Scott Hubbell, MHSc, RRT-NPS, C-NPT, CCT Clinical Education Coordinator/Flight RRT EagleMed
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1 Scott Hubbell, MHSc, RRT-NPS, C-NPT, CCT Clinical Education Coordinator/Flight RRT EagleMed
2 Identify the 12-Lead Views Explain the vessels of occlusion Describe the three I s Basic Interpretation of 12-Lead ECG s
3 Normal limb lead placement should be on wrists and ankles. Circumstance/Standing Orders/Protocol sometimes prevents that. Consistency is the key for a diagnostic ECG. Misplacement by 1 rib can mask a MI or make a normal ECG appear as if there is an MI.
4 Limb Lead Placement
5
6
7 avr should be a negative deflection If avr is a positive deflection, check for reversed limb leads
8
9 Look for: Negative avr One complete cardiac cycle in each lead Diagnostic frequency response Proper calibration Appropriate speed
10 Paper Speed
11 Know what to look for ST elevation > 1mm (some say 2mm) Two contiguous leads Know where you are looking Use ACLS ACS chart as a reference (last slide) You will soon have this memorized
12 I Lateral avr V1 Septal V4 Anterior II Inferior avl Lateral V2 Septal V5 Lateral III Inferior avf Inferior V3 Anterior V6 Lateral
13 I avr V1 V4 II avl V2 V5 III avf V3 V6
14 I avr V1 V4 II avl V2 V5 III avf V3 V6
15 I avr V1 V4 II avl V2 V5 III avf V3 V6
16 I avr V1 V4 II avl V2 V5 III avf V3 V6
17 I avr V1 V4 II avl V2 V5 III avf V3 V6
18 I avr V1 V4 II avl V2 V5 III avf V3 V6
19 Inferior Wall II, III, avf Left Leg I avr V1 V4 II avl V2 V5 III avf V3 V6
20 Inferior Wall I avr V1 V4 II avl V2 V5 III avf V3 V6 Inferior Wall
21 Lateral Wall I and avl Left Arm I avr V1 V4 II avl V2 V5 III avf V3 V6
22 Lateral Wall V5 and V6 Left lateral chest I avr V1 V4 II avl V2 V5 III avf V3 V6
23 Lateral Wall I, avl, V5, V6 Lateral Wall I avr V1 V4 II avl V2 V5 III avf V3 V6
24 Septal Wall V1, V2 Along sternal borders I avr V1 V4 II avl V2 V5 III avf V3 V6
25 Septal Wall V1,V2 I avr V1 V4 II avl V2 V5 III avf V3 V6
26 Anterior Wall V3, V4 Left anterior chest I avr V1 V4 II avl V2 V5 III avf V3 V6
27 Anterior Wall V3, V4 I avr V1 V4 II avl V2 V5 III avf V3 V6
28 Normal ECG
29 Practice
30 Practice
31 Practice
32 Practice
33 Practice
34 The Three I s Ischemia lack of oxygenation ST depression or T inversion Injury prolonged ischemia ST elevation Infarct death of tissue may or may not show in Q wave
35 Well Perfused Myocardium Epicardial Coronary Artery Septum Left Ventricular Cavity Lateral Wall of LV Positive Electrode Interior Wall of LV
36 Ischemia Epicardial Coronary Artery Septum Left Ventricular Cavity Lateral Wall of LV Interior Wall of LV Positive Electrode
37 Ischemia Inadequate oxygen to tissue Subendocardial Represented by ST depression or T inversion May or may not result in infarct
38 ST depression
39 Injury Thrombus Ischemia
40 Injury Prolonged ischemia Transmural Represented by ST elevation Usually results in infarct
41 ST elevation
42 Infarction Death of tissue Represented by Q wave Not all infarcts develop Q waves
43 Infarction Infarcted Area Electrically Silent Depolarization Many infarcts do not develop Q waves
44 Thrombus Infarcted Area Electrically Silent Ischemia Depolarization
45 Q Waves
46 Anatomy Revisited RCA right ventricle inferior wall of LV posterior wall of LV (75%) SA Node (60%) AV Node (>80%) LCA septal wall of LV anterior wall of LV lateral wall of LV posterior wall of LV (10%)
47 Left Coronary Artery Right Coronary Artery Right Ventricle Septal Wall Anterior Descending Artery Left Main Left Circumflex Lateral Wall Anterior Wall
48 Left Coronary Artery (LCA) Left Main (proximal LCA) Left Circumflex (LCX) Left Anterior Descending (LAD)
49 Distribution LAD = anteroseptal LCX = lateral Proximal LCA = extensive anterior
50 Practice ECG
51 Practice ECG
52 Practice ECG
53 Extensive Anterior MI Evidence in septal, anterior, and lateral leads Often from proximal LCA lesion Widow Maker Complications common
54 Definitive Therapy for Extensive AWMI Normal blood pressure Thrombolysis Signs of shock PTCA CABG
55 LCA Occlusions Other considerations Bundle branches supplied by LCA Serious infranodal heart block may occur
56 Right Coronary Artery Left Coronary Artery Lateral Wall Left Ventricle Right Coronary Artery Posterior Descending Artery Posterior Wall Inferior Wall
57 Right Coronary Artery (RCA) Proximal RCA Posterior descending artery (PDA)
58 RCA Distribution Proximal RCA Right ventricle Posterior wall Inferior wall PDA Inferior wall
59 Practice ECG
60 Proximal RCA Occlusion Right Ventricular Infarct (RVI) 12-lead ECG does not view right ventricle Use additional leads V3R - V6R V4R
61 Right Precordial Leads (Right sided ECG) On right side of chest Same anatomical landmarks as V3 - V6
62 Practice ECG
63 ECG Evidence of RVI Inferior MI (always suspect RVI) ST elevation right V leads
64 Cardiac Blood Flow To Lungs From Lungs To Body From Body
65 Physical Evidence of RVI Dyspnea with clear lungs Jugular vein distension Hypotension Relative or absolute
66 Treatment for RVI Use caution with vasodilators Small incremental doses of MS NTG by drip
67 Fluid for Hypotension One to two liters may be required Large bore lines suitable here
68 Posterior Wall MI (PWMI) Usually an extension of an inferior or lateral MI Common with proximal RCA occlusions Occurs with LCX occlusions
69 PWMI Reciprocal changes V1 - V4 Indicative changes V7, V8, V9
70 Posterior Leads V7 Posterior axillary line Level with V6 V8 Mid-scapular line Level with V6 V9 Left para-vertebral Level with V6
71 Indicative Leads ST Infarcted Tissue Q Posterior Wall Ischemic Tissue LV RV Reciprocal Leads R ST
72 PWMI Best to identify with direct leads V7, V8, V9 ST elevation in posterior leads is evidence of posterior MI
73 Practice ECG
74 Practice ECG
75
76
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