Post on 17-Mar-2016
description
12 Lead EKG InterpretationEssentiallyspeaking...
12-lead EKG interpretation has been a lifelong partnerof theEmergency Physicianin patient assessment
Many EPs, though, are not STARS at 12 lead EKG interpretationX
WHY?????
Because most EKG courses are too long, too boring, and teach absolutely unnecessary and unrememberable stuffin ways thatmake students justregurgitate the material
What am INOT talking about? Advanced rhythm assessment Ventricular tachycardia assessment Vtach vs. SVT assessment Block
EinthovenNetherlands ECG 1895
EinthovenString Galvanometer
Einthoven
Fowlers Prime Directiveof Cardiac Emergencies:Some systole is betterthan no systole at all
Pulseless RhythmsCPR, Shock, Intubate with CPR, Epi q 3, Shock, Amio or Lidocaine then ??CPR, Shock, Intubate withCPR, Epi q 3, Shock,Amio or Lidocaine then ??Intubate, IV, Epi q 3,Consider Atropine, Look for cause
Second point:
Much of what we call 12 lead interpretation is in fact actually rhythm strip interpretation.
such as, for example, the evaluation of AV block, which can usually be done in one, or at most, two leads
Third point: AXIS INTERPRETATION IS BORING!!
Hence, I will make it VERY short!
PositiveAs the lead sees the impulse growing (or coming toward it), the machine recordsan upward deflection
PositiveAs the lead sees theimpulse coming then going(or going by the lead), the machine recordsan isoelectric deflection
PositiveAs the lead sees theimpulse coming then going(or going by the lead), the machine recordsan isoelectric deflection
Lead ILead IILead III+++
IIIIII+++The EKG Basic Limb Leads
Lead I is horizontal, and is arbitrarilyestablished at 0 DegreesLead II is 60 degrees down from Lead 1 and is arbitrarilyestablished at Positive 60 DegreesLead III is 120 degreesfrom Lead I, and is arbitrarilyestablished at Positive120 Degrees+++
Lead ILead IILead II+++Augmented Limb LeadsavFavLavRAdded by Goldbergerin 1942
Frontal Plane
V1V2V3V4V5V6Added by AHA and theCardiac Society of Great Britain 1938
The Leads may be movedto the center of the chestIIIIIIIIIIII++++++
IIIIII+++Axis is based on the direction of the hearts depolarization
IIIIII+++IIIIII
IIIIII+++IIIIII
IIIIII+++IIIIII
Rhythm strip interpretation has been a standard for emergency medicinesince the inception ofthe monitor
Basic RhythmStrip InterpretationRateRhythmP WavesPR IntervalQRS ComplexST SegmentT WaveU WaveSummary
Cherchez la P
RateRhythmAxis
Hypertrophy
InfarctionP
PR
QRS
ST
T
U
Assessment
Since serious rhythmdisturbances are the most important issue(like VF, VT, asystole),then if you see a seriousrhythm disturbanceproceed withrhythm strip interpretationFIRST!!!
Normal EKG?
Understanding the Anatomy Is the Key
The coronary circulation
The coronaryarteries supply the three mainwalls of the heart
InferiorAnteriorLateral
ConsideringIschemiaandInjury
The EKG leadsthat are positiveclosest to the site of the infarctionwill showST segment elevation
Concave upwards is probablyearly repolarizationConvex upwards is an injury pattern, meaning infarction
The EKG leadsthat are positiveon the other side of the heart from the infarctionwill show reciprocalST segment depression
The Basic Fundamental of 12 Lead EKG InterpretationYou CANT understand12 leads without understandingthe concept ofGrouped Leads
Grouped LeadsRelate DIRECTLYto Cardiac AnatomySo, if you understand the anatomy,you can quickly look at a 12 lead and understand it immediately!
INFERIORLATERALANTERIOR
INFERIORLATERALANTERIORINFERIORII, III, aVFLATERALI, aVL, V6ANTERIORV1, V2, V3, V4
Inferior wall M.I. = Right Coronary infarction (usually)Elevated ST segmentsin II, III, and avF, withreciprocal depressionin I, avL, and the chest leads
Inferior wall M.I. =
Acute Inferior WallMyocardial Infarction
Lateral wall M.I. = Left Circumflex Coronary infarctionElevated ST segmentin I, L, and V6 with reciprocal depression in II, III, and avF
Acute Lateral WallMyocardial Infarction
Inferior Wall M.I. vs. Lateral Wall M.I.
Normal EKG, right?
Normal vs. abnormalLeft Coronary Artery
The EKG leadsthat are positiveclosest to the site of the infarctionwill showST segment elevation
Acute Anterior WallMyocardial Infarction
Acute Anterior WallMyocardial Infarction
Early RepolarizationPattern
Okay, smarty pants:What exactlywould leads I, II, and IIIshow in the case of an anterior (LAD) infarction?HMMMMM????
Reciprocal depressionin all three leads!!All three leads are on theother side of the heart from the infarction!
Having a 12 lead machine around to keep an eye on the tracings is a good idea sometimes...
Monitoring For Ectopyon a 12 Lead EKG
Sometimes the tracings can bequite hard to interpret
and sometimesalmost worthless...
sometimes VERY interesting...
Acute Hyperkalemia
Acute Hypokalemia
The problemwithletting themachineread the tracing???
but sometimesthe machine canbe RIGHT!!!
Dont forget that 12 leadscan let us forgetto analyze the rhythm!!!
VentricularHypertrophy
Left VentricularHypertrophyLeft Axis DeviationDeep S wave in V1Large R wave in V5V1 plus V5 adds upto more than 35 millimetersAnd/Or aVL 11 mm or greater
Right VentricularHypertrophyLook to the RIGHT sideof the heart to find it,namely V1
Finding VentricularHypertrophyAlways look at V1
Finding VentricularHypertrophyLarge R wave in V1 = RVHDeep S wave in V1 = LVHCorollary: If the complex iswider than 0.12 seconds,this is probably a bundle branch blockand not ventricular hypertrophy
Bundle Branch Block
Normal Conduction
V6Left Bundle Branch Block
V1Right Bundle Branch Block
Bundle Branch BlockPositive Deflection Rabbit Ears in V1with wide complex
RightBundleBranchBlockPositive Deflectionin V6with wide complex
LeftBundleBranchBlock
Right Bundle Branch Block
Left Bundle Branch Block
Left Anterior Hemiblock
Brugada Syndrome
Brugada SyndromeBrugada syndrome is a disorder characterized by coved or saddle-shaped ST-segment elevation in leads V1 through V3 on ECG
Brugada SyndromeBrugada syndrome is most common in people from Asia. The reason for this observation is not yet fully understood but may be due to an Asian-specific sequence in the promoter region of SCN5A (Bezzina, 2005).In Asia (eg, the Philippines, Thailand, Japan), Brugada syndrome seems to be the most common cause of natural death in men younger than 50 years. Brugada syndrome is 8-10 times more prevalent in men than in women,
Brugada Syndrome
Brugada Syndrome
Brugada Syndrome
Brugada Syndrome
Wellens Syndrome
Wellens' syndrome is a pattern of electrocardiographic T-wave changes associated with critical, proximal left anterior descending (LAD) artery stenosis.
The syndrome is also referred to as LAD coronary T-wave syndrome. Syndrome criteria include T-wave changes plus a history of anginal chest pain without serum marker abnormalities; patients lack Q waves and significant ST-segment elevation; such patients show normal precordial R-wave progression.
Wellens Syndrome is an easy to identify cardiac syndrome which indicates a critical high grade occulsion of the proximal LAD. If not identified and properly treated the mean time from onset of symptoms to extensive anterior wall MI is 8.5 days
Wellens Syndrome
Now, kiddiesITS EXAMTIME!!
Crushing Chest Pain with Diaphoresis 58 y/o
Acute Chest Pain in 118 Year Old Patient
Diffuse ST Segment Elevation in Chest Painin a middle-aged lady who has recently had a cold
Check the axis and the PR Interval
Older guy, feeling crummy
Older guy having palpitations and lightheadedness
Middle-aged guy found semi-consciouswith weak radial pulse
What is this patients blood pressure?
Synthesis
Prompt and accurate analysisof the ECG requiresanatomical understandingand continual practice
About the time you thinkyoure getting real good atECG analysis, youve realizedthat you may have forgottennearly as much as youever learned: Remember Wellens and Brugada!
Promise yourself(and your patients)that a lifetime ofcontinual study and refresher courseswill accompanyyour practice
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