The ECG in Prehospital Emergency Care E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 304

Veröffentlichungsjahr: 2012

Beschreibung

Now that state of the art equipment can be carried in ambulances, prehospital emergency staff are able to perform an ECG soon after arrival on scene, enabling the EMS provider to gather important diagnostic information that can not only guide prehospital therapy but also direct hospital-based treatment. 

This book exclusively addresses ECGs for prehospital emergencies, ranging from basic rhythm diagnosis to critical care applications of the electrocardiogram and advanced 12-lead ECG interpretation in the ACS patient.  It provides self testing traces covering all these conditions seen in prehospital and hospital- based environments. It includes 200 randomly presented cases mirroring real life situations, with the answers set out separately together with additional invaluable information.

Written by highly experienced emergency physicians with EMS qualifications and experience, this text is an ideal learning tool for trainees and fully qualified staff alike, including ground EMS advanced life support providers, aeromedical staff, and inter-facility critical care transport personnel.

Leseprobe

Table of Contents

Title Page

Copyright

Dedication

List of Contributors

Foreword

Preface

Section 1: The ECG in Prehospital Patient Care

Chapter 1: Clinical Applications of the Electrocardiogram (ECG)

Electrocardiogram Evaluation of Rhythm Disturbances

Electrocardiograhic Evaluation in the Setting of Acute Coronary Syndrome

Electrocardiograhic Evaluation in the Setting of Non–Acute Coronary Syndrome Pathology

Chapter 2: Clinical Impact of the Electrocardiogram (ECG)

Management of the Patient with Dysrhythmia

Management of the Patient with Acute Coronary Syndrome

Management of Non–ACS Presentations

Ambulatory Electrocardiogram Monitoring

Computer Interpretation of the Electrocardiogram

Chapter 3: Interpretation of the Electrocardiogram—Single-, Multi-, and 12-Lead Analysis

Introduction

Rate

Rhythm

Axis

Intervals

Morphology

Chapter 4: Variants of the Normal, Lead Misplacement, and Electrocardiographic Artifact Encountered in Clinical Practice

Benign Early Repolarization

T Wave Inversion

Sinus Arrhythmia

Conditions Encountered in Athletes

Lead Misplacement

Artifact

Section 2: Cardiac Rhythms and Cardiac Dysrhythmias

Chapter 5: Cardiac Rhythms with Normal Rates

Acknowledgment

Further Reading

Chapter 6: Narrow QRS Complex Tachycardia

Regular Narrow Complex Tachycardia

Irregular Narrow Complex Tachycardias

Further Reading

Chapter 7: Wide QRS Complex Tachycardia

Ventricular Tachycardia—Monomorphic and Polymorphic

Ventricular Fibrillation

Supraventricular Tachycardia with Aberrant Conduction

Further Reading

Chapter 8: Bradycardia

Sinus Bradycardia

Junctional Rhythm

Idioventricular Rhythm

Sinoventricular Rhythm of Severe Hyperkalemia

Other Bradycardias

Acknowledgment

Further Reading

Chapter 9: Atrioventricular Conduction Block

First-Degree Atrioventricular Block

Second-Degree Atrioventricular Block

Third-Degree Atrioventricular Block

Atrioventricular Dissociation

Chapter 10: Intraventricular Conduction Block: Bundle Branch Block and Other Conduction Abnormalities

The Bundle Branch Blocks

The Hemiblocks (Left Anterior and Left Posterior Hemiblocks)

Bifascicular and Trifascicular Blocks

Non-Specific Intraventricular Conduction Abnormality

Chapter 11: Atrial and Ventricular Ectopic Beats

Premature Atrial Contractions

Premature Junctional Contractions

Premature Ventricular Contractions

Section 3: Acute Coronary Syndrome and the 12-Lead ECG

Chapter 12: Ischemic Heart Disease: Anatomic and Physiologic Considerations

Cardiac Anatomy and Basic Physiology of Depolarization

Coronary Anatomy and Electrocardiograhic Regional Anatomic Issues

Cardiac Pathophysiology

Chapter 13: Historical Development of the Prehospital Electrocardiogram (ECG)

Indications for Prehospital 12-Lead Electrocardiogram

Benefits of the 12-Lead Electrocardiogram in the Acute Coronary Syndrome Patient

Conclusion

References

Chapter 14: Electrocardiographic Findings in Acute Coronary Syndrome

Introduction

The 12-Lead Electrocardiogram in ST Segment Elevation Myocardial Infarction—Evolution of Electrocardiogram Abnormalities

The 12-Lead Electrocardiogram in Non-ST Segment Elevation Myocardial Infarction Presentations

Electrocardiogram ST Segment Elevation Myocardial Infarctionmimickers and Confounders

Further Reading

Section 4: Special Populations, High-Risk Presentation Scenarios, and Advanced Electrocardiographic Techniques

Chapter 15: The Electrocardiogram in the Pediatric Patient

Rate and Rhythm

QRS Axis

T Waves

Intervals

Common Dysrhythmias

Chapter 16: The Electrocardiogram in the Poisoned Patient

Potassium Efflux Blocking Agents

Sodium Channel Blocking Agents

Cardiac Glycoside Toxicity

Calcium Channel Blocker Toxicity

β-Adrenergic Blocker Toxicity

Chapter 17: The Electrocardiogram in Hyperkalemia

Electrocardiographic Manifestations

Chapter 18: Life-Threatening Electrocardiographic Patterns

Wellens' Syndrome

Brugada Syndrome

Hypertrophic Obstructive Cardiomyopathy

Long QT Syndrome

Chapter 19: The Electrocardiogram in Patients with Implanted Devices

The Paced Electrocardiogram

Pacemaker Malfunction

The Paced Rhythm and Acute Myocardial Infarction

Chapter 20: Electrocardiographic Tools in Prehospital Care

Additional Electrocardiographic Leads

Serial Electrocardiography

Chapter 21: Wolff–Parkinson–White Syndrome

Chapter 22: Cardiac Arrest Rhythms

Asystole

Pulseless Electrical Activity

Pulseless Ventricular Tachycardia

Ventricular Fibrillation

Section 5: Electrocardiographic Differential Diagnosis of Common ECG Presentations

Chapter 23: Electrocardiographic Differential Diagnosis of Narrow Complex Tachycardia

Chapter 24: Electrocardiographic Differential Diagnosis of Wide Complex Tachycardia

Ventricular Tachycardia

Ventricular Tachycardia versus Supraventricular Tachycardia with Aberrant Conduction

Chapter 25: Electrocardiographic Differential Diagnosis of Bradyarrhythmia

Chapter 26: Electrocardiographic Differential Diagnosis of ST Segment Elevation

Chapter 27: Electrocardiographic Differential Diagnosis of ST Segment Depression

Acute Coronary Syndromes

Left Bundle Branch Block

Left Ventricular Hypertrophy

Rate-Related ST Depression

Other Causes

Chapter 28: Electrocardiographic Differential Diagnosis of T Wave Abnormalities: The Prominent T Wave and T Wave Inversions

Prominent T Waves

T Wave Inversion

Index

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Library of Congress Cataloging-in-Publication Data

The ECG in prehospital emergency care / William J. Brady ... [et al.] ;

associate editors, Kostas Alibertis ... [et al.].

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-4051-8577-6 (pbk.)

I. Brady, William, 1960- II. Alibertis, Kostas.

[DNLM: 1. Electrocardiography– methods. 2. Emergency Medical Services. 3. Emergency Treatment– methods.

4. Heart– physiopathology. 5. Heart Diseases–diagnosis. WG 140]

616.1′207547– dc23

2012027338

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover design by: Fortiori Design Ltd.

1 2013

William Brady—To my wife, King Brady, my partner and a truly amazing person; to my children, Lauren, Anne, Chip, and Katherine, my inspiration; and to my mother, Joann Brady, for all that she has done (and continues to do) for me.

Korin Hudson—I would like to thank my husband for his unwavering support and patience; my parents for inspiring a career in academics; and my mentors and colleagues who demonstrate excellence in clinical medicine and patient care every day

Robin Naples—To my parents for raising me, my sister for pushing me, my husband for understanding me, and my kids for being my everything.

Amita Sudhir—Thank you to my husband, Aaron, my children, Anisha and Anand, and my parents, Romila and Sudhir for their support. Thank you also to Bill Brady for his educating me about ECGs during residency, and for his continued mentorship ever since.

Steven Mitchell—Thank you to my best friend and wife, Kara, for her love and support in this process.

Jeffrey Ferguson—To my wife, Lauren, my parents, friends, and mentors for their years support and education: Thank you.

Robert Reiser—For my wife Bernie, my constant support and inspiration. Thank you.

List of Contributors

Editors

William J. Brady, MD, FACEP, FAAEM

Professor of Emergency Medicine and Medicine, Chair, Resuscitation Committee, Medical Director, Emergency Preparedness and Response, University of Virginia School of Medicine; Operational Medical Director, Charlottesville-Albemarle Rescue Squad and Albemarle County Fire Rescue, Charlottesville, USA

Korin B. Hudson, MD, FACEP, NREMT-P

Assistant Professor, Department of Emergency Medicine, Medical Director, Georgetown Emergency Response Medical Service, Georgetown University Hospital, Washington, USA

Robin Naples, MD, FACEP

Assistant Professor, Temple University School of Medicine, Philadelphia, USA

Amita Sudhir, MD, FACEP

Assistant Professor of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, USA

Steven H. Mitchell, MD, NREMT-P, FACEP

Assistant Professor, Associate Medical Director of Emergency Services, Harborview Medical Center, University of Washington School of Medicine, Seattle, USA

Jeffrey D. Ferguson, MD, NREMT-P, FACEP

Assistant Professor of Emergency Medicine, Brody School of Medicine, Medical Director, EastCare Critical Care Transport, Assistant Medical Director, Pitt County Emergency Services, East Carolina University, Greenville, USA

Robert C. Reiser, MD, FACEP

Associate Professor of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, USA

Advisory Editors

Kostas Alibertis, CC EMT-P

Instructor and Advanced Life Support Training Coordinator, Emergency Preparedness and Response, University of Virginia Medical Center, Charlottesville, USA; Chief, Western Albemarle Rescue Squad, Crozet, USA

James Brady, EMT-P

Captain, Training Division, Albemarle County Fire Rescue, Charlottesville, USA

Christopher Kroboth, EMT-P

Firefighter and Paramedic, Fairfax County Fire Rescue, Fairfax, USA

Stewart Lowson, MD

Associate Professor of Anesthesiology and Surgery Director, Critical Care Anesthesia Director, Critical Care Fellowship, University of Virginia School of Medicine Charlottesville, USA

Amal Mattu, MD

Professor and Vice Chair of Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA

Mark Sochor, MD

Associate Professor of Emergency Medicine, University of Virginia School of Medicine; Associate Professor of Mechanical Engineering, University of Virginia Engineering School, Charlottesville, USA

Benjamin Sojka, EMT-P

Assistant Chief, Charlottesville-Albemarle Rescue Squad, Charlottesville, USA

Sara Sutherland, MD

Assistant Professor of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, USA

Authors

J. Aidan Boswick, BA, EMT-B

Simulation Program Manager, Catholic Health Services Inc., Melville, USA

David Carlberg, MD

Chief Resident, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, USA

Christopher P. Holstege, MD

Associate Professor of Emergency Medicine and Pediatrics, Director, Division of Medical Toxicology, University of Virginia School of Medicine, Charlottesville, USA

Erik Iszkula, MD

Senior Resident, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, USA

Michael Levy, MD, FACEP, FACP

Medical Director, Anchorage Fire Department, Anchorage, USA

Peter Monteleone, MD

Clinical Instructor and Chief Resident, Department of Medicine, University of Virginia School of Medicine, Charlottesville, USA

Francis X. Nolan Jr, BS, MICP

Chief Medical Officer, Anchorage Fire Department, Anchorage, USA

Peter Pollak, MD

Senior Fellow, Cardiovascular Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, USA

Robert Rutherford, MD

Attending Physician, Swedish Medical Center-Edmonds Campus, Edmonds, USA

Courtney B. Saunders, MD

Fellow in the Adult Cardiovascular Disease, Joan C. Edwards School of Medicine, Marshall University, Huntington, USA

Robert C. Schutt, MD

Clinical Instructor, Department of Medicine, University of Virginia School of Medicine, Charlottesville, USA

Megan Starling, MD

Assistant Professor of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, USA; Attending Physician, Culpeper Memorial Hospital, Culpeper, USA

Richard B. Utarnachitt, MD, MS

Assistant Professor, Associate Clerkship Director, Medical Director, Airlift Northwest, Harborview Medical Center, University of Washington School of Medicine, Seattle, USA

Alvin Wang, DO, NREMT-P

Foreword

The Prehospital ECG: It's not just about STEMIs…..

Single lead or three lead cardiac monitoring was the sole means for EMS personnel to assess cardiac rhythm in the prehospital setting for many years. Resourceful EMS providers would use all three channels to verify rhythm, check for axis abnormalities and conduction disturbances, and even attempt to identify ST-T wave abnormalities in patients at risk for acute coronary syndrome. However, for most of EMS, the primary use of cardiac monitoring was to monitor the rhythm in the stable patient, or to determine which ACLS algorithm should be followed incases of cardiopulmonary arrest.

With the advent of fibrinolysis, EMS personnel and ED staff began to recognize the importance of early identification of STEMI patients as a means to reduce the “door-to-drug” time. When patients arrived by EMS with a diagnostic ECG having already been performed, patients received fibrinolysis much more quickly than if an ECG had not been done, or if the patient had arrived by private vehicle.

Fibrinolysis required preparation of the drug and patient screening for contraindications, but was otherwise less resource intense than PCI, which became widely used in the mid to latter 1990s. Like fibrinolysis, PCI is time critical, with “door to balloon” times serving as one of the crucial process metrics. Assembling a team for PCI consumed significant resources, including opening of a catheterization laboratory and the presence of the interventional cardiologist and other personnel who could perform the PCI. Mobilizing these resources during nights and weekends had the potential to engender significant time delays. STEMI systems began to mobilize the catheterization laboratory team based solely on the prehospital ECG interpretation. Many of these systems would rely on paramedic interpretation without a physician's interpretation of the ECG, due to the excellent interpretative skills developed by many EMS providers. The ability to perform 12-lead ECGs in the field has become a required skill in most EMS systems, and is now considered standard for STEMI systems to rely on EMS ECG interpretation to determine not only the destination hospital but also to activate the catheterization laboratory.

As paramedics have become skilled at recognition of STEMI, their interpretation skills in other clinical syndromes have developed. The prehospital ECG is not only administered to patients with suspected ACS, but is also used to better define rate, rhythm, or axis abnormalities first suspected on the single lead cardiac monitor. The 12-lead ECG is better able to define varying degrees of heart block as well as other conduction disturbances. Electrolyte abnormalities can be readily identified and dysrhythmias can be better recognized, thus allowing prehospital providers to tailor treatment to the underlying disorder.

The purpose of this text is to advance the interpretation skills of prehospital providers so that the ECG can be used as a diagnostic instrument for more than just the STEMI. In the same way that prehospital ECGs has reduced the “door-to-drug” and “door-to-balloon” times for STEMI, we are now in the era when the ECG can be used to speed the time to treatment of premalignant dysrhythmias or life-threatening electrolyte abnormalities. Readers of this book will benefit from the expertise of the authors, who have devoted a significant portion of their careers to teaching others the finer points of ECG interpretation. The diagnostic utility of the 12-lead ECG is vast, and after completing this book, readers will come to understand that the prehospital ECG is not only used to diagnose STEMI, but can be used to identify many other clinical condition, which if left untreated, would seriously compromise the health of the patient.

Robert E. O'Connor, MD, MPH

Dr. O'Connor is professor and chair of Emergency Medicine at the University of Virginia in Charlottesville. He is a past President of the National Association of EMS Physicians, a past Chair of the Emergency Cardiac Care Committee for the American Heart Association, and is a current board member of the American College of Emergency Physicians.

Preface

Electrocardiographic monitoring is one of the most widely applied diagnostic tests in clinical medicine today; its first application to the patient occurs in the prehospital setting and its use continues on into the hospital. The electrocardiogram, whether in monitor mode using single or multichannel rhythm monitoring or in diagnostic mode using the 12-lead ECG, is an amazing tool; it assists in establishing a diagnosis, ruling-out various ailments, guiding the diagnostic and management strategies in the evaluation, providing indication for certain therapies, offering risk assessment, and assessing end-organ impact of a syndrome. As noted in this impressive list of applications, it provides significant insight regarding the patient's condition in a range of presentations, whether it be the chest pain patient with ST segment elevation myocardial infarction (STEMI), the patient in cardiac arrest with ventricular tachycardia, the poisoned patient with bradycardia, or the renal failure patient with rhythm and morphologic findings consistent with hyperkalemia, among many, many others…. This extremely useful tool is noninvasive, portable, inexpensive, quickly obtained, and easily performed. Yet, its interpretation is not as easily performed and, in fact, requires considerable skill and experience as well as an awareness of its use in the appropriate clinical settings and limitations of patient data supplied.

This textbook has been prepared to assist the prehospital provider with the interpretation of the electrocardiogram and a solid understanding of its use across the range of presentations and applications. This textbook is arranged into five sections. Section one is a brief introduction and review of the ECG in the clinical setting. Section two focuses on the ECG and rhythm diagnosis, considering the electrocardiographic findings from an in-depth differential diagnostic perspective—in other words, rhythms with normal rates as well as bradycardia and tachycardia, allowing for the QRS complex width and regularity. Section three reviews the 12-lead ECG in patients suspected of acute coronary syndrome, including ST segment elevation myocardial infarction. Section four discusses the range of special presentations, patient populations, and uses of the electrocardiogram. Section five is a listing of various electrocardiographic findings, again from the differential diagnostic perspective; in this section, various rhythm and morphologic presentations are discussed, such as the narrow and wide complex tachycardias and ST segment elevation syndromes.

This textbook addresses the use of the ECG in its many forms by the prehospital provider, whether 911 ground EMS response, aeromedical transport, or interfacility critical care transfer. The novice electrocardiographer can use this text as his or her primary ECG reference; additionally, the experienced interpreter can use this textbook to expand his or her knowledge base. This work stresses the value of the ECG in the range of clinical situations encountered daily by prehospital providers—it illustrates the appropriate applications of the electrocardiogram in acute and critical care EMS settings.

Most importantly, this textbook is written by clinicians for clinicians, with an emphasis on the reality of the prehospital setting. I and my coeditors, advisory editors, and authors have enjoyed its creation—we hope that you the prehospital clinician will not only enjoy its content but also find it of value in the care of your patients. We thank you for what you do every day.

William J. Brady, MD Charlottesville, USA July 2012