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12 12 Lead Lead EKG EKG Interpretation Interpretation Esse ntia spea lly king ... Copyright Copyright 2004, 2004, Ray Ray Fowler, Fowler, M.D., M.D., FACEP FACEP Ray Ray Fowler, Fowler, M.D., M.D., FACEP FACEP Associate AssociateProfessor Professorof ofEmergency EmergencyMedicine Medicine The TheUniversity Universityof ofTexas TexasSouthwestern Southwestern Assistant AssistantProfessor Professorof ofEmergency EmergencyMedicine Medicine The TheMedical MedicalCollege Collegeof ofGeorgia Georgia Deputy DeputyEMS EMSMedical MedicalDirector Director The TheDallas DallasArea AreaBioTel BioTelSystem System Medical MedicalDirector Director Mid MidGeorgia GeorgiaAmbulance AmbulanceService Service Douglas DouglasCounty CountyFire FireDepartment Department Technology Technology is is advancing advancing in in EMS: EMS: Pulse Pulse ox’s ox’s EID’s EID’s New New drugs drugs Monitors Monitors that that really really monitor monitor Capnography Capnography 12-lead 12-lead EKG EKG interpretation interpretation is is aa relative relative newcomer newcomer in in the the field field evaluation evaluation of of the the emergency emergency patient patient Many, Many, perhaps perhaps most most providers providers are are not not adept adept at at 12 12 lead lead EKG EKG interpretation interpretation WHY????? Because Because most most EKG EKG courses courses are are too too long, long, too too boring, boring, and and teach teach absolutely absolutely unnecessary unnecessary and and unrememberable unrememberable stuff stuff to to medics medics who who will will never never use use that that information information What am I NOT talking about? Advanced Advanced rhythm rhythm assessment assessment Ventricular Ventricular tachycardia tachycardia assessment assessment Vtach Vtach vs. vs. SVT SVT assessment assessment Block Block This EKG is the Acute Anterior REASON that 12 Lead EKGInfarction Machines Myocardial are in the field Rhythm Rhythm strip strip interpretation interpretation has has been been aa standard standard since since almost almost the the beginning beginning of of EMS EMS Basic Basic Rhythm Rhythm Strip Strip Interpretation Interpretation •Rate •Rate •Rhythm •Rhythm •P •P Waves Waves •PR •PR Interval Interval •QRS •QRS Complex Complex •ST •ST Segment Segment •T •T Wave Wave •U •U Wave Wave •Summary •Summary Rate Rhythm P PR Axis Hypertrophy Infarction QRS ST T U Assessment Since Since serious serious rhythm rhythm disturbances disturbances are are the the most most important important issue issue (like (like VF, VF, VT, VT, asystole), asystole), then then ifif you you see see aa serious serious rhythm rhythm disturbance disturbance proceed proceed with with rhythm rhythm strip strip interpretation interpretation FIRST!!! FIRST!!! Fowler’s Fowler’s Prime Prime Directive Directive of of Cardiac Cardiac Emergencies: Emergencies: Some systole is is better than no systole at all Pulseless Pulseless Rhythms Rhythms Shock Shock xx 3, 3, Intubate Intubate with with CPR, CPR, Epi Epiqq 3, 3, Shock, Shock, Amio Amio or or Lidocaine Lidocaine then then ?? ?? Shock Shock xx 3, 3, Intubate Intubate with with CPR, CPR, Epi Epiqq 3, 3, Shock, Shock, Amio Amio or or Lidocaine Lidocaine then then ?? ?? Intubate, Intubate, IV, IV, Epi Epi qq 3, 3, Consider Consider Atropine, Atropine, Look Look for for cause cause Second point: Much Much of of what what we we call call “12 “12 lead lead interpretation” interpretation” is is in in fact fact actually actually rhythm rhythm strip strip interpretation. interpretation. … such as, …such as, for for example, example, the the evaluation evaluation of of AV AV block, block, which which can can usually usually be be done done in in one, one, or or at at most, most, two two leads leads Third Third point: point: AXIS AXIS INTERPRETATION INTERPRETATION H IS Heen IS BORING!! BORING!! nccee, , II w wiilll lm maakk ee iit tV VEER RY Y ssh hoorrt t!! As the lead sees the impulse growing (or “coming toward it”), the machine records an upward deflection Positive Positive As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection Positive Positive As the lead sees the impulse coming then going (or “going by the lead”), the machine records an isoelectric deflection Positive Positive The The EKG EKG Basic Basic Limb Limb Leads Leads + I II III + + Lead Lead II isis “horizontal”, “horizontal”, and and isis arbitrarily arbitrarily established established at at “0 “0 Degrees” Degrees” + Lead Lead IIII isis 60 60 degrees degrees down down from from Lead Lead 11 + and and isis arbitrarily arbitrarily established established at at “Positive “Positive 60 60 Degrees” Degrees” + Lead Lead III III isis 120 120 degrees degrees from from Lead Lead I,I, and and isis arbitrarily arbitrarily established established at at “Positive “Positive 120 120 Degrees” Degrees” The The Leads Leads may may be be moved moved to to the the center center of of the the chest chest I + I II III III + + + II + + Axis Axis is is based based on on the the direction direction of of the the heart’s heart’s depolarization depolarization + I II III + + I + I II II III + + III I + I II II III + + III I + I II II III + + III Normal EKG The The coronary coronary circulation circulation The The coronary coronary arteries arteries supply supply the the three three main main walls walls of of the the heart heart Anterior Lateral Inferior Lead I Lead II + Lead II + + Lead I + Augmented Limb Leads Lead II Lead II + + I II + III + + The The EKG EKG leads leads that that are are positive positive closest closest to to the the site site of of the the infarction infarction will will show show ST ST segment segment elevation elevation Convex Convex upwards upwards isis an an injury injury pattern, pattern, meaning meaning infarction infarction Concave Concave upwards upwards isis probably probably early early repolarization repolarization The The EKG EKG leads leads that that are are positive positive on on the the other other side side of of the the heart heart from from the the infarction infarction will will show show reciprocal reciprocal ST ST segment segment depression depression The The Basic Basic Fundamental Fundamental of of 12 12 Lead Lead EKG EKG Interpretation Interpretation You You CAN’T CAN’T understand understand 12 12 leads leads without without understanding understanding the the concept concept of of “Grouped “Grouped Leads” Leads” Grouped Grouped Leads Leads Relate Relate DIRECTLY DIRECTLY to to Cardiac Anatomy So, So, ifif you you understand understand the the anatomy, anatomy, you you can can quickly quickly look look at at aa 12 12 lead lead and and understand understand itit immediately! immediately! + Lead I + Augmented Limb Leads Lead II + Lead II + + + + Lead I + Augmented Limb Leads Lead II + Lead II Frontal Plane + + + V6 V5 V4 V1 V2 V3 LA TE RA L I NF ER IOR R O I R E T AN ANTER IO R V1, V2 , V3, V 4 LA I, a TER VL AL INFERIOR , V LATERAL 6 INFERIOR II, III, aVF ANTERIOR R O I R E T AN LA TE RA L I NF ER IOR Posterior Lateral Inferior Anterior +210 (-150) +60 -30 +90 0 +120 Inferior Inferior wall wall M.I. M.I. == Right Right Coronary Coronary infarction infarction (usually) (usually) Elevated Elevated ST ST segments segments in in II, II, III, III, and and avF, avF, with with reciprocal reciprocal depression depression in in I,I, avL, avL, and and the the chest chest leads leads Inferior Inferior wall wall M.I. M.I. == Acute Acute Inferior Inferior Wall Wall Myocardial Myocardial Infarction Infarction Lateral Lateral wall wall M.I. M.I. == Left Left Circumflex Circumflex Coronary Coronary infarction infarction Elevated Elevated ST ST segment segment in in I,I, L, L, and and V6 V6 with with reciprocal reciprocal depression depression in in II, II, III, III, and and avF avF Acute Acute Lateral Lateral Wall Wall Myocardial Myocardial Infarction Infarction Inferior Inferior Wall Wall M.I. M.I. vs. vs. Lateral Lateral Wall Wall M.I. M.I. Normal EKG, right? (HEY, (HEY, FOWLER, FOWLER, lighten lighten up up and and tell tell ‘em ‘em about about the the three-legged three-legged pig!) pig!) Normal Normal vs. vs. abnormal abnormal Left Left Coronary Coronary Artery Artery The The EKG EKG leads leads that that are are positive positive closest closest to to the the site site of of the the infarction infarction will will show show ST ST segment segment elevation elevation Acute Acute Anterior Anterior Wall Wall Myocardial Myocardial Infarction Infarction Acute Acute Anterior Anterior Wall Wall Myocardial Myocardial Infarction Infarction Acute Acute Anterior Anterior Wall Wall Myocardial Myocardial Infarction Infarction Acute Acute Anterior Anterior Wall Wall Myocardial Myocardial Infarction Infarction Acute Acute Anterior Anterior Wall Wall Myocardial Myocardial Infarction Infarction Early Early Repolarization Repolarization Pattern Pattern Okay, Okay, smarty smarty pants: pants: What What exactly exactly would would leads leads I,I, II, II, and and III III show show in in the the case case of of an an anterior anterior (LAD) (LAD) infarction? infarction? HMMMMM???? HMMMMM???? Reciprocal Reciprocal depression depression in in all all three three leads!! leads!! All All three three leads leads are are on on the the other other side side of of the the heart heart from from the the infarction! infarction! Having a 12 lead machine around to keep an eye on the tracings is a good idea sometimes... Monitoring Monitoring For For Ectopy Ectopy on on aa 12 12 Lead Lead EKG EKG Sometimes Sometimes the the tracings tracings can can be be quite quite hard hard to to interpret interpret …and …and sometimes sometimes almost almost worthless... worthless... …sometimes …sometimes VERY VERY interesting... interesting... Acute Acute Hyperkalemia Hyperkalemia Acute Acute Hypokalemia Hypokalemia The The problem problem with with letting letting the the machine machine read read the the tracing??? tracing??? …but …but sometimes sometimes the the machine machine can can be be RIGHT!!! RIGHT!!! Don’t forget that 12 leads can let us forget to analyze the rhythm!!! Ventricular Hypertrophy Enlargement of of ventricles ventricles Left Left Ventricular Ventricular Hypertrophy Hypertrophy Left Left Axis Axis Deviation Deviation Deep Deep SS wave wave in in V1 V1 Large Large R R wave wave in in V5 V5 V1 V1 plus plus V5 V5 adds adds up up to to more more than than 35 35 millimeters millimeters Right Ventricular Ventricular Hypertrophy Look Look to to the the RIGHT RIGHT side side of of the the heart heart to to find find it, it, namely namely V1 V1 Finding Ventricular Hypertrophy Always Always look look at V1 Finding Finding Ventricular Hypertrophy Hypertrophy Large Large R R wave wave in in V1 V1 == RVH RVH Deep Deep SS wave wave in in V1 V1 == LVH LVH Corollary: Corollary: IfIf the the complex complex is is wider wider than than 0.12 0.12 seconds, seconds, this this is is probably probably aa bundle bundle branch branch block block and and not not ventricular ventricular hypertrophy hypertrophy Bundle Bundle Branch Branch Block Block Normal Normal Conduction Conduction Left Left Bundle Bundle Branch Branch Block Block V6 Right Right Bundle Bundle Branch Branch Block Block V1 Bundle Bundle Branch Branch Block Block Positive Positive Deflection Deflection Rabbit Rabbit Ears Ears in in V1 V1 with with wide wide complex complex Positive Positive Deflection Deflection in in V6 V6 with with wide wide complex complex Right Right Bundle Bundle Branch Branch Block Block Left Left Bundle Bundle Branch Branch Block Block Right Right Bundle Bundle Branch Branch Block Block Left Left Bundle Bundle Branch Branch Block Block Left Left Anterior Anterior Hemiblock Hemiblock Now, kiddies… IT’S EXAM TIME!! Sudden onset of chest pain in middle-aged woman, smoker, with positive family history 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 What isis this this patient’s patient’s blood blood pressure? pressure? Emergency Emergency medicine medicine providers providers are are primary primary members members of of the the medical medical team. team. The The scope scope of of practice practice of of these these professionals professionals continues continues to to grow grow with with passing passing years years The The report report of of the the recent recent Turtle Turtle Creek Creek Conference Conference indicates indicates that that paramedics paramedics and and nursing nursing professionals professionals can can be be trained trained to to have have 12 12 lead lead EKG EKG interpretation interpretation skills skills rivaling rivaling that that of of emergency emergency physicians. physicians. Prehospital Emergency Care, January 2001 Let’s Let’s insist insist that that basic basic 12 12 lead lead interpretation interpretation skills skills (and, (and, later, later, advanced advanced skills) skills) should should become become part part of of the the standard standard of of practice practice of of all all medical medical professionals. professionals. www.doctorfowler.com www.doctorfowler.com