12 Lead ECG Workshop
Benjamin J. Lawner, DO, MS, EMT-P, FACEP
Assistant Professor, Department of Emergency Medicine
University of Maryland School of Medicine
Deputy Medical Director, Baltimore City Fire Department
Approach to 12 Leads
• Rate (fast, slow, ok)
• Rhythm (sinus, ventricular)
• Injury (look at ST segment, Q waves)
Non Specific ECG changes
Non Specific ECG changes
Know the playing field!
• Contiguous leads
• Anatomic groups
• Anterior: Leads V1-V4
• Lateral: Leads I, aVL and V5-V6
• Inferior: Leads II, III, aVF
• Posterior: Leads V1-V3
Inferior wall:
RIGHT CORONARY
Anterior wall:
LEFT CORONARY
Posterior wall:
RIGHT CORONARY
Anterior/lateral wall:
CIRCUMFLEX
Coronary Artery Anatomy and “Contiguous Leads”
STEMI
• ST Elevation > 1mm in contiguous limb leads
• ST Elevation > 2mm in contiguous precordial leads
• Contiguous leads represent an anatomic area
UNIVERSAL STEMI DEFINITION
• Greater than 1 mm STE in 2 contiguous limb leads
• Greater than 2 mm of STE in V2-V3 for men
• Greater than 1.5 mm of STE in V2-v3 for women
HIGH RISK PRESENTATIONS
• STE in aVR with multi-lead ST depression
• STD in V2-V3 with tall R waves (posterior wall MI)
STEMI Guidelines 2013
•ST elevation measured at J point
•Posterior wall MI
•Multilevel ST depression with STE in aVR
•STE > 1 mm in contiguous limb leads
•STE > 2 mm in precordial leads
•Removal of LBBB
J Point: Where STEMI Begins
Locate the J point
A B C
Student Handout 1
Locate the J point
A B C
J Point
Locate the J point
D F
E
Locate the J point
D F
E
ST Segment Ugliness: The Hyperacute T Wave
ST Segment Ugliness: The Hyperacute T Wave
• Broad based and symmetric
• Large T waves
• Found in anatomic distribution
ST Segment Analysis
A B C
STE No change ST depression and T wave inversion
Red is isoelectric, Blue is J point
ST Segment Analysis
Determine if the tracing reveals STE, no change, ST depression and/or T wave inversion
Look for pattern of concordance, if QRS is upright, T-Wave should be upright.
If QRS is upright, and T-Wave is inverted, you have discordance.
D F
E
ST Segment Analysis
D F
STE ST depression and T wave ST depression and T wave
inversion inversion
Red is isoelectric, Blue is J point
12 Lead ECG Interpretation and Localization
ST Elevation Reciprocal Anatomy
Anterior V2-V4 II, III, aVF LMCA
I, aVL LAD
Inferior II, III, aVF I, aVL RCA
V2-V4
Lateral I, aVL II, III, aVF LAD
V5-V6 LCx
Posterior V7-V9 N/A RCA
or
V1-V3
12 Lead ECGs
Anterior Wall STEMI
65 yo male, + CP
Antero-septal MI
35 yo male, chest fluttering
Sinus Tachycardia and T Wave Inversions
Inferior Wall STEMI
Focus on Leads aVR and V1
Sinus Rhythm, Inferio-lateral STEMI
26 yo female, chest pain following IV EPI
Diffuse ST segment elevation in all anatomic areas
70 yo male, syncope during a stress test
60 yo male, indigestion
Lateral wall STEMI
26 yo female, ESRD and weakness
Severe Hyperkalemia 8.4 mEQ/L
• Peaked T waves
• First degree block
• QRS widening
• ST segment elevation
45 yo male, chest pain
Inferior wall STEMI and deWinter’s
Wave
60 yo M, Nausea and Vomiting
Inferior wall MI with Posterior Ext
Posterior Extension
Tall R waves
ST segment depression
Tall R waves
ST segment depression
Terminally upright T wave
52 yo male, aching pain after lifting weights
Left ventricular hypertrophy
The Grand Mimicker
• Take a careful history
• ST elevation
• ST depression
The “strain” of LVH
The “strain” of LVH
72 yo male, SOB
Massive anterior wall STEMI
2 life threatening complications of massive anterior wall STEMIs:
cardiogenic shock / pulmonary edema
Ventricular dysrhythmia
62 yo F, Hx of CP, now pain free
Wellens’ Syndrome
Wellens’ Syndrome
• ECG changes persist in pain free state
• Suggestive of critical LAD disease
• Biphasic T waves in V1-V3
More Wellens’ Syndrome
• Diffuse T wave inversions anteriorly
• Deeply inverted and largely symmetrical
46 yo F, chest pressure
Inferior wall MI with posterior ext
Why so syncopal ?
Why so syncopal ?
• The RCA supplies the nodal artery
• Infarction results in conduction delays and blocks
• This is an inferior wall MI and third degree HB
45 yo female, SOB
Pulmonary Embolism and Right Heart Strain
Pulmonary Embolism and Right Heart Strain
Approach to 12 Leads
• Rate (fast, slow, ok)
• Rhythm (sinus, ventricular)
• Injury (look at ST segment, Q waves)
Thank You
[email protected]
