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Chest pain pdf

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Basic ecg interpretation and management of different anatomical myocardial infarctions

Publié dans : Santé
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Chest pain pdf

  1. 1. AN APPROACH TO ACUTE CHEST PAIN THE FIRST 20 MINUTES
  2. 2. COMPLAINS OF ACUTE CHEST PAIN, WHAT DO YOU DO? YOUR PT IS TRIAGED AS A RED CODE
  3. 3. THATS A LONG ALGORITHM!!!
  4. 4. OUR JOB IS TO STABILISE THEN TO STRATIFY INTO A RISK CATEGORY
  5. 5. ALTHOUGH NOT FOOLPROOF IT IS INVALUABLE OUR MAIN WEAPON IS THE ECG • ONCE WE HAVE AN ECG IT LEADS US DOWN THREE DISTINCT PATHS • WE WILL ATTEMPT TO LOOK AT SIMPLE ECG TRACINGS AND IDENTIFY WORRYING TRAITS • INTERPRETING ECGS IS AN ESSENTIAL SKILL FOR ALL DOCTORS • BOOKS SUCH AS ‘ECG MADE EASY’ OR ‘THE ONLY ECG BOOK YOU WILL EVER NEED’ ARE EASILY AVAILABLE ONLINE
  6. 6. ST ELEVATION MYOCARDIAL INFARCT
  7. 7. CAN YOU NAME THE ABNORMALITIES IN THE ECG? WHICH PARTS OF THE HEART HAVE SUFFERED AN INFARCT? SHOULD I BE WORRIED?
  8. 8. CAN YOU NAME THE ABNORMALITIES IN THE ECG? WHICH PARTS OF THE HEART HAVE SUFFERED AN INFARCT? SHOULD I BE WORRIED?
  9. 9. WHAT NEXT? SO NOW WE’VE MADE THE DIAGNOSIS • THIS IS A HIGH RISK ACS • THE PT REQUIRES EITHER PCI OR THROMBOLYSIS • HOW MUCH OF MORPHINE CAN WE GIVE? • BETWEEN 2-10MG DEPENDING ON RESPONSE • WHY IS THE MORPHINE SO IMPORTANT? • PAIN AND CATECHOLAMINE DECREASE
  10. 10. THIS IS THE POINT YOU INVOLVE THE PHYSICIANS THE PATIENT IDEALLY NEEDS URGENT REPERFUSION • WE DO NOT NEED TO WAIT FOR CARDIAC MARKERS • WHAT DO I ASK THE PATIENT ABOUT? • HOW DO I PRESENT THE PT TO THE PHYSICIAN?
  11. 11. JUST SOME GENERAL GUIDES INTERPRETING AN ECG • FIRST DETERMINE THE AXIS • THEN THE RATE • THEN THE RHTHYM • THEN LOOK FOR CHANGES AND ABNORMALITIES
  12. 12. LETS TRY AND NAME SOME INFARCTS
  13. 13. ANTEROSEPTAL
  14. 14. MORE OF A SEPTAL MI. NOTE THE T-WAVE INVERSIONS. DO WE NEED THE PATIENTS AGE AND GENDER?
  15. 15. • WHEN WE LOOK AT V2 AND V3 THESE ARE SPECIAL CONSIDERATIONS • IN WOMEN > 1.5 BLOCKS IS WORRYING • IN MEN ITS WORRYING IF • > 40 YEARS, 2 BLOCKS • < 40 YEARS , 2.5 BLOCKS
  16. 16. INFERIOR MI IS THERE RIGHT VENTRICULAR SPREAD? AS A RULE OF THUMB, IF THE ST ELEVATION IN III >II, THEN YES BUT YOU HAVE TO DO A 16 LEAD ECG TO CONFIRM!
  17. 17. HOW TO PLACE THE ELECTRODES WE CAN SEE THE ST ELEVATION MUCH BETTER NOW
  18. 18. POSTERIOR MI, ALONG WITH INFERIOR AND RV WE CONFIRM WITH AN 18 LEAD ECG IT VERY RARELY OCCURS IN ISOLATION
  19. 19. WE CAN SEE THE ST ELEVATIONS NOW V7-V9
  20. 20. AND NOW NSTEMI AND UNSTABLE ANGINA
  21. 21. IS OUR PT HIGH RISK OR LOW RISK? WE CONCENTRATE MAINLY ON 9 & 10
  22. 22. WE NEED TO CONSIDER EACH PT IT DEPENDS • IS THE PT UNSTABLE? - HIGH RISK • ARE THERE DYNAMIC CHANGES IN THE ECG? - HIGH RISK • ARE THE CARDIAC MARKERS RISING OR ELEVATED INITIALLY? -HIGH RISK • IS THE PT DETERIORATING IN OUR CARE? • TACHYCARDIAS • HEART FAILURE • PERSISTENT PAIN • HAEMODYNAMIC INSTABILITY • ALL POINT TOWARDS HIGH RISK
  23. 23. THEY ARE MANAGED AS STEMI PTS IF OUR PT IS HIGH RISK? • AND LOW RISK PATIENTS REQUIRE FURTHER EVALUATION BY A CARDIOLOGIST • THEY MUST NEVER BE SENT HOME • THEY REQUIRE SERIAL ECGS AND CARDIAC MARKERS • ALWAYS GIVE THEM LOW DOSE MORPHINE ONLY, 2-5MG AND NOT MORE, AND ONLY IF TNT IS NOT CONTROLLING SXS
  24. 24. BUT IT SOUNDS LIKE CARDIAC PAIN AND THE LOW RISK PT • FIRST, HAVE I CONSIDERED ALTERNATE DIAGNOSIS? • PERICARDITIS • DISECTING ANEURYSM • OESOPHAGEAL RUPTURE • PULMONARY EMBOLI OR PNEUMOTHORAX • SECOND, IF YOU ARE STRONGLY SUSPICIOUS OF A CARDIAC CAUSE, THEN ADMIT FOR SERIAL ECGS AND CARDIAC MARKERS • MANY MI’S SHOW NO ECG CHANGES • CARDIAC MARKERS TAKE TIME TO RISE
  25. 25. JUST A FEW LAST THINGS TO NOTICE ON THE ECG
  26. 26. ST ELEVATION IN AVR IS ALSO VERY, VERY WORRYING
  27. 27. BI PHASIC T-WAVES IN V2-V3 SHOULD MAKE YOU SUSPECT A SERIOUS MI EVEN IF THE PATIENT IS PAIN FREE
  28. 28. CAN YOU MAKE THE DIAGNOSIS? WINNER IS EMPLOYEE OF THE MONTH!! BE SYSTEMATIC, NAME ALL THE CHANGES
  29. 29. THIS IS A PULMONARY EMBOLUS LOOK OUT FOR 1)TACHYCARDIA 2) RBBB 3) S1Q3T3 PATTERN 4)T-WAVE INVERSIONS V2-V3 5) R-AXIS DEVIATION (NOT SEEN HERE)
  30. 30. OUR FIRST 20 MINUTES ARE CRITICAL IN CONCLUSION • AT THE VERY LEAST YOU CAN GET AN ECG AND STRATIFY YOUR PATIENT • YOU CAN START THE PROCESS OF SAVING YOUR PATIENT • IT IS IMPOSSIBLE TO TEACH YOU THE SUBTLETIES OF ECGS IN THESE FEW SLIDES, BUT AT LEAST YOU CAN RECOGNISE OBVIOUS PATTERNS

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