Eric Lynn NREMT-P
Clinical Education SpecialistAmarillo Medical Services
The
12 Lead ECGin Acute Coronary Syndromes
Sponsored by:
12-Lead ECG in ACS Course
Module I Essential InterpretationModule II Acquisition & TransmissionModule III Acute Coronary Syndromes Part
1Module IV Acute Coronary Syndromes Part
2Module V The High Acuity PatientModule VI Bundle Branch Block & the ACS
Imitators
Essential 12-Lead Interpretation
MODULE 1MODULE 1
Essential 12-Lead ECG Interpretation
GoalsRecognize and localize AMI on
the 12-Lead ECGFeel comfortable with 12-lead
interpretation
12-Lead ECG
12-Lead ECG
12-Lead ECG
12-Lead ECG
12-Lead ECG
12-lead ECG
12-Lead ECG
80 milliseconds = 0.08 seconds
0.080 080.0
12-Lead ECG
R Wave
Q Wave
S Wave
QRS
Q wavesPhysiologic Q waves
< .04 sec (40ms)Pathologic Q
>.04 sec (40 ms)
QRS
Q wave
QS Complex
J-Point
ST Segment
Practice
Find J-points and ST segments
Practice
Find J-points and ST segments
ST Segment
Compare to TP segment
ST TP
ST Segment Analysis
12-Lead ECG
AMI recognitionTwo things to know
What to look forWhere you are looking
AMI Recognition
What to look forST segment elevation
One millimeter or more (one small box)
Present in two anatomically contiguous leads
ST Segment Elevation
Presumptive evidence of AMI
Indication for acute reperfusion therapy
Practice
Lead “Views”
Limb Leads Chest Leads
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Lead Groups
Lead “Views”
Anatomical Position
Inferior Wall
II, III, aVFLeft Leg
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Inferior Wall
Inferior Wall
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Lateral WallI and aVL
Left Arm
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Lateral WallV5 and V6
Left lateral chest
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Lateral
I, aVL, V5, V6
Lateral Wall
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Anterior WallV3, V4
Left anterior chest
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Anterior Wall
• V3, V4V3, V4
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Septal WallV1, V2Along sternal borders
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Septal
• V1,V2V1,V2
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
AMI Localization
Anterior: Anterior: V3, V4V3, V4Septal: Septal: V1, V2V1, V2Inferior: Inferior: II, III, AVFII, III, AVFLateral:Lateral: I, AVL, V5, V6I, AVL, V5, V6
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
AMI Recognition
I Lateral
II Inferior
III Inferior
aVR
aVL Lateral
V1 Septal
aVF Inferior
V2 Septal
V3 Anterior
V4 Anterior
V5 Lateral
V6 Lateral
AMI Recognition
Know what to look forST elevation> 1mmTwo contiguous leads
Know where you are lookingUse pocket card as a referenceYou will soon have this memorized
Practice
Practice
Evolution of AMI
• HyperacuteHyperacute
Evolution of AMI
• AcuteAcute
Evolution of AMI
• AcuteAcute
Evolution of AMI
• Age undeterminedAge undetermined
AMI Recognition
A normal 12-lead ECG DOES NOT rule out AMI
Practice
Practice
Practice
Reciprocal Changes
Reciprocal Changes
II, III, aVFII, III, aVF I, aVL, V leadsI, aVL, V leads
Practice
Practice
AMI Recognition
Reciprocal changesNot necessary to presume
infarctionStrong confirming
evidence when present
AMI Recognition
AMI Recognition
Imitators of infarctLVHBBBVentricular beatsPericarditisEarly RepolarizationOthers
Summary
AMI recognitionKnow what you are looking for
1mm of ST elevationTwo contiguous leads
Know where you are lookingPositive electrode as an “eye”Pocket card
Summary
Reciprocal changesNot necessary to presume
infarctionStrong confirming
evidence when present
Summary
ST segment elevation is presumptive evidence for AMI
Other conditions may also cause ST elevation
Summary
A normal 12-Lead ECG DOES NOT rule out AMI
ACS
AMI is part of a spectrum of
disease know as the
Acute Coronary SyndromesAcute Coronary Syndromes