Professional Documents
Culture Documents
Acknowledgments
Steve Anderson, MD, of Auburn, WA, developed the early drafts of these materials. Mary Fran Hazinski, RN, MSN, John Field, MD, and Richard O. Cummins, MD, revised the material. They have generously donated these works to the American Heart Association.
We have adopted, with permission, some of the creative illustrations from the excellent book by Tim Phalen The 12-Lead ECG in Acute Myocardial Infarction; St Louis, MO: Mosby Lifeline; 1996.
2
Learning Objectives
After completing this learning station you should be able to describe
Critical actions for treatment of ST-segment elevation in inferior leads Infarct localization concept using 12-lead ECG to locate involved cardiac area and coronary artery Critical actions to avoid (contraindicated) Treatment for inferior and right ventricular injury
3
60-year-old professor arrives at ED via private car History: CAD, multiple coronary bypass grafts Complaint: severe, substernal chest pain Pain: lasting >20 min Vital signs: T = 96.7F, RR = 30/min, HR = 80 bpm, BP = 80/60 mm Hg Physical exam: distressed, clear chest, marked JVD
Follow Ischemic Chest Pain Algorithm Box 2: Immediate assessment (<10 min) Box 3: Immediate general treatment (MONA) Box 4: Assess initial 12-lead ECG 12-lead ECG In efficient ED: technician records 12-lead ECG per protocol whenever a chest pain patient arrives
6
I lateral
aVR
V1 septal
V4 anterior
II inferior
aVL lateral
V2 septal
V3 anterior
V5 lateral
V6 lateral
III inferior
aVF inferior
Now what are the associations between cardiac anatomy and specific coronary arteries?
9
Circumflex artery Left anterior descending artery Lateral wall I, aVL, V5-V6
10
NOTE 3: KEY you must obtain a RIGHTRight coronary SIDED ECG at once.
artery
V1
V2
V3R
V6R V5R V4R
12
Must get RIGHT-SIDED ECG. In the meantime do NOT give nitroglycerin or morphine. Why? What do you look for in a right-sided ECG?
13
15
Initial ECG: injury occurring in inferior heart Distal left CA occlusion vs Proximal right CA occlusion Right-sided ECG <4 minutes of 1st ECG: >1 mm ST-segment elevation in leads over RV (V4R) Diagnostic of right ventricular MI What is treatment intervention of choice now? What medications are contraindicated? What is best immediate treatment for low BP?
16
Summary: Treatment of RV MI
Therapeutic intervention of choice Immediate catheterization: PTCA or stent placement Thrombolytics not effective in R coronary occlusion What medications are contraindicated? Avoid medications that vasodilate (morphine, nitroglycerin) RV exquisitely sensitive to RV filling: vasodilators cause profound drops in blood pressure, even arrest
17
Summary: Treatment of RV MI
What is the best immediate treatment for low BP? Rapid infusion of normal saline Increases RV preload (stretch); recruits more Starling forces Do not be timid: give volume quickly Evaluate response frequently! Remember: 1 can of Coke = 335 mL. Rapid infusion of 500 mL will not produce pulmonary edema
18