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A Basic

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

? Early notification of cardiologist that


patient has suspected STEMI
– ST elevation MI
? Decrease door to puncture time
? Goal is NOT to bypass ED
Importance of Prehospital
12 Lead EKG’s
? The prehospital 12-lead EKG
establishes a base line from which the
hospital staff can track the progress of
myocardial damage.
12 Lead EKG Introduction
? 12 lead EKG acquisition process
simple to learn
? 12 lead EKG acquisition process can
be taught in a short period of time
? Most 12 lead EKG interpretation
courses require up to 40 hours of
instruction for basic proficiency
Patient Scenario

? Dispatched to a “person with chest pains”


? Engine arrives several minutes before you
do
– Places patient on 2 liters nasal O2
– Taking vitals on your arrival
? Patient’s name is Tom
Patient Scenario

? Tom is 48 years of age


? Medical history
– Obesity
– Sleep apnea
– Hypertension
– Peripheral artery disease (PAD)
– Daytime pedal edema (relieved at night)
– Borderline diabetic
Patient Scenario

? Tom has not been sleeping well


? Worried about his position at work
? Overwhelmed by number of projects at
work
? Experienced substernal chest pain
shortly after a project management
meeting
Initial Assessment

? Awake, alert, oriented to person, place,


time and circumstance
? Color is pale
? Skin is cool to the touch
? Radial pulses are strong & irregular
? Tom is complaining of occipital
headache and pressure type chest pain
radiating to his back
Focused Assessment

? Increasing anxiety and agitation


? Vitals
– B/P 196/120
– Pulse 92 irregular
– Respirations 28
not labored
Focused Assessment
? Breath sounds reveal diffuse wheezing
throughout lung fields – SpO2 95%
Rhythm Identification
? Most rhythm
identification in lead II
? Good for detecting
lethal dysrhythmias
? Electrical impulse
flows from right
shoulder to left leg
Rhythm Identification
? Modified Chest Lead 1
(MCL 1)
– Mimics chest vector lead 1
(V1)
– Shows electrical flow from
center of chest towards left
shoulder
? Shows upright P wave
? Useful in delineation
between atrial and
ventricular rhythms
EKG Review
?P Wave
– Contractions of the atria
? PR interval
– Time electrical impulse takes to spread
through the atria, AV node and Bundle of
His
? QRS
– Contractions of the ventricles
EKG Review
? ST Segment
– Most important to this course
– Measured from end of QRS to beginning of
the T wave
– Used to determine ischemia, injury or
myocardial infarction
?T wave
– Repolarization of the ventricles
EKG Review

? 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

? TEMS protocols are designed to:


– Decrease further injury by increasing
oxygenation
– Dilate the coronary arteries
– Alleviate Tom’s chest pain
– Decrease platelet activity
Would your
treatment
change
based on a
12 lead
EKG ?
3 Lead vs 12 Lead EKG
?3 Lead EKG
– Good for dysrhythmia identification
– May not identify life threatening injury to
myocardium
– Only shows 1 plane of heart
? 12 lead
– Shows multiple planes of heart
– Increases chance of identifying injury to
myocardium
3 Lead EKG
? Ifthe heart was on a
pedestal
– Paramedic would be
looking up at left
ventricle
– Would see inferior
wall of left ventricle
12 Lead EKG
? Standard 12-lead EKGs are designed to
look at the left ventricle.
? Give multiple views of heart
? Does not give three dimensional view of
heart
? Shows myocardial damage by the
disruption of normal electrical activity
? Inference is made about which
anatomical region of the heart is injured
12 Lead Basics
? Standard 12 lead
– 4 limb leads
– 6 chest leads
• Also called vector leads
Planes of Heart
? Frontal Plane
– Divides front and
back
– Limb leads show
frontal plane views
? Horizontal Plane
– Divides top and
bottom
– Chest leads show
horizontal plane
views
Lead Placement

? The person acquiring the 12-lead EKG


must pay close attention to the
application of the EKG leads
? Misplacement of the leads can alter the
EKG machine’s representation of
electrical flow and increase the chances
for misinterpretation
Lead Placement

? Particularly important in the out-of-


hospital setting
? First of progressive 12 lead EKG’s to
manage medical treatment
Lead Placement
? Standard 12 lead
– 4 limb leads
– 6 chest leads
• Also called vector leads
Limb Leads

? 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

Try not to place lead directly over rib

Hint: Angle of Louis at 2nd rib


12 Leads but only 10 electrodes?

Limb Leads Chest Leads


?I ? V1
? II ? V2
? III ? V3
? aVR ? V4
? aVL ? V5
? aVF ? V6
Limb Leads
? Limb leads are used
to view the heart
from more than one
angle on frontal
plane
? Bipolar leads
– Positive and
negative
Limb leads
? Looks at inferior wall
of left ventricle

? 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

? Look at heart from


horizontal plane
? Leads are positive
? Heart is theoretical
negative electrode
? Also called
precordial or vector
leads
What Each Lead “Sees”

LEAD VIEW

II, III, aVF Inferior

V1, V2 Septal

V3, V4 Anterior

V5, V6, I, aVL Lateral


Taking a 12 lead EKG

? Ideally,12 lead EKG’s should be taken


with the patient lying supine or reclined
in a comfortable position
? In acute myocardial infarctions, the
patient may not tolerate lying down
? In Tom’s case, if he is not able to lie flat,
the 12 lead EKG can be obtained in a
reclined position of comfort
Taking a 12 Lead EKG

? Once leads are in place


– Patient should relax as much as possible
– Breath normally
? Muscle tension will show as muscle
tremors on tracing
? If necessary – have patient take a
couple of deep breaths to aid in
relaxation
ST Segment Changes
? Indicative
ST
segment changes
– Raise above the
isoelectric line
– Indicate damage to
myocardium specific
to electrode
– Elevation of 2 mm
coupled with positive
physical findings
indicates an MI
ST Segment Changes
? Reciprocal ST segment
changes
– Drops below the
isoelectric line
– Indicates damage in the
anatomical opposite of
myocardium
– Depression of 1 mm
couples with physical
findings indicates a heart
attack
Areas of Injury
? Blockage of specific arteries in the heart will
cause corresponding specific changes to the
QRS complexes
? 5 locations where damage can be identified
on standard 12 lead EKG
– Left Anterior Wall MI
– Left Inferior Wall MI
– Septal Wall MI
– Left Lateral Wall MI
– Left Posterior Wall MI
Coronary Circulation
1. Aorta
2. Right Coronary Artery
3. Left Anterior
Descending Coronary
Artery
4. Circumflex branch of
Left Coronary Artery
5. Left Coronary Artery
(Main)
Left Anterior Wall MI

? Faces front side of


chest
? Receives blood from
left coronary artery
(LCA) and left
anterior descending
artery (LAD)
Left Anterior Wall MI

? Indicated by ST elevation in chest leads


– V3
– V4
? Mayhave reciprocal changes in limb
leads
– Lead II
– Lead III
– Lead aVF
Left Anterior Wall MI

? Associated with left ventricular failure due to


large amount of muscle mass involved
? Leads to CHF
? Can lead to Mobitz Type 2 block
? Can lead to Complete Heart Block
? Lethal arrhythmias include sudden onset
– Ventricular Tachycardia
– Ventricular Fibrillation
Left Inferior Wall MI

? 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

? Receives blood from


– Arteries perforating septal wall
– Left anterior descending artery (LAD)
? There are 6 septal wall perforating
arteries branch from LAD
Isolated Septal Wall Infarction

? ST elevation in chest leads V1 and V2


? No reciprocal changes associated with
septal wall MI’s
Left Lateral Wall MI
? Faces the left side of
the body
? Receives blood from
Left Coronary Artery –
circumflex branch
? Isolated MI to the left
lateral wall is rare
? Most often associated
with
– Anterior wall
– Inferior wall
Left Lateral 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

? Indicative changes or elevation of ST


segment are not visible with standard
12 lead EKG
? Identified through reciprocal changes in
– V1
– V2
– V3
– V4
Left Posterior Wall MI

? Tricks for identifying posterior wall


? Hold 12-lead EKG to light upside down
and backwards
? Look for ST elevation in V1, V2, V3, V4
Managing and Transporting the
Patient
? Prehospital treatment is determined by
clinical presentation
? Prehospital treatment is focused
relieving hypoxia and restoring
adequate blood flow to the myocardium
? 12 Lead EKG goal is to decrease door
to puncture time
Practice 12 lead #1
Practice 12 lead #2
Practice 12 lead #3
Practice 12 lead #4
Practice 12 lead #5
Practice 12 lead #6
References
? Beasley B, West M. Understanding 12-Lead EKGs: A Practical
Approach. 2001. Brady-Prentice-Hall Inc. Upper Saddle River,
New Jersey.
? Heart Attack and Acute Coronary Syndrome: What is a heart
attack (myocardial infarction) and what causes it? Eastern
Virginia Medical School. Downloaded September 5, 2005 from
http://home.mdconsult.com .
? Phalen, T. The 12-lead ECG In Acute Myocardial Infarction.
1996. Mosby-Year Book. St. Louis, Missouri.
? Wikipedia. Coronary Circulation. Downloaded August 28, 2005
from http://en.wikipedia.org/wiki/Coronary_Circulation.
? University of Chicago Hospitals “Basic EKG Interpretation”
Accessed September 6, 2005 from
http://academyconnect.uchospitals.edu/v1/40222/

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