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Remove the Mystery from 12 Lead EKG Interpretation for Acute MI The simple, rapid 12 lead solution to 12 lead confusion! A 12 Lead Program for ALL health.

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Presentation on theme: "Remove the Mystery from 12 Lead EKG Interpretation for Acute MI The simple, rapid 12 lead solution to 12 lead confusion! A 12 Lead Program for ALL health."— Presentation transcript:

1 Remove the Mystery from 12 Lead EKG Interpretation for Acute MI The simple, rapid 12 lead solution to 12 lead confusion! A 12 Lead Program for ALL health care professionals! Copyright Apex Innovations 2003

2 The Basics….. Lets do the re-view Coronary Anatomy Conduction Paper and rate basics Rhythm Lead placement Vectors and axis R wave progression

3 Coronary Anatomy Right Coronary Artery (RCA) Aorta Circumflex (Cx) Left Anterior Decending (LAD)

4 Conduction: Normal P-QRS-T Constant, Continuous Conduction….the beat goes on P wave Depolarization & contraction of both atria QRS.. Ventricular depolarization T wave… Ventricular repolarization Iso-electric Line

5 Conduction: Normal P-QRS-T Constant, Continuous Conduction….the beat goes on Q - First down slope R - Upward slope S-Down slope Iso-electric Line

6 Normal P-QRS-T P WavePR IntervalQRS ComplexST Segment RepresentsAtrial depolarization Time between onset of atrial depolarization and onset of ventricular depolarization (AV conduction time) Ventricular depolarization Interval between ventricular depolarization and repolarization Duration< 0.12 seconds seconds secondsMeasure from end of QRS to J-point, the beginning of T wave Height< 2.5 mmMeasure start of P wave to start of QRS Q- First negative deflection R- First positive deflection S- Negative deflection after R wave Shape SmoothProlonged indicates a conduction block Shortened indicates accelerated conduction or junctional in origin In relation to iso- electric line: Depression/Negative indicates ischemia Elevation/Positive indicates injury OrientationPositive in Leads I,II,aVF, V4 Negative in aVR

7 Cardiac Conduction System Left Bundle Branch Purkinje fibers Right Bundle Branch Bundle of His AV node Internodal pathways Sinus node

8 Cardiac Conduction System Relationship of ECG to anatomy

9 One Small Block =.04 Seconds Standard paper speed = 25mm per second Note calibration on side of EKG - 2 Large Blocks tall One Large Block =.20 Seconds -Increased paper speed makes complexes wider -Decreased paper speed makes the complexes narrower Rate: EKG Paper Basics One small Block = 1mm Voltage One Large Block = 5mm Voltage

10 Rate: Calculation Options 1.RATE = # of R waves in a 6 second strip X 10 2.RATE = 300 # large squares between R waves 3.RATE Count = Count from a QRS complex on any bold line to the next QRS complex. Count 300, 150, 100, 75, 60, 50 for each bold line after first complex Start End Rate = 82 BPM

11 Rhythms Normal Sinus Sinus Bradycardia Sinus Tachycardia Sinus Arrhythmia Sick Sinus Syndrome Wandering Atrial Pacemaker Sinus Block Sinus Arrest Sinus (SA Node)

12 Rhythms Continued Premature Atrial Contraction (PAC) Paroxysmal Atrial Tachycardia (PAT) Multifocal Atrial Tachycardia Atrial Flutter Atrial Fibrillation Atrial Rhythms

13 Rhythms Continued Premature Junctional Contraction (PJC) Paroxysmal Junctional Tachycardia (PJT) Junctional Flutter Junctional Fibrillation Junctional (AV)

14 Rhythms Continued Premature Ventricular Contraction (PVC) - Bigeminy Trigeminy, Quadrageminy Paroxysmal Ventricular Tachycardia (PVT) Multifocal Ventricular Tachycardia Ventricular Flutter Ventricular Fibrillation Ventricular

15 Rhythms Continued 1 Prolonged PRI 2 Type I - Wenchebach 2 Type II - Mobitz II - 2:1, 3:1 Conduction 3 Complete Heart Block Bundle Branch - Right BB - Left BB AV Blocks

16 The 12 Lead EKG… 6 Limb Leads6 Chest or Pre-cordial Leads I II III AVR AVL AVF V1 V2 V3 V4 V5 V6 12 angles or pictures of the electrical activity of the heart

17 Looking and Learning: Vectors and Axis ~the hard way~ A panoramic view of the hearts electrical activity from 12 different angles The sum of all vectors determines the axis

18 Lead Placement - Lead I, II, III RA LA LL + - LEAD I Bipolar Limb Lead Looks from Right to Left Shoulder Looks at high lateral wall of left ventricle Supplied by circumflex artery–CX Positive/upright P QRS T

19 Lead Placement - Lead I, II, III RA LA LL + - LEAD II Bipolar Limb Lead Looks from R Shoulder to Left Leg Looks at inferior wall of left ventricle Supplied by right coronary artery–RCA Positive/upright P QRS T + -

20 Lead Placement - Lead I, II, III RA LA LL LEAD III Bipolar Limb Lead Looks from Left Shoulder to Left Leg Looks at inferior wall of left ventricle Supplied by right coronary artery-RCA A biphasic QRS complex is expected - +

21 Augmented Limb Leads LA RA LL AVR Augmented Voltage Right Arm All complex waves are negative Typically, this lead not used for diagnosing! AVL Augmented Voltage Left Arm Looks at lateral wall of left ventricle Supplied by circumflex artery - CX All complexes should be positive AVF Augmented Voltage (left) Foot Cross between Leads I and II Looks at inferior wall of left ventricle Supplied by right coronary artery-RCA All complexes should be positive

22 Lead Placement – V-Leads V1-V2 = Septal V3-V4 = Anterior V5-V6 = Lateral V1-V3 = Posterior V1 – 4 th ICS, right of sternum V2 – 4 th ICS, left of sternum V3 – Midpoint between V2 and V4 V4 – 5 th ICS, mid-clavicular line V5 – Level with V4, anterior to axillary line V6 – Level with V4, mid-axillary line

23 V-Lead R Wave Progression - V1 - R wave is generally smallest or most negative - V4 - R wave is typically the tallest or most positive - Lack of R wave progression may mean : Pathology- Disease state, CAD, Septal wall MI Normal- A patient with Congenital state, Rotated heart, Obesity, COPD Other- Breast tissue, poor lead placement The progression or increasing in R wave amplitude from negative to positive in leads V1 to V4 is expected and normal!

24 R Wave Progression in the V Leads V1 – PQRST All negative V2 – PQRST Should be mostly negative but start progression V3 – PQRST Biphasic with upright T waves V4 – PQRST Nearly completely upright V5 – PQRST Upright V6 – PQRST Upright

25 Myocardial Infarction Ischemia Injury Recognition Criteria Infarct Location Template AMI Evolution Practice EKGs Bumps, elevations and tombstones…

26 Myocardial Infarction Occurs when a coronary artery is narrowed and occludes, terminating the blood and oxygen supply. This results in cardiac hypoxia and irritability which may cause fatal arrhythmias. Without a blood supply to the cardiac muscle, depolarization cannot happen and renders the muscle, electrically dead. An EKG can diagnose AMI location, identify the culprit artery and reveal any blocks in ventricular conduction.

27 ST Depression = Ischemia Inverted T waves, sometimes peaked T wave deflection is opposite from QRS (Normally T wave is upright when QRS is upright and vice versa) T wave inversion is usually in same leads that demonstrates signs of acute infarction (Q waves, ST elevation)

28 Causes for ST depression Ischemia Digoxin Toxicity Pulmonary Embolism Ventricular Hypertrophy Left Bundle Branch Block

29 ST Elevation = Current Injury Depicts current myocardial injury Measure J-point to beginning of ventricular repolarization May be elevated >1mm in limb leads and >2mm in precordial leads Will see reciprocal ST depression in other leads

30 Causes for ST elevation Pericarditis Ventricular aneurysm Drug induced Myocardial Infarction

31 Recognition of AMI Know what to look for: –ST elevation > 1 mm –3 contiguous leads PR baseline ST-segment deviation = 4.5 mm J point

32 AMI Requires at least 2 of these criteria: 1.History of characteristic chest pain Crushing-pressure in chest, pain radiation to jaw, arms, back, N/V, SOB, diaphoresis 2.Evolutionary EKG changes ST depression (ischemia) ST elevation (injury) Q wave development (muscle death) 3.Elevated cardiac enzymes Troponin, CKMB-CK, Myoglobin

33 Understanding infarct location Heres the trick! The 12 Lead Solution to 12 Lead Confusion!

34 Simple - Rapid!! Finally……. Remove the mystery! Location, Location, Location!

35 AMI Location Correlation aVF InferiorIII InferiorV 3 Anterior V 6 Lateral aVL Lateral II InferiorV 2 SeptalV 5 Lateral aVRI LateralV 1 SeptalV 4 Anterior

36 Lateral Lead ST Elevation in AMI LEAD IAVLV5V6 Lateral: Usually supplied by Circumflex (CX) Look for reciprocal changes in Lead V1 High Lateral Wall

37 Normal EKG Lateral Reciprocal Change

38 Inferior Lead ST Elevation in AMI LEAD IIAVFLEAD III Inferior: Usually supplied by Right Coronary Artery (RCA) Look for reciprocal changes in Leads I, AVL

39 Normal EKG Inferior Reciprocal Change

40 Septal Lead ST Elevation in AMI V1V2 Septal: Usually supplied by Left Anterior Descending (LAD) Look for reciprocal changes in Leads V3, AVF

41 Normal EKG Septal Reciprocal Change

42 Anterior Lead ST Elevation in AMI V3 V4 Usually supplied by Left Anterior Descending (LAD) Look for reciprocal changes in Leads V2, AVF

43 Normal EKG Anterior Reciprocal Change

44 12 Lead-Paper Heart To better understand rhythm location: 1.Hold left upper corner and right lower corner of EKG 2.Roll EKG to note: inferior leads at apex lateral leads on sides anterior and septal leads in front

45 Height is 1/3 the size of entire QRS complex Width is at least one square or 0.04 seconds in duration Q waves in V1,V2,V3 or V4 indicate anterior or antero- septal infarction Damage from old infarcts cause Q waves that last a lifetime Abnormal if thick on tracing Q wave may be normal in AVR Significant Q Wave Characteristics

46 ST segment Evolution and Q wave development with AMI A

47 Differentiating Between Acute and Old MI Q wave with no other morphology = old MI Q wave and ST segment elevation (with or without T wave inversion) = AMI Q wave and inverted T wave = age undetermined

48 Evolutional Changes of an Acute Myocardial Infarction

49 Identify infarct location using a systematic approach Rhythm ST Depression ST Elevation R Wave Progression Q Waves

50 Lets take a look at… the Good, the Bad and the Ugly! ~EKG Review~

51 Review #1 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL INFERIOR

52 Review #2 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL ANTERIOR LATERAL ANTERIORLATERAL

53 Review #3 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL ANTERIOR LATERAL ANTERIORLATERAL

54 Appearances and History are Important! Your patient, a 58 y/o male, was diagnosed with cancer 2 weeks ago and was scheduled to receive his first chemotherapy treatment this morning. Instead, he was delivered in a wheelchair hurriedly (by his oncologist), to the emergency department in distress. He presents complaining of intense chest pain described as a 10, is very restless, nauseated, diaphoretic and pale. You order the usual cardiac work-up. Here is what his EKG showed…

55 Review #4 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL

56 Later that day… This patients cardiac workup returned within normal limits and was diagnosed with anxiety and released to begin his chemotherapy.

57 Review #5 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL ANTERIOR LATERAL ANTERIORLATERAL

58 Review #6 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL INFERIORLATERAL INFERIOR LATERAL

59 Review #7 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL ANTERIOR LATERAL ANTERIORLATERAL

60 Appearances and History are Important! Your patient, a 62 year old male pharmacist, presents at 6:00AM with chest pressure radiating to his neck, jaw and left arm. He is mildly short of breath and says hes had indigestion all night. You order the usual cardiac work-up. Here is what his EKG showed…

61 Review #8 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTALANTERIOR LATERALSEPTALLATERAL ANTERIORLATERAL

62 Later that day… The Inferolateral/Anteroseptal MI caused massive injury and tissue death, and the patient subsequently died.

63 Review #9 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL INFERIOR

64 Review #10 What Does This 12-Lead ECG Show? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTAL

65 Posterior MIs can be tricky! EKG changes are seen in V1-V3 (the anterior precordial leads) and are a mirror image of an anteroseptal MI Posterior MI HINT: R waves in V1 and V2? Suspect Posterior MI! You will see: Increased R wave amplitude and duration R wave is more prominent than S wave in V1 and V2 ST depression and large inverted T waves V1-V3

66 Review #11 What Does This 12-Lead ECG Show? LATERALSEPTAL?ANTERIOR INFERIORLATERALSEPTAL?LATERAL INFERIOR ANTERIOR?LATERAL POSTERIOR

67 LATERALSEPTAL?ANTERIOR INFERIORLATERALSEPTAL?LATERAL INFERIOR ANTERIOR?LATERAL POSTERIOR INFERIORPOSTERIOR INFERIOR POSTERIOR Review #12 What Does This 12-Lead ECG Show? Look at those R waves!!!

68 ~~ Time is Muscle! ~~ Tick-Tock

69 ~Test Time~ Please stop here! 1.Answer the Self Assessment Sheets first 8 questions. 2. Next proceed to the remaining slides and record the infarct location for each EKG on the self assessment.

70 Quiz #1 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL INFERIOR

71 Quiz #2 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTALANTERIOR SEPTAL ANTERIOR

72 Quiz #3 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL

73 SEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTALANTERIOR SEPTAL ANTERIOR Quiz #4 Where is the elevation or infarct?

74 Quiz #5 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL ANTERIOR LATERAL ANTERIORLATERAL

75 Quiz #6 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTALANTERIOR SEPTAL ANTERIOR

76 Quiz #7 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL INFERIORLATERAL INFERIOR LATERAL

77 Quiz #8 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTALANTERIOR LATERALSEPTALLATERAL ANTERIORLATERAL

78 Quiz #9 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTAL

79 Quiz #10 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL ANTERIOR INFERIORLATERAL INFERIOR ANTERIORLATERAL

80 Quiz #11 Where is the elevation or infarct? LATERALSEPTALANTERIOR INFERIORLATERALSEPTALLATERAL INFERIOR ANTERIORLATERAL SEPTALANTERIOR SEPTAL ANTERIOR

81 Thank you for your participation! Please complete the program and speaker evaluation. Copyright Apex Innovations 2003


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