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Students can use email, live chat or the LMS chat system to communicate with instructors 24 hours a day.
This EMT course includes a Hazardous Materials First Responder Awareness Level Certification upon successful completion. 6 days of Hands on, Professional Instruction at our Training Facilities in Post Falls, Idaho.
Student's don't just get hungry and thirsty at meal time so we provide granola bars, apples, oranges, bananas, juice, coffee, tea, water and soda all day. All students in our EMT courses get their own stethoscope, BP cuff and CPR mask to take home at the completion of the course.
If a student is unable to obtain the necessary 10 patient contacts with an ambulance agency, fire department or hospital, we can arrange for those contacts during practical skills week. Designing an Emergency and Disaster Prevention and Response Program essentially involves carrying out the tasks outlined in the previous chapter, as well as others that will be described below.
If you would like more information on disaster prevention and mitigation measures for water supply and sewerage systems, please consult the bibliography at the end of this book. BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February 2007. The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
Designations used by companies to distinguish their products are often claimed as trademarks.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. I would like to dedicate this book to my family, my parents, my brother Bob, my sisters Ana and Diana, my children Natalie, Oliver, Sophie, Julia, Marina, Charlie and George, my grandchildren Ella, Leo and Amber-Lily and to my loving wife Zaide. Specific recommendations to address recognized deficiencies such as reorganisation of trauma care into regional systems has been shown to improve outcome and this relies on optimising all aspects of pre-hospital and hospital care and using a multidisciplinary approach to optimise patient care in polytrauma.
Rapid acquisition and interpretation of DR, portable US and immediate availability of MDCT are now the mainstay of initial successful management of sick and traumatised patients admitted to Accident and Emergency departments (A&E).
Virtually any condition can present to A&E and so the volume of medical knowledge needed to manage these patients satisfactorily is enormous.
Therefore, it is essential that all staff should be able to interpret DR and basic CT for fast, accurate and effective initial treatment, in order to avoid errors in interpretation, inappropriate treatment and the medicolegal consequences that may result from these errors. This new edition of the ABC of Emergency Radiology has incorporated the latest technological advances (in particular replacing plain radiographs with digital radiographs) and changes in imaging protocols (in particular the use of MDCT). Myself and the contributors have produced a simple and logical step-by-step approach on how to interpret DR and basic CT. This book provides an up-to-date, simple, concise and systematic approach to the interpretation of DR and CT that should be very helpful to medical students, young trainee doctors, consultants in all specialties including radiologists and other health professionals working in A&E, not least radiographers and nurses.
Emergency medicine often brings together critically ill patients and inexperienced and tired doctorsa€”a dangerous combination at the best of times with potentially serious clinical and medicolegal consequences. There have been major technological advances in the past decade which have had a major impact on the management of patients in the ED, not least picture archiving and communication systems (PACS), digital radiography (replacing conventional plain to X rays), portable ultrasound (US; which is now readily available and often, but not often enough, performed by clinicians in the ED) and multidetector computed tomography (MDCT) in the ED. The correct selection of imaging modality, rapid acquisition and the accurate interpretation of these investigations is often the key to quick and successful management of patients in the ED. The Rules of Two (Ro2) is a helpful, simple set of guidelines, which relate to who, what, when and how to radiograph and how to get help or get out of trouble and therefore minimise the chances and the consequences of errors. The ABCs systematic assessment is a simple systematic approach, which starts with basic essential normal radiographic anatomy, common normal variants, which may mimic pathology and in particular how to interpret imaging using a systematic approach, which is logical and easy to remember and therefore hopefully helps to minimise interpretive errors.
These rules represent a simple set of guidelines, most are obvious, some relate to specific clinical problems, but most are common sense useful general principles which should help in avoiding errors in interpretation and management of patients in the ED. Do not stop looking after detecting one abnormality; always keep looking for a second abnormality. Figure 1.5 Saltera€“Harris II of proximal tibia (large arrow for fracture of proximal tibial metaphysis, arrowhead for separation of epiphyseal growth plate) and fracture of shaft of proximal fibula (small arrow).
Figure 1.7 Numerous pelvic fractures (arrows), several in each ring with subtle right sacral foramina fractures (arrowheadsa€”compare with intact left side). Figure 1.8 (a) Left mandibular fracture with bilateral displaced condylar neck fractures, better seen on CT (b).
Figure 1.9 (a) Intact Polo mint and (b) broken mint shows there are at least two fractures in a ring.
Figure 1.13 Suspected avulsion of right medial epicondyle ossification centre, but identical on the left elbow (arrow). Furthermore, there are clinical situations which mandate immediate treatment of the patient to a€?save life or limba€™ and clearly in these circumstances, imaging is inappropriate!
Figure 1.14 Mild avulsion of right medial epicondyle ossification centre (arrow) when compared with left elbow. Figure 1.16 Completely displaced avulsion of left medial epicondyle ossification centre (arrow).
The extreme example is a patient with a penetrating injury to the chest, who clinically has all the signs of a cardiac tamponade and who clearly needs an immediate open thorocotomy and instead the clinical team request a multiple X-rays! Figure 1.20 (b) Initial film showed loss of joint space a large erosion (arrow) and a huge amount of soft tissue swelling, which was not present on X ray taken (arrow) 1 week earlier (a) or after treatment 1 month later (c). Figure 1.21 Patient with fractured ulna (arrow) put in plaster of Paris, but follow-up check X-ray reveals a dislocated radial head (arrowhead)a€”a Monteggia fracture dislocation. Figure 1.24 (a) Initial X ray reported normal, but patient symptomatic, so (b) CT performed which was also normal and (c) an MRI was then performed confirming fracture though the waist of the scaphoid. If you are not sure, get a second opinion from a colleague or the radiographers (who are extremely knowledgeable).
The report and the X-rays should be checked (Figure 1.24) both by your seniors (first specialist) and also a formal report should ALWAYS be sought from the radiologists (second specialist). There are times when the initial X-ray has helped to exclude an obvious abnormality, but the history or clinical findings warrant further investigations (Figure 1.24).
Patients with head injuries and with suspected facial injuries often have a CT scan of the head but the facial injuries are not scanned at the time.
The ABCs systematic approach is without doubt the simplest and worldwide the most popular and widely used system for the assessment of plain X-rays. The ABCs starts in ALL the chapters with a short section on a€?basica€™ radiological anatomy, which is the a€?bread and buttera€™ of radiology! The ABCs for the bony skeleton are the same, although from an interpretive point of view, the order should be changed so that soft tissues are looked at first in the elbow (looking for the displaced fat pad sign) and the knee (looking for fat-fluid levels indicating a lipohaemoarthosis).
Injuries to the hand and wrist are very common, accounting for 20% of acute fractures presenting to emergency departments.
Clinical exam is usually accurate in this scenario and strong clinical suspicion for fracture can often direct close radiologic evaluation for subtle abnormalities.
The goal of treatment is rapid restoration of function with attention given to the prevention of chronic disability. Each ray, apart from the thumb, consists of a metacarpal and proximal, middle and distal phalanges. In children the carpal bones first appear at the age of 3 months and all of the carpal bones are visible by 12 years.
On the lateral views the fingers should be flexed to varying degrees to avoid overlap and confusing composite shadows. In general a minimum of posteroanterior (PA) and lateral views are recommended, but in addition some centres advocate external oblique views whereby the radial side of the wrist is elevated.
Figure 2.2 Scaphoid coned PA view in ulnar deviation allows for visualisation of the full length of the scaphoid.
On a true lateral wrist view, the palmar surface of the pisiform bone should overly between the palmar surfaces of the distal scaphoid pole and the capitate head.
CT is typically reserved for suspected fractures with negative initial and follow-up radiographs or for preoperative planning in cases with significant comminution and intra-articular extension. Figure 2.3 Normal lateral view of the wrist outlining the normal relationship of the lunate and capitate bones and normal anatomy.
On the AP view, the normal fused distal radial epiphysis may present a slight irregularity on the radial aspect and may mimic a fracture. Careful attention should be paid to the cortical margins in regions of soft tissue swelling. These may be transverse or spiral and may show angulation, shortening or rotational deformity. Robin Naplesa€”To my parents for raising me, my sister for pushing me, my husband for understanding me, and my kids for being my everything. Amita Sudhira€”Thank you to my husband, Aaron, my children, Anisha and Anand, and my parents, Romila and Sudhir for their support. Steven Mitchella€”Thank you to my best friend and wife, Kara, for her love and support in this process. Jeffrey Fergusona€”To my wife, Lauren, my parents, friends, and mentors for their years support and education: Thank you. Single lead or three lead cardiac monitoring was the sole means for EMS personnel to assess cardiac rhythm in the prehospital setting for many years.
With the advent of fibrinolysis, EMS personnel and ED staff began to recognize the importance of early identification of STEMI patients as a means to reduce the a€?door-to-druga€? time.
Fibrinolysis required preparation of the drug and patient screening for contraindications, but was otherwise less resource intense than PCI, which became widely used in the mid to latter 1990s.
As paramedics have become skilled at recognition of STEMI, their interpretation skills in other clinical syndromes have developed. The purpose of this text is to advance the interpretation skills of prehospital providers so that the ECG can be used as a diagnostic instrument for more than just the STEMI. Electrocardiographic monitoring is one of the most widely applied diagnostic tests in clinical medicine today; its first application to the patient occurs in the prehospital setting and its use continues on into the hospital. This textbook has been prepared to assist the prehospital provider with the interpretation of the electrocardiogram and a solid understanding of its use across the range of presentations and applications. This textbook addresses the use of the ECG in its many forms by the prehospital provider, whether 911 ground EMS response, aeromedical transport, or interfacility critical care transfer. Most importantly, this textbook is written by clinicians for clinicians, with an emphasis on the reality of the prehospital setting. The electrocardiogram (ECG) has become a mainstay of medical care since Einthoven first introduced the concept of electrical imaging of the heart in 1903. The rapid and accurate detection of ventricular fibrillation leading to sudden cardiac death has led to the development of prehospital emergency medical service (EMS) systems worldwide since the late 1960s. Figure 1.3 Third-degree AV block demonstrating no relationship between P wave (small arrow) and QRS complex (large arrow). Figure 1.4 Brief episode of torsades de pointes in a patient with a QTc interval of 579A ms. One of the most important parts of prehospital medicine is the recognition and treatment of life-threatening dysrhythmias.
Figure 1.5 In rhythm mode, ECG monitoring devices attempt to reduce artifact, enabling a more accurate rhythm evaluation. Figure 1.6 Acute inferior and lateral wall ST segment elevation myocardial infarction (STEMI). The ECG is also a useful tool in the evaluation of non-coronary artery pathology that manifests with changes to the ECG.
There are also a host of conditions that are not primarily related to the heart where the ECG may provide a clue to diagnosis. The impact of the electrocardiogram (ECG) on clinical care is wide ranging and significant. From its inception, rudimentary ECGs have been used to diagnose and treat rhythm disturbances. A significant impact of the ECG and an area of continued research is in the treatment of sudden cardiac death.


Beyond the recognition and treatment of cardiac rhythm disturbances, the ECG has impacted the care of patients with ACS with both the single- and the 12-lead ECG.
Single-lead ECG monitoring is also of significant importance in the ACS patienta€”not aimed at the detection of ST segment and T wave abnormalities associated with ACS but rather for the detection of complicating rhythm disturbances, such as sinus bradycardia, complete heart block, and ventricular fibrillation. The impact of the ECG has been extended beyond the diagnosis and treatment of primary cardiac pathologies. In the setting of poisoning or overdose, the ECG is used not only as a diagnostic study to rule in the condition but also as an indicator of risk to guide the intensity of therapy. The ECG also impacts the care of patients with underlying metabolic or electrolyte disorders such as hyperkalemia. Figure 2.4 Sine wave pattern in untreated hyperkalemiaa€”this rhythm is termed the sinoventricular rhythm.
Figure 2.6 Suggested management issues based on ECG findings in a patient with hyperkalemia. The course curriculum covers all EMT knowledge and skill requirements for the new EMT National Education Standards (NES). We are currently using AAOS Emergency Care and Transportation of the Sick and Injured 10th Edition for the EMT course. Typically a live instructor is only available during normal business hours, but leaving a message will ensure a prompt reply. Once the student has completed and passed the online course work they must attend and pass 6 days of hands on practical training. Blackwell's publishing programme has been merged with Wiley's global Scientific, Technical and Medical business to form Wiley-Blackwell. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners.
The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. Reduced a€?out-of-hoursa€™ survival rates for virtually all forms of acute medicinea€”not least trauma, strokes and heart attacksa€”have led to a rethink in strategy for emergency care in the UK. Despite the reorganisation of acute medical services, unfortunately these patients are still initially seen and often treated by relatively inexperienced staff, most if not all with little or no training in radiology, in particular the interpretation of DR and CT. The book is divided into anatomical chapters, followed by chapters in US, CT, paediatrics and major trauma. Virtually any medical condition can present in the emergency department (ED) and so the volume of medical knowledge needed to manage these patients satisfactorily is enormous. Despite all these advances, plain to X rays (whether conventional or digital) remain the mainstay of initial and successful management of most sick and traumatised patients in the ED. Unfortunately these investigations are often done and interpreted by medical staff who have little, if any, training in radiology and the usual safety net of a specialist radiological service is not available at the time of presentation, when it is most needed.
This is emphasised in each relevant chapter, but it is critical that the correct imaging modality is chosen to save time and to avoid the increased morbidity and mortality of delayed management. The other extreme is when a patient has an open bleeding wound, which just needs dressings and compression initially and instead the clinical team request plain X-rays to look for a fracture! Confident diagnosis of a septic arthritis was made with old film available showing rapid progression. Under these circumstances, you should ALWAYS get a second opinion and record both your interpretations, both in the notes and also in the radiology information system (RIS). If two specialists have missed the abnormality, the likelihood of the case of ending up in court in the UK is virtually zero!
These investigations should be done as soon as possible but often are done the following day on a routine list. Similarly, major trauma patients often have multiple intra-articular fractures detected on the plain X-rays and then have whole body CT, but the intra-articular fractures are not included in the CT scanning protocol.
However, in the context of patients in the ED, the ABCs systematic approach is equally effective for the interpretation and assessment of whole body CT and seamlessly incorporates an advanced trauma life support (ATLS) approach in trauma.
The images are colour coded, so that ALL a€?normala€? anatomy diagrams, lines and annotations are shown in white or shades of blue.
Under adequacy, we have included the imaging investigation of choice and either basic knowledge necessary to understand the modality and the a€?standard viewsa€™ and also the other views available. Both these signs are easy to detect and immediately alert the clinician to the presence of a probable fracture. The hand is the most active part of the body, is the least well protected and thus is often injured. The proximal row (scaphoid, lunate, triquetrum and pisiform) articulates wth the radius and ulna and the distal row (trapezium, trapezoid, capitate and hamate) articulates with the bases of the metacarpals. The age of a child can be estimated by counting the number of epiphyses minus one (see Chapter 16).
At least two views are mandatory and additional views may be necessary for specific injuries, such as scaphoid injuries, where coned views with an AP, lateral, oblique and a dedicated scaphoid view are indicated.
If a scaphoid fracture is suspected, a PA view with ulnar deviation and also a dedicated scaphoid view with 20a€“30A° of tube angulation are recommended in addition to a lateral and an oblique view (Figure 2.2).
MRI is rarely indicated acutely, although some centres are doing MRIs on patient's with anatomical snuff box tenderness who have normal plain X rays (XRs) to exclude scaphoid fractures.
Widening following injury, seen most commonly at the scapholunate articulation resulting in the Terry Thomas or Madonna sign, may be indicative of joint dissociation and ligamentous injury.
It is crucial to assess the alignment of the distal radius, lunate, capitate and 3rd metacarpal.
Fractures typically consist of a cortical step deformity, which may be visible on only one view. The dorsal surface of the distal radius typically shows a small area of irregularity representing Lister's tubercle, a normal anatomic landmark. Narrowing may be due to technical factors (rotation, flexion, tilting) or disease (arthritis). Digital windowing of a radiograph may be required to adequately assess for soft tissue swelling particularly if the radiograph is overexposed.
Angulation is particularly common in fractures through the proximal metaphysis of the proximal phalanx and should be carefully evaluated on the lateral view as there is often some overlap. Blackwell's publishing program has been merged with Wiley's global Scientific, Technical and Medical business to form Wiley-Blackwell. Thank you also to Bill Brady for his educating me about ECGs during residency, and for his continued mentorship ever since. Resourceful EMS providers would use all three channels to verify rhythm, check for axis abnormalities and conduction disturbances, and even attempt to identify ST-T wave abnormalities in patients at risk for acute coronary syndrome. When patients arrived by EMS with a diagnostic ECG having already been performed, patients received fibrinolysis much more quickly than if an ECG had not been done, or if the patient had arrived by private vehicle.
Like fibrinolysis, PCI is time critical, with a€?door to balloona€? times serving as one of the crucial process metrics.
The prehospital ECG is not only administered to patients with suspected ACS, but is also used to better define rate, rhythm, or axis abnormalities first suspected on the single lead cardiac monitor. In the same way that prehospital ECGs has reduced the a€?door-to-druga€? and a€?door-to-balloona€? times for STEMI, we are now in the era when the ECG can be used to speed the time to treatment of premalignant dysrhythmias or life-threatening electrolyte abnormalities.
O'Connor is professor and chair of Emergency Medicine at the University of Virginia in Charlottesville.
The electrocardiogram, whether in monitor mode using single or multichannel rhythm monitoring or in diagnostic mode using the 12-lead ECG, is an amazing tool; it assists in establishing a diagnosis, ruling-out various ailments, guiding the diagnostic and management strategies in the evaluation, providing indication for certain therapies, offering risk assessment, and assessing end-organ impact of a syndrome.
The novice electrocardiographer can use this text as his or her primary ECG reference; additionally, the experienced interpreter can use this textbook to expand his or her knowledge base.
I and my coeditors, advisory editors, and authors have enjoyed its creationa€”we hope that you the prehospital clinician will not only enjoy its content but also find it of value in the care of your patients. He named the five electrical deflections of an a€?electrical heart beata€? with the now well-known descriptorsa€”P, Q, R, S, and T (Figure 1.1). The use of ECG monitoring has grown from this early important step to become a mainstay of patient evaluation, not only for cardiac arrest but also for many other conditions. This ECG nicely demonstrates the intrinsic ventricular rate of 20a€“40 beats per minute and sinus rate of 60a€“80 beats per minute. For prehospital rhythm interpretation, the use of the ECG in a single- or multilead analysis mode is the most appropriate. The 12-lead ECG can not only provide important information regarding the ACS diagnosis but also guides therapy and predicts risk, and can suggest alternative diagnoses. This artifact dampening effect can lead to distortion of the ST segment, producing ST segment changes which are, in fact, not present in diagnostic (or 12-lead ECG) mode.
It has been shown in numerous studies that the prehospital 12-lead ECG markedly reduces the time to hospital-based reperfusion (fibrinolysis and percutaneous coronary intervention) in patients with STEMI. Refer to Table 1.1 for a list of selected diseases not related to coronary obstruction that may have significant abnormalities evident on the ECG. The S wave in lead I is indicated by the long arrow, the Q wave in lead III (medium arrow), and the inverted T wave in lead III (small arrow). The ECG is a primary tool for evaluating the unstable patient and a useful tool in the assessment of the stable patient.
There are now well-established treatment algorithms for both prehospital and hospital treatment of life-threatening cardiac dysrhythmias, and the ECG findings are paramount in these algorithms.
The 12-lead ECG (as opposed to laboratory evaluation with a cardiac enzyme assay such as troponin) is the primary tool for identifying patients with ST segment elevation myocardial infarction (STEMI). The interpretation of the 12-lead ECG, however, is a skill that requires advanced training and practice in order to assure proficiency. In the patient with chest pain or dyspnea, the ECG can suggest alternative diagnoses to ACS; for instance, the ECG can suggest PE. For instance, cardiac sodium channel and potassium efflux blockade will produce worrisome ECG findings, such as widening of the QRS complex and prolongation of the QT interval, respectively. In hyperkalemia, T waves become peaked as the serum potassium level increases (Figure 2.3).
This book and our course includes the new National Education Standards (NES) that follow the new EMT scope of practice. If the agency or institution requests, we will send a certificate of liability directly to them to verify your coverage. In addition, the school is recognized as a training institution by the Idaho Department of Emergency Medical Services. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Although safety nets exista€”in particular now that PACS is widely available in the UKa€”specialist radiological advice is still often not available at the time of presentation, when it is most needed.
Each chapter starts with radiological anatomy, then recommended standard views, then a systematic approach to basic interpretation followed by a review of common abnormalities and finally a summary chart. It is not uncommon for a fracture or an abnormality to be visible only on one view (Figure 1.2).
Similarly, if there is a bony abnormality, an old film will not only confirm whether this is an old or new finding, but also the speed of change will help in the diagnosis (Figure 1.20).
If at a later date, a major abnormality has been missed or overlooked, it means that you can share the blame! The problem is that delaying these investigations often leads to the investigation not being done or the team that looks after the patient forgetting about it! Computed tomography (CT) and magnetic resonance imaging (MRI) are developing increasing roles, particularly as their availability increases. At each metacarpophalangeal (MCP) joint and interphalangeal (IP) joint, lateral stability is provided by the collateral ligaments.
MRI and CT are becoming increasingly available and are being used even in the acute setting.


The lunate is moon shaped (lunar = moon) and lies on its back on the distal radius (saucer on table).
In more subtle cases there may be a subtle intramedullary lucency without significant visible cortical breach at initial presentation. There is a fat plane volar to the distal radial metaphysis, along the volar aspect of the pronator quadratus muscle. However, for most of EMS, the primary use of cardiac monitoring was to monitor the rhythm in the stable patient, or to determine which ACLS algorithm should be followed incases of cardiopulmonary arrest.
Assembling a team for PCI consumed significant resources, including opening of a catheterization laboratory and the presence of the interventional cardiologist and other personnel who could perform the PCI. The 12-lead ECG is better able to define varying degrees of heart block as well as other conduction disturbances. Readers of this book will benefit from the expertise of the authors, who have devoted a significant portion of their careers to teaching others the finer points of ECG interpretation. He is a past President of the National Association of EMS Physicians, a past Chair of the Emergency Cardiac Care Committee for the American Heart Association, and is a current board member of the American College of Emergency Physicians. As noted in this impressive list of applications, it provides significant insight regarding the patient's condition in a range of presentations, whether it be the chest pain patient with ST segment elevation myocardial infarction (STEMI), the patient in cardiac arrest with ventricular tachycardia, the poisoned patient with bradycardia, or the renal failure patient with rhythm and morphologic findings consistent with hyperkalemia, among many, many othersa€¦. This work stresses the value of the ECG in the range of clinical situations encountered daily by prehospital providersa€”it illustrates the appropriate applications of the electrocardiogram in acute and critical care EMS settings. Accurate interpretation of the ECG has become a necessary skill for every clinician who cares for acutely ill patients.
Shown here is a lead II tracing in a patient in diagnostic mode (a) and non-diagnostic rhythm mode (b).
Pericarditis (inflammation of the pericardial sac) leads to a diffuse pattern of PR segment depression and ST segment elevation that can be differentiated from STEMI as the elevation is present in a pattern not anatomically related to a coronary artery distribution. Osborn waves are positive deflections occurring at the junction between the QRS complex and the ST segment that are typically observed in patients suffering from hypothermia with a temperature of less than 32A°F. The ECG aids in clinical decision making for patients experiencing primary cardiac pathology.
The emergent diagnosis and management of life-threatening dysrhythmias is all based on the interpretation of the single-lead ECG (also called a rhythm strip). Sudden cardiac death is a commonly encountered extreme example of symptomatic dysrhythmia in which the ECG plays a pivotal role in assessment and management. In STEMI, the ECG rapidly identifies patients who are in emergent need of revascularization. Inaccurate interpretation of the ECG has been shown to impact the care of patients with ACS. These findings can occur in patients taking prescribed medications as well as in the patient who has overdosed. Left untreated, rising serum potassium level leads to changes in the P wave and QRS complex (Figure 2.3).
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. The selection of the correct imaging modality on admission saves time and saving time, saves lives! The mere fact that you sought out a second opinion and recorded it, shows common sense and insight (even if it's not the case!).
This is clearly not efficient use of CT and it is dangerous to move the a€?stablea€™ polytraumatised patient!
The joint capsule at the MCP and IP joints also demonstrate on the volar aspect areas of dense fibrous thickening, known as the volar plate, which provide further strength. The carpometacarpal articulations in particular, where some degree of overlap is unavoidable, should be carefully scrutinised.
The proximal pole of the capitate sits into the concave distal surface of the lunate (cup in the saucer) and the third metacarpal should line up with the distal pole of the capitate. Remember to use the digital a€?windowsa€™ to look for soft tissue swelling associated with subtle fractures and to help with tricky calls.
Rotation is often difficult to assess on plain radiographs and clinical examination, whereby rotation is more apparent on flexion, is important.
Mobilizing these resources during nights and weekends had the potential to engender significant time delays.
Electrolyte abnormalities can be readily identified and dysrhythmias can be better recognized, thus allowing prehospital providers to tailor treatment to the underlying disorder. The diagnostic utility of the 12-lead ECG is vast, and after completing this book, readers will come to understand that the prehospital ECG is not only used to diagnose STEMI, but can be used to identify many other clinical condition, which if left untreated, would seriously compromise the health of the patient. This extremely useful tool is noninvasive, portable, inexpensive, quickly obtained, and easily performed.
Section two focuses on the ECG and rhythm diagnosis, considering the electrocardiographic findings from an in-depth differential diagnostic perspectivea€”in other words, rhythms with normal rates as well as bradycardia and tachycardia, allowing for the QRS complex width and regularity. The ECG is a non-invasive, inexpensive, easily performed test that allows a clinician to view the electrical activity in the heart. The ability to evaluate the heart rhythm is critical as cardiac dysrhythmias often are symptomatic and require immediate treatment.
Note the appearance of ST segment elevation in rhythm mode, which is not present in the diagnostic mode. The ECG can display evidence of ongoing cardiac injury with T wave inversion or ST segment depression.
At the same time, the diagnosis of pericarditis can be difficult, and the patient may present with chest pain and ST segment elevation, potentially leading to the incorrect diagnosis of STEMI. This includes conduction disturbances, acute coronary syndrome (ACS), and also such non-cardiac pathology as pulmonary embolism (PE), metabolic disarray, and poisoning or overdose. The ECG is used in both the prehospital and hospital environments to detect STEMI and has been shown to favorably impact the time to revascularization. In particular, clinicians must be particularly aware of ominous changes of the ST segment and the T wave. It is important to note that these changes suggest right ventricular a€?straina€? directly, rather than PE. In the setting of tricyclic antidepressant (TCA) overdose (a potent sodium channel blocking agent), an R wave (positive deflection of the QRS complex) that is 3A mm above the isoelectric line in lead aVR has been shown to be predictive of significant cardiotoxicity including the development of seizures and ventricular arrhythmias (Figure 2.2). It is sold on the understanding that the publisher is not engaged in rendering professional services.
Each finger has two flexor tendons on the volar (palmar) surface and an extensor tendon complex on the dorsal surface.
The radiocarpal joint has a 4a€“15A° volar tilt and the hand is usually held in slight flexion and ulnar deviation. Interruption of this alignment is usually secondary to a perilunate or lunate dislocation (and should result in careful assessment for associated carpal and distal radial fractures).
As with all fractures, the location, direction, displacement, angulation and comminution of the fracture as well as the involvement of the articular surfaces should be assessed. In the hand and wrist, soft tissue swelling often also spreads distal to the point of injury. STEMI systems began to mobilize the catheterization laboratory team based solely on the prehospital ECG interpretation. Yet, its interpretation is not as easily performed and, in fact, requires considerable skill and experience as well as an awareness of its use in the appropriate clinical settings and limitations of patient data supplied.
Section three reviews the 12-lead ECG in patients suspected of acute coronary syndrome, including ST segment elevation myocardial infarction. However, even if the dysrhythmia is not symptomatic, treatment may still be required to prevent future complications. The ECG can also help localize the obstructed coronary artery; for example, Wellens' Syndrome has a characteristic ECG pattern with changes to the T wave in the precordial leads, predominantly leads V2a€“V4, which can indicate a high-degree obstruction of the proximal left anterior descending coronary artery. Pericardial effusion with ultimate cardiac tamponade is caused by fluid in the pericardium that can accumulate owing to a variety of causes including recent viral infection or cancer. The use of the ECG is widespread and requires every clinician to work toward competence in the efficient and accurate use and evaluation of the ECG. These rhythm possibilities range from bradycardia to tachycardia, with and without conduction block. Also, when used in the prehospital setting, the ECG may detect ischemic changes that resolve before arrival at the emergency department and provides a valuable snapshot of an ischemic event. Inaccurate interpretation of the ECG, including the lack of recognition of ST segment and T wave abnormalities can have grave consequences for the patients and potentially expose them to inappropriate and dangerous therapies. S1-Q3-T3 is typically present only in large PE and the absence cannot be used to exclude the diagnosis.
If professional advice or other expert assistance is required, the services of a competent professional should be sought. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. Many of these systems would rely on paramedic interpretation without a physician's interpretation of the ECG, due to the excellent interpretative skills developed by many EMS providers.
Section four discusses the range of special presentations, patient populations, and uses of the electrocardiogram. Atrial fibrillation is a good example of a cardiac dysrhythmia easily identified on ECG, where symptoms may be completely absent or may be severe requiring immediate intervention. If the condition is untreated, however, the ECG may progress to widening of the QRS complex and the eventual fusing of the QRS complex and the T wave, resulting in a sine wave configuration and ultimately cardiac arrest.
Clearly, the single-lead ECG enables the clinician to diagnose the rhythm and initiate the most appropriate care based on the ECG information as well as the patient's clinical situation. The benefits of prehospital ECG are realized with little increase in emergency medical service (EMS) resources or on-scene time.
The ability to perform 12-lead ECGs in the field has become a required skill in most EMS systems, and is now considered standard for STEMI systems to rely on EMS ECG interpretation to determine not only the destination hospital but also to activate the catheterization laboratory.
Section five is a listing of various electrocardiographic findings, again from the differential diagnostic perspective; in this section, various rhythm and morphologic presentations are discussed, such as the narrow and wide complex tachycardias and ST segment elevation syndromes. Depending on the rate (either fast or slow), the patient's symptoms may range from a benign fluttering in the chest to more serious symptoms of fatigue, chest pain, or syncope. Electrical alternans is also seen in this setting and is characterized by beat-to-beat alterations in the QRS complex size, reflecting the swinging motion of the heart in the pericardial fluid. Central nervous system (CNS) events such as intraparenchymal hemorrhage, ischemic stroke, and mass lesion may also present with changes in the ECG, largely involving the T wave with inversion and prolongation of the QT interval. Many EMS systems have the capability to transmit the 12-lead ECG for a€?real-timea€? interpretation by a physician.
The ECG initially suggests acute infarction in only 50% of patients ultimately found to have an acute myocardial infarction. With the advent of cellular and handheld technology, an EMS provider can easily transmit an ECG directly to the handheld device of a cardiologist who can make treatment and reperfusion decisions even before the patient leaves the scene of the emergency. A patient who experiences heart block may be symptom free or at risk for syncope or cardiac arrest with a high-degree atrioventricular (AV) block, as seen in Figure 1.3. Even when a patient is stable and without active symptoms, the ECG may provide clues that a patient is at risk for a potentially malignant rhythm. The patient depicted in Figure 1.4 is an example of long QT syndrome complicated by malignant ventricular dysrhythmia. The recognition of a prolonged QT interval is critical as patients with this electrocardiographic finding are at higher risk for dysrhythmia and sudden cardiac death (Figure 1.4).



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