EMC 451 - Advanced ECG Interpretation

Dr. Michael W. Hubble
122 Moore Building
828-227-3516

Course Overview:

This course is designed to provide students with the tools necessary to skillfully interpret the 12-Lead ECG and apply the interpretation to the clinical setting.  In addition to recognizing myocardial infarction, students will gain an understanding of the holistic management of the cardiac patient, including thrombolytics, PTCA, and management of acute coronary syndromes.

Course Objectives:

Upon completion of this course, the student will be able to:

1. Describe the basic electrophysiological principles of the heart, including action potential, vectors, and axis.
2. Describe the procedure for acquiring a 12-lead ECG.
3. Describe the properties of the normal 12-Lead ECG.
4. Identify atrial and ventricular hypertrophy on the 12-Lead ECG.
5. Using the 12-Lead ECG, differentiate between ventricular tachycardia and supraventricular tachycardia with aberrancy.
6. Identify ventricular conduction disturbances on the 12-Lead ECG, including:
   1. LBBB
   2. RBBB
   3. LAFB
   4. LPFB
   5. 1°, 2°, and 3° atrioventricular block
7. Using the 12-Lead ECG, identify the pre-excitation syndromes, including:
   1. Wolf-Parkinson-White Syndrome
   2. Lown-Genong-Levine Syndrome
8. List and discuss the acute coronary syndromes and their management.
9. Using the 12-Lead ECG, recognize and localize myocardial infarction.
10. Discuss the effects of various medications on electrophysiology and their appearance on the 12-Lead ECG.
11. Using the 12-Lead ECG, identify the patterns associated with various medical conditions, including:
    1. Electrolyte disturbances
    2. Pericarditis
    3. Pericardial effusion
    4. Pulmonary embolism
    5. COPD
    6. Q-T prolongation syndrome
    7. Pericardial tamponade

Textbook:  Thaler, M: The Only EKG Book You’ll Ever Need, ed 3.  Lippincott, Williams, and Wilkins.

Grading:

There will not be an opportunity for make-up exams.  For any missed exam, the weight of the final exam will be increased by an equal amount.

Grading Scale:

Course Outline:

Prehospital Cardiac Care Program Assignment

Utopia County EMS is a rural/suburban EMS system located in the “heart” of North Carolina.  The system runs approximately 10,000 emergency 911 calls.  Non-emergency transports are handled by a private ambulance service.  The county has a land mass of 700 square miles which is covered by 5 EMS bases.  Two of the bases house two 24-hour ambulances, and the remaining 3 bases house a single 24-hour ambulance.  In addition, there are two non-transporting “Medic Units” in outlying areas.  The Medic Units carry a full complement of ALS gear and are staffed by a single paramedic 24 hours.  The Medic Units are suburban vehicles that are not configured for transport.  By all accounts, the EMS system is adequately staffed, the bases are appropriately located, and the average response time for the first-arriving EMS unit (transport or Medic) is 7.6 minutes, with a 90th percentile response time of 9.8 minutes.  The “out-of-chute” time is 2 minutes during daytime hours, and 3 minutes after 11pm.  First Responder services are provided by the local fire departments.  All of the county is covered by a first responder program.  There are no organized CPR programs, other than those conducted at the local community college.  No other heart disease public education campaigns exist.

The ambulances are staffed with a paramedic/EMT crew configuration.  All paramedics receive the minimal amount of continuing education as dictated by NCOEMS.  Turnover is at an annual rate of 15 percent.  Sixty-two percent of the paramedics graduated from an AAS program, and 38% are certificate-prepared.  None holds a BS degree.  The more senior paramedics are certificate-prepared.

The ambulances carry the standard complement of ALS gear, meeting NCOEMS standards.  There is not a 12-lead program.  Medical control is provided by UHF Med channels and each truck is also equipped with cell phones.  Treatment of cardiac patients follows standard ACLS protocols.  There is no screening or administration of thrombolytics, nor is there any prehospital troponin screening.  There are 2 hospitals in the county.  One is equipped with a cardiac catheterization lab, and the other is not.  Overall, there is modest competition between the hospitals as well as reasonable cooperation on joint ventures.  Encodes to either hospital alerting them to a patient with suspected infarction does not initiate any special procedures in the emergency department(s) or the catheterization .  There have been no previous assessments of  thrombolytic door-to-drug times at the hospitals.

You have just accepted the position of EMS director of Utopia County.  During your first few weeks on the job, you made a trip to the library and looked at the mortality/morbidity statistics in the North Carolina Vital Statistics book.  You did this in an effort to set your priorities for where you want to focus your efforts on improving the performance of Utopia EMS.  After looking at the mortality/morbidity statistics, your priority was very clear.  Utopia County has a cardiac mortality/morbidity rate that is much higher than the NC average, as well as for counties of similar size and demographics.  Your plan, then, is to design and implement a Prehospital Cardiac Care Program in Utopia County, involving EMS, first responders, both hospitals, and the cardiac catheterization lab.  Please comment in the Bulletin Board between 4/28/01 and 5/5/01, as to what you plan to do and how you will do it.  You have been granted an unlimited budget by the County Commissioners, because they “don’t want to see the tax base dying off.”  You have also been provided a support staff (your EMC 451 classmates) who will assist you, comment on your recommendations, and make recommendations of their own.  At the end of the Bulletin Board discussion, what should emerge is a very formidable cardiac care program that will surely reduce morbidity/mortality in Utopia County.