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Lake EMS Online Review:12-Lead EKG
Created and prepared by: Captain Mike HilliardWith profound thanks and admiration to:
Henry J. L. (Barnie) Marriott, M.D., the father of 12-Lead ECGsTim Phalen, author of "12-Lead ECG: in AMI"Gary Denton, author of "Pre-Hospital 12-lead ECG"
This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only
Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500
352/383-4554 (w); 352/735-4475 (f); [email protected]
Information also based on: American Heart Association Advanced
Cardiovascular Life Support, Professional © 2011
Recommendations for the Standardization and Interpretation of the Electrocardiogram: A Scientific Statement From the American Heart Association
Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology Parts I-VI
EKG paper review
Paper Speed • Most 12-lead EKG's follow a standard format
• This is called a 3x4 format, providing 2.5 seconds of each lead for your review
• The computer is looking at all 12 leads for a full 10 seconds
Calibration
• Paper speed, calibration, and frequency response are typically preset and do not require adjustment
Frequency Response
Lead Identity
One Complete Cardiac Cycle: For accurate EKG interpretation, 1 complete cardiac
cycle must be obtained in each lead Cardiac cycle equals a: P, QRS, and T-wave
Represents complete electrical cycle Hopefully corresponds to mechanical contraction
Patient Sex(now an important tool when assessing V2 & V3)
Patient Age
Patient Information
Measurements
Computerized Interpretive Statement
The Basics: 1 of 2 key points TP-segment:
Baseline from end of T-wave to beginning of P-wave; a more accurate baseline than PR-interval
T-P Segment Baseline
The Basics: 2 of 2 key points J-point:
Juncture angle between QRS and ST-segment
Then locate 0.04 sec. (1-small box) after the J-point
Compare the Two Measure J-point height verses TP-segment Difference of > 1-mm (1-small box) equals a
deviation A deviation in > 1 anatomically contiguous leads
equals problem
How to Measure ST-Segment Deviation
TP baseline
J-pointPlus 0.04 second
Find the:• TP line• J-point• One box to the right
Find the:• TP line• J-point• One box to the right
Find the:• TP line• J-point• One box to the right
Find the:• TP line• J-point• One box to the right
Isoelectric
Find the:• TP line• J-point• One box to the right
Isoelectric
Find the:• TP line• J-point• One box to the right
Isoelectric
Find the:• TP line• J-point• One box to the right
Isoelectric Depressed
Find the:• TP line• J-point• One box to the right
Isoelectric Depressed
Find the:• TP line• J-point• One box to the right
Isoelectric Depressed
Isoelectric ElevatedDepressed
Find the:• TP line• J-point• One box to the right
The 3 "I"s1. Ischemia2. Injury3. Infarction
Ischemia Hallmark Primary hallmark:
ST-segment depression: > 0.5 mm Secondary signs:
Peaked T-waves Inverted T-waves
T-waves
Upright Inverted
It is normally upright (above baseline) in all leads except aVR and V1
T-waves
Upright Inverted
It is normally upright (above baseline) in all leads except aVR and V1
Injury Injury occurs if ischemia > 20-40 minutes Although cell death is threatened, if blood flow
can be restored we can avoid permanent myocardial death
STEMI is ST-segment elevation >2 contiguous leads or new LBBB
2010 (New) AHA STEMI guidelines Threshold values for STEMI are:
2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 V2 and V3 have slightly altered parameters
as we will now demonstrate
2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3
2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3
2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3 Men <40: 2.5 mm elevation in leads V2 & V3
2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3 Men <40: 2.5 mm elevation in leads V2 & V3
ACLS Manual Page 101
This is the rational for the importance of understanding and assessing the patient’s age and inputting their sex
Hallmark sign of Injury:
ST-segment elevation
Infarction Myocardial cell death; cells may demonstrate
injury and ischemia if area becomes larger Hallmark: Q-waves, >1 contiguous lead
Pathological: Q-waves > 1-mm wide and height > 25% of height of R-wave in same cardiac cycle
Physiological: Q-waves not indicative of above
Q-waves equate with myocardial death
Q-waves
Q-waves
Q-waveCorresponding R-wave
The Q-wave is 25% of the corresponding height of it’s R-wave
75%50%25%
See magical legend!
Q-wave
Q-waveCorresponding R-wave
The Q-wave is NOT 25% of the corresponding height of it’s R-wave
75%
50%
25%
See magical legend!
> 1 mm
Q-wave
> 1 mmPathological: Due to BOTH height AND width
Q-wave
< 1 mm
Q-wave
< 1 mm
Q-wave
Physiological: Due to lack of height and width
> 1 mm < 1 mm
Pathological Physiological
Q-wave
Fuzzy Logic Transition from ischemia, to injury, and ending in
infarction is actually a continuum modified by factors including: Extent of muscle involved O2 consumption O2 delivery And presence of collateral circulation
Consider the evolution of a burn with rings of varying degrees of damage
This is what we have to concentrate onThe acute portion of STEMI (Injury)
12-Lead Practice Assess for:
1. ST (1° sign suggestive for ischemia; depression >0.5 mm)
2. T-wave inversion (2° sign suggestive for ischemia)3. ST (suggestive of injury; elevation > 1.0 mm)4. Q-waves (suggestive of infarction)
12-Lead Practice Assess for:
1. Areas suggestive of ischemia2. Areas suggestive of injury3. Areas suggestive of infarction
EKG Practice
Practice Sample
EKG Practice
ST (1° sign suggestive for ischemia)
Practice Sample
ST Depression Leads I, aVL, V1, V2
EKG Practice
Practice Sample
T-wave inversion(2° sign suggestive for ischemia)
Practice Sample
EKG Practice
T Wave InversionFYI: aVR and V1 normally have T wave inversion
Practice Sample
EKG Practice
ST (suggestive of injury)
Practice Sample
EKG Practice
ST Elevation in Leads II, III, aVF
Practice Sample
EKG Practice
Practice Sample
Q-waves (suggestive of infarction)
EKG Practice
Are these pathological Q’s?
Practice Sample
EKG Practice
Nope! Pathological: Q-waves > 1-mm wide and height
> 25% of height of R-wave in same cardiac cycle Physiological: Q-waves not indicative of above
Electrode Placement
"Chest" Lead Placement Leads V1 - V6 are the chest/precordial leads.
The chest leads cannot be obtained without the limb lead wires attached: V1 - Right parasternally, 4th ICS V2 - Left parasternally, 4th ICS V3 - Between V2 and V4
V4 - 5th ICS, mid clavicular line V5 - Between V4 and V6
V6 - Left mid-axillary line, (level with V4)
• The leg lead wires can be placed on the torso above the indicated leg (left or right)
• But MUST stay below the level of the umbilicus
Localizing the 3 "I"s Ischemia: ST-segment depression Injury: ST-segment elevation Infarction: Q-waves > 1-mm wide and height >
25% of R-wave height However, deviation must be demonstrated in > 1
anatomically contiguous lead
LEADS LOOK AT:I, aVL, V5 and V6 Lateral wall of left ventricleII, III, aVF Inferior wall of left ventricleV1, V2 Septal wallV3, V4 Anterior wall of left ventricleV4R, V5R Right ventricle
I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral
Anatomically Contiguous
AHA ACS Nomenclature1. STEMI:
ST elevation MI2. UA/NSTEMI:
High-risk unstable angina/non-ST-elevation MI3. Low/intermediate risk ACS
Normal or non-diagnostic changes in ST segment or T-wave
Where do we need to focus? Inferior, septal, anterior, lateral
1. Non-diagnostic: UA2. Suspicious for ischemia: NSTEMI3. Suspicious for injury: STEMI4. Suspicious for infarct: QWMI
EKG 1, 69 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal (V2 well above 2 mm elevation),
Anterior (V3 well above 2 mm elevation), Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
Computerized InterpretiveStatement In existence for over 50 years Statistically accurate Not always correct Must always be viewed in light of the
surrounding clinical circumstances
Statistically accurate
Statistically accurateNot always correct
****Acute MI**** 52% sensitivity 98% specificity Acute MI = STEMI (ST Elevation MI)
When ACUTE MI statement is present, we should believe it
When ACUTE MI message is absent, do not rule out that either UA, NSTEMI, STEMI, or QWMI exists
Sensitivity Refers to recognition If the test always recognizes the disorder,
sensitivity would be 100% False negatives are failures of sensitivity A false negative occurs when condition exists
but the test fails to find it
Specificity Refers to the number of diagnoses confirmed If the diagnosis were corroborated every time
the test identifies it, it would be 100% specific False positives are failures in specificity A false positive occurs when the test indicates
the disease is present, when in fact it is not. I hate that when that happens!
12-Lead EKG Technology
If statement made, MI age undetermined, it is making claim of an old Physiological QWMI Pathological: Q-waves > 1-mm wide and height > 25%
of height of R-wave in same cardiac cycle
Diagnosis Sensitivity Specificity
Acute MI 52% 98%
RBBB 90-91% 100%
LBBB 78-87% 100%
LVH 32-76% 91-92%
WPW 92% 100%
When to perform 12-Lead? Chest Pain: Anginal or Atypical
Anginal: Fullness, pressure, crushing, may radiate to neck, jaw, back
Atypical: Unilateral, sharp, changes with position, pleuritic, muscular-skeletal, in jaw, neck, back ~15% of myocardial infarction patients describe atypical pain Females tend to experience atypical pain more often than
males
When to perform 12-Lead? Chest Pain: Anginal or Atypical
Anginal: Fullness, pressure, crushing, may radiate to neck, jaw, back
Atypical: Unilateral, sharp, changes with position, pleuritic, muscular-skeletal, in jaw, neck, back ~15% of myocardial infarction patients describe atypical pain Females tend to experience atypical pain more often than
males
Anginal Equivalents 40% of ACS patients will not experience pain
Note: 50% of patients with anginal pain are NOT having ACS event
Note: 40% of patients with ACS events will not have anginal pain
5 additional times toperform a 12-Lead
5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)
5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures
5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures3. Sweating disproportionate to the environment
5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures3. Sweating disproportionate to the environment4. Unexplained weakness, nausea or vomiting
5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures3. Sweating disproportionate to the environment4. Unexplained weakness, nausea or vomiting5. Palpitations/Dysrhythmias
2 Important points on STEMI The 12-Lead ECG is central to the initial risk and
treatment stratification Reports of elevated cardiac markers are not
necessary for a decision to administer fibrinolytic therapy or perform coronary intervention (angioplasty/stent)
Bundle Branch Block (BBB)
The effects of Intra-Ventricular Conduction Defects on the ECG
BBB Widens the QRS Deforms the QRS May Change
Repolarization The gross alteration of
depolarization (QRS widening) results in alteration of repolarization (ST-T changes)
BBB Widens the QRS Deforms the QRS May Change
Repolarization The gross alteration of
depolarization (QRS widening) results in alteration of repolarization (ST-T changes)
It’s kinda like a wolf in sheep’s clothing
BBB Turn Signal Theory Only works in V1
Only if QRS >0.12 Right BBB:
Which way do you push the turn signal indicator in the unit?
Left BBB: Which way do you push the
turn signal indicator in the unit?
• RBBB is identified by a wide QRS with the terminal portion of the QRS being positive in lead V1
• LBBB is identified by a wide QRS with the terminal portion of the QRS being negative in V1
BBB May Cause or Hide ST Elevation May Cause or Hide ST Depression May Change T Wave Polarity
This is particularly true in LBBB
Left Bundle Branch Block LBBB Bottom Line:
QRS in V1 > 0.12 seconds wide, and Terminal portion of QRS is negative
Is this a BBB?
EKG 5, 83 y/o male
Ayuh
EKG 5, 83 y/o male
Now, back to 12-LeadsOr 17-Leads as we might start calling them
Reciprocal Changes Inferior II, III, aVF » Anterior V1-V6, aVL, I Septal V1, V2 » Lateral V5, V6, I, aVL Early Anterior V1-V3 » Posterior V7-V9
When ST elevation is present, ST depression usually appears as well
ST depression typically shows up in opposing leads, AKA reciprocal depression
Special Considerations: RVI Right Ventricular Infarct (RVI):
If ST elevation in 2-contiguous inferior leads (II, III, aVF), obtain V4R
Right Ventricular Leads: V4R - 5th ICS, right mid-clavicular line
90% accurate for identifying RVI
Right Ventricular Infarct Results from Proximal RCA occlusion Accompanies Inferior Wall MI Can cause RVF and reduce LV filling pressure
Treatment for RVISigns of RVI Inferior Wall STEMI plus:
JVD Hypotension Dyspnea with clear lungs ST elevation in V4R AV blocks
Treatment for RVI Fluid for Hypotension NTG by slow drip MS in small careful doses
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
V4R
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
V4R
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended? RV STEMI
EKG 6, 45 y/o male
EKG 7, 50 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
V4R
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended? No RV STEMI
V4R
EKG 7, 50 y/o male
Special Considerations:Posterior Posterior Left Ventricular Infarct:
If ST depression in 2-contiguous early V leads (V1-V3), obtain V7-V9
Posterior leads: V7 - Post axillary line, level with V4
V8 - Mid scapular line, level with V4
V9 - Left paravetebral area, level with V4
What do you see?EKG 8, 92 y/o male
What do you see?EKG 8, 92 y/o male
V2 & V3 depressionEKG 8, 92 y/o male
V2 & V3 depressionequals need to assess posterior
EKG 8, 92 y/o male
Elevation in V7, V8, V9
EKG 8, 92 y/o male
Elevation in V7, V8, V9equals Posterior STEMI
EKG 8, 92 y/o male
And 7 Reasons why we perform serial 12-Leads
Well done Adrian Whicker
Reason number 1This is a 49 y/o woman
7-minutes later
10-minutes later(Adrian has asked his driver to drive without due regard for safety)
16-minutes later(Adrian has told his driver to push over, he's driving now)
23-minutes laterA 15-box elevation!
25-minutes later; What does the notching indicate?
This is what we have to concentrate onThe acute portion of STEMI (Injury)
30-minutes later
Cereal 12-Lead EKGs Assessing a patient's rhythm is a dynamic
process, that is why we monitor the patient's rhythm consistently
When a patient has had their 12-Lead assessed, leave the electrodes and precordial leads in place and reassess during every change in: Discomfort, rhythm, or vital signs
And in Conclusion… What's going on in this last slide? Is there ischemia? Is there injury? Do we need a right sided assessment? Do we need a posterior assessment?
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
AHA ACS Nomenclature1. STEMI:
ST elevation MI2. UA/NSTEMI:
High-risk unstable angina/non-ST-elevation MI3. Low/intermediate risk ACS
Normal or non-diagnostic changes in ST segment or T-wave
KeyEKG NSTEMI STEMI Special1 Inferior Lateral2 Septal, lateral Inferior3 Lateral Inferior4 Inferior Septal, anterior, lateral5 BBB BBB BBB6 Septal, anterior, lateral Inferior RVI7 Septal, anterior Inferior No RVI8 Anterior Inferior. Lateral BBB stops
Posterior Dx9 Inferior, lateral Septal
Ischemia Hallmark Primary hallmark:
ST-segment depression: > 0.5 mm Secondary signs:
Peaked T-waves Inverted T-waves
2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3 Men <40: 2.5 mm elevation in leads V2 & V3
LEADS LOOK AT:I, aVL, V5 and V6 Lateral wall of left ventricleII, III, aVF Inferior wall of left ventricleV1, V2 Septal wallV3, V4 Anterior wall of left ventricleV4R, V5R Right ventricle
I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral
Anatomically Contiguous
Special Considerations: RVI Right Ventricular Infarct (RVI):
If ST elevation in 2-contiguous inferior leads (II, III, aVF), obtain V4R
Right Ventricular Leads: V4R - 5th ICS, right mid-clavicular line
90% accurate for identifying RVI
Special Considerations:Posterior Posterior Left Ventricular Infarct:
If ST depression in 2-contiguous early V leads (V1-V3), obtain V7-V9
Posterior leads: V7 - Post axillary line, level with V4
V8 - Mid scapular line, level with V4
V9 - Left paravetebral area, level with V4
Lake EMS Online Review:12-Lead EKG
Created and prepared by: Captain Mike HilliardWith profound thanks and admiration to:
Henry J. L. (Barnie) Marriott, M.D., the father of 12-Lead ECGsTim Phalen, author of "12-Lead ECG: in AMI"Gary Denton, author of "Pre-Hospital 12-lead ECG"
This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only
Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500
352/383-4554 (w); 352/735-4475 (f); [email protected]