Mod-5-The High Acuity Patient 12 LEAD

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The High Acuity Patient:

The High Acuity Patient MODULE 5

Coronary Artery Anatomy:

Coronary Artery Anatomy Varies from patient to patient General patterns of distribution exist

Left Coronary Artery:

Left Coronary Artery Left Main Left Circumflex Lateral Wall Anterior Wall Septal Wall Right Ventricle Right Coronary Artery Anterior Descending Artery

Left Coronary Artery (LCA):

Left Coronary Artery (LCA) Left Main (proximal LCA) Left Circumflex (LCX) Left Anterior Descending (LAD)

Distribution:

Distribution LAD = anteroseptal LCX = lateral Proximal LCA = extensive anterior

Practice ECG:

Practice ECG

Practice ECG:

Practice ECG

Practice ECG:

Practice ECG

Extensive Anterior MI:

Extensive Anterior MI Evidence in septal, anterior, and lateral leads Often from proximal LCA lesion “Widow Maker” Complications common

Definitive Therapy for Extensive AWMI:

Definitive Therapy for Extensive AWMI Normal blood pressure Thrombolysis Signs of shock PTCA CABG

LCA Occlusions:

LCA Occlusions Other considerations Bundle branches supplied by LCA Serious infranodal heart block may occur

Right Coronary Artery:

Right Coronary Artery Right Coronary Artery Posterior Descending Artery Inferior Wall Posterior Wall Lateral Wall Left Ventricle Left Coronary Artery

Right Coronary Artery (RCA):

Right Coronary Artery (RCA) Proximal RCA Posterior descending artery (PDA)

RCA Distribution:

RCA Distribution Proximal RCA Right ventricle Posterior wall Inferior wall PDA Inferior wall

Practice ECG:

Practice ECG

Proximal RCA Occlusion:

Proximal RCA Occlusion Right Ventricular Infarct (RVI) 12-lead ECG does not view right ventricle Use additional leads V3R - V6R V4R

Right Precordial Leads:

Right Precordial Leads On right side of chest Same anatomical landmarks as V3 - V6

Practice ECG:

Practice ECG

ECG Evidence of RVI:

ECG Evidence of RVI Inferior MI (always suspect RVI) ST elevation right V leads

Slide 20:

To Lungs From Lungs To Body From Body Cardiac Blood Flow

Physical Evidence of RVI:

Physical Evidence of RVI Dyspnea with clear lungs Jugular vein distension Hypotension Relative or absolute

Treatment for RVI:

Treatment for RVI Use caution with vasodilators Small incremental doses of MS NTG by drip

Fluid for Hypotension:

Fluid for Hypotension One to two liters may be required “Large bore” lines suitable here

Posterior Wall MI (PWMI):

Posterior Wall MI (PWMI) Usually an extension of an inferior or lateral MI Common with proximal RCA occlusions Occurs with LCX occlusions

PWMI:

PWMI Reciprocal changes V1 - V4 Indicative changes V7, V8, V9

Posterior Leads:

Posterior Leads V7 Posterior axillary line Level with V6 V8 Mid-scapular line Level with V6 V9 Left para-vertebral Level with V6

Slide 27:

Posterior Wall Infarcted Tissue Ischemic Tissue Reciprocal Leads Indicative Leads

PWMI:

PWMI Best to identify with direct leads V7, V8, V9 ST elevation in posterior leads is evidence of posterior MI

Practice ECG:

Practice ECG

PWMI:

PWMI Look for PWMI when V1 -V4 show ST depression The ECG is normal The story is convincing

Left Coronary Dominance:

Left Coronary Dominance Approximately 10% of population LCX supplies PDA Inferolateral MI

Dominant Left Coronary:

Dominant Left Coronary Left circumflex supplies posterior descending artery

Practice ECG:

Practice ECG

Lab for Module 5:

Lab for Module 5 Lab manual