12lead ekg
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The document discusses 12-lead EKG interpretation for emergency providers, noting that while technology is advancing in EMS, many providers lack proficiency in 12-lead interpretation because courses often teach unnecessary information. It emphasizes the importance of recognizing serious rhythms like VF and VT and interpreting the rhythm strip first before assessing the 12-lead, and of understanding the concept of grouped leads which relate directly to cardiac anatomy.
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12lead ekg
- 1. 12 Lead EKG Interpretation12 Lead EKG Interpretation Essentiallyspeaking... Essentially Essentiallyspeaking... speaking... Copyright 2004, Ray Fowler, M.D., FACEPCopyright 2004, Ray Fowler, M.D., FACEP
- 2. Ray Fowler, M.D., FACEPRay Fowler, M.D., FACEP Associate Professor of Emergency Medicine The University of Texas Southwestern Assistant Professor of Emergency Medicine The Medical College of Georgia Deputy EMS Medical Director The Dallas Area BioTel System Medical Director Mid Georgia Ambulance Service Douglas County Fire Department Associate Professor of Emergency MedicineAssociate Professor of Emergency Medicine The University of Texas SouthwesternThe University of Texas Southwestern Assistant Professor of Emergency MedicineAssistant Professor of Emergency Medicine The Medical College of GeorgiaThe Medical College of Georgia Deputy EMS Medical DirectorDeputy EMS Medical Director The Dallas AreaThe Dallas Area BioTelBioTel SystemSystem Medical DirectorMedical Director Mid Georgia Ambulance ServiceMid Georgia Ambulance Service Douglas County Fire DepartmentDouglas County Fire Department
- 5. Technology is advancing in EMS: Pulse ox’s EID’s New drugs Monitors that really monitor Capnography Technology is advancing in EMS: Pulse ox’s EID’s New drugs Monitors that really monitor Capnography
- 7. 12-lead EKG interpretation is a relative newcomer in the field evaluation of the emergency patient 12-lead EKG interpretation is a relative newcomer in the field evaluation of the emergency patient
- 8. Many, perhaps most providers are not adept at 12 lead EKG interpretation Many, perhaps most providers are not adept at 12 lead EKG interpretation
- 10. Because most EKG courses are too long, too boring, and teach absolutely unnecessary and unrememberable stuff to medics who will never use that information Because most EKG courses are too long, too boring, and teach absolutely unnecessary and unrememberable stuff to medics who will never use that information
- 12. What am I NOT talking about? What am I NOT talking about? Advanced rhythm assessment Ventricular tachycardia assessment Vtach vs. SVT assessment Block Advanced rhythm assessment Ventricular tachycardia assessment Vtach vs. SVT assessment Block
- 13. This EKG is the REASON that 12 Lead EKG Machines are in the field This EKG is the REASON that 12 Lead EKG Machines are in the field Acute Anterior Myocardial Infarction Acute Anterior Myocardial Infarction
- 14. Rhythm strip interpretation has been a standard since almost the beginning of EMS Rhythm strip interpretation has been a standard since almost the beginning of EMS
- 15. Basic Rhythm Strip Interpretation Basic Rhythm Strip Interpretation •Rate •Rhythm •P Waves •PR Interval •QRS Complex •Rate •Rhythm •P Waves •PR Interval •QRS Complex •ST Segment •T Wave •U Wave •Summary •ST Segment •T Wave •U Wave •Summary
- 18. Since serious rhythm disturbances are the most important issue (like VF, VT, asystole), then if you see a serious rhythm disturbance proceed with rhythm strip interpretation FIRST!!! Since serious rhythm disturbances are the most important issue (like VF, VT, asystole), then if you see a serious rhythm disturbance proceed with rhythm strip interpretation FIRST!!!FIRST!!!
- 19. Fowler’s Prime Directive of Cardiac Emergencies: Fowler’s Prime Directive of Cardiac Emergencies: Some systole is better than no systole at all Some systole is better than no systole at all
- 20. Pulseless RhythmsPulseless RhythmsPulseless Rhythms Shock x 3, Intubate with CPR, Epi q 3, Shock, Amio or Lidocaine then ?? Shock x 3, Intubate withShock x 3, Intubate with CPR, Epi q 3, Shock,CPR, Epi q 3, Shock, AmioAmio oror LidocaineLidocaine then ??then ?? Shock x 3, Intubate with CPR, Epi q 3, Shock, Amio or Lidocaine then ?? Shock x 3, Intubate with CPR, Epi q 3, Shock, Amio or Lidocaine then ?? Intubate, IV, Epi q 3, Consider Atropine, Look for cause Intubate, IV, Epi q 3, Consider Atropine, Look for cause
- 21. Second point: Much of what we call “12 lead interpretation” is in fact actually rhythm strip interpretation. Second point: Much of what we call “12 lead interpretation” is in fact actually rhythm strip interpretation. …such as, for example, the evaluation of AV block, which can usually be done in one, or at most, two leads ……such as, for example, the evaluation of AV block,such as, for example, the evaluation of AV block, which can usually be done in one,which can usually be done in one, or at most, two leadsor at most, two leads
- 22. Third point: AXIS INTERPRETATION IS BORING!! Third point: AXIS INTERPRETATION IS BORING!!Hence, I will make it VERY short! Hence, I will make it VERY short! Hence, I will make it VERY short!
- 26. PositivePositive As the lead sees the impulse growing (or “coming toward it”), the machine records an upward deflection As the lead sees the impulse growing (or “coming toward it”), the machine records an upward deflection
- 27. PositivePositive As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection
- 28. PositivePositive As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection
- 31. II IIII IIIIII ++ ++ ++ The EKG Basic Limb LeadsThe EKG Basic Limb Leads
- 32. Lead I is “horizontal”, and is arbitrarily established at “0 Degrees” Lead I is “horizontal”, and is arbitrarily established at “0 Degrees” Lead II is 60 degrees down from Lead 1 and is arbitrarily established at “Positive 60 Degrees” Lead II is 60 degrees down from Lead 1 and is arbitrarily established at “Positive 60 Degrees” Lead III is 120 degrees from Lead I, and is arbitrarily established at “Positive 120 Degrees” Lead III is 120 degrees from Lead I, and is arbitrarily established at “Positive 120 Degrees” ++ ++++
- 33. The Leads may be moved to the center of the chest The Leads may be moved to the center of the chest II IIII IIIIII II IIIIIIIIII ++ ++ ++ ++ ++ ++
- 34. II IIII IIIIII ++ ++ ++ Axis is based on the direction of the heart’s depolarization Axis is based on the direction of the heart’s depolarization
- 40. The coronary circulationThe coronary circulation
- 41. The coronary arteries supply the three main walls of the heart The coronary arteries supply the three main walls of the heart
- 45. Lead ILead I Lead IILead II Lead IILead II ++ ++ ++
- 46. Lead ILead I Lead IILead II Lead IILead II ++ ++ ++ Augmented Limb Leads
- 51. The EKG leads that are positive closest to the site of the infarction will show ST segment elevation The EKG leads that are positive closest to the site of the infarction will show ST segment elevation
- 54. Concave upwards is probably early repolarization Concave upwards is probably early repolarization Convex upwards is an injury pattern, meaning infarction Convex upwards is an injury pattern, meaning infarction
- 55. The EKG leads that are positive on the other side of the heart from the infarction will show reciprocal ST segment depression The EKG leads that are positive on the other side of the heart from the infarction will show reciprocal ST segment depression
- 57. The Basic Fundamental of 12 Lead EKG Interpretation The Basic Fundamental of 12 Lead EKG Interpretation You CAN’T understand 12 leads without understanding the concept of “Grouped Leads” You CAN’T understand 12 leads without understanding the concept of “Grouped Leads”
- 58. Grouped Leads Relate DIRECTLY to Cardiac Anatomy Grouped Leads Relate DIRECTLY to Cardiac Anatomy So, if you understand the anatomy, you can quickly look at a 12 lead and understand it immediately! So, if you understand the anatomy,So, if you understand the anatomy, you can quickly look at a 12 lead andyou can quickly look at a 12 lead and understand it immediately!understand it immediately!
- 59. Lead ILead I Lead IILead II Lead IILead II ++ ++ ++ Augmented Limb Leads +++ ++++++
- 60. Lead ILead I Lead IILead II Lead IILead II ++ ++ ++ Augmented Limb Leads +++ ++++++ Frontal PlaneFrontal Plane
- 64. INFERIORINFERIOR LATERALLATERAL ANTERIORANTERIOR INFERIOR II, III, aVF INFERIOR II, III, aVF LATERAL I, aVL, V6 LATERAL I, aVL, V6 ANTERIORV1, V2, V3, V4 ANTERIORV1, V2, V3, V4
- 70. Inferior wall M.I. = Right Coronary infarction (usually) Inferior wall M.I. = Right Coronary infarction (usually) Elevated ST segments in II, III, and avF, with reciprocal depression in I, avL, and the chest leads Elevated ST segments in II, III, and avF, with reciprocal depression in I, avL, and the chest leads
- 71. Inferior wall M.I. =Inferior wall M.I. =
- 72. Acute Inferior Wall Myocardial Infarction Acute Inferior Wall Myocardial Infarction
- 74. Lateral wall M.I. = Left Circumflex Coronary infarction Lateral wall M.I. = Left Circumflex Coronary infarction Elevated ST segment in I, L, and V6 with reciprocal depression in II, III, and avF Elevated ST segment in I, L, and V6 with reciprocal depression in II, III, and avF
- 75. Acute Lateral Wall Myocardial Infarction Acute Lateral Wall Myocardial Infarction
- 76. Inferior Wall M.I. vs. Lateral Wall M.I.Inferior Wall M.I. vs. Lateral Wall M.I.
- 78. Normal EKG, right?Normal EKG, right?
- 79. (HEY, FOWLER, lighten up and tell ‘em about the three-legged pig!) (HEY, FOWLER, lighten up and tell ‘em about the three-legged pig!)
- 80. Normal vs. abnormal Left Coronary Artery Normal vs. abnormal Left Coronary Artery
- 81. The EKG leads that are positive closest to the site of the infarction will show ST segment elevation The EKG leads that are positive closest to the site of the infarction will show ST segment elevation
- 82. Acute Anterior Wall Myocardial Infarction Acute Anterior Wall Myocardial Infarction
- 83. Acute Anterior Wall Myocardial Infarction Acute Anterior Wall Myocardial Infarction
- 84. Acute Anterior Wall Myocardial Infarction Acute Anterior Wall Myocardial Infarction
- 85. Acute Anterior Wall Myocardial Infarction Acute Anterior Wall Myocardial Infarction
- 86. Acute Anterior Wall Myocardial Infarction Acute Anterior Wall Myocardial Infarction
- 88. Okay, smarty pants:Okay, smarty pants: What exactly would leads I, II, and III show in the case of an anterior (LAD) infarction? HMMMMM???? What exactly would leads I, II, and III show in the case of an anterior (LAD) infarction? HMMMMM????
- 89. Reciprocal depression in all three leads!! Reciprocal depression in all three leads!! All three leads are on the other side of the heart from the infarction! All three leads are on the other side of the heart from the infarction!
- 90. Having a 12 lead machine around to keep an eye on the tracings is a good idea sometimes... Having a 12 lead machine around to keep an eye on the tracings is a good idea sometimes...
- 91. Monitoring For Ectopy on a 12 Lead EKG Monitoring For Ectopy on a 12 Lead EKG
- 92. Sometimes the tracings can be quite hard to interpret Sometimes the tracings can be quite hard to interpret
- 93. …and sometimes almost worthless... …and sometimes almost worthless...
- 94. …sometimes VERY interesting...…sometimes VERY interesting...
- 97. The problem with letting the machine read the tracing??? The problem with letting the machine read the tracing???
- 98. …but sometimes the machine can be RIGHT!!! …but sometimes the machine can be RIGHT!!!
- 99. Don’t forget that 12 leads can let us forget to analyze the rhythm!!! Don’t forget that 12 leads can let us forget to analyze the rhythm!!!
- 100. Ventricular Hypertrophy Ventricular Hypertrophy Enlargement of ventricles Enlargement of ventricles
- 101. Left Ventricular Hypertrophy Left Ventricular Hypertrophy Left Axis Deviation Deep S wave in V1 Large R wave in V5 Left Axis Deviation Deep S wave in V1 Large R wave in V5 V1 plus V5 adds up to more than 35 millimeters V1 plus V5 adds up to more than 35 millimeters
- 102. Right Ventricular Hypertrophy Right Ventricular Hypertrophy Look to the RIGHT side of the heart to find it, namely V1 Look to the RIGHT side of the heart to find it, namely V1
- 103. Finding Ventricular Hypertrophy Finding Ventricular Hypertrophy Always look at V1Always look at V1
- 104. Finding Ventricular Hypertrophy Finding Ventricular Hypertrophy Large R wave in V1 = RVH Deep S wave in V1 = LVH Large R wave in V1 = RVH Deep S wave in V1 = LVH Corollary: If the complex is wider than 0.12 seconds, this is probably a bundle branch block and not ventricular hypertrophy Corollary: If the complex is wider than 0.12 seconds, this is probably a bundle branch block and not ventricular hypertrophy
- 106. Bundle Branch BlockBundle Branch Block
- 108. V6V6 Left Bundle Branch BlockLeft Bundle Branch Block
- 109. V1V1 Right Bundle Branch BlockRight Bundle Branch Block
- 110. Bundle Branch BlockBundle Branch Block Positive Deflection Rabbit Ears in V1 with wide complex Right Bundle Branch Block Positive Deflection Rabbit Ears in V1 with wide complex Right Bundle Branch Block Positive Deflection in V6 with wide complex Left Bundle Branch Block Positive Deflection in V6 with wide complex Left Bundle Branch Block
- 111. Right Bundle Branch BlockRight Bundle Branch Block
- 112. Left Bundle Branch BlockLeft Bundle Branch Block
- 113. Left Anterior HemiblockLeft Anterior Hemiblock
- 114. Now, kiddiesNow, kiddies…… ITIT’’S EXAMS EXAM TIME!!TIME!!
- 115. Sudden onset of chest pain in middle-aged woman, smoker, with positive family history Sudden onset of chest pain in middle-aged woman, smoker, with positive family history
- 116. Crushing Chest Pain with Diaphoresis 58 y/oCrushing Chest Pain with Diaphoresis 58 y/o
- 117. Acute Chest Pain in 118 Year Old PatientAcute Chest Pain in 118 Year Old Patient
- 118. Diffuse ST Segment Elevation in Chest Pain in a middle-aged lady who has recently had a cold Diffuse ST Segment Elevation in Chest Pain in a middle-aged lady who has recently had a cold
- 119. Check the axis and the PR Interval…Check the axis and the PR Interval…
- 120. Older guy, feeling crummy…Older guy, feeling crummy…
- 121. Older guy having palpitations and lightheadednessOlder guy having palpitations and lightheadedness
- 122. Middle-aged guy found semi-conscious with weak radial pulse Middle-aged guy found semi-conscious with weak radial pulse
- 123. What is this patient’s blood pressure?What is this patient’s blood pressure?
- 125. The scope of practice of these professionals continues to grow with passing years The scope of practice of these professionals continues to grow with passing years Emergency medicine providers are primary members of the medical team. Emergency medicine providers are primary members of the medical team.
- 126. The report of the recent Turtle Creek Conference indicates that paramedics and nursing professionals can be trained to have 12 lead EKG interpretation skills rivaling that of emergency physicians. The report of the recent Turtle Creek Conference indicates that paramedics and nursing professionals can be trained to have 12 lead EKG interpretation skills rivaling that of emergency physicians. Prehospital Emergency Care, January 2001Prehospital Emergency Care, January 2001
- 127. Let’s insist that basic 12 lead interpretation skills (and, later, advanced skills) should become part of the standard of practice of all medical professionals. Let’s insist that basic 12 lead interpretation skills (and, later, advanced skills) should become part of the standard of practice of all medical professionals.