Acute Acute CoronaryCoronary Syndrome Syndrome

What is Acute Coronary Syndrome ?What is Acute Coronary Syndrome ?

How can I look at an EKG and tell How can I look at an EKG and tell what part of the heart is affected ?what part of the heart is affected ?

What do ICU RNs need to know ?What do ICU RNs need to know ?

What is Acute Coronary Syndrome What is Acute Coronary Syndrome (ACS) ?(ACS) ?

Acute Coronary Syndrome is when occlusion Acute Coronary Syndrome is when occlusion of one or more of the coronary arteries occurs, of one or more of the coronary arteries occurs, usually following plaque rupture, resulting in usually following plaque rupture, resulting in decreased oxygen supply to the heart muscle. decreased oxygen supply to the heart muscle.

ACS is the largest cause of death in U.S. Over ACS is the largest cause of death in U.S. Over 1 million people will have Myocardial 1 million people will have Myocardial Infarctions this year; almost half will be fatal.Infarctions this year; almost half will be fatal.

Majority of mortality associated with ST Majority of mortality associated with ST Elevation Myocardial Infarction (STEMI).Elevation Myocardial Infarction (STEMI).

Who is at risk for ACS?Who is at risk for ACS?

Anyone with history of CAD, HTN, ESRD, DMAnyone with history of CAD, HTN, ESRD, DM Blood loss due to GI Bleed, surgery, traumaBlood loss due to GI Bleed, surgery, trauma Patients on dialysis with AV Fistulas (Patients on dialysis with AV Fistulas (↑ ↑

myocardial O2 demands)myocardial O2 demands) Decreased O2 saturations (particularly in COPD)Decreased O2 saturations (particularly in COPD) Fever, hyperthyroidism, sustained tachycardia, Fever, hyperthyroidism, sustained tachycardia,

prolonged hypotension, hypothermia, DIC,prolonged hypotension, hypothermia, DIC, drug drug use (especially cocaine)use (especially cocaine)

Who is at risk for ACS?Who is at risk for ACS?

Conditions that may Conditions that may mimicmimic ACS include: ACS include:

Musculoskeletal chest painMusculoskeletal chest pain Pericarditis (can have acute ST changes)Pericarditis (can have acute ST changes) Aortic dissectionAortic dissection Central Nervous System Disease (may Central Nervous System Disease (may

mimic MI by causing diffuse ST-T wave mimic MI by causing diffuse ST-T wave changes) changes)

Pancreatitis/CholecystitisPancreatitis/Cholecystitis

The Three I’sThe Three I’s

IschemiaIschemia== ST depression or T-wave ST depression or T-wave inversioninversion

Represents lack of oxygen to myocardial tissueRepresents lack of oxygen to myocardial tissue

The Three I’sThe Three I’s

Injury Injury = ST elevation -= ST elevation -- represents prolonged - represents prolonged ischemia; significant when > 1 mm above the ischemia; significant when > 1 mm above the baseline of the segment in two or more leadsbaseline of the segment in two or more leads

The Three I’sThe Three I’s

Infarct Infarct = Q wave= Q wave — — represented by first represented by first negative deflection after P wave; must be negative deflection after P wave; must be pathological to indicate MIpathological to indicate MI

What part of the heart is What part of the heart is affected ?affected ?

II, III, aVF = II, III, aVF =

Inferior WallInferior Wall

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Inferior Wall MIInferior Wall MI

Based on the EKG, which vessel in Based on the EKG, which vessel in the heart is blocked?the heart is blocked?

II, III & aVF = Inferior Wall MI = II, III & aVF = Inferior Wall MI =

Right Coronary ArteryRight Coronary Artery

blockage blockage

Which part of the heart is affected ?Which part of the heart is affected ?

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

• Leads V1, V2, V3, and V4 =

Anterior Wall MI

Anterior Wall MIAnterior Wall MI

Based on the EKG, which vessel in Based on the EKG, which vessel in the heart is blocked?the heart is blocked?

V1 - V4 = Anterior WallV1 - V4 = Anterior Wall

(Left Ventricle) =(Left Ventricle) =

Left Anterior Left Anterior

Descending Artery Descending Artery

BlockageBlockage

What part of the heart is What part of the heart is affected ?affected ?

I, aVL, V5 and V6I, aVL, V5 and V6

Lateral wall of left Lateral wall of left ventricleventricle

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Lateral Wall MILateral Wall MI

Based on the EKG, which vessel in Based on the EKG, which vessel in the heart is blocked?the heart is blocked?

I, aVL, V5 + V6 = I, aVL, V5 + V6 =

Lateral Wall = Lateral Wall =

Circumflex ArteryCircumflex Artery

BlockageBlockage

What do ICU RNs need to know?What do ICU RNs need to know?You should do a 12-Lead EKG when:You should do a 12-Lead EKG when:

A patient who has CAD risk factors complains A patient who has CAD risk factors complains of Chest Painof Chest Pain

When you are analyzing your rhythm strip on When you are analyzing your rhythm strip on the flowsheet, and you notice that it looks the flowsheet, and you notice that it looks different from the previous shift; different from the previous shift; OROR any any arrhythmias or changes in rhythmarrhythmias or changes in rhythm

If your patient who is intubated / sedated If your patient who is intubated / sedated suddenly begins to have hemodynamic suddenly begins to have hemodynamic changes putting stress on the heart + lungschanges putting stress on the heart + lungs

What do ICU RNs need to know?What do ICU RNs need to know?

Unexplained tachycardiaUnexplained tachycardia TachypneaTachypnea Sudden elevation in PA catheter #’s or ICP Sudden elevation in PA catheter #’s or ICP

(unexplained)(unexplained) Nausea and/or diaphoresis that doesn’t Nausea and/or diaphoresis that doesn’t

make sensemake sense PallorPallor Symptoms of sudden heart failure Symptoms of sudden heart failure

(pulmonary edema/crackles)(pulmonary edema/crackles) Unexplained restlessness/all of a sudden Unexplained restlessness/all of a sudden

needs more sedation needs more sedation

SummarySummaryAfter completing an EKG, look at each After completing an EKG, look at each

of the leads for ST segment changesof the leads for ST segment changesRemember the three I’s:Remember the three I’s:

Ischemia, Injury, and Infarct !!Ischemia, Injury, and Infarct !! Identify the section of the heart (and Identify the section of the heart (and

vessel supplying it) affected by the vessel supplying it) affected by the blockage according to the groups of blockage according to the groups of leads changing in the EKGleads changing in the EKG

Remember the symptoms that would Remember the symptoms that would prompt you to obtain an EKG!prompt you to obtain an EKG!