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STEMI Basics
Disclosure Statement
Tom Bouthillet, NREMT-P
Captain, Town of Hilton Head Island,
South Carolina, Fire & Rescue Division
12-Lead ECG and STEMI Basics
Speakers Bureau, Physio-Control
No off-label drug uses
No relevant financial relationships to
disclose
Chest pain
Atypical chest pain
Epigastric pain
Back, neck, jaw, or arm pain without chest pain
Palpitations
Syncope or near syncope
Pulmonary edema
Exertional dyspnea
Weakness
Diaphoresis unexplained by ambient temperature
Feeling of anxiety or impending doom
Suspected diabetic ketoacidosis
This patient was observed to collapse from sudden cardiac arrest. The
initial rhythm was ventricular fibrillation. After 2 shocks and minimally
interrupted chest compressions the patient experienced return of
spontaneous circulation (ROSC)
For example
A 66 year old female complains of nausea
and vomiting
Shes certain that she has the flu!
When questioned, she admits to having
mild chest discomfort on and off for the
last 2 days
Right?
Wrong!
Obtain a 12-lead
ECG!
When?
With the first set of vital signs and before
oxygen and nitroglycerin (unless the
patient is in respiratory distress or the
room air SpO2 < 94)
Ideally, the 12-lead ECG should be
captured within 10 minutes of making
patient contact (the at patient time)
Where?
On the scene, prior to relocating the
patient to the ambulance (unless it is
absolutely necessary to protect the
patients dignity)
How?
Whenever possible undress patients from
the waist-up!
For female patients, this can include the
bra but protect the patients modesty and
dignity
Alert and cooperative patients can remove
their own bra if you hold up a towel or
sheet to give them some privacy
Its easier to place electrodes and its the
only way to perform a physical exam!
How?
The proper way to move a patients breast
out of the way is with the back of a gloved
hand
You can also have patients lift up their
own breast
Tip: Obtain gowns from the emergency
department so that patients can be
covered up after the electrodes are placed
Skin Prep
The chest hair should be removed with the
electric clippers if possible
If the patient is diaphoretic, wipe off the
skin!
Benzoin tincture works great! But its also
flammable so dont defibrillate over it.
Lead Placement
The limb leads go on the limbs
The white and black electrodes can be
placed on the center of the muscle
mass of the deltoids (which leaves room
for the BP cuff)
The red and green electrodes can be
placed on the quadriceps (or a nonbony and non-hairy part of the leg)
RA
LA
RA = Right Arm
LA = Left Arm
RL = Right Leg
LL = Left Leg
RA
RL
RL
LL
RA - White
LA - Black
RL - Green
LL - Red
LA
LL
Lead Placement
When placing the precordial leads, keep
the edges of the electrodes lined up! It will
help keep you organized!
V6
V5
V1
V2
V4
V3
Common Mistakes
The limb leads are placed on the chest!
Leads V1 and V2 are placed one or two
intercostal space too high on the chest (or
even higher)
Leads V1 and V2 are placed too far apart
(if you make a peace sign you should be
able to touch both electrodes)
Lead V3 is placed directly beneath lead V2
Lead V4 is under the nipple instead of the
midclavicular line
Now what?
Step 1
Is the patient showing signs and symptoms
of an acute coronary syndrome (ACS)?
This is usually (but not always) chest pain
If yes, then move on to Step 2
Step 2
Have I obtained a 12-lead ECG with
excellent data quality?
This is an extremely important step!
Poor data quality confounds computer
measurements and causes interpretive
algorithm to give inaccurate readings!
Poor data quality makes subtle
interpretation of ST-segments difficult or
sometimes impossible
Step 2
If youre having trouble obtaining a high
quality 12-lead ECG, stop and correct the
problem!
Dont just say, Weve got to go!
Troubleshooting the problem is time well
spent!
I have seen reperfusion delayed because
of poor data quality
I have seen patients cathed because of
poor data quality!
Here the data quality is good, but flutter waves are triggering the
***ACUTE MI SUSPECTED*** message. A STEMI Alert should not be
called from the field. Note: False positive messages are more common
with tachycardias.
Here the data quality is good, but its a wide complex tachycardia (paced
rhythm as evidenced by pacer spikes in leads V4, V5, and V6). This ECG
was captured on an interfacility transport. The patient was unconscious
and intubated, en route to neurosurgery. Question: Were signs and
symptoms of ACS present?
Step 3
Either the computerized interpretation
reads ***ACUTE MI SUSPECTED *** and
the paramedic agrees with the
computerized interpretation.
Or the QRS duration is < 0.12 s, STsegment elevation is present in 2 or more
contiguous leads, and reciprocal changes
are present
In this example, the 12-lead ECG shows an obvious STEMI, but for some
reason the data quality prohibits a computerized interpretation and no
reciprocal changes are present. What should you do?
Answer: Correct the problem and obtain an additional 12-lead ECG. Now
the data quality is acceptable, the interpretive algorithm says ***ACUTE
MI SUSPECTED*** and the paramedic agrees with the computerized
interpretation. This is the ECG that should be transmitted to the
emergency department.
Answer: Perform serial ECGs! Less than 5 minutes later, this evolving STEMI
triggers the ***ACUTE MI SUSPECTED*** message.
Answer: Either call the STEMI Alert based on the hyperacute T-waves and
reciprocal changes or perform serial ECGs! Less than 5 minutes later the
interpretive algorithm is giving the ***ACUTE MI SUSPECTED*** message.
Reciprocal changes
STEMI Recognition
Check out the free webinar STEMI
Recognition: Beyond the Basics online
at EMS World
Normal ECG
V6
V5
V4
V3
V1
V2
V9
V8
V7
V6
V5
V4R
V4
V3
V1
V2
II
Upwardly Concave
Upwardly Convex
(or straight or non-concave)
Inferior STEMI
Inferior STEMI
Inferior STEMI
Inferior STEMI
HR
68
PR
188
QRS
104
P-R-T
84 84 106
V6
V5
V4R
V1
V2
V3
HR
65
PR
190
QRS
102
P-R-T
84 76 107
V4R
HR
80
PR
204
QRS
113
P-R-T
69 84 111
Anterior STEMI
Anterior STEMI
Anterior STEMI
Anterior STEMI
Lateral STEMI
Lateral STEMI
Lateral STEMI
Lateral STEMI
Posterior STEMI
Posterior STEMI
Posterior STEMI
Posterior STEMI
Posterior STEMI
Tom Bouthillet
Email: ems12lead@gmail.com
Phone: 843-247-3453 (cell)
Website: ems12lead.com
Facebook: facebook.com/ems12lead
Twitter: @tbouthillet / @EMS12Lead