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Julio Diaz NREMT-P TEMS
Training Officer
Gwinnett Fire Academy
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review the ECG waveform and intervals Define myocardial ischemia, injury and
infarction Identify the 5 major infarct areas on the
12 lead Name occluded arteries common to the
area Differentiate ECG changes reflecting
ischemia, injury and infarction Identify cardiac enzymes associated with
ACS
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A result of occlusion of arterial flow to the myocardium.
Ischemia, injury and necrosis is result Occlusion occurs via spasm, blood clot or
stenosis
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The Three I’s
Ischemialack of oxygenationST segment depression or T wave inversion
Injuryprolonged ischemiaST segment elevation
Infarctdeath of tissuemay or may not show a Q wave
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Injury/Infarct Recognition
Epicardial Coronary Artery
Lateral Wall of LV
Positive Electrode
Septum
Interior Wall of LV
Well Perfused Myocardium
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Injury/Infarct Recognition
Normal ECG
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Epicardial Coronary Artery
Lateral Wall of LVSeptum
Interior Wall of LV
Ischemia
Positive Electrode
Left Ventricular
Cavity
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Ischemia◦ Inadequate oxygen to tissue◦ Represented by ST depression or T
inversion◦ May or may not result in infarct or Q
waves
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ST Segment Depression
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Thrombus
Ischemia
InjuryInjury
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ST Segment Elevation
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Infarcted AreaElectrically Silent
Depolarization
Infarct
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Infarct◦ Death of tissue◦ Represented by Q wave◦ Not all infarcts develop Q waves
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Inferior: II, III, AVFInferior: II, III, AVFSeptal: V1, V2Septal: V1, V2Anterior: V3, V4Anterior: V3, V4Lateral: I, AVL, V5, V6Lateral: I, AVL, V5, V6
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
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I Lateral
II Inferior
III Inferior
aVR
aVL Lateral
V1 Septal
aVF Inferior
V2 Septal
V3 Anterior
V4 Anterior
V5 Lateral
V6 Lateral
Which coronary arteries are most likely associated with each group of
contiguous leads?
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Left Main
Left Circumflex
Lateral Wall
Anterior Wall of Left Ventricle
Septal Wall
Right Ventricle
Right Coronary Artery
Anterior Descending Artery
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Localization: Left Coronary Artery (LCA)
Left Main (proximal LCA) occlusion◦ Extensive Anterior injury
Left Circumflex (LCX) occlusion◦ Lateral injury
Left Anterior Descending (LAD) occlusion◦ Anteroseptal injury
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Evidence in septal, anterior, and lateral leads
Often from proximal LCA lesion “Widow Maker” Complications common
◦ Left ventricular failure◦ CHF / Pulmonary Edema◦ Cardiogenic Shock
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Proximal RCA occlusion◦ Right Ventricle injured◦ Posterior wall of left ventricle injured◦ Inferior wall of left ventricle injured
Posterior descending artery (PDA) occlusion◦ Inferior wall of right ventricle injured
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Left Coronary Artery◦ Septal◦ Anterior◦ Lateral◦ Possibly Inferior
Right Coronary Artery◦ Inferior◦ Right Ventricular Infarct◦ Posterior
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Hyperacute◦ Early change
suggestive of AMI◦ Tall & Peaked◦ May precede clinical
symptoms◦ Only seen in leads
looking at infarcting area
◦ Not used as a diagnostic finding
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Evolution of AMI
Acute◦ ST segment elevation◦ Implies myocardial injury
occurring◦ Elevated ST segment
presumed acute rather than old
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Age Undetermined◦ Wide (pathologic) Q
wave◦ No ST segment
elevation◦ Old or “age
undetermined” MI
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A normal 12-lead ECG DOES NOT mean the patient is not having
acute ischemia, injury or infarction!!!
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II, III, aVFII, III, aVF I, aVL, V leadsI, aVL, V leads
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ST segment elevation is presumptive evidence for AMI
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12-Lead ECG AMI recognition
◦ Two things to know What to look for Where you are looking
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I and AVL
II, III and AVF
V3 & v4
V1 & v2
V5 & v6 Where the positive
electrode is positioned, determines what part of the heart is seen!
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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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T-wave inversion ( flipped T) ST segment depression T wave flattening Biphasic T-waves
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Baseline
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ST segment elevation of greater than 1mm in at least 2 contiguous leads
Heightened or peaked T waves Directly related to portions of myocardium
rendered electrically inactive
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Baseline
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Inferior Wall
II, III, aVF◦ View from Left Leg ◦ inferior wall of left ventricle
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
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Lateral Wall I and aVL
◦ View from Left Arm ◦ lateral wall of left ventricle
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
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Lateral Wall
V5 and V6◦ Left lateral chest◦ lateral wall of left ventricle
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
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Lateral Wall
I, aVL, V5, V6◦ST elevation suspect lateral
wall injury
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V3, V4◦ Left anterior chest◦ electrode on anterior
chest
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
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I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
V3, V4◦ ST segment elevation
suspect anterior wall injury
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Septal Wall V1, V2
◦ Along sternal borders◦ Look through right ventricle & see
septal wall
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
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Septal
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
V1, V2◦ septum is left
ventricular tissue
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RVI occurs around 40% in inferior MI’s
Significance◦ Larger area of infarct◦ Both ventricles ◦ Different treatment
Right leads “look” directly at Right Ventricle and can show ST elevations in leads II. III. AVF, V4R , V5R and V6R
Occlusion in RCA and proximal enough to involve the RV
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The single most accurate tool used in measuring RVI.
90% sensitive and specific
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Posterior leads V1, V2◦Posterior Infarct with ST Depressions and/ tall R
wave ◦RCA and/or LCX Artery
Understand Reciprocal changes◦The posterior aspect of
the heart is viewed as a mirror image and therefore depressions versus elevations indicate MI
◦Rarely by itself usually in combo
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Anterior MI with lateral involvement
ST elevations V2, V3, V4
ST elevations II, AVL, V5
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Anteroseptal MI
ST elevations V1, V2, V3, V4
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Inferior MI
ST elevation 2,3 AVF
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Inferior lateral MI
ST elevations 2, 3, AVF
ST elevations V5
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•Acute inferior MI
•Lateral ischemia
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Normals◦ CPK- 10-155u/liter
begin rise 3-6 hours and peaks 12-24 with return to norm 3-5 days
◦ CPK-MB < than 5% IU/liter◦ LDH 85-200 IU/liter
Begin rise 12 hours, peaks 36-72 and normal around 10 days
◦ LDH 1- 18.1% - 29% of total◦ LDH 2- 27.4% to 37.5% of total
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Troponins- Now the Gold Standard!◦ Rises after 3-6 hours◦ Negative Troponin
within 6 hours of onset of S&S rules out the MI
◦ Peaks at about 20 hours
◦ May be raised for 14 days
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Troponin T◦ 84% sensitivity for MI 8 hours after onset of
symptoms◦ 22% for unstable angina
Advantages Highly sensitive for detecting myocardial ischemia Levels may help to stratify risks
Disadvantages Less specific than Troponin I Increased in angina Increased in chronic renal failure
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Troponin I◦ 90% sensitivity for MI 8 hours after onset of S&S
and 95% specificity◦ Level greater than 1.2 suggest MI◦ Negative rules out MI◦ Obtain two negative troponin values 4 hours
apart◦ Normally exceedingly low
◦Even a small elevation indicates myocardial damage
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Twelve Lead Electrocardiography for ACLS Providers, D. Bruce Foster, D.O.W.B. Saunders Company
Rapid Interpretation of EKG’s , Dale Dubin, M.D., Cover Publishing Co. 1998
ECG’s Made Easy, Barbara Aehlert, RN, Mosby, 1995 The 12 Lead ECG in Acute Myocardial Infarction, Tim Phalen,
Mosby, 1996 Color Coding EKG’s , Tim Carrick, RN, H &H Publishing, 1994 www.ecglibrary.com/ecghome.html www.urbanhealth.udmercy.edu/ekg/read.html www.ecglibrary.com/ecghome.html www.nyerrn.com/h/ekg.htm
Drawings by Jill Gregory, Medical Illustrator, CGEY
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