Determination The Normal 12-Lead ECG Disease Findings Conduction Abnormalities Prehospital ECG Monitoring

5. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction Single-lead ECG monitoring was principally designed to detect cardiac dysrhythmias. Early detection of acute myocardial infarction has become very important. –Use of fibrinolytics Multilead monitoring is available to prehospital providers.

6. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiac Conductive System

7. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cardiac Conductive System Stimulates the atria and the ventricles to contract –Atrial syncytium –Ventricular syncytium

8. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Recording

9. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Recording –Basic Principles An ECG is a recording of the heart’s electrical activity. Electrical current moving toward the positive electrode causes positive deflection. Electrical current moving away from the positive electrode causes negative deflection. The stronger the current, the stronger the deflection.

10. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Recording The stronger the current, the greater will be the deflection of the stylus on the ECG recorder.

11. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Segments and Intervals

12. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Leads

13. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Leads –Bipolar Leads I, II, and III –Unipolar Leads aVR, aVL, and aVF –Precordial V 1, V 2, V 3, V 4, V 5, V 6

14. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Leads Bipolar Limb Leads –Lead I –Lead II –Lead III –Einthoven’s Triangle

15. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Leads Unipolar or Augmented Limb Leads –Lead aVR –Lead aVL –Lead aVF

16. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Leads The Hexaxial and Semicircle Reference Systems

17. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ ECG Leads The Hexaxial and Semicircle Reference Systems

18. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Precordial Leads –Lead V 1 –Lead V 2 –Lead V 3 –Lead V 4 –Lead V 5 –Lead V 6 ECG Leads

19. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mean QRS Axis Determination

20. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mean QRS Axis Determination Vectors –Averaged Vector Instantaneous Vector –Resultant (Mean) Cardiac Vector The QRS Axis –Representative of Ventricular Depolarization

21. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Axis Deviation Quadrants

22. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Axis Deviation Right Axis Deviation –Abnormal finding Axis equals or exceeds +105 –Often associated with COPD and pulmonary hypertension

23. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Axis Deviation Left Axis Deviation –Abnormal finding Greater than or equal to –30° –Often associated with hypertension, valvular heart disease, and other disease processes Indeterminate Axis ––90° to –180°

24. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Axis Deviation Rapid Axis Determination –Utilizes Leads I, II, and III

25. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Normal 12-Lead ECG

26. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Normal 12-Lead ECG The Normal 12- Lead –Views the same series of electrical events from 12 perspectives.

27. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Normal 12-Lead ECG

28. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings

29. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Ischemia –Inverted T waves in 2 congruent leads Normal in V1 and III –ST segment depression Injury –ST elevation >1mm in 2 congruent leads >2mm in septal leads

30. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Infarction –Path Q waves >.04 sec wide or 1/3 of R, with ST elevation –STEMI –Non-STEMI

31. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Subendocardial Infarction –Affects only the deeper part of the myocardium Typically less tissue damage than full-thickness infarctions –No “Q” wave development Transmural Infarction –Full-thickness –“Q” wave development

32. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Evolution of Acute Myocardial Infarction –STEMI

33. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Evolution of Acute Myocardial Infarction –Non- STEMI

34. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Evolution of Acute Myocardial Infarction –Sub- endocardial Infarction (non-STEMI) Click here to view the subendocardial infarction illustration.here

35. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Localization of Acute Myocardial Infarction Disease Findings

36. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anterior Disease Findings

37. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anterior Leads

38. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anterolateral Disease Findings

39. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anterolateral Leads

40. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Lateral High Lateral Disease Findings

41. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Lateral Leads

42. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ High Lateral Leads

43. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Inferior Inferolateral Disease Findings

44. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Inferior Leads

45. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Inferolateral Leads

46. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings True Posterior

47. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ True Posterior Leads Reciprocal Changes

48. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acute Anterior Wall Infarct Disease Findings

49. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anterolateral Infarct Disease Findings

50. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acute Inferior Wall Infarct Disease Findings

51. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Right Ventricle Infarct –Associated with an inferior wall myocardial infarction –Contractility is highly dependent on the patient’s diastolic pressure Right ventricular diastolic pressure increases substantially and systolic pressure decreases –Blood flow from the right ventricle to the pulmonary artery is impaired

52. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Right Ventricle Infarct –Assessment Consider in all patients who present with an acute inferior wall myocardial infarction Classic triad of symptoms Distended neck veins, clear lung fields, and hypotension –Patients are extremely sensitive to preload- reducing agents such as nitroglycerin and morphine

53. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings Right Ventricle Infarct –Management Maintenance of right ventricular preload Fluid bolus may improve cardiac output Inotropic support Dobutamine Afterload reduction Early reperfusion

54. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disease Findings 15-Lead and 18-Lead ECGs –Supplemental leads specifically look at the right ventricle and the posterior wall of the left ventricle –18-lead ECG Three right-sided chest leads (V4R, V5R, and V6R) and Three posterior leads (V7, V8, and V9) –15-lead ECG Using V4R, V8, and V9 Mirrors left chest lead placement