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Transcript
12 Lead EKG Interpretation 12-lead EKG interpretation has been a lifelong partner of the Emergency Physician in patient assessment Many EP’s, though, are not STARS at 12 lead EKG interpretation WHY????? Because most EKG courses are too long, too boring, and teach absolutely unnecessary and unrememberable stuff in ways that make students just regurgitate the material What am I NOT talking about? Advanced rhythm assessment Ventricular tachycardia assessment Vtach vs. SVT assessment Block Augustus Waller Augustus Waller Einthoven Netherlands – ECG 1895 Einthoven String Galvanometer Einthoven Fowler’s Prime Directive of Cardiac Emergencies: Some systole is better than no systole at all Pulseless Rhythms CPR, Shock, Intubate with CPR, Epi q 3, Shock, Amio or Lidocaine then ?? CPR, Shock, Intubate with CPR, Epi q 3, Shock, Amio or Lidocaine then ?? Intubate, IV, Epi q 3, Consider Atropine, Look for cause 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 Third point: AXIS INTERPRETATION IS BORING!! As the lead sees the impulse growing (or “coming toward it”), the machine records an upward deflection Positive As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection Positive As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection Positive Lead I Lead II + Lead III + + The EKG Basic Limb Leads + I II III + + 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 III is 120 degrees from Lead I, and is arbitrarily established at “Positive 120 Degrees” + Lead I Augmented Limb Leads avL avR Lead II avF + + Lead II Added by Goldberger in 1942 + Lead I + Augmented Limb Leads Lead II + Lead II Frontal Plane + + + V6 V5 V4 V1 V2 V3 Added by AHA and the Cardiac Society of Great Britain 1938 The Leads may be moved to the center of the chest I + I II III III + II + + + + Axis is based on the direction of the heart’s depolarization + I II III + + I + I II II III + + III I + I II II III + + III I + I II II III + + III Rhythm strip interpretation has been a standard for emergency medicine since the inception of the monitor Basic Rhythm Strip Interpretation •Rate •Rhythm •P Waves •PR Interval •QRS Complex •ST Segment •T Wave •U Wave •Summary “Cherchez la P” Rate Rhythm P PR Axis Hypertrophy Infarction QRS ST T U Assessment 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!!! Normal EKG? Understanding the Anatomy Is the Key The coronary circulation The coronary arteries supply the three main walls of the heart + Lead I Augmented Limb Leads avL avR Lead II avF + + Lead II Anterior Lateral Inferior Considering Ischemia and Injury The EKG leads that are positive closest to the site of the infarction will show ST segment elevation Convex upwards is an injury pattern, meaning infarction Concave upwards is probably early repolarization The EKG leads that are positive on the other side of the heart from the infarction will show reciprocal ST segment depression The Basic Fundamental of 12 Lead EKG Interpretation You CAN’T understand 12 leads without understanding the concept of “Grouped Leads” 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! INFERIOR INFERIOR II, III, aVF LATERAL ANTERIOR 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 Inferior wall M.I. = Acute Inferior Wall Myocardial 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 Acute Lateral Wall Myocardial Infarction Inferior Wall M.I. vs. Lateral Wall M.I. Normal EKG, right? Normal vs. abnormal Left Coronary Artery The EKG leads that are positive closest to the site of the infarction will show ST segment elevation Acute Anterior Wall Myocardial Infarction Acute Anterior Wall Myocardial Infarction Early Repolarization Pattern Okay, smarty pants: What exactly would leads I, II, and III show in the case of an anterior (LAD) infarction? HMMMMM???? Reciprocal depression in all three leads!! All three leads are on the other side of the heart from the infarction! Having a 12 lead machine around to keep an eye on the tracings is a good idea sometimes... Monitoring For Ectopy on a 12 Lead EKG Sometimes the tracings can be quite hard to interpret …and sometimes almost worthless... …sometimes VERY interesting... Acute Hyperkalemia Acute Hypokalemia The problem with letting the machine read the tracing??? …but sometimes the machine can be RIGHT!!! Don’t forget that 12 leads can let us forget to analyze the rhythm!!! Ventricular Hypertrophy Left Ventricular Hypertrophy Left Axis Deviation Deep S wave in V1 Large R wave in V5 V1 plus V5 adds up to more than 35 millimeters And/Or aVL 11 mm or greater Right Ventricular Hypertrophy Look to the RIGHT side of the heart to find it, namely V1 Finding Ventricular Hypertrophy Always look at V1 Finding Ventricular Hypertrophy 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 Bundle Branch Block Normal Conduction Left Bundle Branch Block V6 Right Bundle Branch Block V1 Bundle Branch Block Positive Deflection Rabbit Ears in V1 with wide complex Positive Deflection in V6 with wide complex Right Bundle Branch Block Left Bundle Branch Block Right Bundle Branch Block Left Bundle Branch Block Left Anterior Hemiblock Brugada Syndrome Brugada Syndrome Brugada syndrome is a disorder characterized by coved or saddle-shaped ST-segment elevation in leads V1 through V3 on ECG Brugada Syndrome Brugada syndrome is most common in people from Asia. The reason for this observation is not yet fully understood but may be due to an Asian-specific sequence in the promoter region of SCN5A (Bezzina, 2005). In Asia (eg, the Philippines, Thailand, Japan), Brugada syndrome seems to be the most common cause of natural death in men younger than 50 years. Brugada syndrome is 8-10 times more prevalent in men than in women, Brugada Syndrome Brugada Syndrome Brugada Syndrome Brugada Syndrome Wellen’s Syndrome Wellens' syndrome is a pattern of electrocardiographic T-wave changes associated with critical, proximal left anterior descending (LAD) artery stenosis. The syndrome is also referred to as LAD coronary T-wave syndrome. Syndrome criteria include T-wave changes plus a history of anginal chest pain without serum marker abnormalities; patients lack Q waves and significant ST-segment elevation; such patients show normal precordial R-wave progression. Wellens Syndrome is an easy to identify cardiac syndrome which indicates a critical high grade occulsion of the proximal LAD. If not identified and properly treated the mean time from onset of symptoms to extensive anterior wall MI is 8.5 days Wellen’s Syndrome Now, kiddies… IT’S EXAM TIME!! Crushing Chest Pain with Diaphoresis 58 y/o Acute Chest Pain in 118 Year Old Patient Diffuse ST Segment Elevation in Chest Pain in a middle-aged lady who has recently had a cold Check the axis and the PR Interval… Older guy, feeling crummy… Older guy having palpitations and lightheadedness Middle-aged guy found semi-conscious with weak radial pulse What is this patient’s blood pressure? Prompt and accurate analysis of the ECG requires anatomical understanding and continual practice About the time you think you’re getting real good at ECG analysis, you’ve realized that you may have forgotten nearly as much as you ever learned: Remember Wellens and Brugada! Promise yourself (and your patients) that a lifetime of continual study and refresher courses will accompany your practice