12-Lead ECG Interpretation
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Transcript of 12-Lead ECG Interpretation
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12-Lead EKG Interpretation
Judith M. Haluka
BS, RCIS, EMT-P
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ECG Grid
Left to Right = Time/duration
Vertical measure of voltage (amplitude)
Expressed in mm
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P-Wave
Depolarization of atrial muscle Low voltage (2-3mm in amplitude)
Duration
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Abnormal P Waves
P Pulmonale Tall Peaked
Right atrial enlargement secondary to
pulmonary HTN (COPD)
P-Mitrale
Broad notched LA enlargement secondary to mitral valve
disease
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P-wave Abnormalities
Wolfe Parkinson-White Ventricles activated early
Short PR Interval
Delta Wave
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QRS Complex
Depolarization of ventricles Larger Muscle Mass
Amplitude as high as 25mm Duration with Normal Conduction 25mm can mean chamber
enlargement as in ventricular hypertrophy
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QRS Complex
Low Amplitude Diffuse, severe coronary artery disease
Pericardial Effusion
Hypothyroid
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QRS Complex
1st Negative deflection = Q Wave 1st Positive deflection = R wave
Negative deflection after R wave = S wave Positive deflection after R wave = R Prime
Negative deflection after S wave = S Prime
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ST Segment
Time between completion of depolarizationand onset of repolarization
Normally isoelectric & gently blends into
upslope of T wave
Point where ST takes off from QRS= J point
Plays important role in diagnosis of
ischemic heart disease
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ST Segment
ST Elevation = hallmark of AMI Slight elevation across entire tracing is
normal especially in young males
ST DEPRESSION indicative of a # of
conditions . . . Ischemia, ventricular
hypertrophy
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QT Interval
Beginning of QRS to end of T Wave Normal variations with HR and gender
Abnormalities
Prolonged commonly from drugs like Procan
or Quinidine or electrolyte imbalance
Increased opportunity for R on T, ventricularre-entry rhythms and sudden death
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Vectors and Lead Systems
Arrows represent direction as well asamplitude
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Vectors
Vector 1 depolarization of atrial(corresponds to P wave)
Vector 2 Ventricular Septum (1st
deflection of QRS)
Vector 3 Bulk of ventricular muscle
Vector 4 Repolarization of ventricularmuscle
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Limb Leads
Look at heart in Frontal Planes Used to locate axis
V Leads look at heart in Transverse Plane
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Lead Placement
Correct placement a must Small changes in height of R wave are
important
Can be produced with slight movement of
leads
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Lead Placement
V1 Right Sternal Border 4th ICS V2 Left Sternal Border 4th ICS
V3 Midway Between V2 and V4
V4 Midclavicular line 5th ICS
V5 Anterior Axillary line 5th ICS
V6 Mid axillary line 5th ICS
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Determining Axis
Impulse toward electrode = Positive Impulse away from electrode = Negative
The more directly toward or away the
greater the amplitude either positive or
negative
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Axis Deviation
Normal Axis = 60 Degrees (0-90) Further counter clockwise than 0 = Left
Axis Deviation
Further clockwise than 90 = Right Axis
Deviation
> -30 Marked LAD >-120 Marked RAD
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Axis Deviation
Determined by Tallest R Wave Normal is Lead II
PVCs or VT from Right Ventricle = LAD
PVCs or VT from Left Ventricle = RAD
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R-Wave Progression
V1 is small progressively increasing fromright to left until QRS fully upright in V5
and V6
Point where QRS becomes biphasic =transition zone
R wave progression is frequently lost inAnterior Wall Infarction
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Bundle Branch Blocks
Incomplete Conducts slowly QRS between .10 and .12
Complete Total failure of affected bundle
to conduct impulse
QRS >.12
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Bundle Branch Blocks
Right Bundle Branch Blocks Reverse normal pattern of negative QRS in V1
RSR in V1
Wide S wave in V5 and V6
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Left Bundle Branch Block
RSR in V5 and V6 Deep negative QS in V1 and V2
Causes Widespread ST Changes
Non-Diagnostic for ischemia and infarction
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Myocardial Infarction
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Coronary Anatomy
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Myocardial Infarction
Usually result of clot formation at site offixed lesion
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Hallmark of Infarction
Transmural full thickness of myocardialwall
ST Elevation
T Wave Inversion
Q Wave Formation
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Inferior Wall Infarction
Leads II, III and aVF Reciprocal Changes in Anterior Wall
Most common Presentation is Bradycardia
Can be associated with RV Infarction
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Old Inferior Wall MI
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Anterior Wall Infarction
V2, V3 through V4 Loss of R Wave progression
Reciprocal Depression in leads of inferior
wall
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Lateral Wall
I and aVL V5 and V6
Usually associated with another infarction
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ST Elevation
QRS Dos not return to baseline (J-point) 2 or more leads looking at the same wall
Acute Event
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T Wave Inversion
Frequently bi-phasic Same leads as ST elevation
Still in process of infarcting
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Q Wave
Ceases to depolarize Essentially electrically inert
Permanent
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Sneaky Causes of ST Elevation
PERICARDITIS Widespread
No reciprocal changes
PR Segment Depression