12 Lead ECG Interpretation
McHenry Western Lake County EMS System
Topics
Anatomy revisited The 12 Lead ECG device The 12 Lead ECG format Waveform components Lead views
Anatomy Revisited
RCA (Right Coronary Artery)
Right ventricle Inferior wall of LV Posterior wall of LV (75%) SA Node (60%) AV Node (>80%) Septal wall of LV Anterior wall of LV Inferior wall of LV Posterior wall of LV (10%)
LCA (Left Coronary Artery)
Anatomy Revisited
SA node Intra-atrial pathways AV node Bundle of His Left and Right bundle branches
Left anterior fascicle Left posterior fascicle
Purkinje fibers
12 Lead ECG Device
Device serves as a voltmeter
-measures the flow of electricity
Unipolar vs. Bipolar Leads
Bipolar Leads
1 positive and 1 negative electrode
RA always negative LL always positive
Traditional limb leads are examples of these
Lead I Lead II Lead III
View from a vertical plane
Unipolar Leads
1 positive electrode & 1 negative reference point Calculated by using summation of 2 negative leads Augmented limb leads aVR, aFV, aVL View from a vertical plane Precordial or chest leads V1-V6 View from a horizontal plane
12 lead ECG Format
Leads that are produced by devices used in the Pre Hospital setting
12 Lead ECG Format
These typically are not seen Pre Hospital
12 Lead ECG Format
Device prints out 2.5 sec of each lead. The device computer then analyzes all 10 sec of all 12 leads, but only prints 2.5 sec of each group
12 Lead ECG Format
The computer diagnosis is not always accurate! Look at your ECG!
12 Lead ECG Format
The computer is very accurate at measuring intervals and durations
Waveform Components R Wave
First positive deflection R wave includes the down stroke returning to the baseline
Waveform Components Q Wave
First negative deflection before the R wave Q wave includes the negative down stroke and return to baseline
Waveform Components S Wave
Negative deflection following the R wave S wave includes departure from and return to baseline
Waveform Components QRS
Q waves
Can occur normally in several leads
Normal Q waves called physiologic < .04 sec (40ms) >.04 sec (40ms)
Physiologic Q waves
Pathologic Q
Waveform Components QRS
Q wave
Measure width Pathologic if greater than or equal to 0.04 seconds (1 small box)
Waveform Components QS Complex
Entire complex is negatively deflected No R wave is present
Waveform Components J-Point
Junction between the end of QRS and beginning of ST segment Where QRS stops and makes a sudden sharp change in direction
Waveform Components ST Segment
Segment between J-Point and beginning of T wave
Waveform Components ST Segment
Need reference point
Compare to TP segment DO NOT use PR segment as reference!
Waveform Components Practice
Find the J Point and ST segment
Waveform Components Practice
J POINTS
ST SEGMENT
Waveform Components Practice
Find the J Point and ST segment
Waveform Components Practice
J POINTS
ST SEGMENT
Lead Views
Lead Groups
I II III aVR aVL aVF
Limb Leads
VI V2 V3
V4 V5 V6
Chest Leads
Inferior Wall MI
II, III, aVF
View from Left Leg inferior wall of left ventricle
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
Inferior Wall MI
Posterior View
Portion resting on diaphragm ST elevation.suspect inferior injury
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
Lateral Wall MI
1 and AVL
View from Left Arm Lateral wall of left ventricle
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
Lateral Wall MI
V5 and V6
Left lateral chest Lateral wall of left ventricle
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
Lateral Wall MI
I, aVL, V5, V6
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
ST elevation suspect lateral wall injury
Lateral Wall
Anterior Wall MI
V3, V4
Lateral anterior chest + electrode on anterior chest
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
Anterior Wall MI
V3, V4
ST segment elevation.suspect anterior wall injury
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
Septal Wall MI
V1, V2
Along sternal borders Look through right ventricle and see septal wall
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
Septal Wall MI
V1, V2
Septum is left ventricular tissue
I II III
aVR aVL aVF
VI V2 V3
V4 V5 V6
ST Segment Analysis
For each complex, determine whether the ST segment is elevated one millimeter or more above the TP segment
ST Segment Analysis
YES
YES
YES
NO
YES
NO
12 Lead ECG
AMI recognition
Two things to know
What to look for Where you are looking
AMI Recognition
What to look for
ST segment elevation
One millimeter or more (one small box) Present in two anatomically contiguous leads
Summary
The key to 12 lead ECG interpretation for AMI are Q wave, R wave, S wave and pathologic Q wave, the J point and ST segment. Each lead looks at a specific portion of the heart through the + electrode
Summary
Specific changes must appear in two contiguous leads Changes seen in AMI are: tall, peaked T wave, elevated ST segment and a widened Q wave A normal 12 lead ECG does NOT rule out AMI
Special Thanks!
To Acute Coronary Syndrome Consultants, Inc. Tim Phalen, Gary Denton and Assoc. and Temple College for the use of their materials in this presentation
