Introduction to
12 Lead EKG’s
Learning Objectives
? 12 lead EKG use in VBEMS
? EKG review
? Heart A&P
? Correct lead placement for 12 lead EKG
? 12 lead changes indicating cardiac event
Introduction
? 12 Lead EKG
technology in
prehospital setting
still an emerging
process
? Technology around
for years
? Practical use in EMS
not yet clearly
defined
Goals of Prehospital 12 lead EKGs
? QT Interval
– Time for depolarization and repolarization
of the ventricles
? Isoelectric Line
– Flat part of the EKG
– Represents electrical neutral
Remember Tom?
? Assessment indicates
some cardiac injury or
insult is occurring
? Able to identify
unifocal PVC’s on
monitor
? Unable to isolate the
cause of Tom’s chest
pain
Treatment
? High concentration oxygen
? Aspirin324 mg PO
? Sublingual Nitroglycerine X3
– Given at 5 minute intervals
– B/P above 110 systolic without IV
– B/P above 90 systolic with IV
? Morphine 2-4 mg IV every 5 minutes up
to 10 mg
Treatment
? Color coded
– Left leg – Red
– Left arm – Black
– Right arm – White
– Right leg – Green
Limb Lead Placement
? Preferred method is to
place limb leads on arm or
leg between shoulder and
wrist or hip and ankle,
away from bony
prominences.
? In the EMS environment,
the limb leads sometimes
are shifted onto the torso
near their corresponding
attachment point.
Chest Lead Placement
? Chest leads are generally
marked by vector
abbreviations and color-
coded:
– Chest lead 1 – V1 – Red
– Chest lead 2 – V2 – Yellow
– Chest lead 3 – V3 – Green
– Chest lead 4 – V4 – Blue
– Chest lead 5 – V5 – Orange
– Chest lead 6 – V6 – Purple
Chest Lead Placement
? When properly
placed
– Should be in
intercostal spaces
– At specific locations
– On anterior and left
lateral chest wall
? Try not to place lead
directly over a rib
Chest Lead Placement
V1 - 4th intercostal R of sternum
V2 - 4th intercostal L of sternum
V4 – 5th intercostal midclavicular
V6 – 5th intercostal midaxillary
V3 – between V2 and V4
V5 – 5th intercostal between V4 and V6
? Lead I
– RA to LA
? Lead II
– RA to LL
? Lead III
– LA to LL
Augmented Limb Leads
– Voltage is so low it has to be augmented by the
machine
– aVR
• Heart to RA
• augmented voltage right arm
– aVL
• Heart to LA
• augmented voltage left arm
– aVF
• Heart to LL
• augmented voltage left foot
Chest Leads
LEAD VIEW
V1, V2 Septal
V3, V4 Anterior
? Faces the
diaphragm
? Most frequent type
of MI in emergent
setting
? Receives blood from
Right Coronary
Artery – posterior
descending branch
Left Inferior Wall MI
? Isolated inferior wall MI
– Lead II
– Lead III
– Lead aVF
? Reciprocal changes
–I
– aVL
? Can be seen using standard 3 lead EKG
? Do not rely on 3 lead for Dx because will not
show posterior wall or septal wall inclusion
Septal Wall MI
? Muscular wall
separating right and left
ventricle
? Serves as a conduit for
much of the hearts
conduction system
? Isolated septal wall MI’s
are rare
? Most are associated
with left anterior or
inferior wall infarctions
Septal Wall MI
? ST elevation
Limb Leads Chest leads
– Lead I - V5
– Lead aVL - V6
? Reciprocol changes
– V1-V3
Left Posterior Wall MI
? Faces towards the back
of the patient
? Receives blood from
the Right Coronary
Artery (90% of pts) or
circumflex artery (10%
of pts)
? Isolated posterior are
rare
? Usually associated with
lateral or inferior wall MI
Left Posterior Wall MI