EMTV Static Cardiology Card # 35

Hey everyone, welcome back to Static Cardiology here on EMTV. I'll be giving you an ECG rhythm and a scenario. On the bottom of the screen, you'll see a timer for 1 minute and 30 seconds. This time closely resembles the average amount of time you'll want to be spending on each card during an actual National Registry exam. When the time is up, I'll be giving you an answer as well as a treatment. Good luck. 3, 2, 1. So you're given a pretty ugly 12 lead with a pretty bad scenario. Let's go ahead and take a look at the bottom lead too to see if I can't identify what this rhythm is. First thing I'll do is calculate a rate. Now remember on a 12 lead each lead grouping here is two and a half seconds in duration. So what I'll do first is I'll take five seconds and then count five large boxes beyond that to get a six second strip. Now that I have my six second strip I'll count the r-waves and get my rate. Now I left one of the R waves out because I believe that this is a PVC. It's a widened QRS. It tends to break up the R to R interval of the preceding normal R waves, and it doesn't have a P wave associated with it. Generally, I don't count these toward rate because they tend to break up the R to R interval. to be non-perfusing, so I'll say that this rate is approximately 60. Next thing I'll do is identify this actual rhythm. Now knowing that this is a PVC, I'll concentrate on pretty much every other complex that's present here. I have a narrow narrow QRS complex, presence of a P wave, and a consistent R to R interval. Because of this, I'll diagnose this rhythm as normal sinus rhythm with unifocal PVCs. If you look very closely at this rhythm, however, you'll notice that there's another PVC present here, and these are coming after three normal QRS complexes, so it's technically quadremony, but that's a mouthful, so I'm going to stick with my original diagnosis of normal sinus rhythm with unifocal PVCs. Let's take a look. a look at each lead grouping now to see if there's anything more malignant going on. When I'm evaluating a 12 lead ECG the first lead groupings that I look at are the anterior or the anteroceptal leads, leads V1 through V4, and I look at these first because these leads actually will correspond to the LAD or the left anterior descending coronary artery and a blockage here is commonly referred to as a widowmaker. So what we're looking for is ST segment elevation or depression. Now for STEMI criteria for your percordial leads, which these are considered, you need an elevation of at least two millimeters and two millimeters millimeters is equal to two small small boxes. Unfortunately because of the copy process I kind of lost the resolution here on the small boxes but the large boxes that you're seeing make up five small boxes so that'll give us a rough idea. Now when you're looking at V1 the PVC aside so we're going to negate that I'm seeing significant amounts of ST segment elevation above the isoelectric line. In V2 again huge huge elevation off the isoelectric line. In fact, that's about 5mm. Same with V3 and V4. So right away, there is a significant amount of anterior involvement or LED involvement. on this 12 lead. Very, very concerning. Let's go ahead and take a look at the inferior leads next. In my inferior leads, leads 2-3 and AVF, I'm seeing significant amounts of segment depression. However, if you look at lead 3 and AVL, this is what's known as a reciprocal change. What that means is you are seeing an exact mirror image of lead III in AVL. This is very concerning for a lateral MI. Let's go ahead and take a look at those leads now. In my lateral lead grouping, I'm seeing significant ST segment elevation in leads I, AVL, and then possibly V6. So that may be on the fence and V5, it looks like it's not quite enough to make that determination. However, in order to make a positive identification of a STEMI, you need at least two leads within an anatomical contiguous lead grouping to be elevated in order to make a positive identification of STEMI. So knowing that I am seeing lateral involvement here. It's more significant in the anterior leads, but I would diagnose this as a anterolateral STEMI or an anterolateral MI. Let's go ahead and take a look at the scenario now. So we're dispatched to a private residence for a 44-year-old male complaining of crushing chest pain and dizziness that's been getting worse for the last 30 minutes. Patient reports that the pain began after eating a chili dog and he believes he may be experiencing heartburn. Unfortunately, the EKG is showing something a little bit more significant than heartburn. Your partner obtains the following vital signs. BP of 172 over 94. pulse of 70, respiratory rate 18, SpO2 98% on room air, and a blood sugar of 166. Now as the vast majority of your points in static cardiology are actually scored based on how you treat your patient, we must first determine if this patient is stable or unstable. Now the criteria I use for unstable patients, there's an acronym I use called CHAD. And this of course stands for cardiac insufficiency, hypotension, alteration of mental status, and dyspnea. Based on my patient's current vital signs, as well as his presentation, he does not meet any of the CHAD criteria. Remember, patient stability only determines the need for electrical therapy. We will be using the ACS pathway to treat this patient. So based on my scenario, my final diagnosis for static cardiology is going to be normal sinus rhythm with unifocal PVCs, but an acute anterolateral MI. Now let's go ahead and take a look at the treatment. Just like with all my other static cardiology videos, I begin my treatment by regurgitating the mantra, scene safe, BSI, IVO2 monitor. Now because this patient is suffering what appears to be a STEMI, I'll go ahead and base my treatment on the ACS path. pathway, or the acute coronary syndrome pathway. This involves giving nitroglycerin, 0.4 mg sublingual, every 5 minutes up to a maximum dose of 3, giving aspirin, 324 mg PO, I could then give morphine, 2-4mg or fentanyl 50mcg IV push. I'll have fluids running at KVO or TKO and then rapid transport to a facility that is capable of PCI or percutaneous intervention. This is otherwise known as a cath lab. Now for bonus points you could also say that you're going to attach pads to the patient's chest because MIs that involve the left ventricle tend to produce lethal ventricular dysrhythmias like B-fib or pulseless VTAC if they're left untreated. And that's it! If you liked this video, please make sure to subscribe to my channel for more static cardiology. And remember, you can make your own custom playlists using mycards to help you study with for your national registry exam. Until I see you next, have a good rest of your night.

Good luck. 3, 2, 1. So you're given a pretty ugly 12 lead with a pretty bad scenario. Let's go ahead and take a look at the bottom lead too to see if I can't identify what this rhythm is.

First thing I'll do is calculate a rate. Now remember on a 12 lead each lead grouping here is two and a half seconds in duration. So what I'll do first is I'll take five seconds and then count five large boxes beyond that to get a six second strip. Now that I have my six second strip I'll count the r-waves and get my rate. Now I left one of the R waves out because I believe that this is a PVC.

It's a widened QRS. It tends to break up the R to R interval of the preceding normal R waves, and it doesn't have a P wave associated with it. Generally, I don't count these toward rate because they tend to break up the R to R interval. to be non-perfusing, so I'll say that this rate is approximately 60. Next thing I'll do is identify this actual rhythm. Now knowing that this is a PVC, I'll concentrate on pretty much every other complex that's present here.

I have a narrow narrow QRS complex, presence of a P wave, and a consistent R to R interval. Because of this, I'll diagnose this rhythm as normal sinus rhythm with unifocal PVCs. If you look very closely at this rhythm, however, you'll notice that there's another PVC present here, and these are coming after three normal QRS complexes, so it's technically quadremony, but that's a mouthful, so I'm going to stick with my original diagnosis of normal sinus rhythm with unifocal PVCs.

Let's take a look. a look at each lead grouping now to see if there's anything more malignant going on. When I'm evaluating a 12 lead ECG the first lead groupings that I look at are the anterior or the anteroceptal leads, leads V1 through V4, and I look at these first because these leads actually will correspond to the LAD or the left anterior descending coronary artery and a blockage here is commonly referred to as a widowmaker.

So what we're looking for is ST segment elevation or depression. Now for STEMI criteria for your percordial leads, which these are considered, you need an elevation of at least two millimeters and two millimeters millimeters is equal to two small small boxes. Unfortunately because of the copy process I kind of lost the resolution here on the small boxes but the large boxes that you're seeing make up five small boxes so that'll give us a rough idea.

Now when you're looking at V1 the PVC aside so we're going to negate that I'm seeing significant amounts of ST segment elevation above the isoelectric line. In V2 again huge huge elevation off the isoelectric line. In fact, that's about 5mm. Same with V3 and V4.

So right away, there is a significant amount of anterior involvement or LED involvement. on this 12 lead. Very, very concerning.

Let's go ahead and take a look at the inferior leads next. In my inferior leads, leads 2-3 and AVF, I'm seeing significant amounts of segment depression. However, if you look at lead 3 and AVL, this is what's known as a reciprocal change.

What that means is you are seeing an exact mirror image of lead III in AVL. This is very concerning for a lateral MI. Let's go ahead and take a look at those leads now. In my lateral lead grouping, I'm seeing significant ST segment elevation in leads I, AVL, and then possibly V6.

So that may be on the fence and V5, it looks like it's not quite enough to make that determination. However, in order to make a positive identification of a STEMI, you need at least two leads within an anatomical contiguous lead grouping to be elevated in order to make a positive identification of STEMI. So knowing that I am seeing lateral involvement here. It's more significant in the anterior leads, but I would diagnose this as a anterolateral STEMI or an anterolateral MI. Let's go ahead and take a look at the scenario now.

So we're dispatched to a private residence for a 44-year-old male complaining of crushing chest pain and dizziness that's been getting worse for the last 30 minutes. Patient reports that the pain began after eating a chili dog and he believes he may be experiencing heartburn. Unfortunately, the EKG is showing something a little bit more significant than heartburn. Your partner obtains the following vital signs.

BP of 172 over 94. pulse of 70, respiratory rate 18, SpO2 98% on room air, and a blood sugar of 166. Now as the vast majority of your points in static cardiology are actually scored based on how you treat your patient, we must first determine if this patient is stable or unstable. Now the criteria I use for unstable patients, there's an acronym I use called CHAD. And this of course stands for cardiac insufficiency, hypotension, alteration of mental status, and dyspnea. Based on my patient's current vital signs, as well as his presentation, he does not meet any of the CHAD criteria.

Remember, patient stability only determines the need for electrical therapy. We will be using the ACS pathway to treat this patient. So based on my scenario, my final diagnosis for static cardiology is going to be normal sinus rhythm with unifocal PVCs, but an acute anterolateral MI. Now let's go ahead and take a look at the treatment.

Just like with all my other static cardiology videos, I begin my treatment by regurgitating the mantra, scene safe, BSI, IVO2 monitor. Now because this patient is suffering what appears to be a STEMI, I'll go ahead and base my treatment on the ACS path. pathway, or the acute coronary syndrome pathway. This involves giving nitroglycerin, 0.4 mg sublingual, every 5 minutes up to a maximum dose of 3, giving aspirin, 324 mg PO, I could then give morphine, 2-4mg or fentanyl 50mcg IV push.

I'll have fluids running at KVO or TKO and then rapid transport to a facility that is capable of PCI or percutaneous intervention. This is otherwise known as a cath lab. Now for bonus points you could also say that you're going to attach pads to the patient's chest because MIs that involve the left ventricle tend to produce lethal ventricular dysrhythmias like B-fib or pulseless VTAC if they're left untreated. And that's it! If you liked this video, please make sure to subscribe to my channel for more static cardiology.

And remember, you can make your own custom playlists using mycards to help you study with for your national registry exam. Until I see you next, have a good rest of your night.

Transcript for:EMTV Static Cardiology Card # 35

Transcript for:
EMTV Static Cardiology Card # 35