#1 - Leads, Axis, Principles of Monitoring, What’s Normal

Class Description:

To determine what’s abnormal in a 12-lead ECG, it is imperative to know what is normal and be able to make that determination quickly. Determining the QRS axis on the frontal plane, if the T wave and ST segments are directed normally, and thoroughly understanding leads and how to manipulate them are skills fundamental to rapid 12-lead ECG interpretation. Often not taught in arrhythmia interpretation courses, this information is basic and necessary to understand the remaining sessions in this series.

Topics:

I. Leads of the frontal plane

A. Standard, bipolar limb leads
B. Unipolar limb leads
C. Determination of axis

II. Leads of the horizontal plane

A. Two very important leads for monitoring (V1 and V5 or V6)
B. Bipolar substitutes for V-leads

III. Lead choices for various populations
IV. Other leads (posterior, right ventricular, etc.)
V. Rules for monitoring

A. One lead is not enough!
B. Choose lead based on patient, not policy!

Behavioral/Learning Objectives:

1. Recognize a normal 12-lead ECG.
2. Explain how the P wave, QRS complex, and T wave should look in all 12 leads.
3. Determine the electrical axis of the ECG in seconds.
4. Describe the normal precordial pattern and how it is derived.
5. Explain how bipolar substitutes for the V leads are derived, e.g., MCL1, MCL5, MCL6, CM5, etc., and when they are indicated.
6. List advantages of using V1 and V5 for monitoring in cardiac rehabilitation.
   

#2 - Wide QRSs – Bundle Branch Blocks

Class Description:

Wide QRS complexes are caused by a number of factors; among the most common are bundle branch blocks (BBB). Determining whether wide beats are a result of BBB should take only seconds and is imperative to accurate diagnosis. Often not taught in basic arrhythmia interpretation courses, this information is easy, fundamental and necessary to understand the remaining sessions in this series.

Topics:

I. Wide QRS basics: It’s either BBB or ventricular (or rarely preexcitation)
II. Diagnosis of bundle branch blocks (BBB)

A. Right BBB
B. Left BBB

Behavioral/Learning Objectives:

1. Explain the classification of intraventricular conduction delays and identify which may be found in healthy individuals and which may represent disease.
2. Contrast the ECG characteristics and clinical significance of right bundle branch block (RBBB) with left bundle branch block (LBBB) and recognize each on the ECG.
3. Differentiate BBB from ventricular ectopy.
4. Describe methods to diagnose BBB.
5. List leads best to identify BBBs.
   

#3 - Wide QRSs – Hemiblocks and Aberration

Class Description:

Hemiblocks, while not increasing the QRS much, change its appearance and may indicate worsening condition. Aberration will change the QRS depending upon the cause of the aberration, whether it is BBB or hemiblock. Differentiating ventricular premature contractions/beats from aberration is often difficult, but a necessary skill for cardiac clinicians. Differentiating wide QRSs in the presence of atrial fibrillation is also difficult because clues that help in diagnosing VPCs, such as compensatory pauses, or premature P waves, aren’t present in atrial fibrillation.

Topics:

I. Aberration

A. Definition
B. Identification of aberration on the ECG

II. Wide QRS in atrial fibrillation

A. Criteria supporting aberration
B. Criteria supporting ventricular ectopy

III. The hemiblocks

A. Anterior fascicular block
B. Posterior fascicular block
C. Hemiblock aberration

Behavioral/Learning Objectives:

1. Define aberration
2. Differentiate supraventricular complexes conducted with aberration from ventricular ectopy.
3. Identify left anterior fascicular block.
4. Identify left posterior fascicular block.
5. Describe which leads best identify BBBs and which best identify fascicular blocks.
   

#4 - Fat Tachs: Differential Diagnosis of Wide Complex Tachycardias

Class Description:

The wide complex tachycardia may deteriorate within seconds to ventricular fibrillation or be tolerated for hours. Rapid differential diagnosis is imperative in treating this life-threatening arrhythmia. Often not taught in basic arrhythmia interpretation courses, this information is crucial for any practitioner responsible for treating critical arrhythmias. ECG techniques presented will equip the practitioner with the necessary tools to correctly diagnose the etiology of wide complex tachycardias in well over 90% of cases.

Topics:

I. Misdiagnosis and consequences of wide-QRS-complex tachycardias
II. VT versus SVT with aberrant conduction: Rules
III. ECG differential diagnosis: 6 steps
IV. Preexcitation: 3 ways to fat tachs
V. Wide QRS tachycardia treatment

Behavioral/Learning Objectives:

1. Explain various clinical physical signs useful in differential diagnosis of wide complex tachycardias.
2. Determine ECG leads useful in differential diagnosis of wide complex tachycardias.
3. List at least 3 criteria supporting the diagnosis of ventricular tachycardia.
4. List at least 3 criteria supporting the diagnosis of supraventricular tachycardia with aberrant conduction.
5. Explain characteristics of accessory pathway conducted tachycardias and ways to differentiate from VT and SVT with aberration.
   

#5 - Ischemia and Obvious Infarction

Class Description:

Myocardial ischemia and infarction are two conditions the cardiac rehabilitation practitioner must be able to recognize and treat competently. Ischemia and infarction manifest differently and require astute and informed examination of the 12-lead ECG.

Topics:

I. Myocardial ischemia

A. Best leads for identification
B. ECG characteristics: 7 contours
C. Diagnosing ischemia in presence of RBBB

II. Myocardial infarction

A. ECG diagnosis of ST segment elevation MI (STEMI)
B. Location of STEMI
C. Diagnosing in presence of BBB

Behavioral/Learning Objectives:

1. Recognize ST-segment elevation myocardial infarction (STEMI) on the 12-lead ECG.
2. Discuss the locations of STEMI: Septal, anterior, inferior, lateral, true posterior, right ventricular.
3. Describe ECG manifestations of myocardial ischemia.
4. Recognize myocardial ischemia in the presence of RBBB.
5. Explain when exercise should be curtailed in the presence of myocardial ischemia.

#6 - Repolarization Rascals: Ischemia and Infarction Impostors

Class Description:

Left ventricular hypertrophy, electrolyte imbalances, digitalis, pericarditis, cor pulmonale, acute pancreatitis, intracranial hemorrhage, and normal variants are among the many impostors of myocardial infarction and ischemia. A practitioner must be able to differentiate ST segment elevation secondary to infarction from aneurysm, pericarditis, and other causes. This class will be a brief introduction to some of these impostors.

Topics:

I. Repolarization rascals

A. Digitalis
B. LVH
C. Potassium
D. Pericarditis
E. Ventricular aneurysm
F. Early repolarization

II. MI mimics

A. Pericarditis
B. Variant angina

Behavioral/Learning Objectives:

1. Describe the ECG effects of digitalis and compare with ischemia.
2. Compare and contrast the ECG in left ventricular hypertrophy, digitalis, and ischemia.
3. List 3 causes of ST segment depression, not including myocardial ischemia.
4. List 3 causes of ST segment elevation, not including myocardial infarction.

Accreditation Information

Nurses – Academy Medical Systems is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA.

Academy Medical Systems (AMS) is also a provider approved by the California Board of Registered Nursing, provider #CEP14413.

AMS is also a provider approved by the Florida Board of Nursing, provider #50-19.

Iowa Nurses – The Iowa Board of Nurses will recognize the recorded webinars as a home study program. They recognize our ANCC approved provider status as well as our CA and Fl Board of Nursing provider approval for home study products for nurses in Iowa.

All other states recognize our approved provider status listed in the above text for continuing education credit for nurses.

9.0 contact hours will be rewarded to nursing professionals at the completion of this workshop.

Dietitians - Academy Medical Systems is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR.) Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 9.0 continuing professional education units (CPEUs) for completion of this program/material.

Occupational Therapist - Occupational Therapist will receive 9, continuing education hours for completion this program and a test score of 70% or better. AMS is an approved provider for the AOTA , provider # 5470.  This course is an intermediate education level.

Exercise Physiologist – ACSM recognizes AMS’s approved provider status with the ANCC and will honor our continuing education for Certified Exercise Physiologist recertification purposes.
Certified Cardiovascular Techs – Cardiovascular Credentialing International recognizes our approved provider status with the ANCC for continuing education courses for CCTs.

Certified Athletic Trainers – Academy Medical Systems is recognized by the Board of Certification (BOC) to offer continuing education for certified athletic trainers. 9 hours will be awarded at the completion of this program.

Respiratory Therapists - This course meets the requirements for continuing education for Respiratory Care Professionals in AL, CA, CT, DE, FL, ID, IL, IN, IA, KS, LA, ME, MA, MN, MS, MT, NE, NV, NY, OH, OK, OR, RI, SC, TN, TX, WA, WV, WY.

Because each state’s continuing education requirements for respiratory therapists is subject to change, please verify this information with your state board. Thank you.

Physical Therapists - PTs and PTAs in the following states will receive 9 contact hours for completion of all 6 webinars: AK, AL, AZ, CA, CO, CT, GA (Class 1), HI, IA, ID, IN, KS (Cat 2), KY,  MA, ME, MI, MN (Cat 2), MO, MS, MT, NE, NM, ND, OK (Cat 2), OR, RI, SC, SD, UT, VA (Type 2), VT, VI, WA, WI, WY.

We are an approved provider to offer continuing competency courses to CA PTs, approval date 4/5/10.  The following state boards recognize other state’s approval: AL, AZ, GA (Class 1), KY, MO, MS, OK (Cat 2), WI.

Because each state’s continuing education requirements for physical therapists is subject to change, please verify this information with your state board. Thank you.

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