Dr. Fowler's 12 Lead EKG Interpretation Part 1

8/3/2019 Dr. Fowler's 12 Lead EKG Interpretation Part 1

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12 Lead

EKG Interpretation

E s s e n t i a l l y

E s s e n t i a l l y s p e a k i n g ...

s p e a k i n g ...

Copyright 2002, Ray Fowler, M.D., FACEP

Ray Fowler, M.D., FACEP

Assistant Professor of Emergency Medicine

The University of Texas Southwestern

[email protected]


Objectives of this program:

1. Become familiar with cardiac anatomy

as it relates to the electrocardiogram

2. Develop an initial understanding of “Axis”

3. Understand how to interpret hypertrophy

4. Recognize Bundle Branch Blocks

5. Understand how to interpret EKG’s for

signs of myocardial infarction

6. Understand the “grouped leads” concept




12-lead EKG interpretation

is a relative newcomer

in the field evaluationof the emergency patient


Many, perhaps most medics

are not adept

at 12 lead EKG interpretation


WHY?????




Because many EKG courses

are too long,

too boring,

and teach absolutely unnecessaryand unrememberable stuff

to medics

who will never use

that information


Fowler’s handy

and dandy program

will give you ALL

you need to know

about 12 lead EKG’s

in an absolutely rememberable format

(GOOD LUCK, right?!?!?)


What am I NOT talking about?

Advanced rhythm assessment

Ventricular tachycardia assessment

Vtach vs. SVT assessment

Block





This EKG is the

REASON that

12 EKG Machines

are in the field


Acute Anterior

Myocardial Infarction




Rhythm strip interpretation

has been a standardsince almost the beginning of EMS


Basic Rhythm

Strip Interpretation

•Rate

•Rhythm

•P Waves

•PR Interval•QRS Complex

•ST Segment

•T Wave

•U Wave

•Summary


Rate

Rhythm

Axis

Hypertrophy

Infarction

Axis

Hypertrophy

Infarction

P

PR

QRS

ST

T

U

Assessment

P

PR

QRS

ST

T

U

Assessment




Since serious rhythm

disturbances are

the most important issue

(like VF, VT, asystole),

then if you see a serious

rhythm disturbance

proceed with

rhythm strip interpretation

FIRST


Fowler’s Prime Directive

of Cardiac Emergencies:

Some systole is better

than no systole at all!


Pulseless Rhythms

Shock x 3, Intubate withCPR, Epi q 3, Shock,

Lidocaine then Who Knows




Pulseless Rhythms

Shock x 3, Intubate with

CPR, Epi q 3, Shock,


Shock x 3, Intubate withCPR, Epi q 3, Shock,



Pulseless Rhythms







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!!H e n c e , I w i l l m a k e i t V E R Y s h o r t !







Positive


Positive

As the lead sees the impulse growing

(or “coming toward it”),

the machine records

an upward deflection




Positive Positive

As the lead

sees the impulse growing

(or “coming toward it”),the machine records



Positive Positive

As the lead

sees the impulse growing

(or “coming toward it”),

the machine records



Positive




Positive Positive

As the lead sees the

impulse coming then going

(or “going by the lead”),the machine records

an isoelectric deflection


Positive Positive

As the lead sees the

impulse coming then going

(or “going by the lead”),

the machine records

an isoelectric deflection







II

IIII IIIIII

++

++ ++

The EKG Basic Limb Leads




Lead I is “horizontal”, and is arbitrarily

established at “0 Degrees”

Lead II is 60 degrees

down from Lead 1

and is arbitrarily

established at

“Positive 60 Degrees”

Lead III is

120 degrees

from Lead I, and

is arbitrarily

established at

“Positive

120 Degrees”

++

++++


The Leads may be moved

to the center of the chest

II

IIII IIIIII

II

IIIIIIIIII

++

++++

++

++ ++


II

IIIIIIIIII

++

++ ++

Axis is based on the

direction of the heart’s

depolarization




II

IIIIIIIIII

++

++ ++

II

IIII

IIIIII


II

IIIIIIIIII

++

++ ++

II

IIII

IIIIII


II

IIII

IIIIII

++

++ ++

II

IIII

IIIIII




Is this a Normal EKG???Is this a Normal EKG???


Left Axis DeviationLeft Axis Deviation


Ventricular Hypertrophy

Enlargement of

ventricles




Left Ventricular

Hypertrophy


Left Ventricular

Hypertrophy

Left Axis Deviation

Deep S wave in V1

Large R wave in V5


Left Ventricular

Hypertrophy

Left Axis Deviation

Deep S wave in V1

Large R wave in V5

V1 plus V5 adds up

to more than 35 millimeters




Left Ventricular

Hypertrophy

Left Axis DeviationDeep S wave in V1

Large R wave in V5

Left Axis DeviationDeep S wave in V1

Large R wave in V5

V1 plus V5 adds up


V1 plus V5 adds up



Right Ventricular

Hypertrophy


Right Ventricular

Hypertrophy

Look to the RIGHT side

of the heart to find it,

namely V1




Right Ventricular

Hypertrophy



namely V1



namely V1


Finding Ventricular

Hypertrophy


Finding Ventricular

Hypertrophy

Always look at

Lead V1




Finding Ventricular

Hypertrophy

Large R wave in V1 = RVH

Deep S wave in V1 = LVH


Finding Ventricular

Hypertrophy

Large R wave in V1 = RVH

Deep S wave in V1 = LVH

Corollary: If the complex is

wider than 0.12 seconds,

this is probably a bundle branch blockand not ventricular hypertrophy


Bundle Branch Block

Positive Deflection

Rabbit Ears in V1

with wide complex

Right

Bundle

Branch

Block

Positive Deflection

in V6

with wide complex

Left

Bundle

Branch

Block




Right Bundle Branch Block








Left Bundle Branch Block












Left Anterior Hemiblock




This is the END of

Part 1

of 12 Lead EKG

Interpretation!

Please join us for part 2!


Dr. Fowler's 12 Lead EKG Interpretation Part 1

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Transcript of Dr. Fowler's 12 Lead EKG Interpretation Part 1