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80104 12 Lead ECGs: Part I
Debbie S. Morris, EMT-P
My name is Debbie Morris. I am the training chief at Lubbock county EMS. Today we are
going to be going over a short review of 12 lead. This is actually the 12 lead ECG in an acute
coronary syndrome lecture that was developed by Tim Phalan. We have been doing 12 leads
here for approximately two years now and the original cards that came with this course, the
green index cards, I was hoping that we would have that down to memory at this point. Some do
some do not, so I would like to again emphasize how important it is to remember or know what
the leads stand for. In other words lead one, two, and three, aVR, AVL, AVF, what actual
location anatomically on the heart they stand for. This is a slide again showing you the typical
hospital printout of a 12 lead. On the bottom we have the three leads that the hospital likes to
look at. They can pick any three leads that they want to see, typically you see lead one, two, and
three or V1, lead two and V3 or lead three. At the top of the printout is where the actual 12 lead
is printed. It is just like ours it is just in a different format. Ours is more narrow and longer;
theirs is stacked on top of each other. When you do a 12 lead, understanding the basics behind
the monitor is knowing that to do a 12 lead interpretation it takes three leads and in 2.5 seconds
does in interpretation. In other words it will take lead one, two, and three, and in 2.5 seconds
does another three groupings of aVR, AVL, AVF, another 2.5, V1, V2, V3, another 2.5, V4, V5,
V6, for a total of ten seconds it makes in interpretation and it does that by looking at criteria.
Most of the time it is very accurate, but it is still important for you to be able to interpret the 12
lead because, if there is a lot of artifact or movement in the 12 lead it may give you a wrong
interpretation. When in that little circle here it says normal sinus rhythm it may or may not be,
again your interpretation is important. But when it says up here in this circle acute MI, the
monitor is correct 98% of the time. So when you see that it should be a very important clue to
you that something it is seeing, it is matching criteria, per se, nine out of ten or ten out of ten and
criteria points for it to put in great big bold print, acute MI agent, or acute MI. What the monitor
is extremely good at is time intervals, measurement of time intervals, but it does it in
milliseconds versus what we are used to seconds. We have been taught all along that when you
take your graph paper, large boxes, five small boxes, the small boxes inside and each has a time
frame. The small boxes are 0.04 seconds, and the large boxes are 0.20, but again that is seconds
versus your machine doing milliseconds. So it is simply a matter of math and moving a decimal
point over to figure the milliseconds back to seconds, if seconds are easier for you to determine.
Now we look at those in four time intervals, in other words a PRI interval, the QT interval, those
types of things to see if they are prolonged, shortened, and the QT interval specifically is looked
at an awful lot when it is prolonged. Prolonged being, norm or an average for the QT interval
should be half or less then half of the whole cardiac cycle. Again the 12 lead, when it is doing
its interpretation, going back to looking at the groupings of those in 2.5 seconds. It is looking at
one whole cardiac cycle in each lead to do its interpretation. So that is what we do, and that is
what we get used to doing when we look at our interpretations or do our interpretations of the 12
lead. We will take one good cardiac cycle out of each lead. Breaking down the actual
ventricular complex, I think it was extremely hard for the older generation of paramedics and
physicians, nurses to understand. We call that ventricular complex a QRS, but we need to
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understand that the QRS or the ventricular complex is actually broken down into three different
components. They may or may not be there so when you say QRS that does not necessarily
mean that all three components are there. Looking at the ventricular complex, the first positive
deflection of the ventricular complex is the R wave, will always be the R wave. And that is not
talking about the P wave, we are strictly talking about the ventricular complex. Before the R, if
it is there, is a Q wave. It may or may not be there, but the first negative deflection in front of
the positive deflection is a Q wave. The negative deflection after the positive deflection is the S
wave. So as you can see there are three different components, if they are all present. Q waves
specifically when we look at those, there is a physiologic Q, which is less than 0.04 seconds, and
there is a pathologic Q which is greater, obviously, greater than 0.04 seconds which is one small
box on the graph that your monitor prints out. The physiologic versus pathologic is something
that your monitor will pick up looking specifically for the pathologic Q which is shown or may
be possibly thrown by an old MI. Talking about the QRS, again the Q wave monitor looks at
that four Qs, looks for the pathologic Q, which is significant of an old infarct, and that is when
your monitor may print out acute MI, age undetermined. It is seeing a Q or a QS which there
will be a slide here of a QS, but it is the wider Q that it is looking for to identify an old infarct.
This is the slide of the QS. Again there is no R, there is no positive deflection so you can
correctly call this a Q or QS complex. Identification of the J point is extremely important in
identification of ST segment elevation or depression. Your J point is the very beginning of the
ST segment. Sometimes it is easily identified because it makes a, it is where the QRS end of the
S makes a sudden sharp turn in direction to be counted in the beginning of the ST segment. May
not always be a 90 degree angle, as this slide is showing. It may be somewhere in the slope of
the T but the identification of the J is essential to know if you truly have ST segment elevation or
depression. And we are going to compare that beginning with the J point, which is the beginning
of the ST, we are going to compare that to another line as far as a comparison for isometric line
and that will be the TP to determine whether we have elevation or depression. These are three
little practice slides, again, that shows whether we have ST segment elevation or depression.
The first image is obviously not elevation. The second picture is ST segment elevation, the J
point is way above where the TP is and the last picture is a little difficult because the ventricular
complex is a little blurred here. But you have an R deflection and then an S deflection and the J
point is actually below the isometric line of the TP so this would not be elevation it would be
depression. Again continuing with some examples, the first slide the J point in the ST segment is
pretty much isometric so that would not be considered ST segment elevation. The second slide,
again, is not ST segment elevation. The third slide would be considered minor ST segment
elevation; it is more than one millimeter or more above the TP line. Again, this is an example
showing you, we have to have something to compare to for isometric line or your baseline to
compare the ST as far as whether it is elevated or not. The ST segment has to be one millimeter
or more and two or more contiguous leads to identify ST segment elevation anatomically. We
have six pictures here, examples of ST segment elevation to guess whether they are or not. The
first one looking at the J point identifying the ST segment again is not elevation. The second
picture is ST segment elevation. You identify the J point, the ST, compare it to the TP and it is
at least one millimeter or more above baseline. The third picture, again here is a typical
presentation where the J is kind of pushed into the slope of the TP and it is considered an ST
segment elevation. The fourth picture is actually a block, which widened the QRS and makes it
a little confusing, but as the line of the R wave comes down it makes the J point below, or the
beginning of the ST segment below the isometric line. The fifth picture is very minimal but is

considered ST segment elevation and the sixth picture obviously is depression. Acute MI
recognition, we need to know certain things. We need to know what we are looking for. As a
repeat, we are looking for ST segment elevation one millimeter or more above baseline and two
or more contiguous leads. We need to know what we are looking for or what we are looking at
and that goes back to knowing what your leads stand for. Example, leads one, AVL, V5 and 6
are looking at the lateral aspect of the heart. If we continue on down to 2, 3 and AVF, they are
all looking at the inferior aspect of the heart. If you look across to V1, V2 they are septal. V3
and 4 are anterior. Your V leads are pretty much if you look at the location on the patient will
tell you exactly what they are looking at by there position. V1 and V2 sit right on either side of
sternum, sitting right on top pretty much of the heart, they are looking at the septal wall. V3 and
4 are looking pretty much, it is not totally right but they are looking at the anterior aspect of the
heart. And then you look at V5 and 6, which are over here, they are looking at the lateral aspect
of the heart. So their place in the line would tell you what they are looking at. Again ST
segment elevation of one millimeter or more above baseline and two or more anatomically
contiguous leads. They are contiguous by two aspects: One is anatomically, like we just talked
about, the inferior aspect of the heart, the lateral aspect of the heart, septal, all of those are
anatomically connected but they can also be contiguous in the chest leads which was called V
leads, they can be contiguous numerically. And that is confusing when you look at V2 and V3.
V2 is actual septal lead and V3 is anterior, but they are contiguous and they are considered
contiguous because they are chest leads and they are numerically contiguous. ST segment
elevation, and this is a pretty strong statement, is presumptive evidence of acute MI. It is
indications for acute reperfusion therapy, and we do start that in the pre-hospital arena. We start
it with the use of aspirin, the use of nitro, and morphine if pain continues after the nitro is given.
Aspirin is a very important player, we have talked about it in the past how it is comparable to
streptokinase, it is extremely important to convince the patient or educate the patient on taking
the aspirin in the pre-hospital field. We have a practice that is for us to identify an injury pattern.
In lead one we see depression, two, three, and AVF, we have ST segment elevation, and then we
have depression, like I said in one AVL, it is pretty obvious where the depression is. Remember
it is important to look for elevation first. Elevation is where the injury is going to be and
depression tends to be either a reciprocal change to or it may be an ischemic pattern on its own.
When we talk about if we saw depression in V1 through V4 it may be a reciprocal change to a
posterior wall MI which would not show any ST segment elevation on a straight 12 lead, we
would have to move leads to get that picture. Here we are showing again elevation 2, 3, and
AVF, which is an inferior wall injury. This is the one where we need to make some changes as
far as where the electrodes are placed. Some physicians will move four, five, and six to the right
side of the chest wall. We move the four from the left position and move it to V4 right and if we
have ST segment elevation in the V4 right position. Then we know that we potentially have a
very high block of the right coronary artery. Then we talk about lead placement. Again just as a
review, you have your limb leads and you have your chest leads. Limb leads can be placed on
the distal ends of the extremities or the upper position on the extremities, but I like to reinforce
that they are called limb leads for a reason. Typically when we start out you may have put your
monitor on or your three or four lead in the positions normally on the torso or the chest. But
when you decide to make the 12 lead interpretation you need to remember to move those out to
the limbs and it does not matter if it is at the top of the limb or the distal end. Chest leads
however, cannot move. They have to be precise in their placement. This is your grouping
showing again your anatomical what the leads look at 1, AVL, V5 and V6 all are your lateral

leads, V2, 3 and AVF are inferior, V1, V2 are your septal leads, V3 and V4 are anterior. This is
the typical picture of the leads in the correct placement on a male patient. Again it does not take
an awful lot of time to put the leads on we have this type of presentation and now there are some
other type, shaped form leads that come out, the uni-leads where the chest leads are all in one
strip across the chest. If you are using the end leads and you come across an inferior injury
pattern, the one that we just saw earlier, you need to make the decision to go ahead and put all
the leads back on the patient so that you can move your V leads to the right position to see if we
have a high block. This slide is showing you the position of the leads, where and why they get
the picture they do. Two, three, and AVF they are all coming from a positive lead at the lower
left leg so that if you looked at that electrode as a camera, it is actually looking up at the bottom
of the heart, the inferior aspect of the heart and that is again showing you what position or what
part of the heart that it is seeing. One and AVL the electrode, again the positive electrode up on
the shoulder, again if it was a camera it was looking down on the lateral aspect of the heart as
well as V5 and V6 or an AVL or up here, V5 and V6 are right over here on the side of the heart
and all four leads will show you lateral wall. V3 and V4 as we talked earlier, they are sitting on
the heart where they do show the anterior aspect of the heart. V1 and V2 they sit right on top of
the heart and they look exactly at the septal wall. And there are all your different aspects or
locations that are specific to the 12 lead. And if you notice, there is no posterior wall picture
here and we would have to move leads, we will talk about it later in the presentation, on moving
leads to see the posterior wall of the heart. So we know that we have to look for ST segment
elevation one millimeter or more above baseline, your isometric line in two or more contiguous
leads. They are contiguous because of the area of the heart they are looking at or they are
contiguous because they are numerically contiguous in chest leads only, the V leads. When you
originally had this course you were given a pocket card as a reference to put those leads to
memory. Some of you are still using the cards, others have memorized it, but it is in your best
interest to memorize those leads so that when you do look at your printout you know instantly
what location is showing an injury pattern. Evolution of the acute myocardial injury or infarct
pattern starts with the hyperacute phase. We may or may not see this with the patients in the prehospital field. At this point the patient may not be symptomatic at all, but the first evolution is
that the T wave becomes tall and peaked. If there is no invasive therapy at this point the next
progression is that the injury starts occurring and we see that on the 12 lead with the ST segment
elevation. The T wave is still potentially peaked but the ST segment is elevated. Again no
intervention at phases two. Potentially throwing a Q wave, not all infarcts will throw a Q but if it
is going to this would be the time of the staging that a Q evolves in the infarct. The ST segment
is still elevated and the T is still peaked. If the patient survives the MI and it may have been a
silent MI, a lot of your diabetics for example may have silent MIs and they had no intervention
and everything resolved without any deficit to the patient. What there 12 lead will show and
what we have seen already running the 12 lead that we have run is that the Q or the QS is now
present and that is where your monitor shows acute MI, age undetermined. It is seeing a Q or a
QS wave that was developed during the MI. Remember that a normal 12 lead does not rule out
acute myocardial infarction. If your patient is symptomatic you want to treat them just as if the
MI is occurring until we get them to the hospital and it is ruled out by the physician at the
receiving facility. Reciprocal changes pretty much this slide is trying to show you that the
injured wall of the myocardium is electrically silent so your positive electrode that is looking at
the injury pattern will show an ST segment elevation. The electrode that is on the opposite side
of that wall is going to see that injury pattern as depression, that is on the back side and the

actual injury of the myocardium is electrically silent so it sees it as it is coming backwards per se
to the electrode. This is a see saw, I refer to it as a see saw, that shows you where you find your
reciprocal changes. If you have ST segment elevation in 2, 3, and AVF, you look for a
reciprocal change, which is ST segment depression in 1 AVL and the V leads, but it works just
the opposite. If I have ST segment elevation then 1 AVL and the V leads, then I look to 2, 3, and
AVF for ST segment depression, so they are the exact opposites of each other and that is
something that you would need also to put to memory as far as where to look for. Number one,
your ST segment elevation and then where to look for the reciprocal change to that as in ST
segment depression for reciprocal. Reciprocal changes, to summarize again, are not necessarily
needed to be there to presume infarct but they are a strong confirmation when they are present.
The most common imitators showing in this list are your left ventricular hypertrophy, your
bundle branch blocks, ventricular beats, pericarditis, early repolarization, and others, which will
be discussed in module six I believe it is. Summary to this module again, is we have to know
what we are looking for. We are looking for ST segment elevation greater than one millimeter or
more above baseline and two or more contiguous leads. Contiguous being anatomically what
aspect of the heart you are looking at or contiguous by numerically contiguous in V leads only.
We have to know what those leads stand for, what leads location, what the leads are actually
looking at so that when we print our 12 lead we can immediately know if we see 2, 3, and AVF it
is inferior if we see V1, V2 it is septal, and so on and so on, so you have to put those leads to
memory. Again reciprocal changes do not necessarily have to be there to presume infarct but are
strong confirming evidence when present. We do know that ST segment elevation is a very
strong presumptive evidence of acute myocardial infarction but that there are other conditions
that can also cause ST segment elevation and they are referring back to the imitators. And last
but not least a normal 12 lead ECG does not rule out an acute MI. Acute MI is a part of a
spectrum of a disease known as acute coronary syndrome, a very small part. Module II we are
going to talk about acquisition and transmission of the 12 lead. The first thing we know is that it
does not increase your scene time. We have done local studies and there have been national
studies that show when you first start your 12 lead in your system initially until the pre-hospital
medics get used to the placement of the electrodes there was a slight delay. But the down side or
I should say the up side to it is that when they started recognizing ST segment elevation and
significant injury patterns, it did tend to speed up the response time back to the hospital, so it
equaled out. It does not increase the on scene time as we originally thought that it had a potential
to do. Our acquisition goals are to obviously be able to print out a clear and accurate and fast 12
lead. We are going to go over how we do that. We need to understand that the 12 lead is not just
a bunch of extra wires. It actually has a very different internal design then the normal 3 lead or 4
lead monitor. The difference is that in a 3 lead ECG you are running in monitor quality. In
monitor quality there are numerous filters put on built throughout your sixty cycle, your muscle,
your skeletal muscle twitching. It also, in putting on these filters will filter out your ST segment.
What it will give you and why we love it is because it is generally by nature very clear and
precise picture but it is just giving you rate and rhythm. The difference between a 3 lead and 12
lead is the diagnostic mode. When you are running in diagnostic mode all the filters are off the
machine. So because the filters are off we now have to worry about sixty cycle, we have to
worry about muscle movement, we have to worry about all the electrical magnetic interference in
the environment around us. We have to consider what is close to the patient and especially
things like electric blankets, cell phones, the radio you may be carrying, all may produce an
electrical magnetic interference that would not allow you to print out a clear ECG. Frequency

response, one of the ways to determine whether the machine is functioning properly, is to look at
the bottom of your printout and check to make sure that your frequency response is within the
normal limits. Frequency response as standard is 0.05 hertz to 150 hertz and those that are
circled here in this little printout, it shows you where to look for that frequency response.
Diagnostic quality produces a more accurate ST segment and T waves but it is also more
sensitive to artifacts, so it is kind of a catch 22. Just when you need a precise diagnostic tool and
you run a 12 lead, all the filters are off, so it tends to be not as clear and precise as when you are
running in monitor mode. But clinically to say that you are looking at ST segments, you have to
be running in a diagnostic mode. Steps that we take to improve our printout would be hair
removal and skin prep. It is a kind of important that we remove the hair and clean the skin to
have good contact between the electrode and the electrical impulse that is coming up through the
skin to the electrode. Several ways to remove the excess hair would be clippers over razors
which lessens the risk of cuts, we want to lessen that risk if this patient is a candidate for
thrombolytics. It is also quicker and we have the disposable blades or clipper heads available so
for each patient there is a different head to change out as compared to using a clipper, or you do
not want to use a clipper that does not have a head you can change out. This is just one example
that is used by the 3M Company. I am not saying that is a brand you have to use but that is the
one that they actually are making today. I am showing you the disposable head. Skin prep again
happens with the ECG monitor to obtain a signal that is coming up from the underlying surface.
And it is important to understand that the skin has an oil on top that you need to get rid of
obviously for better conduction. And then also what we need to do is to not only remove the oil
but we want to abrade the skin surface so that again we have better contact with the electrode to
the skin. This is a picture showing that one of the services actually uses a very fine grade of
sandpaper to abrade the skin so that the gel of the electrode actually has good contact with the
skin. You can do the same with a dry 4x4 or a towel simply making sure that all the oil is off
and that you have abraded that dead skin layer of the skin. Other causes of artifact would be
patient movement, cable movement, your vehicle movement, and electrical magnetic
interference. Airports for example with their radars, the strong radars are a very good example
of the electrical magnetic interference. So you may have to move your whole unit out of an
environment that would have a strong electrical magnetic interference. The junction box, as far
as where your chest leads plug into the main cable. You want to make sure that it is stable either
on the stretcher or on the bench so that it is not bouncing in between the patient and the bench as
you are driving down the road. If it comes to pulling the unit over and stopping, remember it is
only ten to twelve seconds for interpretation and instructing your patient to lay as still as possible
while the machine runs and interprets the 12 lead. Make the patient as comfortable as possible.
Supine is preferred but if you have to change the patient into a semi-sitting position that is okay.
It is just that you need to write that on your 12 lead that the patients strip was done in a semisitting position. And that is so that if a second or third 12 lead is run in the hospital and they
compare the two and there is any difference they will know that your 12 lead was run in a semisitting position and theirs may have been in a supine so they will know it may have been the
patients position that made the changes in the ECG. Checking the patient for any kind of
movement whether it is toe tapping, shivering, one of the things that is most common is the
grasping of the rail. They are scared and you want to relax them as much as possible so have
them lay there hands down by the side on the stretcher and relax versus a hard grip and a muscle
tremor that you get out of grasping the rail. You want some slack between the monitor and the
patient but not too much slack. You do not want so much that it has a potential of bouncing

around a lot. Again vehicle movement, there are monitors that do extremely well whether the
vehicle is moving or not. If you have a monitor that is sensitive, you may have to pull over but
again it may take ten to fifteen seconds and that is all it takes to get it to do its interpretation and
then you can go ahead and transport. Electrical magnetic interference can be from anything. We
have already talked about airports, we have already talked about cell phones, we have already
talked about radios. Most of your electrical devices can, or all of them have a potential of having
an interference with your 12 lead so you might have to turn your radios, pagers and all of that off
for ten to fifteen seconds. Strategies again for clear ECG would be to make sure the patient
cables do not touch the power cord, move away from any AC equipment, turn off or move
devices that may be not only on the patient but yourself and move away from areas of electrical
noise. Again that would be, example of that would be the airport. Things to look for would be
an ECG that has little or no artifact and a very steady baseline. You do not want this top picture.
The top picture is the wandering baseline. There is no way that your machine or yourself could
interpret this or a physician. You want the bottom picture where the isometric line and the
baseline is steady and you would be able to interpret this type of strip 12 lead. Accuracy
depends on your lead placement. Your frequency response should be within the norms that we
have already talked about, that your machine, your 12 lead is actually calibrating the way that it
should when you are doing your checks of your equipment in the morning. You can do all of
this as far as checking your frequency response, your calibration, and your paper speed, to make
sure that your machine is operating correctly. We talked about limb lead placement earlier in
module I but again we are showing a distal placement here on the limb leads and then also the
proximal portion of the extremities, their placement could be either placed on the limbs, but as
long as they are on the limbs. We have not talked about aVR a lot and as far as anatomically for
this course we are not going to talk about it other then these two aspects and that is that aVR
should always be negative. If you have an aVR that is upright look for reversal of your limb
leads or you potentially have an axis deviation. Chest lead placements however, have to be
precise. V1 and V2 are either side of the sternum in intercostal 4. V4 should be your next
placement and it should be moved clavicular and intercostal 5 then you can go back between V2
and V4 and place V3 in the middle between V2, V4. V5 and V6 are placed in the fifth
intercostal space again in line with V4, but V5 is the anterior axillary line and V6 is the
midaxillary line. Again, this is the actual picture of the leads placed on a male patient. Again, to
print out an accurate ECG we look for a negative aVR, we look for one complete cardiac cycle in
each lead, we look to make sure that our diagnostic frequency response is within its normal
range, that the machine has calibrated properly, and that the paper speed is within its normal
limits. Always use your diagnostic quality for ST segment analysis. Depending on who makes
your monitor, it may be a button that you have to push to go into diagnostic mode. Some
machines automatically go into diagnostic mode when you push the 12 lead button. So knowing
your equipment and knowing whether you have to actually physically make this change or not is
important. Frequency response display screen is nondiagnostic. You use the printed ECG for
ST segment analysis. Again showing you where the frequency response will be printed out on
your 12 lead paper, down on the bottom left hand corner should be 0.05 to 150 hertz. Calibration
is done when you turn the machine on and again it should be that it is calibrating two big boxes
and here is a picture of it circled showing you that the machine has calibrated correctly. Your
paper speed, the standard is to run at 25 milliseconds and again showing you where you would
find that on your printout. Printing out an accurate ECG again your negative aVR, your have
one complete cardiac cycle in each lead, it is within its normal diagnostic frequency response,

your machine is calibrated properly, and it is within the normal appropriate speed. When to
acquire, that is an important question that we get every time we start 12 lead interpretation and it
is highly important to point out that ST segment changes can occur rapidly or within minutes.
We ask that you do your first 12 lead in the house or on scene with a patient. It may be
depending on if the patient is in a home or if they are outside. You do want to keep in mind the
patients privacy but the sooner you get the 12 lead, the first one, the better off the patient will be.
And then the second one in continuing 12 lead should be done every five to ten minutes or with
every change in patient status. And as you can see with these two examples there is quite a
difference between the first printout where you have massive ST segment elevation in V1, 2, 3,
and 4 and then has had a complete change from that picture within minutes from the first
acquisition. We want to acquire the first 12 lead with a first set of vital signs, your oxygen,
getting your brief history. It is important to work with your partner in again acquiring this 12
lead as fast as possible. It is important to know the vital signs as early as possible because that is
going to determine treatment. If the patient is hypotensive we might not be able to give them the
nitroglycerin and morphine, so we want to make sure that the vitals are holding so that we can
continue with all of the treatment. Exposing the chest, obviously that is important. We want to
remove all of the clothing from above the waist and the best picture is to replace that clothing
with a hospital gown. It is easier access to the patient as far as placing your leads and it is also
easier access as far as establishing any lines to just go ahead and hand them a hospital gown and
do that when you are prepping the patient or assisting the patient for transport. Exposing the
chest allows for a complete exam and prevents wire entanglement of your 12 leads and again
easier access for your IV lines, but it also gains or gives you easier access for quick defibrillation
if the patient starts deteriorating. Transmission, if you have the capability to transmit you want
to do it as soon as possible. If you cannot, if you do not have any transmit capability, then you
want to do a second printout or make a copy of any 12 leads that you have done and have them
ready for the physician upon arrival at your emergency department.
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