Session Number 403

12 LEAD ECG WORKSHOP

Linda Bucher, RN, PhD, CEN, CNE Staff Nurse

Virtua Memorial Hospital – Emergency Department Mt. Holly, NJ

Content Description This presentation will provide a basic introduction to 12 lead ECG interpretation. Emphasis will be on normal 12 lead patterns and patterns of myocardial ischemia, injury, and infarction. Small group work will allow participants to apply information to case studies. Learning Objectives At the end of this session and small group work, the participant will be able to: 1. Interpret a normal 12-lead ECG. 2. Differentiate patterns of ischemia, injury, and infarction as seen on 12-lead ECGs. 3. Apply information to the analysis of 12-lead ECG case studies. Summary of Key Points/Outline I. Issues related accurate 12 lead ECGs A. Patient preparation for 12 lead ECG B. Proper lead placement II. Polarity of leads III. Patterns of leads A. I, aVL B. II, III, aVF C. V1-6 IV. PQRST morphology across 12 leads V. Patterns of Ischemia A. ST segment changes B. T wave changes VI. Patterns of Injury A. ST segment changes B. T wave changes VII. Patterns of Infarction A. ST segment changes B. T wave changes C. Q waves

VIII. Reciprocal changes IX. Relationship of patterns of ECG changes to coronary arteries and other cardiac structures X. Case Study Analyses

Bibliography/Webliography 1. Jacobsen, C. (2008). ECG diagnosis of acute coronary syndrome. AACN Advanced Critical Care, 19(1), 101–108. 2. O’Gara PT, Kushner FG, Ascheim DD, et al. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, Journal of the American College of Cardiology, 61(4), e78-e140. doi:10.1016/j.jacc.2012.11.019 3. Sheehan, T., & Gray, T. 12 lead EKG boot camp series: Using case studies to interpret ischemia, injury and infarction. Retrieved from www.aacn.org/DM/CETests/Overview.aspx?TestID=726&mid=2864&ItemID=718 4. Wesley, K. (2011). Huszar’s basic dysrhythmias and acute coronary syndromes (4th ed.). St. Louis, MO: Elsevier. Speaker Contact Information lbucher@udel.edu

12 lead ECG Workshop12 lead ECG Workshop

Presented by Presented by Linda Bucher, PhD, RN, CEN, CNE Linda Bucher, PhD, RN, CEN, CNE

••Interpret a normal 12Interpret a normal 12--lead ECG.lead ECG.

••Differentiate patterns of ischemia, injury, Differentiate patterns of ischemia, injury,

and infarction.and infarction.

••Apply information to analysis of 12Apply information to analysis of 12--lead ECG lead ECG

case studies.case studies.

““the patient needs a 12the patient needs a 12--leadlead””

Improving the accuracy of Improving the accuracy of the 12the 12--Lead ECGLead ECG–– Patient preparationPatient preparation

»»PositioningPositioning

–– Skin preparationSkin preparation

»»Gauze Gauze

»»AlcoholAlcohol

Improving the accuracy of a Improving the accuracy of a 1212--lead ECG: lead ECG: Lead PlacementLead Placement

Four limb leadsFour limb leads––Left armLeft arm

––Left legLeft leg

––Right armRight arm

––Right leg (ground)Right leg (ground)

Improving the accuracy of a Improving the accuracy of a 1212--lead ECGlead ECG

Dealing with Dealing with lead placement lead placement ““challengeschallenges””

––Hair: shave v. clip?Hair: shave v. clip?––DiaphoresisDiaphoresis––Anatomy Anatomy

Implications of incorrect lead Implications of incorrect lead placementplacement

Improving the accuracy of a Improving the accuracy of a 1212--lead ECGlead ECG

Dealing with Dealing with ECG tracing ECG tracing

““challengeschallenges””

––Internal factors (patient)Internal factors (patient)

––External factors (environment)External factors (environment)

What do those 12 leads What do those 12 leads looklook likelike??

Frontal Plane Frontal Plane

––Bipolar (+ and Bipolar (+ and --) limb leads) limb leads

»»Lead ILead I

»»Lead IILead II

»»Lead IIILead III

RA RALA

LL

LA

LL

RA RALA

LL

LA

LL

What do those 12 leads What do those 12 leads look likelook like??

Frontal Plane Frontal Plane

––Augmented (a) limb leads Augmented (a) limb leads (unipolar: +)(unipolar: +)

»»aVRaVR

»»aVLaVL

»»aVFaVF

RA LA

LFoot

What do those 12 leads What do those 12 leads look likelook like??

Horizontal plane (unipolar: +)Horizontal plane (unipolar: +)––VV1 1

––VV22

––VV33

––VV44

––VV55

––VV66

+

+

r

S

q

R

+ ++

++

+

Normal R wave progression

Normal R waveprogression

What are those 12 leads What are those 12 leads looking atlooking at??

InInfferior wall of left ventricleerior wall of left ventricle

RA LA

LEFT FOOTLEFT FOOTLL LL

What are those 12 leads What are those 12 leads looking atlooking at??

LLateral wall of left ventricle (high)ateral wall of left ventricle (high)

RA LA LA

21

What are those 12 leads What are those 12 leads looking atlooking at??

Ventricular septal wall Ventricular septal wall

–– VV11 and Vand V22

Anterior wall of left ventricleAnterior wall of left ventricle

––(V(V22), V), V33, and V, and V44

Lateral wall of left ventricle (low) Lateral wall of left ventricle (low)

––VV55 and Vand V6 6

So So …… moving beyond the basicsmoving beyond the basics

Linking patterns of leads, coronary Linking patterns of leads, coronary

arteries, areas of the myocardium, arteries, areas of the myocardium,

and other (not so obvious) cardiac and other (not so obvious) cardiac

structures structures

Differentiating patterns of ischemia, Differentiating patterns of ischemia,

injury, and infarctioninjury, and infarction

Patterns of Patterns of IschemiaIschemia, Injury, , Injury, InfarctionInfarction

IschemiaIschemia

––ST segment depressionST segment depression

––T wave inversionT wave inversion

62 y.o. male presents with 62 y.o. male presents with ““chest tightness.chest tightness.””Initial ECGInitial ECG

After treatmentAfter treatment…… Patterns of Ischemia, Patterns of Ischemia, InjuryInjury, , InfarctionInfarction

Injury: ST segment elevationInjury: ST segment elevation

Patterns of Ischemia, Injury, Patterns of Ischemia, Injury, InfarctionInfarction

Infarction: Infarction: Hyperacute stageHyperacute stage

Patterns of Ischemia, Injury, Patterns of Ischemia, Injury, InfarctionInfarction

Acute InfarctionAcute Infarction––ST segment elevationST segment elevation––T wave inversionT wave inversion––Reciprocal changesReciprocal changes

»»VV11 through Vthrough V66, I, and aVL , I, and aVL

II, III, aVFII, III, aVF

»»II, III, aVF I, aVL, VII, III, aVF I, aVL, V55, V, V66

Patterns of Ischemia, Injury, Patterns of Ischemia, Injury, InfarctionInfarctionAcute InfarctionAcute Infarction

––Development of a Development of a pathologic pathologic Q wave (wide, >25% of height Q wave (wide, >25% of height of R wave)of R wave)

Patterns of Ischemia, Injury, Patterns of Ischemia, Injury, InfarctionInfarction

Resolution of Acute InfarctionResolution of Acute Infarction

––ST segment returns to baselineST segment returns to baseline

––T wave usually resumes T wave usually resumes

upright positionupright position

––Pathologic Q wave persists for Pathologic Q wave persists for

lifelife

#1Normal 12 lead 

ECG #1

ECG #2

ECG #3

ECG #4

ECG #5

1

12 LEAD ECG WORKSHOP

Linda Bucher, RN, PhD, CEN, CNE Staff Nurse

Virtua Memorial Hospital – Emergency Department Mt. Holly, NJ

Case Study: ECG #1 The patient is a 48 yo male firefighter who presented to the ED with intermittent, midsternal, chest pain that developed today while fighting a fire. He puts on the call light and tells you “I’m having that pain again.” Review the 12 Lead ECG and complete the following information: 1. Basic (underlying) Rate and Rhythm: 2. R wave progression: Normal or Abnormal

If abnormal, describe:

3. Pathologic Q waves present? Yes No If yes, identify leads:

4. ST segments (circle all that apply): Isoelectric Depressed Elevated If depressed, identify leads: If elevated, identify leads:

5. T waves: Normal or Abnormal If abnormal, identify leads and describe:

6. Reciprocal changes present? Yes No

If yes, identify leads: 7. Interpretation: Think about the coronary arteries involved; treatment strategies, including monitoring; and possible complications that would apply to this patient.

2 Case Study: ECG #2 The patient is a 52 yo black female who presents with left arm pain and SOB. PMH: IDDM, HTN. She was brought to the ED by a coworker when these symptoms developed at lunch. Patient tells you that the pain started on her way to work that morning. Review the 12 Lead ECG and complete the following information: 1. Basic (underlying) Rate and Rhythm: 2. R wave progression: Normal or Abnormal

If abnormal, describe:

3. Pathologic Q waves present? Yes No If yes, identify leads:

4. ST segments (circle all that apply): Isoelectric Depressed Elevated If depressed, identify leads: If elevated, identify leads:

5. T waves: Normal or Abnormal If abnormal, identify leads and describe:

6. Reciprocal changes present? Yes No

If yes, identify leads: 7. Interpretation: Think about the coronary arteries involved; treatment strategies, including monitoring; and possible complications that would apply to this patient.

3 Case Study: ECG #3 The patient is an 80 yo female who was admitted from the nursing home because of new onset confusion and agitation. Patient is normally oriented to person and place. Patient is unable to tell you if she has chest pain. B/P: 96/50 (baseline: 136/70), RR: 26 (baseline: 18), T: 98.8, Pulse Ox: 91% (RA), peripheral pulses are weak. The patient’s daughter is in route to the hospital. Review the 12 Lead ECG and complete the following information: 1. Basic (underlying) Rate and Rhythm: 2. R wave progression: Normal or Abnormal

If abnormal, describe:

3. Pathologic Q waves present? Yes No If yes, identify leads:

4. ST segments (circle all that apply): Isoelectric Depressed Elevated If depressed, identify leads: If elevated, identify leads:

5. T waves: Normal or Abnormal If abnormal, identify leads and describe:

6. Reciprocal changes present? Yes No

If yes, identify leads: 7. Interpretation: Think about the coronary arteries involved; treatment strategies, including monitoring; and possible complications that would apply to this patient.

4 Case Study: ECG #4 A 65 yo male presents with a history of intermittent substernal chest pain over the past 4-5 d. He states he saw his PCP today and was sent to the hospital with his ECG. He denies pain at this time. PMH: hyperlipidemia, BMI>30, prostate cancer (in remission). Review the 12 Lead ECG and complete the following information: 1. Basic (underlying) Rate and Rhythm: 2. R wave progression: Normal or Abnormal

If abnormal, describe:

3. Pathologic Q waves present? Yes No If yes, identify leads:

4. ST segments (circle all that apply): Isoelectric Depressed Elevated If depressed, identify leads: If elevated, identify leads:

5. T waves: Normal or Abnormal If abnormal, identify leads and describe:

6. Reciprocal changes present? Yes No

If yes, identify leads: 7. Interpretation: Think about the coronary arteries involved; treatment strategies, including monitoring; and possible complications that would apply to this patient.

5 Case Study: ECG #5 The patient is a 58 yo Hispanic male who presents to the ED with substernal chest pain that he rates 12/10. He states that the pain started approximately 2 hours ago while at work. Patient is diaphoretic, gray, and clutching his chest. VS: B/P: 118/60, RR: 22, T: 98.9, Pulse Ox: 95% (RA). Review the 12 Lead ECG and complete the following information: 1. Basic (underlying) Rate and Rhythm: 2. R wave progression: Normal or Abnormal

If abnormal, describe:

3. Pathologic Q waves present? Yes No If yes, identify leads:

4. ST segments (circle all that apply): Isoelectric Depressed Elevated If depressed, identify leads: If elevated, identify leads:

5. T waves: Normal or Abnormal If abnormal, identify leads and describe:

6. Reciprocal changes present? Yes No

If yes, identify leads: 7. Interpretation: Think about the coronary arteries involved; treatment strategies, including monitoring; and possible complications that would apply to this patient.