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Learning Station 1 Cardiovascular Emergencies Case 2

1999 American Heart Association


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.

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

Case 2. 60-Year-Old Professor: Severe Chest Pain

Time = 8:55 AM

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

How would you approach this patient?


Approach to ACS Patients (Acute Coronary Syndromes)

Follow the Secondary ABCD Survey: Airway: observe air movement, noise of breaths Breathing: listen to lungs, watch level of distress JVD suggests CHF but lungs surprisingly clear Circulation: rapid heart rate, low BP continues Differential diagnosis: check 12-lead ECG

Combine with Ischemic Chest Pain Algorithm


Approach to ACS Patients

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

Case 2. 60-Year-Old Professor: Severe Chest Pain

Time = 9:01 AM

What is your interpretation of this 1st ECG?


Case 2. 60-Year-Old Professor: Severe Chest Pain

ST-segment elevation

Interpretation: significant ST elevation in II, III, and aVF

What area of the heart is injured?

Associations Between Changes on 12-Lead ECG and Cardiac Anatomy

I lateral


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?

Cardiac Anatomy in Relation to Coronary Artery

Anterior wall V3-V4
Left main coronary artery Right coronary artery

Circumflex artery Left anterior descending artery Lateral wall I, aVL, V5-V6

Septal wall V1-V2

Posterior View of the Heart

Circumflex artery (from left coronary artery) Posterior wall
NOTE 1: Inferior wall supplied by either the right (85% to 90% of people) or left coronary artery. NOTE 2: If there is acute injury in inferior leads (II, III, aVF), unknown whether left or right coronary artery is blocked.

NOTE 3: KEY you must obtain a RIGHTRight coronary SIDED ECG at once.

Lateral wall Inferior wall Leads II, III, aVF


Posterior descending artery



Lead Placement for a Right-sided ECG





ST-Segment Elevations in Inferior Leads

You should ALWAYS respond with

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?

Right-sided 12-Lead ECG: Patient With Inferior ST-Segment Changes

How do you interpret this ECG?


Right-sided 12-Lead ECG: Patient With Inferior ST-Segment Changes

Lead V4R = diagnostic ST-segment elevation


Inferior MI vs Right Ventricular MI

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?

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

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