12-Leads Made Easy

12-Leads Made Easy

12-Leads Made Easy Presented by Tim Phalen What’s the big deal about ST elevation? AMI NSTEMI STEMI Clot Composition Occlusion Timing Treatment ...

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12-Leads Made Easy

Presented by Tim Phalen

What’s the big deal about ST elevation? AMI

NSTEMI

STEMI

Clot Composition Occlusion Timing Treatment Copyright Tim Phalen, 2012. All rights reserved.

2

Copyright Tim Phalen, 2012. All rights reserved.

3

Is ST elevation present? Which of these examples meets the ST elevation criteria?

Yes No

Yes No

Yes No

Copyright Tim Phalen, 2012. All rights reserved.

Yes No

4

Is ST elevation is present in 2 contiguous leads?

Copyright Tim Phalen, 2012. All rights reserved.

5

Is the ST elevation from STEMI or a STEMI impostor? What are the 5 most frequent STEMI impostors in ED/911 patients? 1______________________________________ 2______________________________________ 3______________________________________ 4______________________________________ 5______________________________________

List all other STEMI impostors you can think of

Copyright Tim Phalen, 2012. All rights reserved.

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Junction Point or J Point The J Point is identified by located the point where the QRS ends. Often, but not always, there is a sudden or sharp change in direction at the J point.

Place a dot on the J point in the following examples

A

B

C

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D

8

Measuring ST deviation (elevation or depression) Compare the J Point to the TP segment. Estimate the number of millimeters of ST deviation. List elevation as a Positive number and

A

+_______ -_______

B

D

+_______ -_______

C

+_______ -_______

E

Copyright Tim Phalen, 2012. All rights reserved.

+_______ -_______

+_______ -_______

9

Place a check mark next to all leads with at least 1 mm ST elevation

Copyright Tim Phalen, 2012. All rights reserved.

10

Lead Views Label how each electrode is used as a positive electrode for specific leads

Copyright Tim Phalen, 2012. All rights reserved.

11

Lead “views” on the 12-lead ECG

Lateral

Septal

Anterior

Inferior

Lateral

Septal

Lateral

Inferior

Inferior

Anterior

Lateral

Copyright Tim Phalen, 2012. All rights reserved.

12

Copyright Tim Phalen, 2012. All rights reserved.

13

ECG evolution of STEMI A T waves is considered tall if more than ______mm in a limb leads and more than _______mm in a chest lead

Hyperacute

Acute Q wave is considered pathologic in more than ______ ms wide or more than ______% the height of QRS Acute

Remember! A normal ECG does not rule out AMI

Copyright Tim Phalen, 2012. All rights reserved.

Age Undetermined

14

Examine each lead for: 1) pathologic Q wave, 2) ST elevation, 3) ST depression, 4) tall peaked T wave or 5) inverted T wave

Copyright Tim Phalen, 2012. All rights reserved.

15

Reciprocal Changes

II, III, aVF

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I, aVL, V1-V6

16

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17

Remember: Not all STEMI produces reciprocal changes! Copyright Tim Phalen, 2012. All rights reserved.

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Eliminating the Top 5 STEMI Impostors STEMI Impostor: Any cause of ST elevation other than AMI 1) Left Ventricular Hypertrophy 2) Bundle Branch Block (left and right) 3) Ventricular Rhythms (paced and spontaneous) 4) Benign Early Repolarization 5) Pericarditis

When ST elevation is noted, see if the top STEMI impostors can be eliminated as causes of that elevation

Left Ventricular Hypertrophy Enlarged left ventricle May produce ST and T wave changes ! ST elevation and/or tall T waves in V1-V3 ! ST depression and/or inverted T waves in V4-V6 Increases amplitude of QRS ! Mathematical calculation ! Many formulas exist

Means of suspecting LVH 1) Look for this statement in the interpretive statement “Meets voltage criteria for LVH” 2) Obviously and dramatically increased QRS amplitude 3) Do the math yourself

Copyright Tim Phalen, 2012. All rights reserved.

20

Left Ventricular Hypertrophy

V1

Suspecting LVH Step 1 Measure the depth of the S wave in Lead _______

Step 2 Compare leads _____ and _____, determine which has the taller R wave Measure the height of the taller R wave

Step 3 Add the two numbers together Suspect LVH is the sum is greater than _____

Copyright Tim Phalen, 2012. All rights reserved.

21

Is LVH likely to be the cause of the ST elevation found in this ECG?

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Bundle Branch Block and Ventricular Rhythms BBB and ventricular rhythms widen the WRS ! QRS duration > 120 ms If ST elevation is present and the QRS is less than 120 ms, neither BBB nor ventricular rhythms are likely to be the cause. Examine this ECG, how likely is the ST elevation to be from either BBB or a ventricular rhythm?

Copyright Tim Phalen, 2012. All rights reserved.

23

Benign Early Repolarization ECG changes ! ST elevation ! Often in Leads ____ and _____________ _____________ leads ! Notches at the J point and upward concavity of ST segment ! May produce Tall Peaked T waves ! May meet the 35mm criteria for QRS amplitude ! ! Usually without chamber enlargement ! DOES NOT produce reciprocal changes Patient characteristics ! Usually Male ! Usually young and healthy (20-40 years old) ! Pattern seen more frequently in some ethnic groups ! ! African Americans

Copyright Tim Phalen, 2012. All rights reserved.

24

Pericarditis ! ! ! ! ! ! ! ! !

Patient characteristics ! Sharp chest pain ! Affected by movement and position (lying back may hurt worse) ! If suspected, ask if they can localize pain with 1 finger ECG Changes ! ST elevation ! ! either in all/most leads or ! ! in lead groups other than typically seen in STEMI ! DOES NOT produce reciprocal changes

NOTE: If reciprocal changes are observed, then the ST segment elevation in not likely to be from either benign early repolarization or pericarditis.

Copyright Tim Phalen, 2012. All rights reserved.

25

Eliminating the Top 5 STEMI Impostors Three Questions 1) Does the ECG meet the voltage criteria for LVH? 2) What is the QRS duration (width)? 3) Are reciprocal changes seen?

IF the ECG doe not meet the criteria for LVH, the QRS duration is within normal limits and reciprocal changes are present THEN assume the top 5 STEMI impostors are not producing the ST elevation

Copyright Tim Phalen, 2012. All rights reserved.

26

Examine ECG ! Pathologic Q ! ST elevation ! ST Depression ! Tall T wave ! Inverted T wave If ST elevation criteria met ask 3 questions ! Does the ECG meet the voltage criteria for LVH? ! What is the QRS duration (width)? ! Are reciprocal changes seen? Categorize ECG

STEMI

Maybe STEMI

• Clinical suspicion of AMI • ST elevation criteria met • Top STEMI Impostors absent

• Clinical suspicion of AMI • ST elevation criteria met • Top STEMI impostor present

Copyright Tim Phalen, 2012. All rights reserved.

Not STEMI • Clinical suspicion of AMI • ST elevation criteria NOT met

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Categorize ECG

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Categorize ECG

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Categorize ECG

Copyright Tim Phalen, 2012. All rights reserved.

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Categorize ECG

Copyright Tim Phalen, 2012. All rights reserved.

31

Categorize ECG

Copyright Tim Phalen, 2012. All rights reserved.

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Identifying Right Ventricular and Posterior STEMI 15 and 18 Lead ECGs

The 12-lead ECG has two “Blind Spots” !

1) The ___________________________ ventricle

!

2) The ___________________________ wall of the left ventricle

Approximately 40% of inferior STEMI is accompanied by a right ventricular infarction Approximately 3% - 8% of all STEMI is an isolated posterior STEMI

Copyright Tim Phalen, 2012. All rights reserved.

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Coronary Artery Distribution

Left Main

Circumflex

Right Coronary Artery

Right Coronary Artery Left Anterior Descending

Posterior Descending Artery

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Right Sided Leads V3R!! V4R!! V5R!! V6R!!

Mid way between V1 and V4R Mid Clavicular line, 5th intercostal, right side Horizontally level with V4R, anterior axillary line, right side Horizontally level with V4R, mid-axillary line, right side

The single best right sided ECG lead is _______________

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Posterior Leads V7! ! V8! ! V9! !

Horizontally level with V6, posterior axillary line Horizontally level with V6, mid-scapular line Horizontally level with V6, left para-spinal

When looking for an isolated Posterior STEMI, always obtain at least _________ posterior leads.

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Obtaining a 15 Lead ECG One Approach • Obtain a standard 12-lead ECG • Place a new electrode in the V4R position • Move the V4 cable to the V4R electrode • Place two electrodes for contiguous posterior leads (i.e., V7/V8 or V8/V9) • Move the V5 cable to the lower numbered posterior electrode (e.g., V7) • Move the V6 cable to the higher numbered posterior electrode (e.g., V8) • Record a new 12-lead ECG • Annotate the new leads on the ECG • Remember to ignore the interpretation (consider crossing it out) • NOTE: for transmitted ECGs,convey that this ECG has additional leads.

Copyright Tim Phalen, 2012. All rights reserved.

38

Suspecting STEMI in the Presence of a STEMI Impostor

STEMI

Maybe STEMI

No STEMI

Moving an ECG from the “Maybe STEMI” category to the STEMI category.

Copyright Tim Phalen, 2012. All rights reserved.

39

Question: What ECG findings would move an ECG from the “Maybe STEMI: category to the STEMI category? General Answer: Evolutionary waveform changes noted through ST segment __________________ or _________________ ECGs. Specific Answer: For each STEMI impostor certain waveform changes, if noted on the ECG, would suggest STEMI even in the presence of a STEMI Impostor.

Remember: Always make decisions considering both the ECG findings AND the clinical presentation. ECG Findings

Clinical Presentation

ECG Categorization

Copyright Tim Phalen, 2012. All rights reserved.

40

Bundle Branch Block Two findings that when noted together suggest the presence of BBB !

Wide __________ (> 120 ms)

!

Supraventricular __________________

Exceptions to this rule would include;

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41

ECG Practice

Is the QRS wide? Y N Does the rhythm originate above the ventricles? Is BBB suspected in the example? Y N

Copyright Tim Phalen, 2012. All rights reserved.

Y N

42

ECG Practice

Is the QRS wide? Y N Does the rhythm originate above the ventricles? Is BBB suspected in the example? Y N

Copyright Tim Phalen, 2012. All rights reserved.

Y N

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Remember 1) Look for a supraventricualr rhythm, not just _______________________. 2) Evidence of bundle branch block can be found in _________ _________. 3) A _________________ QRS does not necessarily mean BBB exists.

Copyright Tim Phalen, 2012. All rights reserved.

44

Differentiating RBBB from LBBB Waveform Genesis Draw the expected QRS waveform

Right Bundle Branch Block (RBBB)

3 2 1

Copyright Tim Phalen, 2012. All rights reserved.

45

Differentiating RBBB from LBBB Waveform Genesis Draw the expected QRS waveform

Left Bundle Branch Block (LBBB)

2 2 1 Copyright Tim Phalen, 2012. All rights reserved.

46

Differentiating RBBB from LBBB Turn Signal Rule

Only Use lead _____ for this purpose Identify the __ ___________ Determine the direction of the QRS _________ ____________ Compare to the turn signals in your car

Copyright Tim Phalen, 2012. All rights reserved.

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V1

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Practice Assume BBB is present Label these examples as either RBBB or LBBB

V1

!

!

V1

!

RBBB

LBBB!

!

!

!

Copyright Tim Phalen, 2012. All rights reserved.

!

RBBB

LBBB

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Practice Assume BBB is present Label these examples as either RBBB or LBBB

!

!

!

RBBB

LBBB!

!

!

!

Copyright Tim Phalen, 2012. All rights reserved.

!

RBBB

LBBB

50

Practice ECG

Suspect BBB? Y N If so, RBBB or LBBB?

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51

QRS-ST-T Discordance or Concordance Both of these are examples of discordance

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52

QRS-ST-T Discordance or Concordance Both of these are examples of concordance

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Concordant or Discordant?

!

!

!

!

concordant! !

!

!

!

!

!

concordant

!

!

!

!

discordant!

!

!

!

!

!

discordant

!

Copyright Tim Phalen, 2012. All rights reserved.

54

Suspecting STEMI in LBBB Sgarbossa Criteria 1) Concordant ST elevation in ________ lead 2) Concordant ST depression in _______ or ______ or ______ 3) ST elevation of more than ________ mm (less predictive)

The Sgarbossa criteria is very _______________ but poorly sensitive If LBBB does not meet the Sgarbossa criteria then utilize ST segment monitoring or ____________ ECGs.

Copyright Tim Phalen, 2012. All rights reserved.

55

Suspecting STEMI in RBBB Suspect STEMI if the ST elevation is concordant with the _________ _________ of the QRS.

Copyright Tim Phalen, 2012. All rights reserved.

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Practice ECG

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Practice ECG

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58

Suspecting STEMI in LVH 1) ST elevation is present in _____ contiguous leads 2) ST segment elevation is ______________________

Copyright Tim Phalen, 2012. All rights reserved.

59

Suspecting STEMI in Ventricular Paced Rhythms Also studied by Sgarbosa Use same three criteria, EXCEPT with a different order of significance

Sgarbossa criteria for Ventricular Paced Rhythms 1) More than ______ 5mm of ST elevation 2) Concordant ST elevation 3) Concordant ST __________ in V1 or V2 or V3

Copyright Tim Phalen, 2012. All rights reserved.

60

Suspecting STEMI in BER and Pericarditis Clinical presentation can be especially helpful BER ! BER is seen almost exclusively in males, typically younger males !

No clinical symptoms are associated with BER

Pericarditis ! Chest pain may be localized with one or two fingers !

Listen for friction rub

Remember: BER and Pericarditis do not produce reciprocal changes!

Copyright Tim Phalen, 2012. All rights reserved.

61

Practice ECG

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Suspecting STEMI in the presence of a STEMI Impostor STEMI Impostor! !

!

!

!

!

!

Look For

LVH

!

!

________________ ST elevation

LBBB

!

!

________________ Criteria

RBBB

!

!

Concordant ST

V. Paced Rhythms

!

!

Sgarbossa, different order

BER, Pericarditis

!

!

____________ Changes

Copyright Tim Phalen, 2012. All rights reserved.

Vs. _______ ______

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Suspecting STEMI in the presence of a STEMI Impostor

Remember! Reciprocal changes DO NOT suggest STEMI in the presence of LBBB, RBBB, LVH or ventricular rhythms Concordant ST elevation DOES NOT suggest STEMI in the presence of BER or pericarditis

Copyright Tim Phalen, 2012. All rights reserved.

64

Additional STEMI Impostors

!

Intracranial Hemorrhage

Hyperkalemia

Tako-Tsubo Syndrome

Hypocalcemia

Prinzmetal’s angina

Brugada Syndrome

Acute abdomen

Pulmonary embolus

Hypoglycemia

High take off

Hypothermia

WPW

Ventricular aneurysm

Myocardial Metastasis

!

!

!

!

!

!

And others!

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ECG Practice

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ECG Practice

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ECG Practice

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ECG Practice

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ECG Practice

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ECG Practice

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