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8/10/2019 Basic 1-hr 12L
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12 Lead ECG
Basics
Dana Yost, Senior Paramedic
Paramedic Training
Seattle - King County, WA
8/10/2019 Basic 1-hr 12L
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Disclosures and Biases
13 years - 12 Lead Instructor PMT
AHA National & Regional Faculty
Paid consultant on resuscitation and post event analyticsResurgent Biomedical Consulting LLC
Published papers on resuscitation and mechanical CPR
19 years - as a Paramedic in King County, WA
Involved in Resuscitation Outcome Consortium Studies (ROC)
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What is different?
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What is different?
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Plaque Rupture
Lipid Core
Fibrous Cap
Lumen
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Thrombus Formation
Lipid Core
Fibrous Cap
Platelets Adhere
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Thrombus Formation
Platelet Aggregation
Lipid Core
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Thrombus Formation
Platelet AggregationLipid Core
Fibrin
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Vasoconstriction
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Anatomy of the Heart
The layers of the heart muscle
Epicardium
(outer most)
Endocardium(inner most)
Myocardium(muscle mass)
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Evolution of Myocardial Infarction
A Dynamic Process
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ST Segment Elevation
The hallmark of Myocardial Injury
ST Segment DepressionMyocardial Ischemia
Inverted T waves
Myocardial Ischemia
STEMI
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Lead PlacementHow the Leads view the Heart
I
IIIII aVF
aVL
Limb Leads Chest Leads
Basic Patterns
1 23
4 56
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8/10/2019 Basic 1-hr 12L
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What is the underlying rhythm?
Imitators? (LBBB, Pacer, LVH) if yes = STOP!
Look at each pattern systematically:
ST elevation (1mm or more)
ST depression (1mm or more) = ISCHEMIA
Inverted T waves = ISCHEMIA
Need changes in two or more leads in a pattern
Which pattern or patterns are involved?
= STEMI
8/10/2019 Basic 1-hr 12L
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What is the underlying rhythm?Imitators? (LBBB, Pacer, LVH) if yes = STOP!
Look at each pattern systematically:
ST elevation (1mm or more) = STEMI
ST depression (1mm or more) = ISCHEMIA
Inverted T waves = ISCHEMIA
Need changes in two or more leads in a patternWhich pattern or patterns are involved?
8/10/2019 Basic 1-hr 12L
18/30
Lead PlacementHow the Leads view the Heart
I
IIIII aVF
aVL
Limb Leads Chest Leads
Basic Patterns
1 23
4 56
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What is the underlying rhythm?Imitators? (LBBB, Pacer, LVH) if yes = STOP!
Look at each pattern systematically:
ST elevation (1mm or more) = STEMI
ST depression (1mm or more) = ISCHEMIA
Inverted T waves = ISCHEMIA
Need changes in two or more leads in a patternWhich pattern or patterns are involved?
8/10/2019 Basic 1-hr 12L
20/30
Lead PlacementHow the Leads view the Heart
I
IIIII aVF
aVL
Limb Leads Chest Leads
Basic Patterns
1 23
4 56
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What is the underlying rhythm?Imitators? (LBBB, Pacer, LVH) if yes = STOP!
Look at each pattern systematically:
ST elevation (1mm or more) = STEMI
ST depression (1mm or more) = ISCHEMIA
Inverted T waves = ISCHEMIA
Need changes in two or more leads in a patternWhich pattern or patterns are involved?
8/10/2019 Basic 1-hr 12L
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Lead PlacementHow the Leads view the Heart
I
IIIII aVF
aVL
Limb Leads Chest Leads
Basic Patterns
1 23
4 56
8/10/2019 Basic 1-hr 12L
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What is the underlying rhythm?
Imitators? (LBBB, Pacer, LVH) if yes = STOP!
Look at each pattern systematically:
ST elevation (1mm or more) = STEMI
ST depression (1mm or more) = ISCHEMIA
Inverted T waves = ISCHEMIA
Need changes in two or more leads in a patternWhich pattern or patterns are involved?
8/10/2019 Basic 1-hr 12L
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Lead PlacementHow the Leads view the Heart
I
IIIII aVF
aVL
Limb Leads Chest Leads
Basic Patterns
1 23
4 56
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What is the underlying rhythm?
Imitators? (LBBB, Pacer, LVH) if yes = STOP!
Look at each pattern systematically:
ST elevation (1mm or more) = STEMI
ST depression (1mm or more) = ISCHEMIA
Inverted T waves = ISCHEMIA
Need changes in two or more leads in a patternWhich pattern or patterns are involved?
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Lead PlacementHow the Leads view the Heart
I
IIIII aVF
aVL
Limb Leads Chest Leads
Basic Patterns
1 23
4 56
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What is the underlying rhythm?
Imitators? (LBBB, Pacer, LVH) if yes = STOP!
Look at each pattern systematically:
ST elevation (1mm or more) = STEMI
ST depression (1mm or more) = ISCHEMIA
Inverted T waves = ISCHEMIA
Need changes in two or more leads in a patternWhich pattern or patterns are involved?
8/10/2019 Basic 1-hr 12L
28/30
Lead PlacementHow the Leads view the Heart
I
IIIII aVF
aVL
Limb Leads Chest Leads
Basic Patterns
1 23
4 56
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Questions
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Summary
12 lead interpretation is about pattern recognition
Use a systematic approach to interpretation
ST Elevation (STEMI) trumps other ACS finding
Its an art..Practice makes perfect