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STEMI CARE QUESTION: January 24 2018

Great question asked by Stacey, who is the nurse educator in a northern rural hospital.  As many of our readers, like Stacey, are hours to their closest PCI center, their STEMI protocol is to administer TNKase upon meeting the criteria checklist.

The question I was asked is: "why is the Cardiac Care Network recommending NOT starting the IV in the right wrist or hand?"

I checked the Cardiac Care Network's(CCN) website and found the following two documents for reference:

RECOMMENDATIONS FOR BEST-PRACTICE STEMI CARE IN ONTARIO

ACS MANAGEMENT RECOMMENDATIONS FOR REMOTE COMMUNITIES

I was not able to find a direct CCN policy statement or a TNKase manufacturer’s statement indicating which hand to start the IV in. However, the CCN document did provide examples of various organizations' documentation for CODE STEMI in outlying regions. The example from Thunder Bay Regional Health Centre did indicate to start 2 IVs and to avoid right wrist or hand.

Wanting to know the rationale for this policy, I asked my QRS colleagues who work in the cath-lab or in an organization where PCI is standard practice for their STEMI patients. Their responses were all identical: if the patient requires rescue PCI they generally use the right radial artery. They use the right radial because the left is a really tight angle and very challenging to access the coronary ostia. Another response from one of QRS instructors is, would you even want to put a peripheral IV in the hand or wrist of a STEMI patient who is in any way unstable or has the potential to become unstable? Putting IVs in joint areas is usually problematic because patients move their hands and wrists. You always want to ensure readily available venous access for emergent medication or volume administration should the patient deteriorate.

Thanks to Catherine, Betty Anne, Sevi, and Suzanne for their input. Thanks to Stacey for the question.

References:

http://ccn.on.ca/ccn_public/uploadfiles/files/ACS_management_in_remote_communities_FINAL_Sept_2013.pdf

http://www.ccn.on.ca/ccn_public/uploadfiles/files/Recommendations_for_Best_Practice_STEMI_Management_in_Ontario_(6).pdf

Peri-arrest and Arrest Avoidance January 08 2018

Peri-arrest is defined as the moments just prior to and after a cardiac arrest.  With good assessment skills and prompt intervention, peri-arrest situations may be avoided.  Many in-hospital arrests are preceded by recognizable physiologic changes, many of which are evident with routine monitoring of vital signs.  In recent studies, nearly 80% of hospitalized patients with cardiorespiratory arrest have abnormal vital signs documented for up to 8 hours before the actual arrest (Heart and Stroke Foundation, 2017). Untreated early shock and respiratory distress lead to cardiovascular collapse.  
 
The New Heart and Stroke Foundation ACLS for Experienced Providers is now available through QRS.
Answer this short questionnaire to find out if you would benefit from this course:

  1. Are you looking to strengthen your clinical skills?
  2. Do you work in Pre-Hospital, Emergency, CCU, ICU as an Advanced Care Paramedic, Physician, Nurse, or Respiratory Technician?
  3. Have you done ACLS more than once?
  4. Are you planning to do an ACLS recertification in 2018?

If you answered “YES” to all these questions, please consider your next ACLS course an ACLS Experienced Provider course.  Through focused, interactive case discussions, the 1-day ACLS EP course goes beyond the algorithms to gain better knowledge of the processes involved in the patient’s condition. The opportunity to finely tune your assessment skills will lead to improved patient outcomes.

Check out the spring ACLS EP COURSES poster on our FACEBOOK page or website courses and reserve your spot today!


In 2018, QRS is to become established as an organization that will run ACLS for the Experienced Provider. Recently, the Heart and Stroke Foundation (HSF) has launched the ACLS for Experienced Providers course December 18 2017

We are excited about this program and will have more to share with you in the next newsletter.  A few questions for our readers to ponder: how many of you have taken ACLS for many years? How many of you want to have more of a challenging ACLS course to increase your knowledge base and skills?  If you answered ‘yes’ to these questions, you are the ideal person to register for the new 1-day ACLS EP course. This will be a recertification course geared to experienced providers.  If you are interested in setting up this type of course with QRS, please contact me for more details.  More to come….


What happens when you give adenosine to a patient with this rhythm? December 18 2017

For those of you who have never seen how adenosine works, this is a great example of why patients report feeling horrible when given it.

This case wonderfully demonstrates a narrow complex tachycardia and how the administration of adenosine may not always revert the tachycardia to sinus rhythm.

http://hqmeded-ecg.blogspot.ca/2017/08/what-happens-when-you-give-adenosine-to.html


Recipients of 2017 Pamela Twiselton Educational Fund... December 05 2017

A year ago, October 18, 2016, we lost a dear friend and instructor, Pamela Twiselton.  She was very honoured and happy when she found out that QRS was setting up an educational fund in her name to help those who are financially strapped the opportunity to attend one of our QRS educational sessions. I am pleased to announce the recipients of this year’s Pamela Twiselton Education Fund is the McMaster University 4th Year Nursing Students. The strike affected them greatly and despite not having their educational subsidy program available because of the strike, they still reached out as a group to have the Rhythm/ECG course brought to them. The course they’re attending will allow them to develop a good introductory understanding of rhythm and ECG interpretation, recognise when ECGs and rhythms require immediate action, and anticipate the treatment to be given.  Without this fund, not all would have been able to attend. 


February Case Study... February 01 2017

Before starting this month’s case study, I would like to ask our readers two questions to get the gray matter going. These are standard questions I ask when running my courses:

 What is the normal “pacemaker” of the heart? What rate does it normally fire at?
 How would you be able to differentiate a supraventricular beat vs a ventricular beat?

The answers will be viewed at the bottom of this case.

With those questions asked, let’s move on to the case study which was presented in Dawn Altman’s site, ECG Guru. Thank you Dawn, it’s always a pleasure to feature your cases.
Case: A 60-year-old male is brought into the Emergency Department by EMS. He was involved in a MVC, sustained no apparent injuries but is severely intoxicated. He is hemodynamically stable with a heart rate of 170/minute.

Below is the first ECG taken at 1507hrs. What do you think this rhythm is?
a. SVT b. Sinus Tachycardia c. Atrial Flutter d. VT

               

Rate: 170/min and regular. Intervals: P wave – even though the rate is rapid, there is evidence of a P wave prior to each QRS complex. The PR interval is the same. QRS – narrow. Rhythm: Sinus tachycardia. Discussion: The release of stress hormones combined with his intoxication put this patient into a sinus tachycardia. Many may think that any narrow complex tachycardia over 150/min is SVT. SVT can be an atrial flutter, atrial tachycardia, re-entry tachycardia. Oftentimes, we label a narrow complex tachycardia SVT because we are unable to distinguish identifiable features to specifically label the rhythm: such as P waves or flutter waves. In this ECG, there is evidence of one P wave prior to each QRS complex, making this tachycardia likely sinus in origin. 


Below is the second ECG taken at 1543hrs. What is the rhythm?

Note that all complexes are still the same; however, the rate is now 110/min. The rate has gradually decreased from the initial ECG, which supports sinus tachycardia vs. the other SVT options that were discussed.
Conclusion: a narrow complex regular tachycardia less than 150/minute is sinus tachycardia. A narrow complex regular tachycardia over 150/minute may still be sinus tachycardia and may be challenging for the health care provider to properly interpret. Is it SVT or is it Sinus Tachycardia? This is a very important question to answer properly because treatment varies greatly between the two. When deciding SVT vs Sinus Tachycardia, look at the story and presentation. And, here is a great tip: A gradual increase or gradual decrease in the rate occurs in a sinus tachycardia. Whereas for SVT, the rates suddenly increases or suddenly terminates.

Thanks again to Dawn for this great reminder.

Answers to the 2 questions above:
1. The Sinus Node is the normal pacemaker of the heart and usually fires between 60-100/minute. The hallmark of a sinus rhythm is a P wave prior to each QRS complex. Sinus rhythm can be faster than 100/minute = sinus tachycardia or slower than 60/minte = sinus bradycardia. 2. Supraventricular tachycardia originates above the ventricles; therefore, the QRS duration should be normal (unless there is also a bundle branch block). Ventricular tachycardia is always a widecomplex regular rhythm.


The REVERT Study June 06 2016

This was a randomized clinical trial looking at utilizing a modified Valsalva technique to convert supra ventricular tachycardia (SVT) to sinus rhythm. The results of applying the modified Valsalva technique demonstrated a 43% conversion rate versus a 17% conversion rate with standard Valsalva technique.
 
The best way to describe this modified technique is for you to watch this short (2 minutes) You tube video presented by one of the investigators of the REVERT study. This is a great technique that all emergency personnel should be thinking about implementing next time faced with a patient in SVT.
Modified Valsalva – REVERT Study - https://www.youtube.com/watch?v=8DIRiOA_OsA


Question of the Month: December 11 2015

When doing a 12 Lead ECG, can the right leg lead be placed on the left leg to save time?

This discussion took place during the 2 day Rhythm/ECG course that I ran in Vernon BC. I was told that some of the ECG techs put the right leg electrode (which is just a ground lead and produces no picture on the 12 Lead ECG) on the left leg in order to save some time. I was asked if this practice is acceptable.
 
My response to the group was that, while the right leg lead is a ground lead and should not in any way impact on the ECG, I wasn’t 100% sure that was ok to do. I set out to find out if placing the right ground leg electrode on the left leg was acceptable practice.
 
While it is acknowledged that the right leg (RL) electrode acts as an electronic reference that serves to improve unwanted noise, there is no specific mention of where the RL electrode needs to be placed and further discussion on the limb leads only makes reference to the LA, LL, RA electrodes as part of Einthoven’s law (Kligfield et al, 2007).
 

In a separate article published by Philips which described the 12-Lead ECG Monitoring with the EASI System, they described the conventional 12 Lead ECG in the following manner: “…electrodes are placed on the right arm, left arm, and left leg to view leads I, II, and III. In addition, six electrodes are placed on the chest and a ground reference is placed on the right leg, although it could be anywhere”.
 
While this latter statement seemed to be the answer I would hoping to find, I am still not convinced that placing the right leg electrode can be placed anywhere. I need more proof. I spoke with an electrician who stated that one purpose of a ground lead is to close the loop or circuit. In the electrocardiography world, there is a ton of science that goes behind the rationale for where the limb leads are placed. My gut is telling me there’s more of a complicated answer to this question.
 
I am going to leave this question for the time being because time has run out to search out more definitive answers. I will keep looking into this really fascinating question and let you know when I find out anything new. In the meantime, I will be conducting a mini-study by performing ECGs on healthy subjects using the standard placement and compare these to ECGs using the modified approach of using the left leg to place both leg electrodes and see if there are any differences. If you are able to find out any information pertaining to this question, please email me.  

The following articles were reviewed:

  1. Kligfield, P., Gettes, L., Bailey, J., et. al. (2007). Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part I: The Electrocardiogram and Its Technology A Scientific Statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society endorsed by the International Society for Computerized Electrocardiology. Journal of the American College of Cardiology.                                       Retrieved from http://content.onlinejacc.org/cgi/content/full/49/10/1109
  2. Phillips. (2002). 12-Lead ECG Monitoring with the EASI System

Impedance Threshold Devices October 26 2015

This You-Tube video provides an excellent description and video on how Impedance Threshold Devices (IPD)work. As per the new 2015 ACLS Guidelines, they are recommending that the combination of ITD with active compression-decompression CPR may be a reasonable alternative to conventional CPR.


Question of the month: Jody asked: “I'm trying to get my head around what is going on in the heart when it is referred to as a 'flipped bundle'...can you help me out?? July 31 2015

Hi Jody, Thanks for asking this question.  I actually have never heard this expression before but had an idea it would be referring to bundle branch blocks.  I did a search online for “flipped bundle” and “flipped bundle on the ECG” and came across numerous references to bundle branch blocks. So, a “flipped bundle” is either a right or left bundle branch block. By stating the bundle is “flipped” indicates that the direction of the QRS complex has “flipped” from its normal position to the position that results from the bundle branch block.

One reference actually referred to the flipping up or down of the QRS complex as the Turn Signal Theory. In the Turn Signal Theory, when you look at V1 in a Right Bundle Branch Block, the wide QRS complex flips or turns to an upright position above the isoelectric line. When you look at V1 in a Left Bundle Branch Block, the wide QRS complex is in a negative position below the isoelectric line. The Turn Signal refers to when you are driving and approach a turn, you will indicate to other drivers which direction you are turning by putting your turn indicator either ‘up’ or ‘down’. When you want to turn LEFT, you turn your indicator “down”. Left = down (LBBB) in V1.  When you want to turn RIGHT, you turn your indicator “up”.  Right = up (RBBB) in V1.

The rationale for the QRS complex to flip to a certain direction in a RBBB or LBBB is related to the altered electrical force having to compensate for the blocked branch. This altered electrical force will assume a new pathway around the blocked branch and this extra force will start off in the non-affected branch and associated ventricle and travel to the affected branch and associated ventricle.  A basic rule in ECG is that a QRS complex is upright if the energy is traveling towards the positive electrode and a QRS complex is negative if the energy is traveling away from the positive electrode.  Therefore, in a RBBB, because the altered energy is traveling toward the right bundle and right ventricle, V1 (which is sitting pretty much right at the right ventricle) will be an upright QRS complex.  In a LBBB, because the altered energy is now traveling from the right bundle and right ventricle toward the left bundle and left ventricle, and traveling away from V1, the QRS complex will now be negative.  I hope this has helped clear things up.  If not, let me know and I will look into it further.  Darlene

Thanks to Dawn Altman for her fantastic website: ECG Guru.

Jason E. Roediger - Certified Cardiographic Technician (CCT) at http://ecgguru.com/content/bundle-branch-block.

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