I was asked a few months ago to review the American Heart Association's STEMI recognition educational software. This software was created in response to a deficit found during Mission:Lifeline.
Here is the review I gave word for word:
First, I would like to say that it is not advocated to teach 12-lead ECGs in a STEMI vs. not a STEMI manor. While the intentions seem good, there is much more to learn regarding 12-lead ECG interpretation that this type of course does not cover. There is an overwhelming need for a more comprehensive resource for prehospital care providers, and other emergency medical personnel, for that matter.
It is my belief that the ACLS course should provide the base of 12-lead ECG knowledge while an online course could be adequate for continuing education. Initial training could include the six-step method of ECG interpretation.
Six-Step Method:
- Rate & Rhythm
- Axis determination
- Complex, wave, and segment durations
- Morphology
- STE-Mimics
- Ischemia, Injury, Infarct
This method could be taught extensively while breaking down each part to include the physiology of abnormalities. The Learn: Rapid STEMI ID course is a good start, but is at an educational level below that of what prehospital care providers should be at. It is also not adequate enough to be part of the curriculum within a paramedic program. I don’t feel an initial education in 12-lead ECG interpretation should be from an online course because of the inability to ask questions.
Learn: Rapid STEMI ID
Pros:
- The interactive software is top notch.
- The graphics used for the cardiology portion are very nice
- For the most part the cardiology review is very factual
- There is a good amount of ECG cases
- The cost seems to be about right for this type of course
Cons:
- This course is designed only for STEMI recognition, not 12-lead interpretation. While an important part of 12-lead interpretation, it is not the only ailment that can be determined.
- With the absence of any presentation outside of STEMI comes the lack of education regarding axis shift, rate changes, pacemaker changes, bundle branch blocks, electrolyte imbalances, etc. It is possible to create this course in conjunction with more comprehensive resources. For example, using the six-step method, this course would include steps five and six.
- The cardiology review is good, but it should also be explained that some patients have slight differences in their coronary arteries (i.e. stenosis, dominant RCA, dominant Cx).
- During the explanation of electrode application, there should be information about commonly misplaced electrodes and the need to remove all clothing on the patient from the waste up.
- There is no list of indications for 12-lead ECG interpretation. While there is a good explanation of typical and atypical ACS symptoms, ACS symptoms are not the lone reason to acquire a 12-lead ECG. Some research has shown that paramedics have not performed ECGs on nearly half of patients that present with STEMI at emergency departments.
- No information was provided about UA/NSTEMI, informing the learner that it is possible that the patient is suffering from an AMI in the absence of ST-Elevation.
- It is explained how to identify ST-Elevation, Q-waves, and Hyperacute T-waves, but there is no explanation of the physiology. A better understanding of the reasoning behind pathological changes will improve the overall efficiency of 12-lead ECG interpretation.
- There should be more information regarding posterior wall MI changes (i.e. reciprocal changes in septal leads, R/S ratio >1).
- One very easy way to determine the J-point’s location is to identify the J-point in a lead above or below the lead in question.
- Upward concavity is not a conclusive finding with early repolarization. While the “smiley face method” is a good way to get an idea of the ST morphology, it is not the only way to differentiate early repolarization from STEMI. Notched J-points, and mean R-wave amplitude in V2-V4 greater than 5 mm are both indicative of benign early repolarization.
- The information on the STE-Mimics that where covered was good. However, there is a lot more that could be provided.
o LVH was covered, but not RVH
o Pericarditis symptomology is the easiest way to differentiate it from STEMI.
o Hyperkalemia vs. Hyperactute T-waves
o Bundle branch blocks
o Brugada Syndrome
- Contiguous leads should have been explained better V1 & V6 are not contiguous.
- The differentiation between Septal, Anterior, and Low Lateral should be made. V1-V6 are not all considered anterior.
- The depth of Q-waves was not covered pathological vs. physiological. Width was appropriately taught, but not depth.
- It should be made known that MI is not the most common cause of ST-Elevation.
Overall, I am pleased to see that the AHA is making an attempt at 12-lead ECG education. I am a big fan of the AHA and its use of evidence-based medicine. In fact, there is plenty of evidence supporting ECG findings, and a need for better interpretation. Here is an example of something that might be missed out on if this course was the base of the responding paramedic’s ECG knowledge; patient with syncope who has long QT syndrome or Brugada syndrome. This patient may never even have a 12-lead ECG obtained even though that the two conditions described can both be lethal. I am optimistic about the possibilities to come.
