12 LEAD ECG ACQUISITION & TRANSMISSION FOR BLS PROVIDERS (Revised 2/26/13-c.shroy)

LESSON PLAN
  1. Introduction (Slide 1-2)
  2. Course development and philosophy
  3. Course agenda
  4. Lecture
  5. PPT with instructor notes
  6. Resource citations
  7. Credit to contributors and reviewers
  8. Hands on practice
  9. Scenarios within the PPT for practice
  10. Written test (80% passing score)
  11. Sample written test meets CECBEMS testing standards
  12. Final practical test
  13. DOH approved skill sheet included
  1. Purpose (Slide 3)
  2. To provide rationale and benefits of cardiac care systems.
  3. To train BLS providers to acquire and transmit 12 Lead ECG data.
  4. To improve identification of patients with STEMI in BLS systems.
  5. To facilitate transport to the most appropriate facility.
  1. Objectives (Slide 4-7)
  2. Describe the components of a cardiac system.
  3. List the benefits of a cardiac system.
  4. Review the anatomy and physiology of the cardiovascular system.
  5. List the components of the electrical conduction system of the heart.
  6. List some examples of acute coronary syndromes.
  7. Identify risk factors for coronary syndromes.
  8. List and describe three events that are responsible for initiating acute coronary syndromes.
  9. List and describe the stages of progression in the cascade of events during an acute coronary syndrome.
  10. Describe symptoms of classic chest pain.
  11. Describe symptoms of atypical chest pain and list the most common characteristics of patients affected by this type of chest pain.
  12. Describe the symptoms of anginal equivalent chest pain.
  13. List some indications for the acquisition of a 12 Lead ECG.
  14. List the three main steps to acquiring a 12 Lead ECG.
  15. Describe the proper placement of the 10 ECG leads that must be applied to the patient for 12 lead acquisitions.
  16. List at least three tips for success related to acquiring a 12 lead ECG.
  17. List some common causes of ECG signal noise/artifact.
  18. Demonstrate successful 12 lead ECG acquisition in a training scenario.
  19. Successfully complete a written exam with a passing score equal or greater to 80%.
  1. Cardiac Systems - National Epidemiology (Slide 8)
  2. Acute MI is the leading cause of death in the US
  3. 1.1 Million people have an MI annually
  4. 439,000 women
  5. 668,000 men
  6. Costs for Coronary Artery Disease in 2010: $444 billion, and treatment accounts for $1 of every $6 spent on health care in the US. (Source: CDC)
  1. Cardiac Systems - Needs Assessment (Slide 9)
  2. Emergency Cardiac and Stroke Care Executive Summary for Washington State
  1. People aren’t getting proven treatments
  2. <50% of heart attacks get PCI
  3. <3% of ischemic strokes get tPA
  4. Variation in care and outcomes across the state
  5. Population at greatest risk increasing rapidly
  6. Time to treatment makes big difference in outcomes
  7. Because we can do better
  1. Cardiac Systems - Door to Balloon Time (Slide 10)
a. The door-to-balloon time is typically defined as the interval from when the patient first arrives in the emergency department until balloon inflation in a catheterization lab.
  1. Cardiac Systems - Proven Performance (Slide 11)
  2. National momentum
  3. American Heart Association
  4. American College of Cardiology
  5. Centers for Disease Control
  6. Society for Chest Pain Centers
  7. Center for Medicare Services (CMS)
  8. Examples
  9. North Carolina RACE
  10. Los Angeles
  11. Minnesota Cardiac Level 1
  1. Cardiac Systems – Minimize Delay in the Chain of Survival (Slide 12)
  2. Goals of the Cardiac System
  3. To Deliver the right patient
  4. to the right place
  5. In the right amount of time.
  1. Cardiac System Components (Slide 13)
  1. Cardiac Systems - Washington’s Approach (Slide 14)
  2. Emergency Cardiac & Stroke Technical Advisory Committee provides direction on:
  3. Recommended dispatch guidelines
  4. Standardized EMS protocol guidelines
  5. Standardized EMS triage tools
  6. Voluntary hospital categorization
  7. Quality improvement & data collection
  8. Public education
  1. Cardiac Systems - EMS Guidelines and Tools (Slide 15)
  2. Pre-hospital protocol guidelines
  3. Triage tool
  4. Hospital levels
  1. Cardiovascular Anatomy (Slide 16)
  2. Muscular pump consisting of four chamber
  3. Two Atria
  4. Two Ventricles
  5. Great vessels to & from the heart
  6. Venacava
  7. Pulmonary Artery
  8. Pulmonary Vein
  9. Aorta
  1. Cardiovascular Physiology (Slide 17)
  2. Coronary circulation
  3. Heart is fed through two (2) Coronary Arteries
  4. Right Coronary Artery (RCA)
  5. Left Coronary Artery (LCA)
  6. Left Circumferential Artery
  7. Originate from base of aorta
  8. The heart is fed during diastole (while heart is at rest)
  1. Basic Electrophysiology (Slide 18)
  2. The heart has a electrical conduction system that sends electrical current throughout the heart.
  3. Electrical current causes contractions of the heart that produces pumping of blood.
  4. Pathophysiology that occurs within the heart may affect the electrophysiology and vice versa.
  1. Basic Electrophysiology - Components of the electrical conduction system (Slide 19)
  2. SA node
  3. Three intermodal pathways
  4. AV node
  5. Bundle of His
  6. Right and left bundle branches
  7. Electrical conduction system in action
  1. Basic Electrophysiology – Electrical Conduction System in Action (Slide 20)
[See Figure on slide]
  1. Basic electrophysiology and the ECG (Slide 21)
  2. The electrophysiology of the heart can be detected and analyzed with a 12 Lead ECG machine.
  3. ECG electrodes placed on the skin detect the electrical activity of the heart.
  4. The ECG machine converts the detected activity to wave forms.
  5. Lead placement is important for the most accurate results.
  1. Basic Electrophysiology - The ECG Complex (Slide 22)
  2. One complex represents one contraction (beat) of the heart
  3. The complex consists of several wave forms.
  4. P
  5. Q
  6. R
  7. S
  8. T
  9. Each waveform represents a different phase of coronary circulation and electrophysiological function.
  1. Basic Electrophysiology - The ECG Complex (Slide 23)
  2. A segment is a specific portion of the complex.
  3. An interval is the distance, measured in time, occurring between two cardiac events.
  1. Basic Electrophysiology – Principles of an ECG Tracing (Slide 24)
  2. An ECG is a recording of the heart’s electrical activity.
  3. Just because there is electrical activity doesn’t mean there is mechanical activity.
  4. Electrical current moving toward the positive electrode causes positive deflection of a waveform on an ECG tracing.
  5. Electrical current moving away from the positive electrode causes negative deflection of a waveform on an ECG tracing.
  6. The stronger the current, the larger the deflection.
  1. Basic Electrophysiology - The Normal Sinus Rhythm (Slide 25)
  2. All the P waves should be the same
  3. A normal heart rate 60-100 beats/min.
  1. Acute Coronary Syndromes (Slide 26)
  2. ACS is a term used to describe a continuum of similar disease processes that include;
  3. Angina
  4. Unstable Angina
  5. ST Elevation MI (STEMI)
  6. Non-ST Elevation MI (NSTEMI)
  7. It is often NOT possible for EMS to determine which event is occurring in the early minutes of a heart attack.
  1. Tip for Success (Slide 27)
  2. IF a patient is having a STEMI, studies show these patients have the most to gain from rapid transport and heart catheterization.
  1. Acute Coronary Syndromes - Risk Factors for ACS (Slide 28)
  2. Cigarette smoking (doubles the risk)
  3. Family history of heart attack
  4. Male over 35
  5. Women over 40
  6. Diabetes mellitus
  7. Hypertension
  8. Obesity
  9. Elevated blood cholesterol levels
  10. Sedentary life style-lack of sufficient exercise
  11. Stress
  1. Acute Coronary Syndromes - Initiating Events (Slide 29)
  2. Plaque rupture
  3. Thrombus formation
  4. Vasoconstriction
  1. Acute Coronary Syndromes -Cascade of Events (Slide 30)
  2. Ischemia
  3. Injury
  4. Infarct
  1. Acute Coronary Syndromes (Slide 31)
  2. 50% of the population discover they have Coronary Artery Disease when they go into cardiac arrest!
  3. The other 50% present as one of the following chest pain stories;
  4. Classic
  5. Atypical
  6. Anginal equivalent
  1. Acute Coronary Syndromes - Classic Chest Pain (Slide 32)
  2. Central anterior chest
  3. Dull, fullness, pressure, tightness, crushing
  4. Radiates to arms, neck, back
  1. Acute Coronary Syndromes - Atypical Chest Pain (Slide 33)
  2. Musculoskeletal, positional or pleuritic features
  3. Often unilateral
  4. May be described as sharp or stabbing
  5. Includes epigastric discomfort
  6. Often seen in female;
  7. Diabetics
  8. Post menopausal
  9. Elderly
  1. Acute Coronary Syndromes - Anginal Equivalent(Slide 34)
  2. Dyspnea
  3. Palpitations
  4. Syncope or pre-syncope
  5. General weakness
  6. Diabetes
  1. Acute Coronary Syndromes - Treatment (Slide 35)
  2. Follow local protocols and AHA Guidelines
  3. Treatment and 12 lead should be provided concurrently
  4. Don’t delay treatment to acquire 12 lead
  5. Transport to the most appropriate facility
  1. Indications for BLS 12 Lead ECG (Slide 36)
  2. Chest Pain
  3. Classic
  4. Atypical
  5. Anginal Equivalent
  6. Discomfort
  7. Shortness of breath
  8. Nausea
  9. Lightheadedness
  10. Stroke
  11. Post-Resuscitation
  1. Tip for Success (Slide 37)
  2. Even if a 12 lead is NORMAL – it doesn’t mean the patient isn’t having an MI!
  1. Tip for Success (Slide 38)
  2. Know your Cardiac System. Use the Washington State Cardiac Triage Tool (WSCTT) to determine the most appropriate facility for your patient
  1. Pre-hospital 12 Lead ECG Machines (Slide 39)
  2. Benefits
  3. Quick
  4. Reliable
  5. Early and accurate identification of acute ischemia and arrhythmias
  6. Variety of models
  7. Set of cables
  8. Electrodes
  9. Transmission capabilities
  1. Steps for Acquiring a 12 Lead ECG (Slide 40)
  2. Prepare the equipment
  3. Prepare the patient
  4. Perform the procedure
  1. Steps for Acquiring a 12 Lead ECG - Prepare the Equipment (Slide 41)
  2. Assure there is sufficient paper in the monitor
  3. Or: Assure the monitor is ready for transmission
  4. Attach monitor cables to self-adhesive leads
  5. Confirm electrodes are not expired
  6. Attach electrodes cables to monitor
  7. Attach electrodes to the ECG cables
  8. Ensure cables area attached to monitor.
  1. Steps for Acquiring a 12 Lead ECG- Prepare the Patient (Slide 42)
  2. Explain the procedure to the patient
  3. Expose the chest
  4. Prepare the skin for electrode
  5. Ensure skin is not broken or bleeding
  6. Clean area with alcohol prep pad, towel or 4x4 by rubbing briskly
  7. Shave excessive hair at the electrode site.
  1. Steps for Acquiring a 12 Lead ECG- Perform the Procedure (Slide 43)
  2. Turn the monitor ON
  3. Attach the electrodes to the prepared skin
  4. Grasp electrode tab and peel electrode from carrier
  5. Inspect electrode gel, replace electrode if gel is dried or otherwise inadequate
  6. Attach the electrodes to the prepared skin
  7. Avoid pressing in the center of the electrode
  1. Steps for Acquiring a 12 Lead ECG–Lead Placement (Slide 44)
  2. Lead Placement
  3. Four (4) limb leads
  4. Six (6) chest leads
  5. Limb leads should be placed on the LIMBS.
  6. Chest leads should be placed on the CHEST.
  7. Chest leads are also known as precordial leads
  1. Steps for Acquiring a 12 Lead ECG - Limb Lead Placement (Slide 45)
  2. “White on right, smoke over fire”
  3. White lead on right shoulder or arm.
  4. Black lead on left shoulder or arm.
  5. Red lead on the left leg.
  6. Green lead on the right leg.
  1. Steps for Acquiring a 12 Lead ECG - Precordial Lead Placement (Slide 46)
  2. V1 & V2
  3. Each side of sternum
  4. 4th intercostal space
  5. V4
  6. midclavicular
  7. 5th intercostal space
  8. V3
  9. Between V2 and V4
  10. V5
  11. Anterior axillary line
  12. V6
  13. Left midaxillary line
  14. 5th intercostal space
  1. Tip for Success (Slide 47)
  2. Place the electrodes on the patient in the position they will be in during acquisition.
  3. Tip for Success (Slide 48)
  4. On female patients, always place leads V3 – V6 under the breast rather than on the breast.
  1. Steps for Acquiring a 12 Lead ECG - Perform the Procedure (Continued) (Slide 49)
  2. Make sure all connections are made
  3. Cable to monitor
  4. Leads to patient
  5. Enter the patient’s name into the machine.
  6. Encourage patient to remain still and breathe normally
  7. Acquire ECG tracing following machine specific acquisition procedure
  1. Steps for Acquiring a 12 Lead ECG – Perform the Procedure (Continued) (Slide 50)
  2. If configured, the LP 12 will automatically print the 12 Lead ECG Tracing.
  3. Check the ECG tracing for artifact
  4. Address artifact, may need to reposition leads as needed.
  5. Re-run the ECG if necessary
  6. Document the procedure
  1. Tip for Success (Slide 51)
  2. There is no need to interpret the ECG. All you have to do is acquire and transmit.
  1. Troubleshooting Common Errors (Slide 52)
  2. If the monitor detects signal noise, the 12 lead acquisition will be interrupted until the noise is removed.
  3. Take action to eliminate signal noise, or press 12 Lead again to override.
  4. Use the trouble shooting tips on the next slide to address common signal noise issues.
  1. Troubleshooting Common Errors – ECG Signal Noise (Slide 53)
  2. Artifact
  3. Causes
  4. Poorly placed leads
  5. Loose electrodes
  6. Broken cables or wires
  7. Muscle tremors
  8. Breathing difficulties
  9. Patient movement
  1. Troubleshooting Common Errors (Slide 54)
  2. Refer to your machines manufacture guide for trouble shooting specific to your machine.
  3. Check your electrodes to make sure they are secured on the skin and have adequate conductive gel.
  4. Reduce excessive body hair where electrodes are placed.
  5. Dry the skin to minimize wetness from diaphoresis or other fluids.
  6. Check to ensure your leads are placed in the most appropriate and correct location.
  7. Check to ensure your cables are connected to the machine.
  8. Check the cables for broken, loose, exposed wires, or pinch points where damage may have occurred.
  9. Check for missing electrodes.
  10. Check and try to manage patient
  11. Movement
  12. Tremors
  13. Breathing patterns
  1. Transmitting the 12 Lead ECG (Slide 55)
  2. Review the manufacturer’s instructions for the ECG machine you are using.
  1. Transmitting the 12 Lead ECG – LIFEPAK (Slide 56)
  2. LIFEPAK will transmit the data to a pre-prescribed ER or receiving station.
  3. Press Transmit
  1. Transmitting the 12 Lead ECG – LIFEPAK (Slide 57)
  2. Select Data
  3. If the REPORT, SITE, and PREFIX settings are correct, select SEND to transmit.
  1. Transmitting the 12 Lead ECG – LIFEPAK (Slide 58)
  2. If the REPORT, SITE, and PREFIX settings are not correct;
  3. Turn dial to adjust each item and push to select the correct options.
  4. Transmitting the 12 Lead ECG – LIFEPAK (Slide 59)
  5. Watch bar across bottom of screen to see transmission status.
  6. Transmitting the 12 Lead ECG – LIFEPAK (Slide 60)
  7. Verify transmission report indicates it was “completed”
  8. Transmitting the 12 Lead ECG – LIFEPAK (Slide 61)
  9. Prepare the equipment
  10. Prepare the patient
  11. Perform the procedure
  1. Case Presentation 1 – (Slide 62 - 64)
  1. Case Presentation 2 – (Slide 65-67)
  1. Resources and Tools
  1. References
  1. Contributors and Reviewers
/ INSTRUCTOR NOTES
(Also present on PPT slides)
This course was developed by members of the Washington State EMS Pre-hospital Education Workgroup. The materials are designed to provide the minimum recommended information for this skill, however with the exception of the DOH skill sheet, we encourage instructors to modify and tailor content to their specific area’s needs.The course agenda is competency based meaning that there is no specified time requirement for delivering course materials. Content should be delivered until students demonstrate competency by successfully passing the written and practical examinations.
Instructors should review the Cardiac and Stroke system website (links available in the PPT) and associated resources to review and be empowered to explain the benefits of the cardiac care system in Washington State.
In EMS systems, acquiring and transmitting 12-leads from the field to more highly trained clinicians in hospitals can substantially improve the timeliness of identification and intervention in patients suffering a particular form of heart attack, specifically ST segment-elevation myocardial infarction (STEMI).
The 12-lead can mean the difference between services transporting the patient to the most appropriate facility for optimal care vs. a facility that may not have the services necessary to provide the level of cardiac care a patient needs, thus resulting in an increased time to definitive care which can result in poorer patient outcomes.
The goal for BLS services in acquiring 12 leads is oriented to data acquisition as opposed to interpreting data.
There are cognitive, affective and psychomotor objectives listed in the slides for the course.
The written exam includes at least one test question for each of the objectives in accordance with CECBEMS standards.
How big of a problem is ACS?
In 2006 the EMS and Trauma Care Steering Committee with help of the Washington State Department of Health formed an Emergency Cardiac and Stroke Work Group to assess whether people in Washington were getting the treatments proven to save lives. The findings of the work group were published in a report in 2008 and revealed that less than 50% of heart attacks were receiving percutaneous coronary intervention (PCI) and less than 3% of ischemic strokes
were getting tPA to break up the blood clot (while 10-20% are eligible), despite these being the recommended treatments. The study also found that there was wide variation in care and outcomes across the state.
These findings are particularly alarming since the population at highest risk of cardiovascular emergencies is increasing rapidly.
Despite these challenges, we know that reducing time to evidence-based treatment makes a big difference in patient outcomes. Thus, the report also identified recommendations to make the needed improvements through a system approach.
The benefits of early defibrillation and treatment for cardiac arrest are well known. Clearly minutes also matter when it comes to other cardiac emergencies, especially ST-segment elevation myocardial infarctions (STEMIs). This graph shows a dramatic increase in mortality for patients that had longer hospital door to balloon (or PCI) times. One of the well-documented strategies for helping hospitals reduce door to balloon times is through early activation by EMS.
The door-to-balloon time is typically defined as the interval from when the patient first arrives in the emergency department until balloon inflation in a catheterization lab.
The published papers laid a foundation for nation-wide momentum to approach care from a more holistic viewpoint. The American Heart Association launched initiatives for STEMI systems and the American College of Cardiology worked with hospitals to reduce door to balloon times. The CDC provided funding to heart disease and prevention programs to create cardiac systems. The Society for Chest Pain Centers began certifying Chest Pain Centers and Center for Medicare Services is monitoring quality of cardiac and stroke care.
Many regions of the country have established systems that are working. North Carolina has a statewide system for STEMI care, Los Angeles and the surrounding areas determined which hospitals are STEMI receiving centers