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Geraldine Leong - ECG for paramedics
1. ECG: Is it really that simple?ECG: Is it really that simple?
Paramedic Track
SEMS 2014
12th
April 2014
Geraldine Leong, Singhealth Senior Resident
2. Contents
• EMS in SG
• Case Scenarios
– Illustrating mainly STEMIs, SVTs, malignant
bradycardias
• Take home messages
3. EMS in SG
• Single tier, Scoop and Run system
• Mostly intermediate level paramedics
• Each ambulance team consist of:
– SAMO
– Medic
– Paramedic
• Standby system
4. Scenario 1
You’ve just started your ambulance shift at 8 pm… there is a call
for chest pain that just came in from the casino at MBS.
6. Scenario 1
What do you see in the ECG?
STANDBY?
Treatment?
100% NRM?
GTN spray?
Load aspirin 300 mg?
(if no contraindications, as per EAS protocol 12)
9. How to pick up STEMIs?
• New ST elevations at J point in:
>/= 2 contiguous leads of >/= 2 mm in men in V2-3
>/= 2 contiguous leads of >/= 1.5 mm in women in V2-3
>/= 1 mm in other contiguous chest/limb leads
Special Cases
Dx STEMI in the presence of LBBB
Dx STEMI in the presence of paced rhythm
J point
10. Why is picking up STEMIs important?
• Time = muscle
• Pre-hospital ECGs shorter reperfusion times
lower mortality rates from STEMIs1
• Pre-hospital ECGs + comms of STEMI dx + transport to
PCI-capable hospital = rapid reperfusion time +
excellent clinical outcomes2
1. TingHH et al. Circulation. 2008;118:1066-79
2. SorensenJT et al. Eur Heart J. 2011;32:430-6
20. Scenario 2
What do you see in the ECG?
STANDBY?
Treatment?
Supplemental O2?
Vagal Maneuvers? (i.e. valsalva)
(if no contraindications, as per EAS protocol 08)
21. SupraVentricular Tachycardia
• Definition:
– Rapid heart rate (tachycardia >100 bpm)
– Originating at or above the sino-atrial node (ie. above
the bundle branches in the ventricles)
28. Treating the rhythm
STANDBY
High flow O2
IVD
ECG: regular narrow complex tachycardia - SVT
Haemodynamically stable?
Vagal Maneuvers
- Valsalva -
NO Yes
29. What do we do in ED?
• Haemodynamically unstable:
– Sedate and synchronised cardioversion starting at
50J and increasing energy level if unsuccessful
• Haemodynamically stable:
– AV nodal blocking agents
• Adenosine
• Calcium channel blockers
like verapamil or diltiazem
30. Scenario 3
You have reached the home of a 80 year old Chinese gentleman
who called the 995 hotline for syncope.
BP 102/58 HR 44
SPO2 97% on RA
32. Scenario 3
What do you see in the ECG?
STANDBY?
Treatment?
100% NRM?
IV atropine?
(if no contraindications, as per EAS protocol 07)
33. Complete Heart Block
• Definition:
– Also called third degree heart block
– Rhythm when atrial contraction is normal but no
beats are conducted to the ventricle
– Ventricle then are excited by a slow “escape
rhythm” from a depolarising foci within the
ventricle
34. How to pick up CHB?
• ECG features:
– Presence of both P waves and QRS complexes
– No relationship between P waves and QRS
complexes P waves not conducted
– Sometimes abnormal/broad QRS complexes – due
to abnormal spread of depolarisation from
ventricular focus
36. What should I do for CHB?
STANDBY
High flow O2
IV atropine 0.6 mg q3-5
min (max 2.4 mg)
IVD
ECG: complete heart block
Haemodynamically stable?
Check for signs/sympts of shock (as per EAS protocol 07)
– Transfer to ED ASAP for
further Mx
– Con’t monitoring along
the way for shock
NO Yes
37.
38. Take Home Messages
• Do not fear the ECG!
– Pattern recognition practice makes perfect
• Always treat the patient!
– Not the ECG.
– STANDBY if high clinical suspicion
40. References
• SINGAPORE MYOCARDIAL INFARCTION REGISTRY REPORT NO. 1: TRENDS IN ACUTE
MYOCARDIAL INFARCTION IN SINGAPORE 2007-2010; National Registry of
Diseases Office, MOH
• PT.O’Gara, FG.Kushner et al 2013 ACCF/AHA Guidelines for the Management of
ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines.
Circulation. Published online Dec 17 2012 Online ISSN 1524-4539
• TingHH et al. Implementation and integration of prehospital ECGs into systems of
care for acute coronary syndrome. Circulation. 2008;118:1066-79
• SorensenJT et al. Urban and rural implementation of pre-hospital diagnosis and direct referral
for primary percutaneous coronary intervention in patients with acute STEMI. Eur Heart J.
2011;32:430-6
• Sarah AS, Robert C. Tachydysrhythmias, Emerg Med Cli N Am 24 (2006) 11-40
• Jacqueline D, Christopher H, Amal M, William J. The electrocardiogram in the
patient with syncope, American Journal of Emergency Medicine (2007) 25, 688–
701
Intro myself/thanks
It may initially look like a mass of incomprehensible squiggles on a piece of paper, but I hope with this talk today to reassure you that it really isn’t that difficult! It’s all about practice and pattern recognition.
As one of my teachers used to say “repetition is the key to retention”… so today there will be a lot of that… Also feel free to ask questions as this is set up to be a fun and interactive session. By all means I’m not the ECG guru but I will try my best to answer all your questions… So let us begin
This is a brief intro into the prehospital EMS system in SG just to put things into perspective for this lecture esp for our friends that are not from SG.
The main focus of the talk is about recognising malignant ECGs and what to do with limited resources in the pre-hospital setting
Arriving at the MBS casino, there is a middle aged gentleman sitting on a chair near the roulette table clutching at his left chest. He is in visible distress and is noted to be breathless and diaphoretic.
You get your medic to take a first set of parameters and proceeded to obtain a 12-lead ECG…
If in doubt of the ECG, as long as characteristics sympts present (ie crushing chest pain/diaphoresis/SOB) treat as a MI and standby!
Definition by European society of cardiology/AHA/ACCF/World heart federation task force for the Universal Definition of Myocardial Infarction
In prehospital setting unable to get prev ECGs to know if this is a new onset
Various criteria for the dx of STEMi in LBBB has been proposed, but it is not within the scope of this lecture
Why is it important? Why are we all jumping on the patient when it’s a STEMI?
Is it just about good door-to-balloon timings?
Performance of pre-hospital ECGs by trained personnel are assoc with shorter reperfusion times and lower mortality rates from STEMIs1
Use of pre-hospital ECGs + comms of STEMI dx + transport to PCI-capable hospital = rapid reperfusion time + excellent clinical outcomes2
ST elevation V2-6/lead I
Antlat STEMI
ST elevation hyperacute T waves V2-4
Ant STEMI
ST elevation inferiorlat leads with ST dep i/AVL/ant leads – reciprocal changes
ST elevation inferior leads – rhythm junctional initially NSR
Tall R wave in V1-3 with ST dep and T inv
Posterior STEMI
Leads are looking anteriorly at the heart thus if you want to look at the posterior part of the heart you will have to imagine a mirror image of this ECG which shows a STEMI!
ST depressions all leads with ST elevation in aVR
Indicative of LM dx or pLAD dx
As you arrive at the offices, you meet a young 21 year old girl looking very anxious. Her lecturer tells you that she was having an exam when she started feeling unwell. She described it as her “heart was pounding” and that she felt “chest discomfort and breathless”. She had never experienced this before.
Your trusty medic has taken her vitals – BP 140/89 HR 168 SpO2 98% on RA. In view of her complaints and tachycardia, you proceed to obtain a 12-lead ECG for her…
Not comprehensive list but most impt things that u need to know
Regular – all the R-R intervals are constant
Narrow complex – the QRS duration is <120
Tachy – HR >100
In our prehospital setting – for unstable pt – defined as decreased consciousness or signs of shock - to expedite t/f to ED
Be very cautious when doing a carotid sinus massage in patients who are more than 60 years of age and has a history of diabetes mellitus, hypertension, ischaemic heart disease, transient ischaemic attacks and strokes. These patients are at risk of having carotid plaques which could be dislodged during a carotid sinus massage resulting in a stroke. Do bear in mind that the absence of a murmur on auscultation of the carotid arteries does not mean that no carotid stenosis and plaques are present. In such patients, it will be wise to choose valsava manoeuvres over carotid sinus massage.
He has been having worsening giddiness over the last few days and was about to have lunch when he fainted at the table. He has now woken up and is awake and alert, though lethargic.
Your enthusiastic medic has taken the vitals: BP 102/58 HR 44 SPO2 97% on RA. In view of his presenting symptoms and bradycardia, you proceed to obtain a 12-lead ECG…
Presence of both P and QRS (show)
No relationship btwn P and QRS
S/s of shock AMS/hypotensive/diaphoresis/dec cap refill/chest pain/SOB/Giddy/syncope
Be very cautious when doing a carotid sinus massage in patients who are more than 60 years of age and has a history of diabetes mellitus, hypertension, ischaemic heart disease, transient ischaemic attacks and strokes. These patients are at risk of having carotid plaques which could be dislodged during a carotid sinus massage resulting in a stroke. Do bear in mind that the absence of a murmur on auscultation of the carotid arteries does not mean that no carotid stenosis and plaques are present. In such patients, it will be wise to choose valsava manoeuvres over carotid sinus massage.
Yes it is really that simple!
ST elevation inferior leads – rhythm junctional initially NSR
Knowing that this is an inferior STEMI and that the same blood vessel that supplies the inferior part of the heart also supplies the right side of the heart – we do a right sided ECG to search for right ventricular infarction
This shows a right sided ECG where instead of placing V4-6 where you would usually put on the left side, it is placed in it’s mirror image on the right side – this is to look at the right side of the heart
In this case there is ST elevations of 1mm in the right sided leads of V4-6 – thus there is an ongoing right ventricular infarct as well