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