Coronary Artery Anatomy (11:53)
Expect either a type one or a wenckebach blockage if the AV node becomes ischemic. Other parts of the heart that obtain blood from the right coronary artery include the SA node, bundle of his, the right atrium and ventricle, the wall of the left ventricle and a third of the septum. The left main coronary artery branches into the left anterior descending (LAD) and the left circumplex (LCX).
Six Lead Monitoring (08:45)
Place the white, black, red, and green electrodes on the right arm, left arm, left leg, and right leg respectively. AV stands for augmented voltage; contiguous leads examine the same part of the heart. Learn where to place the chest leads in telemetry monitoring.
R, Q, and S Wave Progressions (16:10)
The R wave should only be a quarter of the size of the q wave. A pathological Q wave myocardial infarction or ischemia to the anterior septal wall can cause poor r wave progression. Add additional chest or posterior leads to diagnose other types of cardiovascular disease; limb leads that demonstrate reciprocal change does not necessarily mean ischemia.
Acute Coronary Syndrome: Pathophysiology (07:37)
ACS can be an ST-elevated MI (STEMI), non-ST elevated ACS, or unstable angina (NSTEMI). Fatty streaks become fatty plaques after an inflammatory response. Normal stress tests can occur even if there is a 70% occlusion because the body compensates.
Acute Coronary Syndrome: EKG Changes— NSTE-ACS (08:54)
NSTE-ACS manifests with inverted symmetrical t waves that are flattened or biphasic. A positive cardiac enzyme test is required to diagnose an NSTEMI. Cathy Lockett describes her systematic approach to interpret a 12 lead EKG.
Acute Coronary Syndrome: STEMI (07:12)
All the layers are affected and there is more damage in a STEMI. Changes include a hyperacute phase, an st segment elevation, and a T wave inversion; during necrosis or the infarction phase, the muscle dies. Learn the differences between an anterior, lateral, inferior, right ventricular, and posterior infarctions.
Acute Coronary Syndrome: Treatment Modalities (13:46)
If a doctor suspects a STEMI, perform a standard 12 lead ECG and obtain labs including serial cardiac markers, a complete blood count, a chem 7 panel, lipid panel, brain natriuretic peptide test, and a partial thromboplastin time tests. Review the MONA (morphine, oxygen, nitroglycerine, and aspirin) protocol for treatment. Other treatments include anticoagulation, P2Y12 inhibitor, and antiplatelet therapy medications.
EKG Examples (19:27)
Review EKG's for ischemia first. For an Extensive Anterior STEMI, treat using the MONA protocol, fibrinolytic or PCI, re-perfusion, anti-coagulant, and beta-blocker therapies. An acute Inferior and RV infarct diagnosis has an increased incidence of life-threatening arrhythmias and AV block.
STEMI Imposters: Prinzmetal Angina (10:03)
The ST segment elevates during periods of ischemia and changes in R and S wave amplitude occur. Spasm usually last only a few minutes but can be long enough to produce lethal arrhythmias.
STEMI Imposters: Early Repolarization (07:13)
Early repolarization causes concave ST segment changes and normally occurs in male athletes. Doctors believe it is a result of a vasovagal response. STEMI imposters do exhibit reciprocal change.
STEMI Imposters: Pericarditis (10:15)
Pericarditis produces similar findings as early repolarization on the EKG but is not rate related and is benign. The patient may also have a pulmonary embolism or cardiac tamponade condition. Causes include viral, chronic renal failure, recreational drugs, and open heart surgery.
STEMI Imposters: Left Bundle Branch Block (07:45)
The QRS pattern may have some notching in it. An LBBB can mimic an interior septal STEMI on an EKG and affect the deflection of the QRS pattern in lead two. The T wave goes in the opposite direction as the QRS.
STEMI Imposters: Ventricular Paced Rhythm (06:53)
This is not the same pacemaker installed in heart failure or cardiomyopathy patients. Electrical capture and ST elevation occur. Sgarbossa criteria will help determine if a patient is having a STEMI with an LBBB.
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