12 lead-lesson 1

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  • You can troubleshoot artifact in a logical manner. If one of the precordial leads has artifact, check that lead. If leads 1 & 3 are showing some artifact, check the left shoulder. You should check the right shoulder if leads 1 & 2 have artifact and the left leg if leads 2 & 3 are of poor quality.
  • Contiguous leads are are leads that look at the same portion of the heart. We will discuss this in more detail later. Look at this image, the leads of the same color are contiguous.
  • aVR looks at basal portion of septum
  • Is it a left axis deviation (left superior axis), which might suggest left anterior fascicular block, inferior MI, or paced rhythm? Is it a right axis deviation (right inferior axis), which might suggest left posterior fascicular block, lateral MI, right ventricular hypertrophy or acute right-sided strain? Is it an extreme axis deviation (right superior axis), which might suggest VT, electrolyte derangement, or misplaced limb lead electrodes? Notice R-wave progression, the transition, and whether or not there is positive or negative concordance of QRS complexes in the precordial leads.
  • Is it a left axis deviation (left superior axis), which might suggest left anterior fascicular block, inferior MI, or paced rhythm? Is it a right axis deviation (right inferior axis), which might suggest left posterior fascicular block, lateral MI, right ventricular hypertrophy or acute right-sided strain? Is it an extreme axis deviation (right superior axis), which might suggest VT, electrolyte derangement, or misplaced limb lead electrodes? Notice R-wave progression, the transition, and whether or not there is positive or negative concordance of QRS complexes in the precordial leads.
  • Is it a left axis deviation (left superior axis), which might suggest left anterior fascicular block, inferior MI, or paced rhythm? Is it a right axis deviation (right inferior axis), which might suggest left posterior fascicular block, lateral MI, right ventricular hypertrophy or acute right-sided strain? Is it an extreme axis deviation (right superior axis), which might suggest VT, electrolyte derangement, or misplaced limb lead electrodes? Notice R-wave progression, the transition, and whether or not there is positive or negative concordance of QRS complexes in the precordial leads.
  • Is it a left axis deviation (left superior axis), which might suggest left anterior fascicular block, inferior MI, or paced rhythm? Is it a right axis deviation (right inferior axis), which might suggest left posterior fascicular block, lateral MI, right ventricular hypertrophy or acute right-sided strain? Is it an extreme axis deviation (right superior axis), which might suggest VT, electrolyte derangement, or misplaced limb lead electrodes? Notice R-wave progression, the transition, and whether or not there is positive or negative concordance of QRS complexes in the precordial leads.
  • Is it a left axis deviation (left superior axis), which might suggest left anterior fascicular block, inferior MI, or paced rhythm? Is it a right axis deviation (right inferior axis), which might suggest left posterior fascicular block, lateral MI, right ventricular hypertrophy or acute right-sided strain? Is it an extreme axis deviation (right superior axis), which might suggest VT, electrolyte derangement, or misplaced limb lead electrodes? Notice R-wave progression, the transition, and whether or not there is positive or negative concordance of QRS complexes in the precordial leads.
  • All modern 12-lead monitors currently use the GE Marquette 12SL interpretive algorhythm to perform automated ECG interpretations. These printed interpretations can be unpredictable and unreliable at times. As you can imagine, the accuracy of the interpretive algorhythm is very dependant on a clean ECG tracing.
  • All modern 12-lead monitors currently use the GE Marquette 12SL interpretive algorhythm to perform automated ECG interpretations. These printed interpretations can be unpredictable and unreliable at times. As you can imagine, the accuracy of the interpretive algorhythm is very dependant on a clean ECG tracing.
  • This is the basic layout of a 12-lead ECG.
  • The standard calibration mark can show up at the beginning or end of the ECG, and the base of the calibration mark provides your iso-electric line.
  • The standard print speed of an ECG is 25mm per second.
  • Look in the red box on this 12-lead. That is a continuous rhythm. The only thing that changes is the lead that the rhythm is viewed in. In fact the two rows above it are continuous rhythms as well.
  • Now look at this red box. All three QRS complexes in the red box are the same complex. The only difference is the lead that they are viewed from. That is true for every other column of QRS complexes on a 12-Lead.
  • It is an important concept to understand. Every QRS complex under each arrow is the same complex, just viewed from a different lead.
  • The first thing you should do with any 12-lead ECG is confirm lead placement. Lead 1 should be positive and aVR negative in almost every 12-lead. There are some circumstances where they wont be and we will cover them. If lead 1 is negative and aVR is positive, check the limb leads to confirm proper lead placement.
  • At first glance, you might thing that there are just a few premature atrial beats that are causing the irregularity. If you look at the normally conducted beats, however, the RR-interval between them is not regular.
  • Some rules are more concrete than others.
  • 12 lead-lesson 1

    1. 1. 12-LeadElectrocardiography a comprehensive course sson1 Le Adam Thompson, EMT-P, A.S.
    2. 2. Resource
    3. 3. Course Objectives• Learn the basic concept behind electrical vectors.• Learn the 6 step process to 12-lead ECG interpretation.• Learn how to identify chamber enlargement.• Learn how to differentiate between atrial & ventricular rhythms.• Learn how to identify bundle branch blocks.• Learn how to differentiate a STEMI from STE-Mimic• Learn when to perform a right-sided or posterior 12- lead ECG.
    4. 4. Lesson One• Learn the appropriate placement of the 12- lead ECG electrodes.• Learn how to eliminate artifact and obtain a clean recording.• Learn about the 6 step interpretation process.• Learn and apply the ability to determine rate & rhythm.
    5. 5. 12-Lead ECG“In lead II? You’ve got NO clue.” - Bob Page
    6. 6. 12-Lead Placement V1 - 4th ICS, right of sternum V2 - 4th ICS, left of sternum V3 - Between V2 & V4 V4 - 5th ICS, left midclavicular line V5 - Lateral to V4, left anterior axillary line V6 - Lateral to V5, left midaxillary line
    7. 7. Eliminate Artifact• The patient’s chest should be bare.• All hair that inhibits adequate electrode contact should be shaved.• Benzoin tincture may be used to enhance adhesive.
    8. 8. The Culprit Electrode• Precordial leads are easy. V1 has artifact? Check V1 electrode.• If Leads I & III have artifact, check left shoulder.• If Leads I & II have artifact, check right shoulder.• Leads II & III? Check left leg electrode.
    9. 9. Precordial LeadsPrecordium - area of chest over heart
    10. 10. Precordial Leads• Right Precordial Leads
    11. 11. Precordial Leads• Left Precordial Leads
    12. 12. Limb Leads• Obtained from Red, White, Black, & Green electrodes
    13. 13. 12 Leads Limb Leads Precordial LeadsLead I aVR V1 V4Lead II aVL V2 V5Lead III aVF V3 V6
    14. 14. Contiguous LeadsLead I aVR V1 V4Lead II aVL V2 V5Lead III aVF V3 V6
    15. 15. Contiguous LeadsLead I aVR V1 V4 high lateral septal anteriorLead II aVL V2 V5 inferior high lateral septal low lateralLead III aVF V3 V6 inferior inferior anterior low lateral
    16. 16. The 6-Step Method• 1. Rate & Rhythm• 2. Axis Determination• 3. Intervals• 4. Morphology• 5. STE-Mimics• 6. Ischemia, Injury, & Infarct
    17. 17. The 6-Step Method Rate & Rhythm• What is your initial rhythm interpretation?• Is the rhythm too fast or too slow?• Are we certain it is supraventricular?• If the QRS complexes are wide, it is ventricular until proven otherwise.
    18. 18. The 6-Step Method Axis Determination• Is the axis normal?• Is it left axis deviation?• Is it right axis deviation?• Extreme right axis deviation?• Consider pathologies!
    19. 19. The 6-Step Method Intervals• Double check PR-interval and QRS duration• Identify the QT or QTc interval• Consider pathologies for abnormal intervals.
    20. 20. The 6-Step Method Morphology• If QRS is wide, what is morphology in V1?• Bundlebranch block?• Bifascicular block?• Identify chamber enlargement.• Consider T-wave morphology• Consider possible pathologies that correlate with altered morphologies.
    21. 21. The 6-Step Method STE-Mimics• Determine if a paced rhythm, LBBB, LVH, Early repol, pericarditis, WPW, or hyperkalemia is present.• By this step, many possible pathologies have already been ruled out or in.
    22. 22. The 6-Step Method Ischemia, Injury, & Infarct• Is it an obvious STEMI? ie. Tombstones?• Identify ST-elevation, & ST-depression.• Identify hyperacute T-waves or Q-waves.• Consider reciprocal changes.• Do you show changes in contiguous leads?• Consider culprit artery, and affected area of the heart.
    23. 23. 12-Lead Basics• Measurements are usually accurate
    24. 24. 12-Lead Basics• GE-Marquette 12SL Interpretive Algorhythm – Relatively reliable on clean ECG tracing.
    25. 25. 12-Lead Basics• The patient age and gender should always be entered into the 12-lead monitor.
    26. 26. 12-Lead BasicsTypical 12-Lead ECG
    27. 27. 12-Lead BasicsTypical 12-Lead ECG
    28. 28. 12-Lead BasicsTypical 12-Lead ECG
    29. 29. 12-Lead BasicsTypical 12-Lead ECG
    30. 30. 12-Lead BasicsTypical 12-Lead ECG
    31. 31. 12-Lead Basics
    32. 32. 12-Lead BasicsTypical 12-Lead ECG
    33. 33. 12-Lead Basics QuickTime™ and a mpeg4 decompressor are needed to see this picture.
    34. 34. Rate & Rhythm• Interpret the rhythm – Identify the rate – Is it regular or irregular? – Identify P-waves – Identify PR-interval
    35. 35. Rate & Rhythm Calculate the Rate300 150 100 75 60
    36. 36. Rate & Rhythm• Is the rate too fast or too slow?• Intrinsic Rates: – SA Node - 60 to 100 – AV Junction - 40 to 60 – Purkinje Fibers - 20 to 40
    37. 37. Rate & RhythmRegular or Irregular
    38. 38. Rate & RhythmRegular or Irregular
    39. 39. Rate & Rhythm P-Waves• Are P-waves present?• Is there a P-wave for every QRS?• Is there a QRS for every P-wave?• Do the P-waves appear after the QRS?
    40. 40. Rate & Rhythm PR-Interval• Is the PR-interval consistent?• Is the PR-interval > 0.20 sec (200ms)?• Does the PR-interval lengthen?
    41. 41. Rate & Rhythm• The next step is to interpret the rhythm that the patient is in.• The following is a brief ECG arrhythmia review.
    42. 42. Sinus Rhythms
    43. 43. Normal Sinus Rhythm• Rate: 60 - 100 bpm• Rhythm: Regularly Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
    44. 44. Normal Sinus Rhythm
    45. 45. Normal Sinus Rhythm
    46. 46. Normal Sinus Rhythm
    47. 47. Normal Sinus Rhythm
    48. 48. Normal Sinus Rhythm
    49. 49. Sinus Arrhythmia• Rate: 60 - 100 bpm• Rhythm: Varies with respiration• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
    50. 50. Sinus Arrhythmia
    51. 51. Sinus Bradycardia• Rate: < 60 bpm• Rhythm: Regularly-Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
    52. 52. Sinus Bradycardia
    53. 53. Sinus Bradycardia
    54. 54. Sinus Bradycardia
    55. 55. Sinus Bradycardia
    56. 56. Sinus Tachycardia• Rate: > 100 bpm• Rhythm: Regularly-Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
    57. 57. Sinus Tachycardia
    58. 58. Sinus Tachycardia
    59. 59. Sinus Tachycardia
    60. 60. Sinus Tachycardia
    61. 61. Sinus Pause/Arrest• Rate: Varies• Rhythm: Irregular• P wave: Present except for pause• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
    62. 62. Premature Atrial Contraction• Rate: Determine underlined rate• Rhythm: Irregular• P wave: Present, may be different w/ PAC• P:QRS ratio: 1 to 1• PR-interval: Normal, may vary w/ PAC• QRS Width: < 120 ms (0.12 sec)
    63. 63. Ectopic Atrial Tachycardia• Rate: 100 - 180 bpm• Rhythm: Regular• P wave: Present, may be different w/ ectopy• P:QRS ratio: 1 to 1• PR-interval: Normal, different w/ ectopy• QRS Width: < 120 ms (0.12 sec)
    64. 64. Wandering Atrial Pacemaker• Rate: < 100 bpm• Rhythm: Irregularly-Irregular• P wave: At least 3 different morphologies• P:QRS ratio: 1 to 1• PR-interval: Variable• QRS Width: < 120 ms (0.12 sec)
    65. 65. Multifocal Atrial Tachycardia• Rate: > 100 bpm• Rhythm: Irregularly-Irregular• P wave: At least 3 different morphologies• P:QRS ratio: 1 to 1• PR-interval: Variable• QRS Width: < 120 ms (0.12 sec)
    66. 66. Atrial Flutter
    67. 67. Atrial Flutter• Rate: Atria (250-350), Ventricles (125-175)• Rhythm: Usually Regular• P wave: Saw toothed “F waves”• P:QRS ratio: Variable, 2:1 is common• PR-interval: Variable• QRS Width: < 120 ms (0.12 sec)
    68. 68. Atrial Flutter 3:1
    69. 69. Atrial Flutter 2:1
    70. 70. Atrial Fibrillation
    71. 71. Atrial Fibrillation
    72. 72. Atrial Fibrillation• Rate: Variable, depending on ventricles• Rhythm: Irregularly-Irregular• P wave: None, chaotic atrial activity• P:QRS ratio: None• PR-interval: None• QRS Width: < 120 ms (0.12 sec)
    73. 73. Atrial Fibrillation
    74. 74. Atrial Fibrillation
    75. 75. Atrial Fibrillation
    76. 76. Atrial Fibrillation
    77. 77. Premature Junctional Contraction• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
    78. 78. Junctional Escape Beat• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
    79. 79. Junctional Rhythm• Rate: 40 - 60 bpm• Rhythm: Regular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
    80. 80. Accelerated Junctional Rhythm• Rate: 60 - 100 bpm• Rhythm: Regular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
    81. 81. Narrow Complex Tachycardia Sinus Tach P MAT P Ectopic A-Tach P Junctional P AVNRT/AVRT P A-Flutter F F F F P P-Wave F Flutter Wave
    82. 82. Premature Ventricular Contraction• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: None with PVC• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
    83. 83. Premature Ventricular Contraction • Polymorphic – More than one one shape of QRS complex • Multifocal – More than one focus or site of initial impulse.
    84. 84. Premature Ventricular Contraction 1 2
    85. 85. Ventricular Escape Beat• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: None with PVC• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
    86. 86. Ventricular Rhythms
    87. 87. Idioventricular Rhythm• Rate: 20 - 40 bpm• Rhythm: Regular• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
    88. 88. Idioventricular Rhythm
    89. 89. Accelerated Ventricular Rhythm• Rate: 40 - 100 bpm• Rhythm: Regular• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
    90. 90. Ventricular Tachycardia• Rate: 100 - 200 bpm• Rhythm: Regular• P wave: None, complete AV disassociation• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
    91. 91. Ventricular Tachycardia
    92. 92. Torsade de Pointes• Rate: 200 - 250 bpm• Rhythm: Irregular• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
    93. 93. Ventricular Fibrillation• Rate: Indeterminate• Rhythm: Chaotic• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: None
    94. 94. 1st Degree Heart Block• Rate: Identify underlying rate• Rhythm: Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: > 200 ms (0.20 sec)• QRS Width: < 120 ms (0.12 sec)
    95. 95. 1st Degree Heart Block
    96. 96. 2nd Degree Heart Block - Type I• Rate: Identify underlying rate• Rhythm: Regularly-Irregular• P wave: Present• P:QRS ratio: Variable• PR-interval: Variable (going, going, gone…)• QRS Width: < 120 ms (0.12 sec)
    97. 97. 2nd Degree Heart Block - Type I 1st Degree AVB 2nd Degree AVB - Type I
    98. 98. 2nd Degree Heart Block - Type II• Rate: Identify underlying rate• Rhythm: Regularly-Irregular• P wave: Present• P:QRS ratio: x:x - 1• PR-interval: Normal *Dropped QRS• QRS Width: < 120 ms (0.12 sec)
    99. 99. 3rd Degree Heart Block• Rate: Atrial & Ventricular rates differ• Rhythm: Regular• P wave: Present• P:QRS ratio: Variable• PR-interval: No pattern• QRS Width: Normal or WIDE
    100. 100. 3rd Degree Heart Block QuickTime™ and a decompressor are needed to see this picture.
    101. 101. 3rd Degree Heart Block
    102. 102. AV Blocks Is the PR-interval a constant length? Yes No Dropped QRS? P-wave for every QRS? Yes No Yes No2nd Degree Type II 1st Degree 2nd Degree Type I 3rd Degree
    103. 103. Interpretation Pearl• When interpreting an ECG rhythm, always consider the company it keeps. – Associated Signs & Symptoms – Past medical history – Medications…etc
    104. 104. ECG Rhythms• You must understand the basic ECGarrhythmias prior to moving on.• Review the previous slides until you thinkyou’ve got it.• The next slide may assist you if you’re stillhaving a hard time.
    105. 105. The ECG Dance QuickTime™ and a mpeg4 decompressor are needed to see this picture.
    106. 106. The Golden RuleECG Interpretation is largely based on THEORY.Give five cardiologists the same ECG to interpret,and you may receive five different interpretations.
    107. 107. The End• End of Lesson 1• Lesson 2 will include axis determination

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