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= 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
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
12 Lead
Current Concepts
Dana$Yost,$Senior$Paramedic$
Paramedic$Training$
King$County,$WA$
Curriculum in Cardiology
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.)
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
2004 ACC/AHA
guideline
recommendation
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
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.
Class I-A
LBBB = Discordance
or
or
or
or
Isolated Posterior MI
LMCAO
Wellen s Syndrome
Wellen s Syndrome
DeWinter T waves
Brugada Syndrome
Brugada Syndrome
Brugada Syndrome
Brugada Syndrome
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
V1
V4
II
aVL
V2
V5
III
aVF
V3
V6
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.
Page: 1 of 1
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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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$(87%)$