12 Lead Annual Competency - By Dr Bennett

1. 12-LEAD
COMPETENCY
Bennett Shamsai, MD, MPH

2. New Competency Requirements
• All Paramedics must ensure competencies in acquisition
and interpretation of 12 lead ECG’s by December 2011,
and every 2 years after that
• This needs to include a written and practical test.

3. Indications
• Typical Presentations: Chest pain or Heaviness with SOB,
Sweats, N/V, Etc…
• Atypical Presentations: Shock, Syncope, SOB, DKA, and
Acute Abdomen
• Remember, ACS symptoms without trauma are of cardiac
origin until proven otherwise.

4. Cardiac Conduction

5. Wave Form Interpretation
•

6. STEMI Criteria
• > or = 1 mm ST elevation in a Limb lead
• Usually > or = 2 mm in a precordial lead (though many
places will go with 1 mm in the right clinical setting)
• New Left BBB

7. 12-Lead Acquisition

8. Lead Placement
Note: R Leg is for grounding

9. EKG Lead Distributions
Inferior
II, III, AVF
Posterior
V1, V2, V3
Antero-Septal
V1, V2, V3, V4
Lateral
V5, V6
Far Lateral
I, AVL

10. Coronary Artery Distribution

11. STEMI Distributions
Anatomic Region
of Heart
Coronary Artery
(most likely
associated)
Inferior Right coronary
Anteroseptal
Left anterior
descending
Anteroapical
Left anterior
descending (distal)
Anterolateral Circumflex
Posterior
Right coronary
artery

12. Normal EKG

13. J-point vs Ischemia

14. Ischemia
Ischemia presents with ST depressions (here in the lateral leads), (just make sure it isn’t
reciprocal changes.)

15. Anterior STEMI
Probably a Proximal LAD lesion
(note reciprocal changes inferiorly)

16. Infero-Lateral STEMI
Usually from an occluded Dominant Circumflex Artery

17. Inferior STEMI

18. Right Sided EKG

19. Right side EKG Example
Note inferior Mi findings with reciprocal changes in far lateral leads. V4 is VR4 (just not indicated on EKG)

20. Posterior Lead Placement

21. Posterior Infarct EKG
Usually from an occluded PDA
80% of which come off the RCA

22. Posterior V7-9 Example

23. Hyperacute T waves

24. Cardiac Conduction System

25. Left Bundle Branch Block

26. Old MI (Q’s)

27. Mimics
• Pericarditis
• Early Repolarization
• Left Ventricular Hypertrophy
• Other Wide Complex Imitators (Paced, V-tach, old BBB’s,
Metabolic, Junctional Rhythms, etc…

28. Pericarditis

29. Early Repolarization

30. Left Ventricular Hypertrophy
(with strain)