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BASE HOSPITAL GROUPONTARIO
Chapter 6 for 12 Lead Training
-Introduction to 12 Lead Interpretation-
Ontario Base Hospital GroupEducation Subcommittee
2008
TIME IS MUSCLE
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OBHG Education Subcommittee
Introduction to 12 Lead Interpretation
REVIEWERS/CONTRIBUTORSNeil Freckleton, AEMCA, ACPHamilton Base Hospital
Jim Scott, AEMCA, PCPSault Area Hospital
Ed Ouston, AEMCA, ACPOttawa Base Hospital
Laura McCleary, AEMCA, ACPSOCPC
Tim Dodd, AEMCA, ACPHamilton Base Hospital
Dr. Rick Verbeek, Medical DirectorSOCPC2008 Ontario Base Hospital Group
AUTHORGreg Soto, BEd, BA, ACPNiagara Base Hospital
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OBHG Education Subcommittee
Chapter 6 - Objectives Recognize the usefulness of ECG data provided
by computerized 12 Lead ECG Identify important features of ECG such as Q, R,
S, T waves and relate to 12 Lead interpretation Find J-points and compare to TP segments Recognize ST-elevation and relate to clinical
significance Become comfortable with recognizing and
locating AMI on 12 Lead ECG Practice a bit of 12 Lead interpretation
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12 Lead Interpretation
Interpretation vs. STEMI RecognitionIt is important to note that upon
completion of this training, it is not expected that paramedics will be “interpreting” a 12 Lead but rather recognizing STEMI patients
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Learning 12 Lead ECG Interpretation
Common Paramedic responses prior to learning 12 Lead ECG Interpretation:
I can’t interpret a 12 Lead ECG like a Cardiologist!
Are you kidding me?Common Paramedic responses after learning
12 Lead ECG Interpretation: Hey – that wasn’t as hard as I thought it
would be!
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Essential Interpretation
GoalsRecognize and localize
AMI on the ECGFeel comfortable with 12
Lead interpretation
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OBHG Education Subcommittee
12 Lead ECG
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OBHG Education Subcommittee
12 Lead ECG
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OBHG Education Subcommittee
12 Lead ECG
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R Wave
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Q Wave
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S Wave
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J-Point
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ST Segment
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J point - end of QRS complex & beginning of ST segment
The J PointThe J Point
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Practice
Find J-points and ST segments
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Practice
Find J-points and ST segments
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12-Lead ECG
AMI recognitionTwo things to know
What to look forWhere to look
Local medical oversight will determine the criteria used to identify a STEMI patient. All stakeholders must be consulted to determine what criteria should be utilized
in a given centre.
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What to look for
Example - ST segment elevation One millimetre or more (one small
box) in limb leadsTwo millimetres or more (two small
boxes) in chest leadsPresent in two anatomically
contiguous leads
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Contiguous Leads
Limb leads that “look” at the same area of the heart
OR
Numerically consecutive chest leads
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Contiguous Leads Inferior wall: II, III, avF Lateral wall: I, aVL, V5, V6 Septum: V1 and V2 Anterior wall: V3 and V4
Posterior wall: V7, V8, V9(leads placed on the patient’s back 5th
intercostal space creating a 15 lead EKG)
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Where to look
ST segment elevation measurement0.04 seconds after J point
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ST Segment Elevation
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ST Segment Elevation
Presumptive evidence of AMI
Indication for acute reperfusion therapy
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ST Segment
Compare to TP segment
ST TP
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ST Segment Analysis
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OBHG Education Subcommittee
Practice
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Lead “Views”
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Limb Leads Chest Leads
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Lead Groups
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OBHG Education Subcommittee
Lead “Views”
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Inferior Wall
II, III, aVFLeft Leg
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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Inferior Wall
Inferior Wall
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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Lateral Wall I and aVL
Left Arm
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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Lateral Wall V5 and V6
Left lateral chest
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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Lateral
I, aVL, V5, V6
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Lateral Wall
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Anterior Wall V3, V4
Left anterior chest
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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OBHG Education Subcommittee
Anterior Wall
• V3, V4V3, V4
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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Septal Wall V1, V2 Along sternal borders
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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Septal
• V1,V2V1,V2
IIIIII
aVRaVLaVF
V1V2V3
V4V5V6
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AMI Localization
Anterior: V3, V4Anterior: V3, 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
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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
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AMI Recognition Know what to look for
ST elevation> 1mm in limb leads > 2mm chest leadsTwo contiguous leads
Know where you are lookingYou will soon have this memorized
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Mnemonic for Location Rhyme, phrase or device for remembering
something “LII – LI – ASS (backwards) – ALL”
L = I (Lateral)I = II (Inferior)I = III (Inferior)L = aVL (Lateral)I = aVF (Inferior)
S = V1 (Septal)S = V2 (Septal)A = V3 (Anterior)A = V4 (Anterior)L = V5 (Lateral)L = V6 (Lateral)
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OBHG Education Subcommittee
Using mnemonic on ECG You may want to write the Letters in the
corner of each Lead when interpreting
L
L L
L
I
I I
S
S
A
A
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Antero Septal
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Extensive Anterior
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Inferior
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Extensive Anterior
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Inferior
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Extensive Anterior
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Normal ECG
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Inferior
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Infero-lateral
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Inferior
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OBHG Education Subcommittee
Inverted T-waves = ischemia
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BASE HOSPITAL GROUPONTARIO
QUESTIONS?
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BASE HOSPITAL GROUPONTARIO
Well Done!
Education Subcommittee
START QUIT