lake ems online review: 12-lead · pdf filelake ems online review: 12-lead ekg ... american...
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Lake EMS Online Review:12-Lead EKG
Created and prepared by: Captain Mike HilliardWith profound thanks and admiration to:
Henry J. L. (Barnie) Marriott, M.D., the father of 12-Lead ECGsTim Phalen, author of "12-Lead ECG: in AMI"Gary Denton, author of "Pre-Hospital 12-lead ECG"
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This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only
Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500
352/383-4554 (w); 352/735-4475 (f); [email protected]
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Information also based on: American Heart Association Advanced
Cardiovascular Life Support, Professional © 2011
Recommendations for the Standardization and Interpretation of the Electrocardiogram: A Scientific Statement From the American Heart Association
Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology Parts I-VI
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EKG paper review
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Paper Speed • Most 12-lead EKG's follow a standard format
• This is called a 3x4 format, providing 2.5 seconds of each lead for your review
• The computer is looking at all 12 leads for a full 10 seconds
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Calibration
• Paper speed, calibration, and frequency response are typically preset and do not require adjustment
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Frequency Response
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Lead Identity
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One Complete Cardiac Cycle: For accurate EKG interpretation, 1 complete cardiac
cycle must be obtained in each lead Cardiac cycle equals a: P, QRS, and T-wave
Represents complete electrical cycle Hopefully corresponds to mechanical contraction
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Patient Sex(now an important tool when assessing V2 & V3)
Patient Age
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Patient Information
Measurements
Computerized Interpretive Statement
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The Basics: 1 of 2 key points TP-segment:
Baseline from end of T-wave to beginning of P-wave; a more accurate baseline than PR-interval
T-P Segment Baseline
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The Basics: 2 of 2 key points J-point:
Juncture angle between QRS and ST-segment
Then locate 0.04 sec. (1-small box) after the J-point
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Compare the Two Measure J-point height verses TP-segment Difference of > 1-mm (1-small box) equals a
deviation A deviation in > 1 anatomically contiguous leads
equals problem
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How to Measure ST-Segment Deviation
TP baseline
J-pointPlus 0.04 second
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Find the:• TP line• J-point• One box to the right
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Find the:• TP line• J-point• One box to the right
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Find the:• TP line• J-point• One box to the right
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Find the:• TP line• J-point• One box to the right
Isoelectric
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Find the:• TP line• J-point• One box to the right
Isoelectric
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Find the:• TP line• J-point• One box to the right
Isoelectric
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Find the:• TP line• J-point• One box to the right
Isoelectric Depressed
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Find the:• TP line• J-point• One box to the right
Isoelectric Depressed
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Find the:• TP line• J-point• One box to the right
Isoelectric Depressed
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Isoelectric ElevatedDepressed
Find the:• TP line• J-point• One box to the right
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The 3 "I"s1. Ischemia2. Injury3. Infarction
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Ischemia Hallmark Primary hallmark:
ST-segment depression: > 0.5 mm Secondary signs:
Peaked T-waves Inverted T-waves
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T-waves
Upright Inverted
It is normally upright (above baseline) in all leads except aVR and V1
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T-waves
Upright Inverted
It is normally upright (above baseline) in all leads except aVR and V1
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Injury Injury occurs if ischemia > 20-40 minutes Although cell death is threatened, if blood flow
can be restored we can avoid permanent myocardial death
STEMI is ST-segment elevation >2 contiguous leads or new LBBB
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2010 (New) AHA STEMI guidelines Threshold values for STEMI are:
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2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 V2 and V3 have slightly altered parameters
as we will now demonstrate
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2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3
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2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3
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2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3 Men <40: 2.5 mm elevation in leads V2 & V3
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2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3 Men <40: 2.5 mm elevation in leads V2 & V3
ACLS Manual Page 101
This is the rational for the importance of understanding and assessing the patient’s age and inputting their sex
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Hallmark sign of Injury:
ST-segment elevation
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Infarction Myocardial cell death; cells may demonstrate
injury and ischemia if area becomes larger Hallmark: Q-waves, >1 contiguous lead
Pathological: Q-waves > 1-mm wide and height > 25% of height of R-wave in same cardiac cycle
Physiological: Q-waves not indicative of above
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Q-waves equate with myocardial death
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Q-waves
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Q-waves
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Q-waveCorresponding R-wave
The Q-wave is 25% of the corresponding height of it’s R-wave
75%50%25%
See magical legend!
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Q-wave
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Q-waveCorresponding R-wave
The Q-wave is NOT 25% of the corresponding height of it’s R-wave
75%
50%
25%
See magical legend!
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> 1 mm
Q-wave
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> 1 mmPathological: Due to BOTH height AND width
Q-wave
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< 1 mm
Q-wave
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< 1 mm
Q-wave
Physiological: Due to lack of height and width
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> 1 mm < 1 mm
Pathological Physiological
Q-wave
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Fuzzy Logic Transition from ischemia, to injury, and ending in
infarction is actually a continuum modified by factors including: Extent of muscle involved O2 consumption O2 delivery And presence of collateral circulation
Consider the evolution of a burn with rings of varying degrees of damage
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This is what we have to concentrate onThe acute portion of STEMI (Injury)
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12-Lead Practice Assess for:
1. ST (1° sign suggestive for ischemia; depression >0.5 mm)
2. T-wave inversion (2° sign suggestive for ischemia)3. ST (suggestive of injury; elevation > 1.0 mm)4. Q-waves (suggestive of infarction)
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12-Lead Practice Assess for:
1. Areas suggestive of ischemia2. Areas suggestive of injury3. Areas suggestive of infarction
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EKG Practice
Practice Sample
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EKG Practice
ST (1° sign suggestive for ischemia)
Practice Sample
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ST Depression Leads I, aVL, V1, V2
EKG Practice
Practice Sample
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T-wave inversion(2° sign suggestive for ischemia)
Practice Sample
EKG Practice
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T Wave InversionFYI: aVR and V1 normally have T wave inversion
Practice Sample
EKG Practice
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ST (suggestive of injury)
Practice Sample
EKG Practice
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ST Elevation in Leads II, III, aVF
Practice Sample
EKG Practice
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Practice Sample
Q-waves (suggestive of infarction)
EKG Practice
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Are these pathological Q’s?
Practice Sample
EKG Practice
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Nope! Pathological: Q-waves > 1-mm wide and height
> 25% of height of R-wave in same cardiac cycle Physiological: Q-waves not indicative of above
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Electrode Placement
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"Chest" Lead Placement Leads V1 - V6 are the chest/precordial leads.
The chest leads cannot be obtained without the limb lead wires attached: V1 - Right parasternally, 4th ICS V2 - Left parasternally, 4th ICS V3 - Between V2 and V4
V4 - 5th ICS, mid clavicular line V5 - Between V4 and V6
V6 - Left mid-axillary line, (level with V4)
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• The leg lead wires can be placed on the torso above the indicated leg (left or right)
• But MUST stay below the level of the umbilicus
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Localizing the 3 "I"s Ischemia: ST-segment depression Injury: ST-segment elevation Infarction: Q-waves > 1-mm wide and height >
25% of R-wave height However, deviation must be demonstrated in > 1
anatomically contiguous lead
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LEADS LOOK AT:I, aVL, V5 and V6 Lateral wall of left ventricleII, III, aVF Inferior wall of left ventricleV1, V2 Septal wallV3, V4 Anterior wall of left ventricleV4R, V5R Right ventricle
I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral
Anatomically Contiguous
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AHA ACS Nomenclature1. STEMI:
ST elevation MI2. UA/NSTEMI:
High-risk unstable angina/non-ST-elevation MI3. Low/intermediate risk ACS
Normal or non-diagnostic changes in ST segment or T-wave
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Where do we need to focus? Inferior, septal, anterior, lateral
1. Non-diagnostic: UA2. Suspicious for ischemia: NSTEMI3. Suspicious for injury: STEMI4. Suspicious for infarct: QWMI
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EKG 1, 69 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 1, 69 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 2, 53 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 3, 58 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal (V2 well above 2 mm elevation),
Anterior (V3 well above 2 mm elevation), Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
EKG 4, 47 y/o male
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Computerized InterpretiveStatement In existence for over 50 years Statistically accurate Not always correct Must always be viewed in light of the
surrounding clinical circumstances
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Statistically accurate
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Statistically accurateNot always correct
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****Acute MI**** 52% sensitivity 98% specificity Acute MI = STEMI (ST Elevation MI)
When ACUTE MI statement is present, we should believe it
When ACUTE MI message is absent, do not rule out that either UA, NSTEMI, STEMI, or QWMI exists
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Sensitivity Refers to recognition If the test always recognizes the disorder,
sensitivity would be 100% False negatives are failures of sensitivity A false negative occurs when condition exists
but the test fails to find it
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Specificity Refers to the number of diagnoses confirmed If the diagnosis were corroborated every time
the test identifies it, it would be 100% specific False positives are failures in specificity A false positive occurs when the test indicates
the disease is present, when in fact it is not. I hate that when that happens!
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12-Lead EKG Technology
If statement made, MI age undetermined, it is making claim of an old Physiological QWMI Pathological: Q-waves > 1-mm wide and height > 25%
of height of R-wave in same cardiac cycle
Diagnosis Sensitivity Specificity
Acute MI 52% 98%
RBBB 90-91% 100%
LBBB 78-87% 100%
LVH 32-76% 91-92%
WPW 92% 100%
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When to perform 12-Lead? Chest Pain: Anginal or Atypical
Anginal: Fullness, pressure, crushing, may radiate to neck, jaw, back
Atypical: Unilateral, sharp, changes with position, pleuritic, muscular-skeletal, in jaw, neck, back ~15% of myocardial infarction patients describe atypical pain Females tend to experience atypical pain more often than
males
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When to perform 12-Lead? Chest Pain: Anginal or Atypical
Anginal: Fullness, pressure, crushing, may radiate to neck, jaw, back
Atypical: Unilateral, sharp, changes with position, pleuritic, muscular-skeletal, in jaw, neck, back ~15% of myocardial infarction patients describe atypical pain Females tend to experience atypical pain more often than
males
Anginal Equivalents 40% of ACS patients will not experience pain
Note: 50% of patients with anginal pain are NOT having ACS event
Note: 40% of patients with ACS events will not have anginal pain
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5 additional times toperform a 12-Lead
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5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)
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5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures
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5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures3. Sweating disproportionate to the environment
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5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures3. Sweating disproportionate to the environment4. Unexplained weakness, nausea or vomiting
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5 additional times toperform a 12-Lead1. Dyspnea (especially if associated with CHF)2. Syncope, near syncope, and new onset
seizures3. Sweating disproportionate to the environment4. Unexplained weakness, nausea or vomiting5. Palpitations/Dysrhythmias
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2 Important points on STEMI The 12-Lead ECG is central to the initial risk and
treatment stratification Reports of elevated cardiac markers are not
necessary for a decision to administer fibrinolytic therapy or perform coronary intervention (angioplasty/stent)
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Bundle Branch Block (BBB)
The effects of Intra-Ventricular Conduction Defects on the ECG
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BBB Widens the QRS Deforms the QRS May Change
Repolarization The gross alteration of
depolarization (QRS widening) results in alteration of repolarization (ST-T changes)
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BBB Widens the QRS Deforms the QRS May Change
Repolarization The gross alteration of
depolarization (QRS widening) results in alteration of repolarization (ST-T changes)
It’s kinda like a wolf in sheep’s clothing
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BBB Turn Signal Theory Only works in V1
Only if QRS >0.12 Right BBB:
Which way do you push the turn signal indicator in the unit?
Left BBB: Which way do you push the
turn signal indicator in the unit?
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• RBBB is identified by a wide QRS with the terminal portion of the QRS being positive in lead V1
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• LBBB is identified by a wide QRS with the terminal portion of the QRS being negative in V1
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BBB May Cause or Hide ST Elevation May Cause or Hide ST Depression May Change T Wave Polarity
This is particularly true in LBBB
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Left Bundle Branch Block LBBB Bottom Line:
QRS in V1 > 0.12 seconds wide, and Terminal portion of QRS is negative
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Is this a BBB?
EKG 5, 83 y/o male
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Ayuh
EKG 5, 83 y/o male
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Now, back to 12-LeadsOr 17-Leads as we might start calling them
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Reciprocal Changes Inferior II, III, aVF » Anterior V1-V6, aVL, I Septal V1, V2 » Lateral V5, V6, I, aVL Early Anterior V1-V3 » Posterior V7-V9
When ST elevation is present, ST depression usually appears as well
ST depression typically shows up in opposing leads, AKA reciprocal depression
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Special Considerations: RVI Right Ventricular Infarct (RVI):
If ST elevation in 2-contiguous inferior leads (II, III, aVF), obtain V4R
Right Ventricular Leads: V4R - 5th ICS, right mid-clavicular line
90% accurate for identifying RVI
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Right Ventricular Infarct Results from Proximal RCA occlusion Accompanies Inferior Wall MI Can cause RVF and reduce LV filling pressure
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Treatment for RVISigns of RVI Inferior Wall STEMI plus:
JVD Hypotension Dyspnea with clear lungs ST elevation in V4R AV blocks
Treatment for RVI Fluid for Hypotension NTG by slow drip MS in small careful doses
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
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V4R
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 6, 45 y/o male
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V4R
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended? RV STEMI
EKG 6, 45 y/o male
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EKG 7, 50 y/o male
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
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V4R
Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended?
EKG 7, 50 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a V4R assessment recommended? No RV STEMI
V4R
EKG 7, 50 y/o male
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Special Considerations:Posterior Posterior Left Ventricular Infarct:
If ST depression in 2-contiguous early V leads (V1-V3), obtain V7-V9
Posterior leads: V7 - Post axillary line, level with V4
V8 - Mid scapular line, level with V4
V9 - Left paravetebral area, level with V4
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What do you see?EKG 8, 92 y/o male
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What do you see?EKG 8, 92 y/o male
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V2 & V3 depressionEKG 8, 92 y/o male
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V2 & V3 depressionequals need to assess posterior
EKG 8, 92 y/o male
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Elevation in V7, V8, V9
EKG 8, 92 y/o male
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Elevation in V7, V8, V9equals Posterior STEMI
EKG 8, 92 y/o male
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And 7 Reasons why we perform serial 12-Leads
Well done Adrian Whicker
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Reason number 1This is a 49 y/o woman
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7-minutes later
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10-minutes later(Adrian has asked his driver to drive without due regard for safety)
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16-minutes later(Adrian has told his driver to push over, he's driving now)
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23-minutes laterA 15-box elevation!
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25-minutes later; What does the notching indicate?
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This is what we have to concentrate onThe acute portion of STEMI (Injury)
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30-minutes later
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Cereal 12-Lead EKGs Assessing a patient's rhythm is a dynamic
process, that is why we monitor the patient's rhythm consistently
When a patient has had their 12-Lead assessed, leave the electrodes and precordial leads in place and reassess during every change in: Discomfort, rhythm, or vital signs
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And in Conclusion… What's going on in this last slide? Is there ischemia? Is there injury? Do we need a right sided assessment? Do we need a posterior assessment?
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
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Non-diagnostic (UA)
Suspicious for ischemia (NSTEMI): Inferior, Septal, Anterior, Lateral
Suspicious for injury (STEMI): Inferior, Septal, Anterior, Lateral
Suspicious for infarct (QWMI): Inferior, Septal, Anterior, Lateral
Suspicious for BBB: LBBB, RBBB
Is a right sided assessment recommended?
Is a posterior assessment recommended?
EKG 9, 57 y/o male
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AHA ACS Nomenclature1. STEMI:
ST elevation MI2. UA/NSTEMI:
High-risk unstable angina/non-ST-elevation MI3. Low/intermediate risk ACS
Normal or non-diagnostic changes in ST segment or T-wave
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KeyEKG NSTEMI STEMI Special1 Inferior Lateral2 Septal, lateral Inferior3 Lateral Inferior4 Inferior Septal, anterior, lateral5 BBB BBB BBB6 Septal, anterior, lateral Inferior RVI7 Septal, anterior Inferior No RVI8 Anterior Inferior. Lateral BBB stops
Posterior Dx9 Inferior, lateral Septal
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Ischemia Hallmark Primary hallmark:
ST-segment depression: > 0.5 mm Secondary signs:
Peaked T-waves Inverted T-waves
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2010 (New) AHA STEMI guidelines Threshold values for STEMI are: 1 mm elevation in leads I, II, III, aVR, aVL,
aVF, V1, V4, V5, & V6 Women: 1.5 mm elevation in leads V2 & V3 Men >40: 2 mm elevation in leads V2 & V3 Men <40: 2.5 mm elevation in leads V2 & V3
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LEADS LOOK AT:I, aVL, V5 and V6 Lateral wall of left ventricleII, III, aVF Inferior wall of left ventricleV1, V2 Septal wallV3, V4 Anterior wall of left ventricleV4R, V5R Right ventricle
I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral
Anatomically Contiguous
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Special Considerations: RVI Right Ventricular Infarct (RVI):
If ST elevation in 2-contiguous inferior leads (II, III, aVF), obtain V4R
Right Ventricular Leads: V4R - 5th ICS, right mid-clavicular line
90% accurate for identifying RVI
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Special Considerations:Posterior Posterior Left Ventricular Infarct:
If ST depression in 2-contiguous early V leads (V1-V3), obtain V7-V9
Posterior leads: V7 - Post axillary line, level with V4
V8 - Mid scapular line, level with V4
V9 - Left paravetebral area, level with V4
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Lake EMS Online Review:12-Lead EKG
Created and prepared by: Captain Mike HilliardWith profound thanks and admiration to:
Henry J. L. (Barnie) Marriott, M.D., the father of 12-Lead ECGsTim Phalen, author of "12-Lead ECG: in AMI"Gary Denton, author of "Pre-Hospital 12-lead ECG"
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This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only
Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500
352/383-4554 (w); 352/735-4475 (f); [email protected]