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ECG Webinar SeriesEpisode 4: Acute Coronary Syndromes
1st June 2020 at 19:00
Presented by:
Mr Innes Eaton
Paramedic Practitioner
STC Training SolutionsAsk us about our BLS and ILS refresher training for
healthcare professionals!
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Ways to Interact
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
1. Grab your smart phone
2. Go to: www.menti.com
3. Enter the code
4. Answer the question
07535 382223
Tweet us:
@STCTrainingLtd
Email us:
webinars@stctrainingsolutions.co.uk
In the Zoom chat:
STC Admin
Session Plan
• Pathophysiology of ACS
• Refresher on views and ECG layout
• STEMI criteria
• Alternate lead views
• Refresher on Sgarbossa’s Criteria
• Management of ACS
• Q&A Session
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Case Study 1
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Pathophysiology
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Pathophysiology
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Definitions
• Stable vs Unstable Angina• Stable Angina = predictable chest pain +/- ST +/- TWI on exertion
• Diagnosis made clinically +/- stress ECG (chest pain + >1mm ST)
• May be candidates for PCI or CABG
• Unstable Angina = chest pain +/- ST +/- TWI at rest/random onset• Diagnosis made clinically + normal biomarkers
• The 3 Acute Coronary Syndromes• Unstable Angina
• Normal biomarkers and no ST
• Non-ST-elevation myocardial infarction (NSTEMI)• Abnormal biomarkers and no ST
• ST-elevation myocardial infarction (STEMI)• Abnormal biomarkers and ST
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Refresher on Lead Views
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Refresher on ECG Layout
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Reciprocal Changes
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Case Study 2
• 999 call: 57 y/o male, chest pain
• HPC: sudden onset after dinner, 30 minutes ago
• Feels like he is going to faint, vomited x3
• Poorly perfused, diaphoretic++, anxious++
• PMH: HTN, pre-diabetes, cholesterol, BMI
• RR 24, SpO2 NT, HR 56 (Reg), BP 72/40, T36.2°C, BGL 9.8, GCS 4/4/6 (14)
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Case Study 2
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Locating the Culprit Lesion
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
ST-Depression & ST-Elevation
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
ST-Elevation or High Take-Off?
• Benign Early Repolarisation (BER) is a relatively common finding of widespread ST in young, healthy patients <50 y/o• May mimic MI or pericarditis• Uncommon in >50s - ST more likely to be ischaemic changes• Rare in >70s
• Diagnostic Criteria:• Widespread concave ST, most prominent in V2-V5
• Notched/slurred J-point• Prominent, asymmetric, concordant T-waves• ST <25% of T-wave height in all leads
• No reciprocal changes suggestive of ischaemia • No changes in serial ECGs
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Benign Early Repolarisation (BER)
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
STEMI Criteria
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Inferior MI:
>1mm ST in 2 consecutive leads
Anterior MI:
Men: >2mm ST in 2 consecutive leads
Women: >1.5mm ST in 2 consecutive leads
Lateral MI:
>1mm ST in 2 consecutive leads
Inferior STEMI
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Anterior STEMI
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Classification of Anterior STEMI
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
• Septal• V1 – V2
• Anterior• V2 – V5
• Anteroseptal • V1 – V4
• Anterolateral• V3 – V6 plus I & aVL
• Extensive Anterior/Anterolateral• V1 – V6 plus I & aVL
Lateral STEMI
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
What about the Posterior?
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
What to look for:
• V1 – V3
• Horizontal ST
• Positive T-Waves
• Tall R-Waves
Alternate Views
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Suspected Posterior STEMI
• V7, V8, V9 – to confirm diagnosis
• >0.5mm ST in any lead is diagnostic
Inferior STEMI
• V4(R) – to look for Right Ventricular Infarction (RVI)
• >0.5mm ST is diagnostic
Posterior STEMI
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Inferior STEMI with RVI
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
• Likely to be haemodynamically unstable
• Careful use of GTN
• Careful use of fluids
Sgarbossa’s Criteria in LBBB
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
A:
Concordant ST↑ ≥1mm in any one lead with
a positive QRS complex (5 points)
B:
Concordant ST↓ ≥1mm in any one of leads
V1-V3 (3 points)
C:
Excessive discordance (>5mm) in any one lead with a
negative QRS complex (2 points)
Modified C:
Discordance of ≥25% of preceding S-wave
in any one lead with a negative QRS
complex
Sgarbossa’s Criteria in LBBB
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Sgarbossa A Postive
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Sgarbossa B Postive
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
The Eaton Triage Tool?
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
The ACS Care Bundle
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
• Emergency access to PPCI (+/- via ED)
• Dual anti-platelet therapy• 300mg PO Aspirin (chewed)• 300mg/600mg PO Clopidogrel (only in diagnosed MI)
• Glyceryl Trinitrate (GTN)• 800mcg SL stat dose (if not hypotensive)• 400-800mcg repeated every 5-10 minutes (monitor BP)
• Analgesia• Nitrous oxide (Entonox)• Morphine Sulphate 5-10mg IV then titrated PRN <20mg (+/- antiemetic)
• Consider fluid challenge if hypotensive• Increased risk of APO
• Consider atropine if bradycardic• Be cautious with increasing myocardial oxygen demand
• Consider applying defibrillator pads• High risk of ventricular arrhythmias
Always refer to
local guidelines
Interactive Quiz
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
No PPCI: What then?
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
• Thrombolysis• Within 6 hours of symptom onset
• No PPCI available or extended delay in access
• Tecteneplase• 30-50mg IV by rapid injection, dose dependant on weight
• Multiple side effects
• Multiple cautions & contraindications
• Limit clopidogrel to 300mg PO
• Transfer patient to nearest ED
Always refer to
local guidelines
Thank You!
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ECG Webinar Series | Episode 4 | Acute Coronary Syndromes
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