Download 12 Lead EKG Interpretation

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