12 Lead EKG / Ischemia (DM)

What can we get from a 12-lead EKG

MI Infract Location

Coronary artery involved

Axis; hemi-blocks

V-Tach from Asystole

Specific BBB location

Ventricle / Atrial Hypertrophy

Drug / Electrolyte disturbances

Raise suspicion for pericarditis, and acute PE

What is needed to compare two 12-lead EKG

Consistent placment

Steps to Applying 12 Lead EKG

1. Place limb leads on the limbs

2. Place the V leads

Where do the limb leads go

Arms = Below the shoulder anywhere

Legs = Below inguinal fold (Anterior) or Gluteal Fold (Posterior)

Where do the V leads go in 12 - lead

V1 = 4th ICS, right of sternum

V2 = 4th ICS, left of sternum

V3 = Halfway between V2 and V4

V4 = 5th ICS, left MCL

V5 = Level with V4, left AAL

V6 = 5th ICS, left MAL

Why do we clean / remove hair from the 12-lead placment

Prevents artifact

What are the leads on a 12-lead EKG

I, II, III

avR, avL, avF,

V1, V2, V3

V4, V5, V6

What are the characterisitcs of a normal 12-lead EKG

Sinus Rhythm

Upright P waves

withing PRI limits

Rate = 60-100 bpm

Normal Axis

Normal QRS

Normal ST segement

Normal QTi

No pathologic Q waves

Normal T wave

No ectopy

What aspects of the EKG reading are important to identify MI and ischemia

J point

ST segement

J point

Where QRS and ST segement meet

If monitoring ST segments, what must be done

Print the strip to interrupt

No video

A depressed ST segement can indicate

Late ischemia

An elevated ST segment can indicate

Myocardial injury

An inverted T wave can indicate

Early ischemi

How do we determine ST segement elevation/depression

Compare the J point to isoelectric line

• If J point is higher than isoelectirc = Elevation

  • If J point is lower than isoelectric = Depression

How do the type of leads differ in the view of the heart

Limb = Looks through the heart (Wide view)

Precoridal (V leads) = Look at the heart (Narrow view)

What leads look at the inferior wall

Left Leg

II

III

aVF

What leads look at the septal wall

V1

V2

What leads look at the anterior wall

V3

V4

What leads looks at lateral wall

I

avL

V5

V6

What are the quality types of 12-lead EkG

Monitor = Adds tight filters to the printout

Diagnostic = Adds loose filters to the printout

Where does 12-lead EKG have a bad time looking at

Right side of the heart

When should we RV involvement of ischemia on inferior wall MI on 12-lead

Dyspnea with clear loungs

JVD

Normal or hypotension

What type of MI affects the right side

Inferior Wall MI

How do we do we run RV EKG

Move V4 to the right side and re-run

What can cause ST elevations outside of MI

LV Hypertrophy

LBBB

Pericarditis

Benign Early Repolarization

Ventricular Pacemakers

Sgarbossa Criteria

A list of crtiera for dx of STEMI with LBBB / Pacer

1. ST elevation > 5 mm that is in the opposite direction of a predominantly negative QRS complex

2. ST depression > 1 mm in leads V1,V2,V3

3. ST elevation > 1mm that is in the same direction of predominantly positive QRS

Inferior Wall MI w/ RV involvement

Inferior Wall MI

Left Main MI

• Elevatiion V1,V2,V3,V4 = LAD

• Elevation I, aVL, V5, V6 = LCX

• LAD + LCX = Left Main

What leads look at LAD

V1

V2

V3

V4

What leads look at Left Circuflex

I

avL

V5

V6

What leads look at RCA

II

III

avF

Left arm and right arm lead reversed = + aVR

LAD Lesion (Anterioseptal MI)

What type of coronary lesion is not balloon

Left ,ain

What coronary lesion is the widowmaker

Left Main

High Lateral Wall (Elveation in I and aVL)

Inferior Wall MI

Inferior Wall MI (RCA)

• II, III, aVF

Anterior MI

Inferior w/Posterior MI

Inferior Wall w/ RV