Post-TTM Rebound Pyrexia after Ischemia-Reperfusion Injury ...
12 Lead ECGs: Ischemia, Injury & Infarction Part...
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12 Lead ECGs:
Ischemia, Injury & InfarctionPart 2
McHenry Western Lake County McHenry Western Lake County EMS EMS
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Localization: Left Coronary Artery
Right Coronary Artery
Right Ventricle
Septal Wall
Anterior Descending Artery
Left Main
Left Circumflex
Lateral Wall
Anterior Wall of Left Ventricle
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Localization: Left Coronary Artery (LCA)
Left Main (proximal LCA) occlusionExtensive Anterior injury
Left Circumflex (LCX) occlusionLateral injury
Left Anterior Descending (LAD) occlusion
Anteroseptal injury
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Localization Practice ECG
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Localization Practice ECG: Anterior/Septal Wall
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Localization Practice ECG
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Localization Practice ECG: Lateral Wall
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Localization Practice ECG
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Localization Practice ECG: Septal, Anterior and Lateral commonly referred to as Extensive Anterior
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Localization: Extensive Anterior MI
Evidence in septal, anterior, and lateral leads
Often from proximal LCA lesion
“Widow Maker”
Complications commonLeft ventricular failure
CHF / Pulmonary Edema
Cardiogenic Shock
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Localization: Definitive Therapy for Extensive AWMI
Normal blood pressure Thrombolysis may be indicated
Signs of shockPTCA: Percutaneous transluminalcoronary angioplasty CABG: Coronary Artery Bypass Graft
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Coronary Artery Bypass Graft
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Localization: LCA Occlusions
Other considerationsBundle branches supplied by LCASerious infranodal heart block may occur
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Localization: Right Coronary Artery
Left Coronary Artery
Lateral Wall
Left Ventricle
Right Coronary Artery
Posterior Descending Artery
Posterior WallInferior Wall of left ventricle
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Localization: Right Coronary Artery (RCA)
Proximal RCA occlusionRight Ventricle injuredPosterior wall of left ventricle injuredInferior wall of left ventricle injured
Posterior descending artery (PDA) occlusion
Inferior wall of right ventricle injured
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Localization Practice ECG
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Localization Practice ECG: IWMI – RCA is occluded. Unknown if proximal or distal
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Localization: Proximal RCA Occlusion
Right Ventricular Infarct (RVI)12-lead ECG does not view right ventricleUse additional leads
V3R - V6R
Right precordial leadssame anatomical landmarks as on left for V3 - V6 but placed on the right side
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Localization Practice ECG
Note: “R” designation manually placed on this ECG for teaching purposes
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Localization Practice ECG: V4R,V5R and V6R show elevation The proximal RCA must be occluded
Note: “R” designation manually placed on this ECG for teaching purposes
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Localization: ECG Evidence of RVI
Inferior MI (always suspect RVI)
Look for ST elevation in right-sided V leads (V3-V6)
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Localization: Physical Evidence of RVI
Dyspnea with clear lungs
Due to failure of the right ventricle during an acute RVI
Dyspnea is caused by the decrease of pulmonary perfusion from the failing RV.
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Localization: Physical Evidence of RVI
Jugular vein distension
Backup of blood waiting to enter the failed RV
HypotensionRelative or absolute
(the left heart gets all its blood for ejection from the right heart, and the right heart has failed.)
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Localization: Treatment for RVI
Use caution with vasodilatorsSmall incremental doses of MSNTG by drip
Treat hypotension with fluidOne to two liters may be requiredLarge bore IV lines
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Localization: Posterior Wall MI (PWMI)
Usually extension of an inferior or lateral MIPosterior wall receives blood from RCA & LCA
Common with proximal RCA occlusions
Occurs with LCX occlusions
Identified by reciprocal changes in V1-V4 May also use Posterior leads to identify
V7: posterior axillary line level with V6
V8: mid-scapular line level with V6
V9: left para-vertebral level with V6
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Localization Practice ECG
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Localization: Left Coronary Dominance
Approximately 10% of populationLCX connects to posterior descending artery and dominates inferior wall perfusion
In these cases when LCX is occluded, lateral and inferior walls infarct
Inferolateral MI
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Localization Practice ECG: Infero-Lateral Wall MI
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Localization Summary
Left Coronary ArterySeptalAnteriorLateralPossibly Inferior
Right Coronary ArteryInferiorRight Ventricular InfarctPosterior
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Evolution of AMI
HyperacuteEarly change suggestive of AMITall & PeakedMay precede clinical symptomsOnly seen in leads looking at infarcting areaNot used as a diagnostic finding
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Evolution of AMI
AcuteST segment elevationImplies myocardial injury occurringElevated ST segment presumed acute rather than old
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Evolution of AMI
AcuteST segment ElevatedQ wave at least 40 ms wide = pathologicQ wave associated with some cellular necrosis
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Evolution of AMI
Age Undetermined
Wide (pathologic) Q waveNo ST segment elevationOld or “age undetermined” MI
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AMI Recognition
A normal 12-lead ECG DOES NOT mean the patient is not having
acute ischemia, injury or infarction!!!
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Thanks!!
Please continue to part 3 of this presentation