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What is the underlying rhythm?

Any Imitators? (LBB, Pacer, LVH) if yes


Look at each pattern systematically:
ST elevation (1mm or more)
ST depression (1mm or more)
Inverted T waves
Pathologic Q waves (1mm wide or more)
Need changes in two or more leads in a pattern
Which pattern or patterns are involved?
Localize the Coronary Artery (LCA or RCA?)

MOST COMMON IMITATORS


Pacemaker
Left Ventricular Hypertrophy
Ventricular Rhythms
Left Bundle Branch Block

= STOP!
= INFARCT
= ISCHEMIA
= ISCHEMIA
= OLD

COMBINATION PATTERNS
Anteroseptal
Anterolateral
Inferolateral
Inferoposterior
rd

If a 3 pattern is involved
call it extension
Example: Anteroseptal MI w/ Lateral Extension

LVH CRITERIA

BUNDLE BRANCH CRITERIA

Deepest S wave in V1 or V2
Rhythm must be supraventricular
+
QRS must be wide (0.12 or greater)
Tallest R wave in V5 or V6
Look in V1 & find the J-point
=
If the QRS is negative: LBBB
If sum equals 35mm or greater
If the QRS is positive: RBBB

Front and Back. Same size as before (3 X 4) total size with lamination,
(rounded corners)

!
!
12!Lead!ECG!!
MI!Imitators!
!
!
Dana$Yost,$Senior$Paramedic$
Paramedic$Training$
King$County,$WA$

BBB!Recognition!

BBB!Recognition!

$$

$$

LVH!
(V1 or V2) + (V5 or V6) = _____mm

Summary!
Summary$
Most!Common!Imitators!
LVH$
LBBB$
PACED$

Axis%Devia*on%
% % %&%
% % % %Hemiblocks%

Dana%Yost,%Senior%Paramedic%
Paramedic%Training%
King%County,%WA%

Marked RAD

-90
-120

-60
LAD

aVR

-30

-150

aVL
0

180

I
150

30
120

III

RAD

60
90 aVF

II
Normal Axis
-30 to +100

SA%
Marked RAD

-90
-120

-60
LAD

aVR

-30

-150

aVL
0

180

I
150

30
120

III

RAD

60
90 aVF

II
Normal Axis
-30 to +100

SA%
Marked RAD

-90
-120

-60
LAD

aVR

-30

-150

aVL
0

180

I
150

30
120

III

RAD

60
90 aVF

II
Normal Axis
-30 to +100

SA%
Marked RAD

-90
-120

-60
LAD

aVR

-30

-150

aVL
0

180

I
150

30
120

III

RAD

60
90 aVF

II
Normal Axis
-30 to +100

SA%
Marked RAD

-90
-120

-60
LAD

aVR

-30

-150

aVL
0

180

I
150

30
120

III

RAD

60
90 aVF

II
Normal Axis
-30 to +100

Physiologic%LeQ%Axis%Devia*on%

Pathologic%LeQ%Axis%Devia*on%

%%%%Rules%
%
%%%%Cannot%be%a%LBBB%%
%%%%Cannot%be%a%Pacer%
%
%%%%Cannot%be%Ventricular%
%%%Method%
%
%%%Pathologic%%LeQ%Axis%=%LAFB%
%%%Right%Axis%=%%LPFB%

12 Lead
Case Series

Dana Yost, Senior Paramedic


Paramedic Training
King County, WA

12 Lead
Current Concepts

Dana$Yost,$Senior$Paramedic$
Paramedic$Training$
King$County,$WA$

Curriculum in Cardiology

Appropriate Cardiac Cath Lab activation: Optimizing


electrocardiogram interpretation and clinical decisionmaking for acute ST-elevation myocardial infarction
Ivan C. Rokos, MD, a William J. French, MD, b Amal Mattu, MD, c Graham Nichol, MD, d Michael E. Farkouh, MD, MSc, e
James Reiffel, MD, f and Gregg W. Stone, MD f Los Angeles, CA; Baltimore, MD; Seattle, WA; Toronto, ON; and
New York, NY

Heartclinical
Journal
2010
During the last few decades, acute ST-elevation on an electrocardiogramAmerican
(ECG) in the proper
contextDec
has been
a reliable
surrogate marker of acute coronary occlusion requiring primary percutaneous coronary intervention (PPCI). In 2004, the
American College of Cardiology/American Heart Association ST-elevation myocardial infarction (STEMI) guidelines specified
ECG criteria that warrant immediate angiography in patients who are candidates for primary PPCI, but new findings have
emerged that suggest a reappraisal is warranted. Furthermore, as part of integrated and efficient STEMI systems, emergency
department and emergency medical services providers are now encouraged to routinely make the time-sensitive diagnosis of
STEMI and promptly activate the cardiac catheterization laboratory (Cath Lab) team. Our primary objective is to provide a
practical summary of updated ECG criteria for emergency coronary angiography with planned PPCI, thus allowing clinicians to
maximize the rate of appropriate Cath Lab activation and minimize the rate of inappropriate Cath Lab activation. We review the
evidence for ECG interpretation strategies that either increase diagnostic specificity for classic STEMI and left bundlebranch block or improve diagnostic sensitivity in identifying 4 STEMI-equivalents: posterior MI, acute left main occlusion, de
Winter ST/T-wave complex, and certain scenarios of resuscitated cardiac arrest. (Am Heart J 2010;160:995-1003.e8.)

American Heart Journal


Volume 160, Number 6

Rokos et al 997

Table I. Comparison of 2004 ACC/AHA guidelines and authors' proposed update for ECG criteria that enhance the rate of appropriate Cath
Lab activation for acute MI
Indications for
appropriate Cath
Lab activation
Classic STEMI
Anterior

Inferior

Lateral

STEMI-equivalents
New or presumed
new-onset LBBB

Diagnostic criteria for


patients with
symptoms <12 h

2004 ACC/AHA
guideline
recommendation

Proposed update vs.


ACC/AHA guidelines

ST-elevation 1 mm in 2
contiguous leads V1-V4

Class I-A

Agree

ST-elevation 1 mm in 2
contiguous leads
(II, III, or AVF)
ST-elevation 1 mm in 2
contiguous leads
(I, AVL, V5, or V6)

Class I-A

Agree

Class I-A

Agree

Presumed new LBBB


assumed when prior
ECG unavailable
New LBBB when prior
ECG available

Preexisting LBBB with


Concordance noted between
Sgarbossa concordance QRS complex and ST/T-wave

Class I-A

None

Comment

ST-elevation 2 mm (men)
and 1.5 mm (women)
improves diagnostic
specificity.15
Presence of reciprocal
changes (ST-depression in
opposite leads) improves
diagnostic specificity.
Presence of reciprocal
changes improves diagnostic
specificity.
As above.

Proposed demotion in future Unless clinically unstable,


ACC/AHA guidelines
most LBBB should be
evaluated with biomarkers
and non-emergent
angiography if indicated.
An old ECG without LBBB
does not necessarily confirm
that the new LBBB is acute.
Proposed addition to future Use of these decision criteria
ACC/AHA guidelines
provides N95% specificity

(I, AVL, V5, or V6)


STEMI-equivalents
New or presumed
new-onset LBBB

Proposed demotion in future Unless clinically unstable,


ACC/AHA guidelines
most LBBB should be
evaluated with biomarkers
and non-emergent
angiography if indicated.
An old ECG without LBBB
does not necessarily confirm
that the new LBBB is acute.
None
Proposed addition to future Use of these decision criteria
Preexisting LBBB with
Concordance noted between
ACC/AHA guidelines
provides N95% specificity
Sgarbossa concordance QRS complex and ST/T-wave
and avoids the need to find a
complex, with ST elevation
prior ECG for comparison.
1 mm in 1 lead
Discordant ST-elevation
5 mm is also a Sgarbossa
criteria, but some studies
found it a weak predictor.
Posterior MI (isolated)
ST-depression 0.5 mm in
Fibrinolytics: class IIa-C
Proposed clarification in
Recent data34 demonstrated
leads V1-V3
Primary PCI: class I-A implied future ACC/AHA guidelines that most posterior MIs are
currently evaluated with
Associated T-waves are either
urgent (rather than
upright or inverted.
emergent) angiography, but
Appearance of tall R-waves
this delay is associated with
in V1-V2 may be delayed.
worse clinical outcomes.
Left Main coronary
ST-depression 1 mm in
None
Proposed addition to future Most relevant in any ECG
occlusion
6 or more leads
ACC/AHA guidelines
with diffuse ST-depression
Lead aVR with ST-elevation 1 mm
1 mm that does not meet
ST-elevation in lead aVR V1
classic STEMI criteria, thus
providing a subtle clue that
emergency angiography
may be warranted
de Winter ST/T-wave
ST depression 1 mm
None
Proposed addition to future Tall T waves and up-sloping
complex
up-sloping at the J-point in
ACC/AHA guidelines
ST depression are persistent,
leads V1-V6
not transient.
Precordial T waves are tall,
Associated with proximal
upright, symmetric
LAD occlusion
Normal QRS duration
None
Potential addition to future Generally prudent to perform
Hyper-acute T-waves
Tall peaked T waves
ACC/AHA guidelines
serial ECGs, because true
immediately following
HATW generally morph
symptom onset may
quickly into a classic STEMI
represent acute ischemia,
pattern13
but clinical studies
are lacking.
Hyperkalemia is another
common cause of tall T waves
Presumed new LBBB
assumed when prior
ECG unavailable
New LBBB when prior
ECG available

Class I-A

LBBB = Discordance

or

Paced Rhythms = Discordance

or

LBBB w/ Concordance !!!

or

Paced Rhythm w/ Concordance !!!

or

Isolated Posterior MI

LMCAO

Wellen s Syndrome

Saturday, October 13, 2012


9:31 PM

Wellen s Syndrome

Saturday, October 13, 2012


8:59 PM

DeWinter T waves

Brugada Syndrome

Brugada Syndrome

Saturday, October 13, 2012


9:42 PM

Brugada Syndrome

Brugada Syndrome

Saturday, October 13, 2012


9:42 PM

Brugada Syndrome

Tachycardia S1 Q3 T3 (IRBBB)

Name:
ID:
Patient ID:
Incident ID:
Age: 37

Tachycardia S1 Q3 T3 (IRBBB)

ZENTER,JILL 12-Lead 1
101512182201 10/15/2012
PR 0.142s
QT/QTc:
Sex: F P-QRS-T Axes:

aVR

HR 116bpm
18:26:11
QRS 0.102s
0.324s/0.422s
54 -12 -20

Abnormal ECG **Unconfirmed**


Sinus tachycardia
rSr'(V1) - probable normal variant
Possible inferior infarct - age undetermined
Anterolateral ST-T abnormality is borderline for age and gender

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

x1.0 .05-150Hz 25mm/sec


Physio-Control, Inc. Comments:

MEDIC 35 M35 3306808-005 LP1538191234

ST measurements are measured at the J point and are expressed in mm.


I
-0.49

II
-0.47

III
0.02

aVR
0.49

aVL
-0.26

aVF
-0.23

V1
0.26

V2
0.04

V3
-0.26

V4
-0.40

V5
-0.42

V6
-0.41

To ensure printer accuracy, confirm that the calibration markers are 10mm high and the grid squares are 5mm wide.

LIFENET Report Renderer (5.1.4.1)

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Summary
! Use a systematic approach to interpretation
! Recognize Concordance in LBBB and Pacer
! Recognize:
!
!
!
!
!
!

Posterior
LMCAO
Wellen s Syndrome
DeWinters
Brugada Syndrome
PE

!
!
12!Lead!ECG!!
Review!
!
!

Dana$Yost,$Senior$Paramedic$
Paramedic$Training$
King$County,$WA$

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3$

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5$

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6$

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7$

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13$
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12$
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Ventricular
Tachycardia!
!
vs.!
!
!
S V T!

Dana$Yost,$Senior$Paramedic$
Paramedic$Training$
King$County,$WA$

$Nega?ve$Precordial$Concordance$(96%)$
$RBBB$I$LeK$RabbitIEar$Taller$Than$Right$(95%)$
$V6$Completely$Nega?ve$(95%)$
$LBBB$$Short$Fat$R$Wave$in$V1$(90%)$
$ERAD$(90%)$
$$
$V6$Nega?ve$with$a$liTle$R$Wave$(87%)$

Nega?ve$Precordial$Concordance$(96%)$

RBBB$I$LeK$RabbitIEar$Taller$Than$Right$(95%)$

RBBB$I$LeK$RabbitIEar$Taller$Than$Right$(95%)$

V6$is$completely$nega?ve$(95%)$

LBBB$in$V1$with$short$fat$R$(90%)$

LBBB$in$V1$with$short$fat$R$(90%)$

ERAD$(90%)$

V6$Nega?ve$with$a$liTle$R$Wave$(87%)$

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