2 Minute 12 Leads V5

1. ““2 Minute 12 Leads”2 Minute 12 Leads” John Bray, MA, NRP, CCEMTP Master Instructor Indian River State College

2. Why all the fuss? • Because a 12-Lead shows a 3 dimensional view of the heart • Because a simple 3-Lead shows a flat, 1 dimensional view (cartoon character) • Infarcts can be hiding from a quick glance • 12-Lead is a true DIAGNOSTIC ECG

3. Cardiology Review

4. Anatomy Revisited

5. Localization: Right Coronary Artery Right Coronary Artery Posterior Descending Artery Inferior Wall of left ventricle Posterior Wall Lateral Wall Left Ventricle Left Coronary Artery

6. Localization: Left Coronary Artery Left Main Left Circumflex Lateral Wall Anterior Wall of Left Ventricle Septal Wall Right Ventricle Right Coronary Artery Anterior Descending Artery

7. Anatomy Revisited • SA node • Intra-atrial pathways • AV node • Bundle of His • Left and Right bundle branches – left anterior fascicle – left posterior fascicle • Purkinje fibers

8. Cardiac Conduction

9. Waveform Components: Q Wave First negative deflection before R wave; Q wave includes the negative downstroke & return to baseline

10. Waveform Components: R Wave First positive deflection; R wave includes the downstroke returning to the baseline

11. Waveform Components: S Wave Negative deflection following the R wave; S wave includes departure from & return to baseline

12. Waveform Components: ST Segment Segment between J- point and beginning of T wave

13. Waveform Components: QRS • Q wave – Measure width – Pathologic if greater than or equal to 0.04 seconds (1 small box)

14. Waveform Components: J-Point Junction between end of QRS and beginning of ST segment;

15. Waveform Components: ST Segment • Need reference point – Compare to TP segment – DO NOT use PR segment as reference! ST TP

16. Waveform Components: Practice • Find J-points and ST segments

17. Waveform Components: Practice • Find J-points and ST segments

18. ST Segment Analysis Which Segments are over 1mm high?

19. Obtaining the 12 Lead ECGObtaining the 12 Lead ECG

20. Lead “Views”

21. Prehospital ECG Monitoring

31. Check for Proper Calibration

32. “R” Wave Progression • Used to confirm proper lead placement – V1 is small and progressively increasing from right to left until the QRS is fully upright in V5 and V6 The QRS size goes from negative to positive

36. InterpretationInterpretation

37. What can a 12 Lead find? • Clots block distal blood flow

38. Coronary Artery Occlusion

39. Mapping the 12 Lead ECG aVF inferiorIII inferior V3 anterior V6 lateral aVL lateralII inferior V2 septal V5 lateral aVRI lateral V1 septal V4 anterior

40. I See All Leads • I – Inferior Leads II, III, AVF • S – Septal Leads V1, V2 • A – Anterior Leads V3, V4 • L – Lateral Leads V5, V6, I, AVL

41. Recognition of AMI • Focus on the ST Segment!!! • ST elevation is the most important thing you are looking for!! PR baseline ST-segment deviation = 4.5 mm J point plus 0.04 second

42. Inferior Wall • II, III, aVF – Left Leg I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

43. Inferior Wall Inferior Wall I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

44. Lead-Specific ST Elevation • Inferior MI • Leads II, III, aVF, visualize the inferior [ nearest the diaphragm ] surface of the heart • Leads are adjacent and view adjoining tissues located in inferior region of the left ventricle

45. Septal Wall • V1, V2 • Along sternal borders I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

46. Septal • V1,V2V1,V2 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

47. Anterior Wall • V3, V4 – Left anterior chest I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

48. Anterior Wall • V3, V4V3, V4 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

49. Lead-Specific ST Elevation • Anterior MI • Leads v3 and v4 visualize the anterior wall of the heart’s left ventricle.

50. Lead-Specific ST Elevation • Anterior MI • Rarely do MIs involve the anterior wall exclusively, most often , either the septal or lateral walls of the ventricles are included.

51. Lateral Wall • V5 and V6 – Left lateral chest I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

52. Lateral Wall • I and aVL – Left Arm I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

53. Lateral Lateral Wall • I, aVL, V5, V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

54. Lead-Specific ST Elevation • Lateral MI • Leads V3, V4, V5, and V6 will illustrate an anterolateral MI • Leads II, III, aVF, v5, and v6 will illustrate an inferolateral MI • Leads v5, and v6 only will illustrate a low Lateral MI • Leads v5, v6, Lead I and aVL will illustrate a High Lateral MI

55. Coronary Arteries Semilunar valve Aorta RCA Left Main Septal LAD CXL CXL

56. No ST elevation? Look for: • Inverted T Waves • ST Depression – Look for reciprocal changes • Q Waves

57. The Three I’s • Ischemia – lack of oxygenation – ST depression or T inversion • Injury – prolonged ischemia – ST elevation • Infarct – death of tissue – may or may not show in Q wave

58. Injury/Infarct Recognition Epicardial Coronary Artery Lateral Wall of LV Positive Electrode Septum Interior Wall of LV Well Perfused Myocardium

59. Injury/Infarct Recognition Epicardial Coronary Artery Lateral Wall of LV Septum Interior Wall of LV Ischemia Positive Electrode Left Ventricular Cavity

60. ST Segment Depression • ST Segment Depression occurs due to Myocardial Ischemia • Hypoxia results in altered repolarization • Characterized by a dip below isoelectric line of 1 to 2 millimeters or 1 to 2 small boxes

61. ST Segment Depression • Other Causes: – Ventricular Hypertrophy – Intraventricular Conduction defects – Medication: Digitalis – No irreversible injury to the myocardium – TIME IS MUSCLE !

62. Injury/Infarct Recognition Thrombus Ischemia InjuryInjury

63. Injury/Infarct Recognition Infarcted Area Electrically Silent Depolarization Infarct

64. Injury/Infarct Recognition Infarcted Area Electrically Silent Thrombus Depolarization Ischemia

65. ST Segment Elevation • ST Segment Elevation is a rise above the isoelectric line of 1 to 2 millimeters or one to two small boxes • Most common cause is myocardial injury

66. ST Segment Elevation • Other Causes: – Coronary Artery Vasospasm [Prinzmetal’s Angina] – Pericarditis [ all leads ] – Ventricular aneurysm – Early repolarization

67. ST Segment Elevation • Will occur within the first 1 to 2 hours after onset of myocardial hypoxia • TIME IS MUSCLE

68. Pathologic Q Waves • Pathologic Q Waves indicate irreversible tissue damage or death of myocardial tissue • Defined as a width greater then or equal to one small box [ 1mm ] or depth greater then one third of the R wave in the same lead

69. EKG changes that occur at each stage of an MI

70. Reciprocal Changes

71. Reciprocal Changes • ST ↑ in II, III, AVF • ST ↑ in V2, V3, V4 • ST ↓ in V1-V4 • Reciprocal ST ↓ in I, AVL • Reciprocal ST ↓ in II, III, AVF • Reciprocal to Posterior – 15 Lead ECG

72. 15 Lead ECG • Posterior MI • Leads V1, V2, V3, and V4 will illustrate a posterior MI with ST depression • Utilize Leads. – Take V4, V5, and V6 and place them posteriorly in V7, V8, and V9. This is sometimes referred to as a 15-lead EKG. • V4 is placed in the 5th intercostal space, posterior axillary position = V7. • V5 is placed in the 5th intercostal space, midscapular line position = V8. • V6 is placed in the 5th intercostal space, 2cm to the left of the spine

73. BUNDLE BRANCH BLOCKS

74. Bundle Branch Block • Can be pre-existing condition • Can be caused by ACS • If AMI caused – 60-70% associated with pump failure – 40-60% mortality w/o reperfusion

75. Bundle Branch Block • May Produce – ST elevation – ST depression – Tall T waves – Inverted T waves – Wide Q waves • May Hide – ST elevation – ST depression – Tall T waves – Inverted T waves – Wide Q waves Can Mimic or Hide Evidence Needed to Identify AMI

76. BBB Problem • BBB Problem – ACS harder to identify on ECG when BBB present – New or presumably new BBB is an indication for thrombolytic therapy

77. BBB Recognition Forget About the Notch!

78. BBB Recognition • Fundamental Criteria – Wide QRS • > 100 ms (or, 0.10 sec) – Supraventricular rhythm

79. BBB Recognition

80. Normal Ventricular Conduction • Normal Conduction – fibers of LBB begin conduction – impulse travels across interventricular septum from left to right • towards + electrode creates small r wave – travels across ventricles causing depolarization of both simultaneously • LV contributes most to complex – impulse travels away from + electrode creates primarily negative complex

81. RBBB • RBBB in V1 R-S-R´

82. LBBB • LBBB in V1

83. BBB Recognition • Terminal Force in V1 – direction of deflection prior to J point J point

84. BBB Recognition • Use V1 • Find Terminal force • Identify direction of terminal force – Downward  LBBB – Upward  RBBB • Picture a Steering Wheel – Right turn  turn signal goes up – Left turn  turn signal goes down

85. BBB Recognition Practice

86. BBB Recognition Practice

87. Axis & HemiblocksAxis & Hemiblocks

88. Axis and Hemiblocks • AXIS is defined as the general direction that the electrical impulse travels down the heart • Normal impulses should travel downward from R to L. This is shown in Lead I and VF as an upright QRS. • Normal Range -30 to +90 DegreesNormal Range -30 to +90 Degrees

91. Left Axis Deviation • Axis Range: 0 to –30 Degrees – Physiologic Left Axis Deviation (LAD) • Axis Range: -30 to –90 Degrees – Pathological LAD – Anterior Hemiblock – Left BBB – May develop into Complete Heart Block!

92. Right Axis Deviation • Ranges 90-180 Degrees • Downward QRS in Lead I – Common in children and tall, thin adults – HX of COPD? • Over 180 Degrees? Think V-TACH!!

95. Assess Initial 12-Lead ECG Findings Classify patients with acute ischemic chest pain into 1 of the 3 groups above. • ST elevation or new or presumably new LBBB: strongly suspicious for injury • ST-elevation AMI • ST depression or dynamic T-wave inversion: strongly suspicious for ischemia • High-risk unstable angina/ non–ST-elevation AMI • Nondiagnostic ECG: absence of changes in ST segment or T waves • Intermediate/low-risk unstable angina

96. OK, Great. So I see an infarct. • You should be continuing your assessment but allow yourself no more than 2 minutes to analyze the 12 Lead ECG. • After 2-3 mins, you may have to give repeat doses or other meds. • Look for “trending”: How is the patient responding to treatment?

97. Medical ControlMedical Control • Think about what you will say before getting on the phone. • Understand that you are not a doctor, but that does not make you an idiot! • Presentations should be given in plain English, not “EMS-speech”

98. Talking on the phone • Present the patient in this order: – Identify yourself to the doctor – Give your pt’s age, sex and chief complaint – Describe how you found the patient – If unconscious, what was told to you by others – Patient’s medical Hx and Allergy status – Initial V/S – Pertinent Physical Exam findings

99. Still on the phone… • Tell your interventions – Start with BLS and then ALS – Patient response to treatment • Briefly discuss your 12 Lead findings – NOT an interpretation, but where you see ST elevation • Give an ETA • Request further orders

100. IV Therapy and the MI Patient • IV placement is important, but not vital! • Start with your PO and SL meds • Obtain a 12 Lead ECG • Start the IV – Avoid more than 1 attempt – Think Thrombolytic Therapy!

101. Arrival at the ED • Present patient as “Mr. or Mrs.” not “the chest pain” or “the heart attack” • Have your 12 Lead out and ready for the doctor to review • Answer questions that are posed to you! – Meds given – IV attempts (be truthful!)

102. What is Angioplasty?What is Angioplasty?

103. Three Percutaneous Coronary Interventions (PCIs) 1. PTCA: Percutaneous Transluminal Coronary Angioplasty 2. PTCA + stent placement 3. Atherectomy: “grinds away” the plaque

105. Now let’s practice!Now let’s practice!

106. What’s your interpretation?

107. Anterior Septal AMI

108. What Does This 12-Lead ECG Show?

110. Left Ventricular Hypertrophy

112. Practice Case 1 • 48 year old male – Dull central CP 2/10, began at rest • Pale and wet • Overweight, smoker • Vital signs: RR 18, P 80, BP 180/110, Sa02 94% on room air

113. Practice Case 1

114. Practice Case 2 • 68 year old female – Sudden onset of anxiety and restlessness, – States she “can’t catch her breath” – Denies chest pain or other discomfort • History of IDDM and hypertension • RR 22, P 110, BP 190/90, Sa02 88% on NC at 4 lpm

115. Practice Case 2

116. Questions?

2 Minute 12 Leads V5

2 Minute 12 Leads V5

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