Feb 2009 12 Lead EKG's

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					 Overview of Revised
CMC EMS System CE;
   12 Lead EKG’s
             February 2009 CE
                 Site Code #107200E1209
                       Prepared by:
        Bill Glade, DC Wauconda Fire Department
                Sharon Hopkins, RN, BSN
 Upon successful completion of this module, the
  EMS provider will be able to accomplish the
   Identify changes in the Advocate Condell EMS System
    CE program as taught in class.
   Identify the appropriate components of the cardiac
    conduction system with the correct wave form on a
    rhythm strip.
   Identify when it is appropriate to obtain an EKG
   Identify the criteria for significant ST elevation following
    guidelines reviewed in class.
   Identify EKG leads that view the anterior, inferior,
    lateral walls, and septum
 Recognize the patterns of an MI after viewing the
  components of a 12 lead EKG
 Identify typical and atypical presentations of AMI
 Identify complications associated with an inferior wall MI
 Identify complications associated with an anterior/septal
  wall MI
 Identify complications associated with a lateral wall MI
 Identify interventions for complications related to heart
  block, pulmonary edema, and cardiogenic shock
 Identify the SOP guidelines for the patient presenting with
  acute coronary syndrome as written in the Region X
 State dosing and precautions for Aspirin,
  Nitroglycerin, and Morphine
 Identify ED staff expectations of EMS personnel when
  calling the hospital to report a patient with ST
  elevation identified on a 12 lead EKG
 Identify EMS expectations when delivering a patient
  to a hospital after ST elevation has been identified on
  a 12 lead EKG
 Actively participate in 12 lead EKG scenario practice
  and discussion
 Given a picture, correctly trace the order of the
  cardiac conduction system.
 Given a manikin, correctly place electrodes to obtain
  a 12 lead EKG.
    CMC EMS CE Process For 2009
 Educational committee formed to develop a new
    CE process that will be evolving
   7 CE’s presented by EMS staff
   2 CE’s presented by department members
   Total of 27 hours of CE per year
   Objectives and references for each CE sent to
    departments for preview
   Each department will receive a detailed copy of
    the CE material for reference
   CE power points will continue to be posted on
    the Condell website
           2009 CE Process
 All CE’s must be completed by year’s end
    Medical Officer will oversee the completion for
     those not completing during EMS staff
 There will no longer be biannual exams
 Quizzes will be administered at the completion
  of each CE
   Successful completion is at 80%
   Number of quiz questions may be variable dependent
    on topic and will be based on objectives
 Handouts at class will only be material
  applicable to complete that topic and no longer
  the full power points
  Why Are We doing Pre-hospital
 Early recognition and fast, appropriate
 treatment can prevent the extension of an

    Early recognition = early intervention

 An important diagnostic tool will also be
 the patient’s general appearance
   Cardiac Conduction System
 Electrical cells arranged in a systematic
 Predominant pacemaker starting the
  electrical flow comes from the SA node
 Electrical cells are part of the conduction
 Muscle cells are the mechanical cells

                EKG Waveforms
 P wave represents atrial stimulation
    P wave is rounded and upright
 PR interval
   Includes the P wave and the isoelectric PR
   PR interval is the time it takes for an impulse
    to travel from the SA node through the
    internodal pathways toward the ventricles
   Includes delay time in the AV node
 Normal PR interval is 0.12 – 0.20 seconds
     PR Interval Abnormalities
 PR interval <0.12 seconds
    Impulse did not begin in the normal
     pacemaker site of the SA node but
     somewhere in the atria
 PR interval >0.20 seconds
    There was a longer than normal delay
     transmitting the impulse through the AV node
 A change in the PR interval measurement
  generally will not make the patient symptomatic
      EKG Wave Forms cont’d
 QRS complex
   Consists of the Q, R, and S waves collectively
   Represents ventricular depolarization or discharge of
    electrical energy throughout ventricular muscle
   Larger than the P wave because ventricular
    depolarization involves a larger muscle mass than
    atrial depolarization
 Palpation of a pulse is generated by ventricular
  depolarization (seen as the QRS complex)
 Normal timing usually considered between 0.06
  and 0.11 seconds
    Normal is less than 0.12 seconds
QRS Complex
  QRS Complex Measurement
 From beginning of Q wave – usually fairly
  straight forward
 Stop measurement at end of S wave; not
  necessarily where QRS intersects baseline
 On S wave, watch for small notch or other
  indicator that electrical flow is changing
    Not always so easy to determine stop point
 Do not include ST segment or T wave
 Abnormally wide QRS indicates delay in
  conduction time through the ventricles
      EKG Wave Forms cont’d
 T wave
    Represents ventricular repolarization
    Repolarization is the phase of electrical activity
     where electrical charges (influenced primarily
     by sodium (Na+) and potassium (K+)) return to
     their original state and prepare to respond to
     the next electrical charge received

 Atria repolarize during ventricular depolarization
  so the small atrial T wave is hidden during the
  larger QRS complex
  When To Obtain a 12-Lead EKG
 Any patient presenting with signs and/or
  symptoms of an acute coronary syndrome
       Consider atypical AMI presentations
          Elderly
          Women
          Patient with long standing history of
 Any patient presenting with a Second degree
  Type II (classical) or 3rd degree heart block
    Consider the origin from an AMI until proven
    What Are We Looking For?
 Abnormalities that indicate interruption in the
  blood flow to the myocardium
    Plaque formation diminishes blood flow
     through the coronary arteries
       Patients may be asymptomatic while
        damage silently develops
    Plaque rupture begins a cascade of events
     that further compromises blood flow through
     the injured vessel(s)
 This cascade of events could lead to an acute
  coronary syndrome (ie: acute MI)
        Coronary Circulation
 Coronary arteries and veins
 Myocardium extracts the largest amount of
  oxygen as blood moves into general
 Oxygen uptake by the myocardium can
  only improve by increasing blood flow
  through the coronary arteries
 If the coronary arteries are blocked, they
  must be reopened if circulation is going to
  be restored to that area of tissue supplied
            12-Lead Electrodes
 A lead is a tracing of the electrical activity
  between 2 electrodes
 Leads view the heart from the front of the body
    Top, bottom, right, and left side of heart
 Leads view the heart as if it were sliced in half
    Front, back, right, and left sides of heart
 Each lead has a positive and a negative
     Standard 12-Lead EKG
 Six limb leads
    Leads I, II, III, aVR, aVL, aVF
 Six chest leads (precordial leads)
    V1, V2, V3, V4, V5, V6
 Information from 12 leads obtained
  from the attachment of only 10
     View The Leads Provide
 II, III, aVF – view inferior wall of heart
 V1 and V2 – view septal wall of heart
 V3 and V4 – view anterior wall of
 I, aVL, V5, V6 – view lateral wall of
 Preparation for 12 Lead EKG
 Skin preparation
   Hair removal
     clip hair if necessary so electrodes
   Clean and dry skin surface
     gently rub skin area with gauze pad
        need to remove skin oils & dead skin
     if diaphoretic patient wipe with
      towel/gauze or use antiperspirant spray
 Patient positioning
   Preferably flat
      Heart rotates position as the patient
       position changes
   If patient is elevated, note that
    information on the EKG
        Precordial Chest Leads
For every person, each precordial lead placed in
 the same relative position
V1 - 4th intercostal space, R of sternum
V2 - 4th intercostal space, L of sternum
V4 - 5th intercostal space, midclavicular
V3 - between V2 and V4, on 5th rib
V5 - 5th intercostal space, anterior axillary line
V6 - 5th intercostal space, mid-axillary line
             1st ICS

             2nd ICS

             3rd ICS
           12 Lead EKG Printout
 Standard format 81/2 x 11 paper
 12 lead format:
       I       aVR     V1       V4
      II       aVL     V2       V5
     III       aVF     V3       V6

Machines can analyze data obtained
  but humans must interpret data
Lateral View – I, aVL, V5, V6
Inferior View – II, III, aVF
Septal View – V1 & V2
Anterior View – V3 & V4
            Myocardial Insult
 Ischemia
   lack of oxygenation
   ST depression or T wave inversion
   permanent damage avoidable
 Injury
   prolonged ischemia
   ST elevation
   permanent damage avoidable
 Infarct
   death of myocardial tissue; damage
    permanent; may have Q wave
     Why A Pre-hospital EKG?
 EMS looking for ST segment elevation
    Indicates injury that can be reversible if found
     early and acted upon early
    The earlier the discovery of an acute cardiac
     event, the quicker the patient can receive the
     most appropriate care
 EKG’s sent to the ED before patient arrival
  allows for the right personnel to be available to
  properly care for the patient in the most time
  efficient manner
    What Do You Have to Do?
 Obtain a 12 lead EKG
 Evaluate the leads yourself as you are
  sending the 12 lead to the ED
 Identify for the presence or absence of ST
 Report what you see, not just what is
  printed on the machine copy of the EKG
 Upon arrival, hand a copy of your 12 lead
  to the ED staff while you give bedside
     Evaluating for ST Segment
 Locate the J-point
 Identify/estimate where the isoelectric line
  is noted to be
 Compare the level of the ST segment to
  the isoelectric line
 Elevation (or depression) is significant if
  more than 1 mm (one small box) is seen in
  2 or more leads facing the same
  anatomical area of the heart
  (ie: contiguous leads)
  The J Point

 J point – where the QRS complex and ST
  segment meet
 ST segment elevation - evaluated 0.04 seconds
  (one small box) after J point
 Coved
 acute injury

 Concave
 shape is
 especially if
 patient is
       Significant ST Elevation
 ST segment elevation measurement
   starts 0.04 seconds after J point
 ST elevation
   > 1mm (1 small box) in 2 or more contiguous
    chest leads (V1-V6)
   >1mm (1 small box) in 2 or more anatomically
    contiguous leads
 Contiguous lead
   limb leads that “look” at the same area of the
    heart or are numerically consecutive chest
        Contiguous Leads
 Lateral wall: I, aVL, V5, V6
 Inferior wall: II, III, avF
 Septum: V1 and V2
 Anterior wall: V3 and V4
 Posterior wall: V7-V9 (leads placed
 on the patient’s back 5th intercostal
 space creating a 15 lead EKG)
Evolution of AMI
  A - pre-infarct (normal)
  B - Tall T wave (first few
    minutes of infarct)
  C - Tall T wave and ST
    elevation (injury)
  D - Elevated ST (injury),
    inverted T wave (ischemia),
    Q wave (tissue death)
  E - Inverted T wave
    (ischemia), Q wave (tissue
  F - Q wave (permanent
ST Segment
EKG monitoring
   Evaluates electrical activity of the heart
   Can indicate myocardial insult and location
     ischemia - initial insult; ST depression seen
     injury - prolonged myocardial hypoxia or
      ischemia; ST elevation seen
     infarction - tissue death
         dead tissue no longer contracts
         amount of dead tissue directly relates to
          degree of muscle impairment
         may show Q waves
      Contiguous ECG Leads
 EKG changes are
 significant when they
 are seen in at least
 two contiguous leads

 Two leads are
 contiguous if they
 look at the same area
 of the heart or they
 are numerically
 consecutive chest
       Groups of EKG Leads
 Inferior wall - II, III, aVF
 Septal wall - V1, V2
 Anterior wall - V3, V4
 Lateral wall - I, aVL, V5, V6

 aVR is not evaluated in typical groups
 Standard lead placement does not look at
  posterior wall or right ventricle of the heart -
  need special lead placement for these views
    Basic 12-Lead EKG Format
  Lead I            aVR           V1            V4
Lateral wall    not evaluated   Septum     Anterior wall

  Lead II          aVL            V2            V5
Inferior wall   Lateral wall    Septum     Lateral wall

  Lead III          aVF           V3            V6
Inferior wall   Inferior wall   Anterior   Lateral wall
 Lateral Wall MI: I, aVL, V5, V6

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
      Inferior Wall MI II, III, aVF

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
    Septal MI: Leads V1 and V2

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
         Anterior Wall MI V3, V4

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
 Posterior MI – Reciprocal Changes
 ST Depression V1, V2, V3, poss V4

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
Complications of Lateral Wall MI
 I, aVL, V5,V6
   Complications arise due to the conduction
    components that are in the septum
   Conduction dysrhythmias most common
      Second degree Type II – classical
      3rd degree – complete heart block
      Bundle branch blocks
   Monitor patient closely for these blocks
      2nd degree Type II and 3rd degree are serious
      dysrhythmias that need to be treated aggressively
      with TCP
  Complications of Inferior Wall MI
 II, III, aVF
    40% of patients with inferior MI’s have right
     ventricular infarcts
    In the presence of a right ventricular infarct, there is a
     high likeliness of both ventricles being damaged
        Contraction capabilities will be negatively affected
    Patients may present hypotensive
    Nitrates and Morphine alone will dilate blood vessels
     worsening hypotension
    Under Medical Control direction patients are often
     treated with a fluid challenge with the nitrates
    1st degree heart block and Second degree Type I
     Wenckebach most common heart blocks
Complications of Septal Wall MI
 V1 and V2
 Significant amount of conduction components
  are in the septal area
 Patient predisposed to dysrhythmia
   Second degree Type II – classical
   3rd degree heart block
   Bundle branch block
 Lethal heart blocks treated aggressively - TCP
 Rare to have a septal MI alone
   Common to have anterior or lateral involvement along
    with septal area
 Complications of Anterior Wall MI
 V3, V4
 Known as the “widowmaker” due to the potential
  for a massive area of infarction from blockage of
  the large amount of myocardium supplied by the
  LAD (left anterior descending artery)
 Often the septal or lateral walls are also involved
 Watch for lethal ventricular dysrhythmias and
  cardiogenic shock
 Second degree Type II and 3rd degree heart
  block are more common than other blocks
      Anterior Wall MI - V3, V4
 Early death within a few days often from CHF
   Massive area of ventricular tissue infarcted if LAD
    totally occluded
 Important to obtain history of recent MI
  diagnosis and hospital discharge
    Increased incidence of ventricular tachycardia
     (VT) and ventricular fibrillation (VF) up to 1 -2
     weeks post acute anterior MI
     Additional Complications
 Acute pulmonary edema
   Nitroglycerin to dilate blood vessels and
    reduce preload
   Lasix to dilate blood vessels and reduce
    preload; as a diuretic
   Morphine to dilate blood vessels and reduce
    preload; reduce anxiety
     Additional Complications
 Cardiogenic shock
   Ineffective pumping from the damaged heart
   IV fluid challenge if lung sounds are clear
   Dopamine drip titrated to maintain a systolic
    blood pressure of >100 mmHg
      Start at a low dose (5mcg/kg/min)
          Estimate the patient’s pounds (ie: 100 #)
          Take the 1st 2 numbers dropping the last
           number (“10”)
          This is the starting point for
           minidrips/minute (8 minidrips/minute)
 Common Terms Patients
Use To Describe Chest Pain
Heaviness     Burning

Pressing      Constricting band

Suffocating   A weight in the
                center of my chest
               A vise tightening
Strangling     around my chest
  Additional Patient Complaints or

 Difficulty breathing    Syncope or near-
 Excessive sweating       syncope
 Unexplained nausea      Palpitations
  or vomiting             Isolated arm or jaw
 Generalized              pain
  weakness                Fatigue
 Dizziness               Dysrhythmias
         Typical Injury Patterns

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.
Atypical Presentation in the Elderly
  Most frequent symptoms of acute MI:
    Shortness of breath
    Fatigue and weakness (“I just don’t feel well”)
    Abdominal or epigastric discomfort
  Often have preexisting conditions making this
   an already vulnerable population
    Hypertension
    CHF
    Previous AMI
  Likely to delay seeking treatment
Atypical Presentation in Women
 Discomfort described as:     Frequent acute
   Aching                      symptoms:
   Tightness                    Shortness of breath
   Pressure                     Weakness
   Sharpness                    Unusual fatigue
   Burning                      Cold sweats
   Fullness                     Dizziness
   Tingling                     Nausea/vomiting

  Often have no actual chest pain to offer as a
   complaint. Often the pain is in the back,
   shoulders, or neck
   Atypical Presentation in the
      Patient With Diabetes
 Atypical presentation due to autonomic

 Common signs/symptoms:
     Generalized weakness
     Generalized feeling of not being well
     Syncope
     Lightheadedness
     Change in mental status
 Region X SOP – Acute Coronary
 A 12 lead EKG is obtained on all patients
  presenting with signs and symptoms of
  acute MI
 For patients where suspicions are raised
  that the patient may be experiencing an
  acute MI (ie: heart block)
12-Lead Electrode Placement
 Region X SOP – Acute Coronary
 Determine if the patient is stable or
  unstable to proceed with interventions
 Easiest way to determine stability is to
  evaluate blood flow
   What is the level of consciousness?
   What is the blood pressure / is there a radial
 Remember: A B/P reading of 100/systolic
  does not necessarily indicate the presence
  or absence of symptoms
 In the presence of an acute MI, the
  myocardium is being deprived of blood
  flow and therefore adequate oxygen levels
 Provide what the patient needs
 Evaluate each individual clinical
 All patients deserve some form of oxygen
  in this early period of myocardial starvation
  for it
 Used to prevent platelet aggregation
    When a plague ruptures, chemicals are released.
     Platelets congregate to the area to seal the rupture.
     Platelet aggregation further increases the degree of
     vessel blockage.
 Dosage is 4 – 81 mg (324 mg total) baby aspirin
    Chewing breaks down the aspirin and allows for
     faster absorption
 Give dose if patient not reliable about taking
  their own dose or has not taken any aspirin
 Venodilator
   Improves coronary blood flow
   By dilating blood vessels, pools blood away
    from the heart which decreases preload. This
    decreases the work load of a stressed heart.
   Carefully monitor blood pressure before and
    after dosages
 Dosage is 0.4 mg tablet sl
   Dosage can be repeated in 5 minutes if blood
    pressure remains stable
   FYI: Pain level will not drop to “0” until the clot
    is removed
For CMC EMS System Participants
 If the patient is <35 years of age
    Follow Acute coronary Syndrome SOP by
     administering aspirin
    Contact Medical control prior to administration of
     nitroglycerin or morphine
 There should be no delay in obtaining a 12 lead
  EKG in the field and transmitting it to the ED
 Your visual interpretation is to be given during
  report to the receiving hospital
 CNS depressant to reduce anxiety
 Venodilates blood vessels to reduce the
  volume of blood returning to the heart to
  decrease the heart’s workload
 Dosage is 2 mg slow IVP
   Dosage started when the 2nd dose of
    nitroglycerin proves ineffective
   Dosage may be repeated every 2 minutes as
   Maximum dosage is 10 mg
 Watch for hypotension
      Receiving Hospital Report
 When sending a 12 lead EKG, inform the
 receiving hospital what identifiers have
 been used
     Department ID number
     Patient sex (M / F)
     Patient age
     Any other identifier
 Always give your visual interpretation of
 what you have observed for ST elevation
      Activating a Cardiac Alert
 The ED activates a cardiac alert to prepare the
  cardiac team to provide optimal care for the
 Typical cardiac alert team members
     ED staff – MD, RN, tech, secretary
     Cardiologist
     Cath lab personnel
     EKG tech (may be an ED staff member)
     Lab tech
     X-ray tech
 Not all hospitals use all members in a formalized
  team but all of these members are somehow
  integrated into the care of the patient
  When Does a Cardiac Alert Get
 When you send a 12 lead EKG with ST
  elevation, the team gets activated
 When you confirm what you see on the 12
  lead, whether the EKG is sent or not, may
  trigger a cardiac alert
 There is a direct link in your accuracy,
  completeness in patient report, and EKG
  interpretation with pre-hospital activation
  of the cardiac alert team
Transferring Care of The Patient to
              The ED
 Bedside report is restated to the ED
 personnel in the room
   The main report must be to an RN or MD
 Rhythm strips and 12 lead EKG are
 Important to note positive and negative
  changes in the patient condition
   Pain level has decreased
   Blood pressure has dropped
 Follow OPQRST guidelines
 Some of this information is added into a check
  box or other prompt; otherwise the information is
  written into the narrative
 Onset – what was the patient doing when the
  problem/pain began? Any contributing factors?
  Add this information to the narrative.
 Provocation/palliation – what makes the pain
  worse/makes it better; added to narrative
 Quality- in the patient’s own words; added to
 Region/Radiation – where is the problem/pain;
  radiation is typically to the jaw, down an arm, felt
  in the back; added to narrative
 Severity – on a scale of 0-10, 0 being no pain
  and 10 being the worse pain the patient has
  experienced; use the “pain scale” box
 Time – when did the problem/pain begin and
  how long has it lasted? Use the “time of onset”
 Include associated symptoms like dyspnea or
             EKG Practice
 Practice reviewing the following 12 lead
  EKG’s for ST segment elevation
 Evaluate the ST segment at the J point
 Note: A peaked T wave is not equivalent
  with ST elevation
 Consider potential complications to
  monitor for based on the location of the
  acute MI
Practice Identifying ST Segment

> 1mm (1 small box) above the baseline in 2 leads
 from any group or 2 or more contiguous leads
(>2 mm (2 small boxes) in limb leads considered
 alternative elevation by some) measured 0.04
 seconds after J point
Case #1
                        Case #1
 52 year-old patient complains of
  indigestion after pizza & beer dinner.
 VS: 124/82; P – 108; R - 18
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #2
                    Case #2
 62 year-old female developed chest & jaw
  pain while in the shower
 VS: 110/62; P – 66; R – 20
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #3
                    Case #3
 45 year-old patient who complains of chest
  heaviness & lightheadedness
 VS: 90/56; P – 86; R - 22
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #4
                    Case #4
 87 year-old female patient complains of
  dizziness and being extremely tired
 VS: 88/52; P – 30; R - 16
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #5
                        Case #5
 58 year-old male patient who complains of chest
  pain radiating down the left arm after working
  out in the gym
 VS: 110/72; P – 100; R - 18
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #6
                    Case #6
 92 year-old patient complaining of
  pounding in her chest for one hour
 VS: 98/66; P – 110; R- 16
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #7
                    Case #7
 66 year-old patient with history of diabetes
  for 25 years complains of being
  lightheaded and is sweaty
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #8
                        Case #8
 70 year-old patient had a syncopal episode
  when they stood up from the couch
 VS: 156/98; P – 76; R - 16
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
Case #9
                         Case #9
 82 year-old patient complains of sudden onset of
  slurred speech, inability to grasp a coffee cup,
  and inability to follow simple commands
 VS: 122/84; P – 110; R - 18
 Is there ST elevation:
      I, aVL, V5, V6?
      II, III, aVF?
      V1, V2?
      V3, V4?
 What are you going to do for this patient?
Case #10
                   Case #10
 36 year-old patient who passed out
  standing in line at a bank
 VS: 128/78; P – 80; R - 20
 Is there ST elevation:
     I, aVL, V5, V6?
     II, III, aVF?
     V1, V2?
     V3, V4?
 What are you going to do for this patient?
 Aehlert, B. EKG’s Made Easy third Edition.
    Elsevier Mosby. 2006.
   Beasley, B. Understanding EKG’s A
    Practical Approach. Brady. 2003.
   Bledsoe, B., Porter, R., Cherry, R.
    Paramedic Care Principles and Practices.
    Third Edition. Brady. 2009.
   Ellis, K. EKG Plain and Simple. Prentice
    Hall. 2002.
   Page, B. 12 Lead EKG for Acute and
    Critical Care Providers. Brady. 2005.
 Phalen, T., Aehlert, B. The 12 Lead EKG in
    Acute Coronary Syndromes. Second Edition,
    Elsevier Mosby. 2006.
   Region X SOP’s. March 2007, Amended
    January 1, 2008.
 (Acute Coronary Syndrome 9/2008)

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