12-lead ekg mepn level iv
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12-Lead 12-Lead EKGEKG
MEPN Level MEPN Level IVIV
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• Discuss the changes in T wave and ST segment morphology with an MI
• List the criteria for identification of right or left bundle branch blocks.
• List the anatomically congruent leads associated with an inferior, lateral and anterior wall MI
• Describe morphology of Q wave presence
EISLO’sEISLO’s
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Myocardial A&PMyocardial A&P
http://www.healthline.com/vpvideo/how-the-heart-works
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Heart wall - Three layersHeart wall - Three layers
Epicardium (outer)visceral layer of pericardiumthin, transparentsmooth, slippery
Myocardium (middle)mass of cardiac muscle
Endocardium (inner)endothelium over thin connective tissuesmooth lining for the chambers and valvescontinuous with blood vessel endothelium
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Cardiac EnzymesCardiac Enzymes• Myoglobin
– Released by all striated muscle
– Rises fast (2 hours) after myocardial infarction
– Peaks at 6 - 8 hours– Returns to normal in
20 - 36 hours
• CK– Released by all muscles
in the body– Rises in 4-6 hours after
injury– Peaks in 24 hours– Returns to normal in 3-4
days– CK-MB is myocardial
“specific”• Peaks in 3-4 hours • Returns to normal in
2 days
• Troponin– More specific for
myocardial injury– Rises 2-6 hours after
injury– Peaks in 12 hours– Remains elevated for 5-14
days
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Arteries Arteries first branches off the aortablood moves more easily into the myocardium when it is relaxed between beats during diastoleblood enters coronary capillary beds
Coronary Coronary Blood Blood FlowFlow
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Collateral CirculationCollateral Circulation
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Coronary CirculationCoronary Circulation
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Coronary Circulation PathologiesCoronary Circulation Pathologies
Compromised coronary circulation due to:Compromised coronary circulation due to:emboli: blood clots, air, amniotic fluid, tumor fragmentsfatty atherosclerotic plaquessmooth muscle spasms in coronary arteries
ProblemsProblemsischemia (low supply of nutrients)hypoxia (low supply of O2)infarct (cell death)
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Internodal tracts
Bundle of His
Right Bundle Branch
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SA NodeSA Node
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Intranodal PathwaysIntranodal Pathways
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AV Node ConductionAV Node Conduction
Normal conduction pathway from atria to ventricles
Limits number of atrial impulses sent to the ventricles
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Bundle BranchesBundle Branches
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Action PotentialAction Potential
Phase 0Begins at -70 mV with a slow influx of sodium ions; gradually raising the potential toward threshold When threshold is reached fast sodium channels open; causing the cell to fire
Phase 1Rapid sodium pumps are slowed by influx of potassium
Phase 2Plateau phaseSodium influx slows; calcium begins to enter the cellCalcium stimulates cellular contraction by stimulating the myocyte
Phase 3Reverse pumps open; rapid repolarization
Phase 4Back to the -70 mV resting potential
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Myocardial Action PotentialDepolarization
Phase 1 of the action potentialStimulation of the cardiac cell by the pacemaker cell causing an influx of Na and Ca, outflow of K.
Repolarization Phase 2 of the action potentialNo impulse entering the cells can cause it to depolarize
Relative refractory periodPhase 3 of the action potentialImpulses entering the cardiac cell now can cause serious, uncontrolled reactions.
Absolute refractory periodPhase 4 of the action potentialThe return of the cardiac cells to resting state.
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EKG BasicsEKG Basics
25 mm per secEach small box - horizontally = 0.4 secEach small box - vertically = 1 mm
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EKG Review - AnalysisEKG Review - Analysis
RhythmRegular or irregular
RateToo fast, too slow, just right
P wavesUpright, inverted, not there, not related
P-R Interval0.12-0.20; >0.20; <0.12
QRS complex<0.12
QT Interval.34-.44
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P wave: Represents positive and negative deflections of atrial contraction and relaxation
PR Interval: Distance between the P wave and the Q/R wave .12 -20
QRS Complex: represents ventricular depolarization
•Q wave: First negative deflection
•R Wave: First positive deflection
•S Wave: second negative deflection
ST Segment: Essentially isoelectric, slopes gently upward•Normal > .08 sec
J point: the point where the S wave meets the isoelectric line
T Wave: Ventricular repolarization•always upright in leads I, II, V2-V6•aVR is always negative.•Leads III, aVL, aVF, and V1 can be positive or negative
U Wave: unclear etiology, commonly seen in V2-V3 due to proximity to ventricular mass; common in bradycardia, hypokalemia, digitalis
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QT intervalbeginning of the QRS complex to the end of the T wave represents ventricular depolarization and repolarization ---- Changes with heart rate
QTcQT corrected for heart rate QT / R-R = QTcEvaluates the recovery of the ventricle
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ECG LeadsECG Leads• 6 limb leads (frontal plane)6 limb leads (frontal plane)
– 3 bipolar leads– 3 unipolar leads
• 6 precordial leads (horizontal plane)6 precordial leads (horizontal plane)– V1 – V6
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Lead IRA (-) to LA (+)
Lead IIRA (-) to LL (+)
Lead IIILA (-) to LL (+)
Einthoven’s TriangleEinthoven’s Triangle
Limb LeadsLimb LeadsBIPOLARBIPOLAR
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AUGMENTED (UNIPOLAR) LEADSAUGMENTED (UNIPOLAR) LEADS
Augmented leads combine 2 leads together (the null point) from the center point of the triangle with one positive pole.
aVRaVR (Augmented Voltage Right Arm positive) is a combination of bipolar Leads I and IIaVLaVL (Augmented Voltage Left Arm Positive) is a combination of I and IIIaVF aVF (Augmented Voltage Left Foot positive) is a combination of Bipolar Leads II and III
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I & AVL
II, III & AVF
WHAT ARE THE LEADS
LOOKING AT?
LIMB and AUGMENTEDLEADS
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Precordial Lead PlacementPrecordial Lead Placement
V1 – 4th intercostal space right of sternumV2 - 4th intercostal space left of sternumV4 – 5th intercostal space midclavicular lineV3 – midway between V2 and V4V6 – 5th intercostal space midaxillary lineV5 – same level as V4 at anterior axillary line between V4 and V6
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RIGHT SIDED EKG
Same lead position as left side – looks directly at the
Right ventricle
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Posterior ViewPosterior ViewPosterior leads:
V7 – lateral to V6 at posterior axillary line
V8 – level of V7 at the mid-scapular line
V9 – level of V8 at the paravertebral line (left posterior thorax midway from spine to V8)
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V3 & V4
V1 & V2
V5 & V6
PRECORDIAL LEADS
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calibrationcalibration marker
Bottom line is continuous strip
LIMB LEADS AUGUMENTED LEADS
PRECORDIAL LEADS
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R – Wave ProgressionR – Wave Progression
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R – Wave ProgressionR – Wave Progression
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Myocardial ischemiaMyocardial ischemiaVarious definitions are used. The term commonly refers to diffuse ST segment depression, usually with associated T wave inversion
Myocardial injuryMyocardial injuryInjury always points outward from the surface that is injured with ST segment elevation
Myocardial infarctionMyocardial infarctiondeath of heart muscle
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Ischemia, Injury, Infarction Ischemia, Injury, Infarction WaveformsWaveforms
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ST segment should be electrically neutral
ST ST SegmentsSegments
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• Visual aid in determining:– Ischemia or
injury to myocardium
– Normal should be at baseline
– Depressed ST segment - >2 mm below baseline
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40EKG 1
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ST Segment ElevationST Segment Elevation
• ST segment elevation is attributed to impending infarction – but can also be due to pericarditis or
vasospastic (variant) angina.
• The height of the ST segment is measured at a point 2 boxes after the end of the QRS complex– significant if it exceeds 1 mm in a limb
lead or 2 mm in a precordial lead.
42EKG 2
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T WavesT Waves
• T waves are normally positive in leads with a positive QRS
• T waves are normally asymmetrical• T waves are normally not more
than 5 mm high in limb leads or 10 mm high in precordial leads or 2/3 the height of the R wave
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T waveT wave
Hyperkalemia Ischemia
Ischemia
Ischemia
45HyperkalemiaHyperkalemia
EKG 3
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ST-T WaveST-T Wave• Combination of infarction and often
hyperkalemia• Called Tombstone ‘T’Tombstone ‘T’ because of
the shape.• Usually a sign of impending cardiac
death.
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Inferior-Anterior-LateralInferior-Anterior-Lateral
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Pathology of an MIPathology of an MI
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Localization of ECG PathologyLocalization of ECG Pathology
• InferiorInferior: Abnormalities that appear in leads II, III, and aVF (called the inferior leads) indicate pathology on the inferior or diaphragmatic surface of the heart.
• Lateral:Lateral: Leads I, aVF, and V5-V6 are called lateral leads. Abnormality in these leads indicates pathology on the lateral, upper surface of the heart.
• Anterior:Anterior: Anterior pathology is seen in leads V1-V4, and often in lead I.
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Overview of InfarctsOverview of Infarcts
Location of Infarct
Arterial Supply
Indicative Changes
Reciprocal Changes
Anterior LAD V1-V4 II, III, aVF
Inferior RCA II, III, aVF I, aVL
Lateral Circumflex I, aVLV5, V6
V1
Posterior Posterior Descending (RCA)
V7, V8, V9 - elevation
V1, V2 -ischemia
Septal Septal Perforating (LAD)Posterior Descending (RCA
Possible loss of R wave in
V1, V2, V3
None
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PathologicalQ Wave
ST Segment Elevation
Q
Q Q
STST
T
T
T Wave Elevation
T Wave Inversion
T
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EKG Changes from InfarctionEKG Changes from Infarction
First Detectable Change in EKG•Tall T-waves
•increase in height
•more symmetric
•may occur in the first few minutes
Hyper-acute PhaseHyper-acute Phase
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Acute PhaseAcute Phase
•ST Segment Elevation•Primary indication of injury•Occurs in first hour to hours
ST Segment Elevation in Leads•1mm or greater in limb leads•2 mm or greater in chest leads
•Hallmark indication of AMI
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CASE STUDY – EVOLUTION of MICASE STUDY – EVOLUTION of MI
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Leads Leads IIII, , IIIIII, , aVFaVF- Looks at inferior Looks at inferior
heart wallheart wall
View of InferiorInferior Heart Wall
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InferiorInferior
EKG 5
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InferiorInferior
EKG 6
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Leads Leads II and and aVLaVL– Looks at lateral heart Looks at lateral heart
wall wall – Looks from the left Looks from the left
arm toward heartarm toward heart
View of LateralLateral Heart Wall
*Sometimes referred to as High Lateral or
High Apical view*
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Leads Leads V5V5 & & V6V6– Looks at lateral heart Looks at lateral heart
wallwall– Looks from the left Looks from the left
lateral chest toward lateral chest toward heartheart
View of LateralLateral Heart Wall
*Sometimes referred to as Low
Lateral or Low Apical view*
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Leads Leads II, , aVLaVL, , V5V5, , V6V6- - Looks at the lateral wall of Looks at the lateral wall of the heart from two different the heart from two different perspectivesperspectives
View of Entire LateralLateral Heart Wall
Lateral Wall
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LateralLateral
EKG 7
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LateralLateral
EKG 8
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• Leads Leads V3V3, , V4V4– Looks at anterior Looks at anterior
heart wallheart wall– Looks from the left Looks from the left
anterior chestanterior chest
View of AnteriorAnterior Heart Wall
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AnteriorAnterior
EKG 9
75EKG 10
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Leads Leads V1V1, , V2V2- Looks at septal Looks at septal
heart wallheart wall- Looks along sternal Looks along sternal
bordersborders
View of SeptalSeptal Heart Wall
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Putting it ALL togetherPutting it ALL together
ANTERIOR
INFERIOR
LATERAL
LATERAL
LATERAL
SEPTAL
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Q WavesQ Waves• DefinitionDefinition
– Septal depolarizationSeptal depolarization– Normally present in I, aVL, V6Normally present in I, aVL, V6
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Two types of Q Two types of Q waveswaves
– Non-pathologic• Narrow, shallow Q
waves• Not visible in all leads
– Pathologic • > 0.04 in duration; at
least 1/4 to 1/3 height of R wave
• Represent an infarcted area of myocardium
80PATHOLOGICAL Q WAVES
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Bundle Branch BlocksBundle Branch Blocks
If the QRS duration is > .12 there is usually an abnormality of conduction of the ventricular impulse
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RBB Block
Most common ventricular conduction defect
Can be acute or chronicAcute RBBB is associated
with an acute anterior MI
83EKG 11
RBBB
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LBB Block
Always indicates a diseased heart
More common in older adults
85EKG 12
LBBB
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