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Dr. R. Irabagon
Myocardial Infarction
Permanent destruction of the myocardium.
Usually caused:
by reduced blood flow in a coronary artery
due to rupture of an atherosclerotic plaque
subsequent occlusion of the artery by a thrombus.
Assessment findings:
CVS: chest pain or discomfort, palpitations. Heart sounds may include S3, S4 &
new onset of a murmur. Jugular vein distention, decreased/increased BP, ST
segment changes
RS: Dyspnea, tachypnea, crackles
GIT: n/v
GUT: decreased UO
SKIN: cold, clammy, diaphoretic, pale
Neurologic: Anxious, restless, HA, visual disturbance
Psychological: fear of impending death
Treatment of Acute MI
Obtain diagnostic tests including ECG within 10 minutes of admission to the ED.
Oxygen
Aspirin, nitroglycerin, morphine, beta-blockers
Angiotensin-converting enzyme inhibitor within 24 hours
Evaluate for percutaneous coronary intervention or thrombolytic therapy.
As indicated; IV heparin or LMWH, clopidogrel or ticlopidine, glycoprotein IIb/IIIa
inhibitor
Bed rest
Collaborative Problems
Acute pulmonary edema
Heart failure
Cardiogenic shock
Dysrhythmias and cardiac arrest
Pericardial effusion and cardiac tamponade
arrhythmia: most common cause of death in the first several hours following MI
myocardial rupture: a catastrophic complication within the 1st 4-7 days & may
result in death from cardiac tamponade
Mural thrombosis
Ventricular aneurysm: w/in 3- 6 months after MI
The 12 conventional ECG leads record the difference in potential between electrodes
placed on the surface of the body.
These leads are divided into two groups: six extremity (limb) leads and six chest
(precordial) leads.
The extremity leads record potentials transmitted onto the frontal plane, and the chest
leads record potentials transmitted onto the horizontal plane.
The six extremity leads are further subdivided into three bipolar leads (I, II, and III) and
three unipolar leads (aVR, aVL, and aVF). Each bipolar lead measures the difference
in potential between electrodes at two extremities: lead I = left arm-right arm voltages,
lead II = left leg-right arm, and lead III = left leg-left arm. The unipolar leads measure
the voltage (V) at one locus relative to an electrode (called the central terminal or
indifferent electrode) that has approximately zero potential. Thus, aVR = right arm,
aVL = left arm, and aVF = left leg (foot)
Together, the frontal and horizontal plane electrodes provide a three-dimensional
representation of cardiac electrical activity. Each lead can be likened to a
different camera angle "looking" at the same events¾atrial and ventricular
depolarization and repolarization¾from different spatial orientations
The electrocardiogram is ordinarily recorded on special graph paper which is
divided into 1-mm2 gridlike boxes . Since the ECG paper speed is generally 25
mm/s, the smallest (1 mm) horizontal divisions correspond to 0.04 s (40 ms),
with heavier lines at intervals of 0.20 s (200 ms). Vertically, the ECG graph
measures the amplitude of a given wave or deflection (1 mV = 10 mm with
standard calibration; the voltage criteria for hypertrophy mentioned below are
given in millimeters)
Heart Rate
3 Possibilities
Bradycardia : <60 beats per minute
Normal Rate : 60-100 beats per minute
Tachycardia : > 100 beats per minute
Rate Analysis
Formula
Short cut
If R to R interval > 5 big square: Bradycardia
If R to R interval between 3-5 big square: Normal Rate
If R to R interval < 3 big square: Tachycardia
Mnemonic
Heart Rate Determination
Normal Sinus Rhythm
Sinus Bradycardia
Sinus Tachycardia
Rhythm
Common Rhythm Interpretations:
Sinus rhythm
Common supraventricular arrythmias:
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
Ventricular Arrhythmias
Premature Ventricular Contraction
Ventricular tachycardia
Ventricular fibrillation
Heart Blocks
First degree AV block
Second degree AV block Mobitz type 1 (wenckebach)
Second degree AV block mobitz type II
3rd degree AV block
Left or rigth bundle branch block( complete & incomplete)
Rhythm Analysis
Identify the P wave
Determine frm the configuration if this is a sinus P.
Check the relation of P wave to QRS
P wave is before QRS (Normal)
P wave is buried or after QRS (ex. SVT, complete HB)
Check PR interval (Normal PR interval: 0.12-020 sec)
Short PR (WPW syndrome)
Normal PR
Prolonged PR (1st degree or 2nd degree AV block)
RVH
Right axis deviation
Lead V1: Rwave >Swave
Deep S wave in leads V5 & V6
ST depression & T wave inversion in V1 – V3
Myocardial Infarction: correspondence of specific ECG lead
ECG criteria for MI
ST elevation≥ 2mm in 2 or more chest lead (chest lead)
Or ≥1mm in 2 or more limb leads.
Q wave ≥ 0.04 sec (1 ml square)
Miscellaneous
Hypokalemia
U wave as tall or taller than the T wave at leads V2 & V3
Normal serum Potassium: 3.6-5.5 mEq/L
Hyperkalemia
Chest leads: T wave> 10mm in most leads, in limb leads,T wave > 5mm in most leads
Digitalis effect
Prolonged PR interval, scooping of ST segment, short QT interval
Hypocalcemia
Prolonged QT interval
Hypercalcemia
Shortened QT interval