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12-LeadElectrocardiography       a comprehensive course        sson5      Le            Adam Thompson, EMT-P, A.S.
The 6-Step Method• 1. Rate & Rhythm• 2. Axis Determination• 3. Intervals• 4. Morphology• 5. STE-Mimics• 6. Ischemia, Injur...
Lesson Five• STEMI  – ST-Segment Elevated Myocardial Infarction  – ST-Segment Elevation of > 1mm in two    contiguous lead...
Objectives• Learn how to identify a STEMI• Learn how to localize the infarcted area• Apply everything learned thus far
What are Contiguous Leads?Lead I      aVR        V1          V4  • lateral     Contiguous leads are leads that look at    ...
Coronary CirculationRight Coronary Artery      Left Main       (RCA)                             Circumflex               ...
Coronary Circulation Right Coronary Artery       Left Circumflex Artery     Left Anterior Descending        (RCA)         ...
Coronary Occlusion
Heart Anatomy                           SeptalAnterior                   Lateral WallInferior
Heart AnatomyEndocardium               Epicardium  Myocardium
Ischemia, Injury, Infarct
ST-Elevation• The most common cause of ST-  elevation is not myocardial infarction.• Less than 50% of STEMI alerts called ...
ST-Elevation           TP-Segment• ST-Elevation is elevation of the J-Point which  causes elevation of the following ST-  ...
ST-Elevation• The J-Point is where the QRS complex           J-Point  and the ST-Segment meet.
ST-Segment Morphology   Concave       Convex       J-Point      J-Point
Evolution of MI• Insufficient blood supply to the myocardium.  – Ischemia, injury or infarction, or all three.• The branch...
Evolution of MIIschemi          Injury       InfarctionaNeeds O2       Damage from   Irreversible                 lack of ...
Ischemia• Subendocardial ischemia  – Ischemia in this area prolongs local recovery time.    Since repolarization normally ...
Ischemia• Transmural ischemia  – is said to exist when ischemia extends    subepicardially. This process has a more visibl...
Ischemia• Hyperacute T-Waves  –   Results from subendocardial ischemia  –   Symmetrical & tall  –   Wide with blunt peak (...
IschemiaAsymmetricalSymmetrical
Ischemia
Ischemia-Mimic  Hyperkalemia STE-Mimic           Inverted T-WavesPeaked T-Waves
Injury• Injury to the myocardial cells results when the  ischemic process is more severe.• In patients with coronary arter...
Injury• ST-Depression  – Subendocardial• ST-Elevation  – Subepicardial  – Transmural.
Injury
Injury                    ST-ElevationST-Depression
Injury-MimicHyperkalemia STE-Mimic             ST-Elevation
Infarct• The term infarction describes necrosis or  death of myocardial cells.• Atherosclerotic heart disease is the most ...
Infarct• During acute myocardial infarction, the central  area of necrosis is generally surrounded by  an area of injury, ...
Infarct• Pathological Q-waves  – Wider than 0.04sec / 40ms (1 small box)  – Deeper than 25% the height of R-Wave
Reciprocal Changes     Site           Facing          Reciprocal• ST-Depression found in leads opposite     Septal        ...
Reciprocal ChangesReciprocal ST-Depression                               QuickTime™ and a                                 ...
Location of MI                    Septal                      Anterior Wall                      Lateral WallInferior Wall
Location of MI         Left VentricleRight Ventricle
Antero-Septal Wall• Leads V1 & V2 view the septal wall• Leads V3 & V4 view the anterior wall                  LV          ...
Septal Wall
Anterior Wall• Leads V3 & V4 view the Anterior Wall                  LV                                      V6           ...
Anterior Wall
Lateral Wall• Leads I, aVL, V5 & V6 view the lateral  wall                  LV                                      V6    ...
Lateral Wall
Inferior WallInferior Wall
Inferior Wall
Inferior Wall
Right Ventricular Wall• With a proximal occlusion of the RCA, a right  ventricular infarct is possible.  – Hypotension is ...
Right Ventricular Wall• Hypotension is most common assessment  finding with RV-Infarction.   – NTG should be used very con...
Right Ventricular Wall               Move V3 & V4 to mirrored               position on right side of               chest ...
Right Ventricular Wall                 I     aVR V1     V4RAlways make      II    aVL   V2   V7sure to denotethe leads you...
Posterior Wall• Dominant RCA  – When the RCA supplies the posterior descending    coronary artery  – 85% of people have do...
Posterior Wall• The reciprocal leads are V1 & V2• ST-depression in V1 & V2 may actually be  representing ST-elevation of t...
Posterior WallV1/V2         To identify a posterior wall MI, a technique         commonly taught is to pretend you are    ...
Posterior Wall                   V7, V8, V9                                   I      aVR V1     V7                        ...
LBBB With MIModified Sgarbossa’s criteria• Any concordant ST-Elevation!• ST-Elevation > 25% of depth of preceding S-  Wave...
Sgarbossa’s Criteria
Sgarbossa’s Criteria
Other MI Findings• If ECG print out does not read ***Acute MI***, it is  highly unlikely that the capture meets STEMI crit...
Practice
RBBB With MI
Practice
Antero-septal MI
Antero-septal MIAB
Practice
Anterior MI
PracticeAB
Inferior MI
Practice
Inferior MI
Practice
Antero-septal MI
Practice
RBBB, Inferior MI
Practice
Practice
RBBBNo ST-Elevation!
Practice29 y/o Male
WPW29 y/o Male
PracticeAB
Practice
PracticeA               RB         R
PracticeA               RB         R
Inferior-Posterior MIA                       RB               R
Practice
Antero-septal MIAB
Practice
Bigeminy Anterior MI
Practice
Antero-septal-lateral MI
Practice Scenarios“Always consider the company it keeps”                 - Dr. Thomas Garcia
Practice Scenario 1• You respond to an 87 year-old female who  states that she awoke with “a fast heart rate”.• She states...
Practice Scenario 1• No abnormal physical exam findings• BP: 156/74• HR: 124 irregularly irregular• O2 Sat:96% on room air
Practice Scenario 1
Practice Scenario 2• You respond to a 51 year-old female who  reportedly became unconscious and slumped  over in a chair.•...
Practice Scenario 2• She is flushed and diaphoretic• She is awake but disoriented•   BP: 180/120•   HR: 110 Regular•   Res...
Practice Scenario 2
Practice Scenario 3• You respond to a 94 year-old female in  a nursing home.• She had a syncopal episode per the  LPN, and...
Practice Scenario 3•   She is pale but dry•   BP: 142/57•   HR: 88•   Respirations: 24•   O2 Sat: 88% on High-flow O2
Practice Scenario 3
Practice Scenario 3
Practice
Trigeminal PVCsPossible Antero-septal Infarct
Trigeminal PVCs
Trigeminal PVCs
Lesson 5• This concludes lesson 5• Please review the course materials
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12 lead-lesson 5

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12 lead-lesson 5

  1. 1. 12-LeadElectrocardiography a comprehensive course sson5 Le Adam Thompson, EMT-P, A.S.
  2. 2. The 6-Step Method• 1. Rate & Rhythm• 2. Axis Determination• 3. Intervals• 4. Morphology• 5. STE-Mimics• 6. Ischemia, Injury, & Infarct
  3. 3. Lesson Five• STEMI – ST-Segment Elevated Myocardial Infarction – ST-Segment Elevation of > 1mm in two contiguous leads. – In V2 & V3, ST-Segment elevation must be at least 2mm. *The smaller the QRS complex, the more significant minimal ST- Elevation is.
  4. 4. Objectives• Learn how to identify a STEMI• Learn how to localize the infarcted area• Apply everything learned thus far
  5. 5. What are Contiguous Leads?Lead I aVR V1 V4 • lateral Contiguous leads are leads that look at septal anterior the same area of the heart.Lead II aVL V2 V5 •inferior show up on the 12-lead proximal They high lateral septal low lateral to each other.Lead III aVF V3 V6 inferior inferior anterior low lateral
  6. 6. Coronary CirculationRight Coronary Artery Left Main (RCA) Circumflex (LCx)Left Anterior Descending (LAD)
  7. 7. Coronary Circulation Right Coronary Artery Left Circumflex Artery Left Anterior Descending (RCA) (LCx) (LAD)•Right Atrium •Inferior Wall •Anterior•Inferior Wall •Isolated Right Ventricle •Anteroseptal•Inferior-Right Ventricle •Posterior Wall •Anteroseptal-lateral•Posterior Wall - 15% of population - 85% of population •Anterolateral •Inferolateral •Posterolateral *Nicknamed “Widow-maker”
  8. 8. Coronary Occlusion
  9. 9. Heart Anatomy SeptalAnterior Lateral WallInferior
  10. 10. Heart AnatomyEndocardium Epicardium Myocardium
  11. 11. Ischemia, Injury, Infarct
  12. 12. ST-Elevation• The most common cause of ST- elevation is not myocardial infarction.• Less than 50% of STEMI alerts called by paramedics are actually Acute Coronary Syndrome (ACS) patients
  13. 13. ST-Elevation TP-Segment• ST-Elevation is elevation of the J-Point which causes elevation of the following ST- Segment.• Elevation is defined as anything above the T P isoelectric line.• Find the isoelectric line by locating the TP- Segment.
  14. 14. ST-Elevation• The J-Point is where the QRS complex J-Point and the ST-Segment meet.
  15. 15. ST-Segment Morphology Concave Convex J-Point J-Point
  16. 16. Evolution of MI• Insufficient blood supply to the myocardium. – Ischemia, injury or infarction, or all three.• The branches of coronary arteries arising from the aortic root are distributed on the epicardial surface of the heart.• These in turn provide intramural branches that supply the cardiac muscle.• Myocardial ischemia generally appears first.
  17. 17. Evolution of MIIschemi Injury InfarctionaNeeds O2 Damage from Irreversible lack of O2 damage
  18. 18. Ischemia• Subendocardial ischemia – Ischemia in this area prolongs local recovery time. Since repolarization normally proceeds in an epicardial-to-endocardial direction, delayed recovery in the subendocardial region due to ischemia does not reverse the direction of repolarization but merely lengthens it.
  19. 19. Ischemia• Transmural ischemia – is said to exist when ischemia extends subepicardially. This process has a more visible effect on recovery of subepicardial cells compared with subendocardial cells. Recovery is more delayed in the subepicardial layers, and the subendocardial muscle fibers seem to recover first.
  20. 20. Ischemia• Hyperacute T-Waves – Results from subendocardial ischemia – Symmetrical & tall – Wide with blunt peak (unlike Hyperkalemia) – Present for about first 30 min. of AMI• Inverted T-waves – Results from transmural ischemia
  21. 21. IschemiaAsymmetricalSymmetrical
  22. 22. Ischemia
  23. 23. Ischemia-Mimic Hyperkalemia STE-Mimic Inverted T-WavesPeaked T-Waves
  24. 24. Injury• Injury to the myocardial cells results when the ischemic process is more severe.• In patients with coronary artery disease, ischemia, injury and myocardial infarction of different areas frequently coexist, producing mixed and complex ECG patterns.
  25. 25. Injury• ST-Depression – Subendocardial• ST-Elevation – Subepicardial – Transmural.
  26. 26. Injury
  27. 27. Injury ST-ElevationST-Depression
  28. 28. Injury-MimicHyperkalemia STE-Mimic ST-Elevation
  29. 29. Infarct• The term infarction describes necrosis or death of myocardial cells.• Atherosclerotic heart disease is the most common underlying cause of myocardial infarction.• The left ventricle is the predominant site for infarction; however, right ventricular infarction occasionally coexists with infarction of the inferior wall of the left ventricle.
  30. 30. Infarct• During acute myocardial infarction, the central area of necrosis is generally surrounded by an area of injury, which in turn is surrounded by an area of ischemia.• Various stages of myocardial damage can coexist.• The distinction between ischemia and necrosis is whether the phenomenon is reversible.
  31. 31. Infarct• Pathological Q-waves – Wider than 0.04sec / 40ms (1 small box) – Deeper than 25% the height of R-Wave
  32. 32. Reciprocal Changes Site Facing Reciprocal• ST-Depression found in leads opposite Septal V1, V2 V7, V8, V9 ofAnterior with ST-Elevation is considered those V3, V4 None toLateral reciprocal change. be a I, aVL, V5, V6 II, III, aVF – This is caused by III, view from the opposite a aVF Inferior II, I, aVL direction. Posterior V7, V8, V9 V1, V2
  33. 33. Reciprocal ChangesReciprocal ST-Depression QuickTime™ and a decompressor are needed to see this picture. Inferior Injury
  34. 34. Location of MI Septal Anterior Wall Lateral WallInferior Wall
  35. 35. Location of MI Left VentricleRight Ventricle
  36. 36. Antero-Septal Wall• Leads V1 & V2 view the septal wall• Leads V3 & V4 view the anterior wall LV V6 RV V5 V4 V1 V3 V2
  37. 37. Septal Wall
  38. 38. Anterior Wall• Leads V3 & V4 view the Anterior Wall LV V6 RV V5 V4 V1 V3 V2
  39. 39. Anterior Wall
  40. 40. Lateral Wall• Leads I, aVL, V5 & V6 view the lateral wall LV V6 RV V5 V4 V1 V3 V2
  41. 41. Lateral Wall
  42. 42. Inferior WallInferior Wall
  43. 43. Inferior Wall
  44. 44. Inferior Wall
  45. 45. Right Ventricular Wall• With a proximal occlusion of the RCA, a right ventricular infarct is possible. – Hypotension is most common finding. – Right-sided placement of V3 & V4 can be used to view the right ventricle for ST-Elevation. • V4R is most sensitive lead for right-sided changes. • QRS complexes and ST-Elevation may be of much lesser amplitude in right-sided leads.
  46. 46. Right Ventricular Wall• Hypotension is most common assessment finding with RV-Infarction. – NTG should be used very conservatively – Fluids should be administered if unstable• ST-Elevation in lead III > than STE in lead II is very specific for RV-Infarction
  47. 47. Right Ventricular Wall Move V3 & V4 to mirrored position on right side of chest to obtain V3R & V3 V4R.V4 The same can be done for V5 & V6.
  48. 48. Right Ventricular Wall I aVR V1 V4RAlways make II aVL V2 V7sure to denotethe leads you III aVF V3R V6change.
  49. 49. Posterior Wall• Dominant RCA – When the RCA supplies the posterior descending coronary artery – 85% of people have dominant RCA• Dominant Circumflex – When LCx supplies the posterior descending coronary artery – 15% of people have dominant circumflex
  50. 50. Posterior Wall• The reciprocal leads are V1 & V2• ST-depression in V1 & V2 may actually be representing ST-elevation of the posterior wall• Tall R-waves in V1 & V2 may actually be representing pathological Q-waves of the posterior wall
  51. 51. Posterior WallV1/V2 To identify a posterior wall MI, a technique commonly taught is to pretend you are looking at the complex upside-down through a mirror
  52. 52. Posterior Wall V7, V8, V9 I aVR V1 V7 II aVL V2 V8 III aVF V3 V9Move V4 to V7 - posterior axillary lineMove V5 to V8 - midscapularMove V6 to V9 paraspinal
  53. 53. LBBB With MIModified Sgarbossa’s criteria• Any concordant ST-Elevation!• ST-Elevation > 25% of depth of preceding S- Wave = MI – This is an advanced skill, and is completely reliant on the T-wave discordance found with a LBBB• This same criteria may be used with paced rhythms
  54. 54. Sgarbossa’s Criteria
  55. 55. Sgarbossa’s Criteria
  56. 56. Other MI Findings• If ECG print out does not read ***Acute MI***, it is highly unlikely that the capture meets STEMI criteria. – It is possible that the 12-lead is not a true STEMI even with the “Acute AMI” reading.• Wellen’s phenomenon - Biphasic or inverted T-waves (Most commonly in V2 & V3), precursor to AMI from LAD stenosis.
  57. 57. Practice
  58. 58. RBBB With MI
  59. 59. Practice
  60. 60. Antero-septal MI
  61. 61. Antero-septal MIAB
  62. 62. Practice
  63. 63. Anterior MI
  64. 64. PracticeAB
  65. 65. Inferior MI
  66. 66. Practice
  67. 67. Inferior MI
  68. 68. Practice
  69. 69. Antero-septal MI
  70. 70. Practice
  71. 71. RBBB, Inferior MI
  72. 72. Practice
  73. 73. Practice
  74. 74. RBBBNo ST-Elevation!
  75. 75. Practice29 y/o Male
  76. 76. WPW29 y/o Male
  77. 77. PracticeAB
  78. 78. Practice
  79. 79. PracticeA RB R
  80. 80. PracticeA RB R
  81. 81. Inferior-Posterior MIA RB R
  82. 82. Practice
  83. 83. Antero-septal MIAB
  84. 84. Practice
  85. 85. Bigeminy Anterior MI
  86. 86. Practice
  87. 87. Antero-septal-lateral MI
  88. 88. Practice Scenarios“Always consider the company it keeps” - Dr. Thomas Garcia
  89. 89. Practice Scenario 1• You respond to an 87 year-old female who states that she awoke with “a fast heart rate”.• She states that she has had this condition for over 50 years, and denies any pain or dyspnea.• She has had heart surgery in the past.
  90. 90. Practice Scenario 1• No abnormal physical exam findings• BP: 156/74• HR: 124 irregularly irregular• O2 Sat:96% on room air
  91. 91. Practice Scenario 1
  92. 92. Practice Scenario 2• You respond to a 51 year-old female who reportedly became unconscious and slumped over in a chair.• Family states that she has been unconscious for 5 minutes.• She has a history of hypertension and takes Xanax and hydrochlorothiazide.
  93. 93. Practice Scenario 2• She is flushed and diaphoretic• She is awake but disoriented• BP: 180/120• HR: 110 Regular• Respirations: 16• O2 Sat: 95%
  94. 94. Practice Scenario 2
  95. 95. Practice Scenario 3• You respond to a 94 year-old female in a nursing home.• She had a syncopal episode per the LPN, and is currently complaining of unlocalized pain.
  96. 96. Practice Scenario 3• She is pale but dry• BP: 142/57• HR: 88• Respirations: 24• O2 Sat: 88% on High-flow O2
  97. 97. Practice Scenario 3
  98. 98. Practice Scenario 3
  99. 99. Practice
  100. 100. Trigeminal PVCsPossible Antero-septal Infarct
  101. 101. Trigeminal PVCs
  102. 102. Trigeminal PVCs
  103. 103. Lesson 5• This concludes lesson 5• Please review the course materials

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