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12 Lead ECGMI Imitators

Dana Yost, Senior Paramedic

Paramedic TrainingKing County, WA

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MI Imitators LBBB

LVH

Paced

Ventricular Rhythms

Benign Early

Depolarization

Left Ventricular

Aneurysm

Pericarditis

Cardiomyopathy

Acute Myocarditis

WPW

Hyperkalemia

Hypothermia

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Bundle Branch Block

Delayed depolarization

Can be pre-existing condition

Can be caused by MI

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Bundle Branch Block

Can mimic MI

Can hide evidence of MI

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Bundle Branch Block

May Produce

ST elevation

ST depression

Tall T waves

Inverted T waves

May Hide

ST elevation

ST depression

Tall T waves

Inverted T waves

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BBB Recognition

Forget About the Notch!

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BBB Recognition

Wide QRS > 120ms

Supraventricular rhythm

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RBBB vs. LBBB

Use V1

Identify direction of

terminal force

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Bundle Branch Block

V1

Right Left

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BBB Recognition

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BBB Recognition

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RBBB vs. LBBB

LBBB distorts the 12 lead !!!

RBBB distorts the 12 lead but ST Elevation is real

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Vent. Paced Rhythms

Generally present like a LBBB

Pacer spikes

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Left Ventricular Hypertrophy

Enlarged left ventricle

Pumping against increased resistance

Chronic overfilling

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LVH

May Produce

ST elevation ST depression

Tall T waves

Inverted T waves

May Hide

ST elevation ST depression

Tall T waves

Inverted T waves

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LVH

Does not abnormally widen QRS

Increases height and depth of QRS

Recognized by this increase

Three step recognition formula

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LVH Recognition

Step 1

Look in V1 and V2

Pick the deepest negative deflection

Count small boxes of negative deflection in that

lead

Remember that number

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LVH Recognition

Step 2

Look in V5 and V6

Pick the tallest positive deflection

Count small boxes of positive deflection

Remember that number

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LVH Recognition

Step 3

Add the two numbers together

Suspect LVH if the sum equals 35 or

more

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LVH

(V1 or V2) + (V5 or V6) = _____mm

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Most Common Imitators

LBBB

PACED

LVH

SummarySummary