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A Basic Overview of How to Interpret 12 Lead EKGs and Treat a Cardiac Patient
Region IV Pre-Hospital Systems Coordination Committee
Purpose:
The purpose of this course is to provide pre-hospital clinicians with the tools necessary to identify the basic A&P of the heart, interpret 12 Lead EKGs, localize and treat AMIs as well as recognize imposters and potential complications.
These vessels then branch off into smaller and smaller vessels along the surface of the heart.
In order to perform work, the heart needs oxygen and nutrients. There are two main arteries: Right coronary artery (RCA) Left coronary artery (LCA). The left coronary artery divides into: Left anterior descending (LAD) branch Left circumflex branch(LCX) The right coronary artery and the branches of the left coronary artery provide numerous smaller branches which penetrate the heart muscle, supplying it with blood.
Both coronary arteries originate from the aorta and run along the surface of the heart. In the majority of human hearts, coronary circulation follows a predictable pattern.
Left Main Coronary Artery Branches quickly into the LAD & LCX. Involves almost 2/3 of the heart muscle
Right Coronary Artery (RCA) The RCA supplies blood to the bottom (inferior) portion and part of the back (posterior) portion of the left ventricle. The posterior portion of the septum is also supplied with blood from the RCA. SA Node 55% AV Node 90% AV Blocks Left Anterior Descending Branch (LAD) The LAD supplies blood to the front (anterior) portion of the left ventricle, apical including most of the anterior portion of the septum separating the ventricles. Bundle Branch Block, AMI, CHF Left Circumflux Branch (LCX) The LCX supplies blood to the left side (lateral) portion and the back (posterior) portion of the left ventricle. SA Node 45% AV Node 10% Lateral & posterior MI
Sino-Atrial (SA) Node: natural cardiac pacemaker. The heartbeat starts here and spreads throughout the network of conduction fibers in the two atria causing them to contract.
Normally, the heartbeat can only reach the ventricles (the two lower chambers), after it has passed through the atrioventricular (AV) node. Atrioventricular (AV) Node: slows down the electrical signal so that the atrial contractions can finish filling the ventricles completely. The AV node also prevents the lower chambers from beating too fast if the atria develops a fast rhythm (tachyarrhythmia).
His Bundle, bundle branches, and the Purkinje system : The electrical signal finally passes to the ventricles causing the ventricles to contract
Anatomy of an EKG
The EKG, or a measure of this electrical activity of the heart, is comprised of 3 primary parts...
P wave: Represents positive and negative deflections of atrial contraction and relaxation PR Interval: Distance between the P wave and the R wave. Should be consistent QRS Complex Q wave: First negative deflection Normal in I, aVL, V1, V6 Significant or pathologic is one box wide and/or 1/3 the height of the R wave R Wave: First positive deflection
ST Segment: Essentially isoelectric, slopes gentely upward J point: the point at which the ST Segment takes off from the QRS complex T Wave: Upright always in leads I, II, V2-V6. aVR is always negative. Leads III, aVL, aVF, and V1 can be positive or negative U Wave: Seen best in V3, same polarity as T wave, sign of hypokalemia QT Interval: One complete ventricular cycle. None are > the preceding R-R
Einthovens Triangle
Lead I
extends from the right to the left arm
+ Lead III
extends from the left arm to the left foot
Lead II
extends from the right arm to the left foot
When you see ACUTE MI SUSPECTED the machine is right about 98% of the time.
In order to attain specificity, if the computer isnt absolutely sure that an AMI is present, it will not say anything about it.
In other words YOU are the primary interpreter, the computer is your backup.
The portion of the left ventricle that each leads sees is determined by the location of that positive electrode.
Different placements of the electrodes will yield different viewpoints.
Limb Leads
Chest Leads
Lateral Wall
V1 Septal
V4 Anterior
V2 Septal
V5 Lateral
V3 Anterior
V6 Lateral
The Three Is
Ischemia
Injury
prolonged ischemia ST elevation death of tissue may or may not show in Q wave
Infarct
CARDIAC ISCHEMIA
( Myocardial ischemia, Ischemic heart disease, Ischemia, Myocardium ischemia, Silent ischemia )
Cardiac ischemia is a situation in which the blood flow within a coronary artery is limited to the point where the oxygen needs of the heart muscle cannot be met (hypoxia).
CARDIAC ISCHEMIA
Minor episodes of cardiac ischemia tend to cause little long-term damage to the heart, but these episodes can sometimes cause serious effects in some patients: They can cause arrhythmias, which can lead to either syncope or cardiac arrest and sudden cardiac death. Severe or lengthy episodes can trigger a result in myocardial infarction. The collective effects of minor episodes of cardiac ischemia can potentially lead to cardiomyopathy.
Tracing taken during an episode of anginal pain that occurred while the patient was at rest. Marked ST elevation in leads V2-5 with some ST depression in aVF.
This tracing was taken 30 minutes after the initial. The patient was pain-free and asymptomatic. The ST segments are isoelectric, and the ECG is normal
Septum
Normal ECG
Ischemia
Epicardial Coronary Artery
Lateral Wall of LV Left Ventricular Cavity
Septum
Positive Electrode
Interior Wall of LV
Ischemia
ST depression
Injury
Prolonged ischemia
Transmural
Represented by ST elevation
Usually results in infarct
ST elevation
Injury
Thrombus
Ischemia
Infarct
Death of tissue
Represented by Q wave Not all infarcts develop Q waves
Infarction
Infarcted Area Electrically Silent
Depolarization
Q Waves
Ischemia
Depolarization
Summary
A normal ECG does NOT rule out ACS ST segment depression represents ischemia
Possible infarct
Process of an AMI
Impaired blood flow: Produces varying degrees of myocardial injury Damage dependent on flow reduction and duration Tissue death progress quickly in a wave pattern Begins with endocardium Ends with epicardium Infarction becomes larger toward the surface of the heart. Ischemia Shortage of oxygen at cellular level Injury Diminishing supply of oxygen Infarct cardiac cells die of anoxia.
T wave inversion
presence of ischemia May precede ST elevation
*ST segment elevation provides the strongest evidence of early recognition of AMI*
Changes
ST segment elevation is helpful in detecting an MI in its early stages
ECG Variants
Coronary Spasm: Printzmetals angina Injury pattern that resolves w/ rest, NTG,O2 etc.
Early Repolarization: elevated J point seen best in V3,4. Key to Dx pts are usually young & asymptomatic
Hypokalemia: lg U waves ( usually taller than T) seen best in precordial leads. <2.7 Hyperkalemia:
Tall peaked T waves > 6.0
Hypocalcemia:
Prolonged QT interval
Hypercalcemia:
Shortened QT interval
ST depression- downsloping, curved ST segments. scooping, sagging, flat or inverted Ts in lateral leads PR prolonged QT shortened
Digitalis effect:
Clinical significance:
Bundle branch is a significant complication of infarction. Since the left anterior descending artery is the primary supplier of the bundle branches, BBB is considered a complication of anterior septal infarcts. When BBB is the result of MI, the incidence of pump failure is 65-70% and the in-hospital mortality rate is 40%-60%. The BBB itself is not dangerous, but the high mortality rate is due to the extensive amount of tissue death occurring when an infarct is serious enough to cause a BBB. Another manifestation of BBB is in the form of AV Block. This is why infranodal AV blocks are more serious and have wide QRS complexes.
looks at Localizing Infarct: Note which lead is displaying evidence and which portions of heart they are looking at
Leads Displaying Indicative Changes II, III, aVF V1 & V2 V3 & V4 V5, V6, I, and aVL Location of Infarct Site Inferior Septal Anterior Lateral
*Simply knowing the changes to look for and which part of the heart each lead looks at*
Anterior Wall MI
Anterior Wall infarct: Occlusion of the Left Anterior
Descending Artery (LAD) 2mm ST segment elevation in two or more of leads V1-V4 Reciprocal changes in leads II, III, aVF Lethal due to large myocardium involvement Possible conduction defects: Bundle Branch Block 2nd Degree Block Type II CHB
Anterior Wall MI
Inferior Wall MI
Inferior Wall MI: Occlusion of Right Coronary Artery (RCA)
At least 1mm ST segment elevation in leads II, III, aVF Reciprocal ST depression in leads I & aVL or precordial leads Conduction defects: Sinus bradycardia
Sinus arrest
1st degree block Accelerated Idoventricular rhythm Complications: Bradyarrhythmias protective mechanism, 90% of blood supply for SA & AV nodes from the RCA Hypotension treated with fluids, consider right side involvement
Inferior Wall MI
Lateral Wall MI
Lateral Wall MI: results from occlusion of the Left
Circumflex Artery At least 1 mm ST segment elevation in leads I, aVL, V5 & V6 and /or 2 mm ST segment elevation in V5 & V6
Reciprocal ST depression in V1
Sometimes an extension of an Anterior or Inferior MI Conduction defects are rare
Anterior/Lateral Wall MI
Posterior Wall MI
Posterior Wall MI: Occlusion of the Right Coronary Artery
(RCA) or the Posterior Descending Artery
ST depression in V1 & V2
Tall R waves in V1 and/or V2 Most often associated with Inferior MI
Posterior Wall MI
Right Ventricular MI
Right Ventricular MI: caused by proximal occlusion of the
Right Coronary Artery (RCA)
Associated with Inferior Wall MI Can happen independently Standard 12-Lead does not assess right side of heart Infarction is significant Indicates large infarction Indicates involvement of both ventricles If the possibility of RVI exists a set of chest leads can be applied to the right side of the chest V1-6R leads look at right ventricle Lead V4R most accurate
Right Ventricular MI
Septal Wall MI
Septal Wall MI: caused by septal perforation involving the
LAD or the Posterior Descending Most often in the setting of an Anterior MI Loss of R-wave in leads V1, V2 or V3 May have ST segment elevation in V1 & V2 No reciprocal changes
Overview of Infarcts
Location of Infarct
Anterior Inferior Lateral Posterior
Arterial Supply
LAD RCA Circumflex Posterior Descending (RCA)
Indicative Changes
V1-V4 II, III, aVF I, aVL, V5, V6 None
Reciprocal Changes
II, III, aVF I, aVL V1 V1, V2
Septal
Septal Perforating Loss of R wave in None (LAD) V1, V2, or V3 Posterior Descending (RCA
Overview of Infarcts
Suspect infarction when there are indicative changes in at least two anatomically contiguous leads
Stability
Generally Stable
Often Unstable
Often does not respond
Although RV Infarcts may require significant boluses to offset loss of preload, continuously monitor the patient for signs and symptoms of developing left sided failure. Hypotension in the setting of an anterior wall infarction may not tolerate fluid boluses and may require a dopamine infusion.
AV Block
Hypotension
Clinical Pearls
Suspect infarction when there are indicative changes in at least two anatomically contiguous leads Indicative changes in a greater number of contiguous leads suggests a more extensive infarction RV or Posterior infarcts should be considered in setting of Inferior Wall MI
Questions