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12 Lead ECG

Basics

Dana Yost, Senior Paramedic

Paramedic Training

Seattle - King County, WA

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Disclosures and Biases

13 years - 12 Lead Instructor PMT

AHA National & Regional Faculty

Paid consultant on resuscitation and post event analyticsResurgent Biomedical Consulting LLC

Published papers on resuscitation and mechanical CPR

19 years - as a Paramedic in King County, WA

Involved in Resuscitation Outcome Consortium Studies (ROC)

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What is different?

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What is different?

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Plaque Rupture

Lipid Core

Fibrous Cap

Lumen

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Thrombus Formation

Lipid Core

Fibrous Cap

Platelets Adhere

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Thrombus Formation

Platelet Aggregation

Lipid Core

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Thrombus Formation

Platelet AggregationLipid Core

Fibrin

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Vasoconstriction

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Anatomy of the Heart

The layers of the heart muscle

Epicardium

(outer most)

Endocardium(inner most)

Myocardium(muscle mass)

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Evolution of Myocardial Infarction

A Dynamic Process

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ST Segment Elevation

The hallmark of Myocardial Injury

ST Segment DepressionMyocardial Ischemia

Inverted T waves

Myocardial Ischemia

STEMI

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Lead PlacementHow the Leads view the Heart

I

IIIII aVF

aVL

Limb Leads Chest Leads

Basic Patterns

1 23

4 56

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What is the underlying rhythm?

Imitators? (LBBB, Pacer, LVH) if yes = STOP!

Look at each pattern systematically:

ST elevation (1mm or more)

ST depression (1mm or more) = ISCHEMIA

Inverted T waves = ISCHEMIA

Need changes in two or more leads in a pattern

Which pattern or patterns are involved?

= STEMI

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What is the underlying rhythm?Imitators? (LBBB, Pacer, LVH) if yes = STOP!

Look at each pattern systematically:

ST elevation (1mm or more) = STEMI

ST depression (1mm or more) = ISCHEMIA

Inverted T waves = ISCHEMIA

Need changes in two or more leads in a patternWhich pattern or patterns are involved?

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Lead PlacementHow the Leads view the Heart

I

IIIII aVF

aVL

Limb Leads Chest Leads

Basic Patterns

1 23

4 56

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What is the underlying rhythm?Imitators? (LBBB, Pacer, LVH) if yes = STOP!

Look at each pattern systematically:

ST elevation (1mm or more) = STEMI

ST depression (1mm or more) = ISCHEMIA

Inverted T waves = ISCHEMIA

Need changes in two or more leads in a patternWhich pattern or patterns are involved?

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Lead PlacementHow the Leads view the Heart

I

IIIII aVF

aVL

Limb Leads Chest Leads

Basic Patterns

1 23

4 56

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What is the underlying rhythm?Imitators? (LBBB, Pacer, LVH) if yes = STOP!

Look at each pattern systematically:

ST elevation (1mm or more) = STEMI

ST depression (1mm or more) = ISCHEMIA

Inverted T waves = ISCHEMIA

Need changes in two or more leads in a patternWhich pattern or patterns are involved?

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Lead PlacementHow the Leads view the Heart

I

IIIII aVF

aVL

Limb Leads Chest Leads

Basic Patterns

1 23

4 56

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What is the underlying rhythm?

Imitators? (LBBB, Pacer, LVH) if yes = STOP!

Look at each pattern systematically:

ST elevation (1mm or more) = STEMI

ST depression (1mm or more) = ISCHEMIA

Inverted T waves = ISCHEMIA

Need changes in two or more leads in a patternWhich pattern or patterns are involved?

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Lead PlacementHow the Leads view the Heart

I

IIIII aVF

aVL

Limb Leads Chest Leads

Basic Patterns

1 23

4 56

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What is the underlying rhythm?

Imitators? (LBBB, Pacer, LVH) if yes = STOP!

Look at each pattern systematically:

ST elevation (1mm or more) = STEMI

ST depression (1mm or more) = ISCHEMIA

Inverted T waves = ISCHEMIA

Need changes in two or more leads in a patternWhich pattern or patterns are involved?

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Lead PlacementHow the Leads view the Heart

I

IIIII aVF

aVL

Limb Leads Chest Leads

Basic Patterns

1 23

4 56

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What is the underlying rhythm?

Imitators? (LBBB, Pacer, LVH) if yes = STOP!

Look at each pattern systematically:

ST elevation (1mm or more) = STEMI

ST depression (1mm or more) = ISCHEMIA

Inverted T waves = ISCHEMIA

Need changes in two or more leads in a patternWhich pattern or patterns are involved?

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Lead PlacementHow the Leads view the Heart

I

IIIII aVF

aVL

Limb Leads Chest Leads

Basic Patterns

1 23

4 56

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Questions

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Summary

12 lead interpretation is about pattern recognition

Use a systematic approach to interpretation

ST Elevation (STEMI) trumps other ACS finding

Its an art..Practice makes perfect