Submitted by Dawn on Sat, 07/14/2012 - 00:39
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Answer:
I think it is important for them to be able to identify the common mimics that cause ST elevation. At the very least, right and left bundle branch blocks, left ventricular hypertrophy, pacemaker rhythms and ventricular rhythms.
Most paramedic students are taught pacemaker and ventricular rhythms, but they may not be proficient in identifying them on a 12 lead.
Early repolarization is good to learn, but my experience has been that it is a little more difficult to identify.I know that some programs teach axis deviation, however, I think this is a little more advanced than most paramedic students need to know. It is certainly good knowledge, but I would save it for an advanced 12 lead class rather than the basic one usually taught in the paramedic program.
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Comments
I believe medics should be
I believe medics should be taught how to recognize a bifisiculating block. This is a good indicator to possible heart failure.
Michelle Baughman
Bifascicular Blocks
Hi Michelle,
I liked your response and agree that the recognition of a bifascicular block as important, especially in the setting of a fresh MI. However, I respectfully disagree with your statement that this should be a skill taught to pre-hospital care personnel.
First of all, assessment of a bifascicular block would need to include the assessment of axis deviation. Not that determination of axis is difficult; however, in my experience, I have realized that very few people teach axis deviation well and, more importantly, very few people retain the knowledge of how to determine axis. Also, from experience, I have found that the most common period of time to develop a bifasciular block is in the patient who has infarcted within the last day or two, not in the immediate infarcting phase. Also, when a bisfascicular block has rarely occurred in this setting, the problem for this patient wasn't necessarily the development of heart failure, but rather the potential to develop profound syncope requiring prophylaxis pacing.
If during transport of a patient having an anterior MI, the paramedics should be prompted on the high probability of developing heart failure based on the MI type, not on the development of a bifascicular block.
Darlene Hutton RN, BScN, MSN
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Bifascicular block
I totally agree with Darlene Hutton. Our cardiology practice has hundreds of patients with bifascicular block and most do not have heart failure. The combination of right bundle and left anterior fascicular block is very common. If they also develope a first degree AV block along with this, it could be indicative of trifascicular disease and they need to be watched for intermittant stokes-adams. If this occurs, they may need to be paced.
Heart failure
Bifasicular block can be a harbinger of complete heart block also. On the topic of heart failure, I have always thought paramedics should be taught more about valve disorders and myopathies. Alas, as a long time paramedic instructor, I realize that time is short in Paramedic School, and there is so much to learn.
Dawn Altman, Admin
Pre-hospital care in the STEMI patient
It is relatively easy to teach the recognition of a STEMI on the ECG. The systematic approach used to assess the ECG in a patient presenting with chest pain needs to be done rapidly in order to provide treatment without delay. What I feel needs to go hand-in-hand with teaching a quick yet systematic assessment of the 12 Lead ECG is the anticipated complications that are associated with the inferior and anterior infarcts.
Knowing that the inferior infarct is likely to have an RV infarct or develop significant bradycardia prompts the paramedic to anticipate the potential need to administer fluids or initiate pacing while en route to the hospital. Knowing that the anterior infarct is likely going to develop heart failure will prompt the paramedic to closely observe the potentially rapid or slow development of this anticipated complication and administer prompt treatment.
Hutton, D. (2005). A novel systematic approach to ECG interpretation. Journal of the Canadian Association of Critical Care Nurses.
Darlene Hutton RN, BScN, MSN
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Early repolarization
What I did in my program was to stress the importance of the clinical picture when trying to differentiate an ECG with changes that appear to be early repolarization. If the patient has no symptoms and the ECG is an incidental finding, especially in a young, otherwise healthy person, early repolarization is likely. If on the other hand the patient has chest pain or any other symptom that could be cardiac, the patient should be given the benifit of the doubt. It could be either pericarditis or early MI. You may not be able to tell which. Some patients are much more likey to have early repolarization. It is more common in males, in blacks, and also more common in tall individuals. None of this is absolute of course. The clinical setting is most important.