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12 Lead EKG Interpretation

Cardiac
Conduction
System
1
3
2
4
4
5
Purkinje
fibers

12-Lead Electrodes
A lead is a tracing of the electrical activity
between 2 electrodes
Leads view the heart from the front of the body
Top, bottom, right, and left side of heart

Leads view the heart as if it were sliced in half


horizontally
Front, back, right, and left sides of heart

Each lead has a positive and a negative


electrode

Standard 12-Lead EKG


Six limb leads
Leads I, II, III, aVR, aVL, aVF

Six chest leads (precordial leads)


V1, V2, V3, V4, V5, V6

Information from 12 leads obtained


from the attachment of only 10
electrodes

View The Leads Provide


II, III, aVF view inferior wall of heart
V1 and V2 view septal wall of heart
V3 and V4 view anterior wall of
heart
I, aVL, V5, V6 view lateral wall of
heart

1st ICS
2nd ICS
3rd ICS

Precordial
leads

12 Lead EKG Printout


Standard format 81/2 x 11 paper
12 lead format:
I
II
III

aVR
aVL
aVF

V1
V2
V3

V4
V5
V6

Machines can analyze data obtained


but humans must interpret data

II

III

aVR

V1

V4

aVL

V2

V5

V3
aVF

V6

Lateral View I, aVL, V5, V6

I
aVL

V5

V6

Inferior View II, III, aVF

II

III

aVF

Septal View V1 & V2

V1

V2

Anterior View V3 & V4

V4

V3

Myocardial Insult
Ischemia
lack of oxygenation
ST depression or T wave inversion
permanent damage avoidable

Injury

prolonged ischemia
ST elevation
permanent damage avoidable

Infarct
death of myocardial tissue; damage permanent; may have Q
wave

Evaluating for ST Segment


Elevation
Locate the J-point
Identify/estimate where the isoelectric line
is noted to be
Compare the level of the ST segment to
the isoelectric line
Elevation (or depression) is significant if
more than 1 mm (one small box) is seen
in 2 or more leads facing the same
anatomical area of the heart
(ie: contiguous leads-see slide #41, #42)

The J Point

J point where the QRS complex and ST

segment meet
ST segment elevation - evaluated 0.04 seconds
(one small box) after J point

Coved
shape
usually
indicates
acute injury

Concave
shape is
usually
benign
especially if
patient is
asymptomatic

Significant ST Elevation
ST segment elevation measurement
starts 0.04 seconds after J point

ST elevation
> 1mm (1 small box) in 2 or more contiguous chest
leads (V1-V6)
>1mm (1 small box) in 2 or more anatomically
contiguous leads (ie: II, III, aVF; I, aVL, V5, V6)

Contiguous lead
limb leads that look at the same area of the heart or
are numerically consecutive chest leads (ie: V1 V6)

Contiguous Leads
Lateral wall: I, aVL, V5, V6
Inferior wall: II, III, avF
Septum: V1 and V2
Anterior wall: V3 and V4
Posterior wall: V7-V9 (leads placed
on the patients back 5th intercostal
space creating a 15 lead EKG)

Evolution of AMI
A - pre-infarct (normal)
B - Tall T wave (first few
minutes of infarct)
C - Tall T wave and ST
elevation (injury)
D - Elevated ST (injury),
inverted T wave (ischemia),
Q wave (tissue death)
E - Inverted T wave
(ischemia), Q wave (tissue
death)
F - Q wave (permanent
marking)

ST Segment
Elevation

EKG monitoring
Evaluates electrical activity of the heart
Can indicate myocardial insult and location
ischemia - initial insult; ST depression seen
injury - prolonged myocardial hypoxia or
ischemia; ST elevation seen
infarction - tissue death
dead tissue no longer contracts
amount of dead tissue directly relates to
degree of muscle impairment
may show Q waves

Contiguous ECG Leads


EKG changes are
significant when they are
seen in at least two
contiguous leads

Two leads are


contiguous if they look at
the same area of the
heart or they are
numerically consecutive
chest leads

Groups of EKG Leads


Inferior wall - II, III, aVF
Septal wall - V1, V2
Anterior wall - V3, V4
Lateral wall - I, aVL, V5, V6
aVR is not evaluated in typical groups
Standard lead placement does not look at posterior
wall or right ventricle of the heart - need special lead
placement for these views

Basic 12-Lead EKG Format


Lead I
Lateral wall

aVR
not evaluated

V1
Septum

V4
Anterior wall

Lead II
Inferior wall

aVL
Lateral wall

V2
Septum

V5
Lateral wall

Lead III
Inferior wall

aVF
Inferior wall

V3
Anterior

V6
Lateral wall

Lateral Wall MI: I, aVL, V5, V6

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.

Inferior Wall MI II, III, aVF

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.

Septal MI: Leads V1 and V2

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.

Anterior Wall MI V3, V4

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.

Posterior MI Reciprocal Changes


ST Depression V1, V2, V3, poss V4

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.

12-Lead Electrode Placement

Case #1

Case #1
52 year-old patient complains of

indigestion after pizza & beer dinner.


VS: 124/82; P 108; R - 18
Is there ST elevation:

I, aVL, V5, V6?


II, III, aVF?
V1, V2?
V3, V4?

What are you going to do for this patient?


(There is no ST elevation)

Case #2

Case #2
62 year-old female developed chest & jaw pain
while in the shower
VS: 110/62; P 66; R 20
Is there ST elevation:

I, aVL, V5, V6?


II, III, aVF?
V1, V2?
V3, V4?

What are you going to do for this patient?


(ST elevation II, III, aVF Inferior wall MI)

Case #3

Case #3
45 year-old patient who complains of chest
heaviness & lightheadedness
VS: 90/56; P 86; R - 22
Is there ST elevation:

I, aVL, V5, V6?


II, III, aVF?
V1, V2?
V3, V4?

What are you going to do for this patient?


(ST elevation V2-V5 anterior infarction)

Case #4

Case #4
87 year-old female patient complains of
dizziness and being extremely tired
VS: 88/52; P 30; R - 16
Is there ST elevation:

I, aVL, V5, V6?


II, III, aVF?
V1, V2?
V3, V4?

What are you going to do for this patient?


(ST elevation II, III, aVF, V2-V4)

Case #5

Case #5
58 year-old male patient who complains of chest
pain radiating down the left arm after working
out in the gym
VS: 110/72; P 100; R - 18
Is there ST elevation:

I, aVL, V5, V6?


II, III, aVF?
V1, V2?
V3, V4?

What are you going to do for this patient?


(ST elevation II, III, aVF)

Case #6

Case #6
92 year-old patient complaining of pounding in
her chest for one hour
VS: 98/66; P 110; R- 16
Is there ST elevation:

I, aVL, V5, V6?


II, III, aVF?
V1, V2?
V3, V4?

What are you going to do for this patient?


(ST elevation V1-V4 anterioseptal MI)

Case #7

Case #7
36 year-old patient who passed out standing in
line at a bank
VS: 128/78; P 80; R - 20
Is there ST elevation:

I, aVL, V5, V6?


II, III, aVF?
V1, V2?
V3, V4?

What are you going to do for this patient?


(ST elevation II, III, aVF)