Transcript for:
Understanding 12-Lead EKG Interpretation

really going to start at the really basics of 12-lead ekg interpretation and the sense of what are we looking at um and what are we looking for and where are we looking at it and to hopefully getting the imitators with bundle branch blocks and left ventricular hypertrophy so before we jump into the actual 12 lead ekg interpretation it's extremely important to understand coronary artery anatomy so your left and your right coronary artery obviously come off the branch of your aorta uh i'm sorry the base of your aorta and that these two coronary arteries are the main arteries that supply the actual myocardium itself with oxygenated blood they ultimately have several different branches that branch off of them to supply the different areas of the myocardium but the left main coronary artery and the right main coronary artery are the two large main suppliers of the myocardium so the left coronary artery it supplies the left ventricle the interventricular septum which is that um thick piece of muscle that separates your right and your left ventricle part of the right ventricle and the heart's conduction system so our sa node our av node av junction the bundle of his our bundle branches and our purkinje fibers it's really what helps perfuse that electrical system there's two main branches of the um left coronary artery so uh the first major branch is this left anterior descending okay and here's my left coronary artery coming off of the base of the aorta and this main artery coming down the anterior side of the left ventricle that is my left anterior descending which if you think about it it's pretty easy to keep that straight because it's coming off of our left coronary artery and it is going down so it is our left anterior descending or artery that is the branch off of the left coronary artery the other major branch of the left coronary artery is the circumflex and you can kind of see it here branching off near the top of that left coronary artery or the left main coronary artery and that circumflex actually wraps around to the posterior side of that left ventricle trying to get us to advance there there we go so the right coronary artery it supplies portion of the right atrium portion of the right ventricle the posterior and the inferior side of the right ventricle and part of the conduction system there's two major branches of the right coronary artery that we need to be familiar with there's the posterior descending artery and there's a marginal branch and just to kind of highlight those real quick we have our right coronary artery right i'm riding in blue this comes off the base of our aorta as that right coronary artery travels down you can see right in here it branches off part of it wraps around the posterior portion of the heart and the other branch comes continues down and goes down um the anterior side of the heart but over here to where our right ventricle would be okay so the posterior descending artery this is the portion that wraps around to the posterior side of the heart appropriately named and we see this wrapping around here under our right atrium and continuing down the posterior side of the the heart and the right ventricle so not only is it important to understand coronary anatomy as it applies to the 12 lead ekg but but you also see test questions on this i can almost guarantee you'll see test questions on coronary artery anatomy not only in your program but also on the national registry um and you know and what those questions could potentially look like is you're giving a 12 lead ekg and you're not being asked to identify whether it is an anterior wall of mine or a septal wall of mine or an inferior wall of mine rather you're being asked to identify which coronary artery is most likely affected to give you that type of mi on the 12 lead ekg that you have in front of you so keep that in mind coronary artery anatomy is kind of difficult to remember as you progress to the paramedic program but there's definitely going to be several areas where you see a pop-up in testing and that you're expected to know what portion of the heart correlates with which coronary artery so lead placement limb leads must be placed on the limbs right and there are some exceptions that we can move higher up on the limbs um or maybe even the lower trunk uh or the abdominal cavity but truly limb leads are called limb leads for a reason they should be placed on the limbs and that's because that is what gives us the best view of the myocardium when we're looking for a stemi or to rule out a stemi not going to spend too much time on that chest lead placement or precordial lead placement remember your precordial leads that's just another term for chest leads so we might use that interchangeably today v1 goes to the is it the fourth intercostal space to the right of the sternum v2 is at the fourth intercostal space to the left of the sternum we're then actually going to go to v4 v4 goes in the fifth intercostal space at the left mid clavicular line and then we're going to place v3 directly between leads v2 and v4 and then v5 and v6 they should all be on the same plane or at the same level as v4 so v5 is at the left anterior axillary line and v6 is level with v5 still but it's at the mid axillary line so v4 v5 and v6 they should all be on the same plane they should all be on the same level um and i think if you pay attention to how 12 lead ekgs are done not only in the pre-hospital setting but also the clinical setting you'll see some pretty significant varieties with chest lead placement but you start a good habit early in your career that way you can you can place 12 lead ekgs appropriately because obviously all of these electrodes are being placed in a particular area for a reason so global negativity so this slide in the next slide i'm going to talk about what is what are some things that we can kind of check to make sure that we have a good 12 lead ekg and i don't mean a good 12 lead ekg in the sense of a clinical status but more so in okay um i have appropriate placement and the things that i'm seeing on this 12 lead should therefore be valid because i have good limb lead placement so um global negativity is if you look at the 12 lead ekg strip and if you have um if all of your leads lead one lead two lead three if all of those are deflected downwards then your your upper limb leads are probably switched you probably have your right arm lead on the left arm and vice versa so that's something that that's good to look at so look at lead one if it is deflected down and i mean the qrs complex if the qrs complex and lead one on your 12 lead is deflected negatively that probably means that you have your left and your right switched okay and i have done that right where we all do 2 and 3 a.m 12 leads um and i have done that and fortunately i was able to catch it because when you do enough 12 lead ekgs it just kind of stands out when things are going different directions and what they should be but it's always a good idea to look at lead one it should be pointing up the lead right next to it avr should always be pointing down and we'll talk about that a little bit more when we get into the strips then we have r wave progression so this is kind of another good thing to look at just to make sure that your leads are on appropriately they're placed correctly so if you go to your precordial leads remember your chest leads v1 through v6 we should have a good progression from negative and v1 so negative deflection in v1 to a positive deflection in v6 so if i start here in v1 and as i work my way down through these leads you can see that my qrs complexes slowly have a progression from entirely negative like we see in v1 to entirely positive like we do in v6 so that's called r wave progression and um that's just another tool that you can kind of have to make sure that your limb leads are placed appropriately and that they're not switched you don't have your your left leg lead put on the right leg vice versa you don't have your um right arm lead placed on the left arm lead so what are our goals when we're looking at a 12 lead ecg and we're looking at a 12 what are our actual goals so our goals are to recognize and localize that acute myocardial infarction on the ecg and we also have to understand that associated coronary artery anatomy and do we expect that this 12 or that this myocardial infarction is going to spread to other areas um do we suspect that the patient's going to become bradycardic or tachycardic based on the findings that we're seeing based on the areas that we're seeing are injured or infarcted so a normal 12-lead ecg does not rule out an acute myocardial infarction and i hope if you learn nothing more in this lecture i hope you learned that um i i cringed when i was in the medic unit and i would hear my partner say um well sir we did a 12 lead ekg and everything looks great you're not having a heart attack right because we don't know that he may not be having the specific type of mi or heart attack that we're trained to look for on 12 lead ekg but there is a such thing as a non stemi and um they happen about 50 percent of the time so when there's a heart attack 50 percent of the time it is a stemi and 50 of the time it is a non stemi so just because we do a 12 lead ekg and it comes back with no st segment elevation that does not mean that you and your patient are in clear okay so what my advice to you is is sir we did a 12-lead ekg from the test that we can run we can rule out the type of heart attack that we're trained to look for however that doesn't mean that you're necessarily out of the woods yet right you can still be having an mi you got to get you the hospital they need to do blood work before we can totally rule this thing in or out so just kind of becoming familiar with the anatomy of a 12 lead ekg so i'm not talking about coronary anatomy but really the layout um there's several different variances of this you know depending on if you're printing it off from an ekg in the clinical setting or an ekg monitor in the clinical setting like we see here if you're printing off a physio control monitor if you're printing it off a zoll monitor or phillips monitor all of them look a little bit differently right but i think that um you'll kind of get the adjust of it after we talk about it so there's three different parts that are circled here and i'm going to start with this top left section first where it says um march 4th uh or march 30th of 2004 um it talks about the patient demographics and then down below that it gets into the pr interval it gets into the qrs duration um all that different data there so that area there um when when you get a 12 lead ekg printout and you have actual data to go off of an actual measurements to go off of that is 100 percent diagnostic and that is accurate information that are those are measurements that the machine took okay that is objective information to the right of that where you have the machine's interpretation my advice is to you is do not get comfortable reading that and using that to dictate what type of heart attack this patient's having or if the patient's having a heart attack um there's been multiple studies done out there on um the accuracy of that reading or of that measurement or of that printout and adam if i think you're probably familiar with this study um and feel free to chime in if i get this incorrect but when um that prints out and says there is an acute mi suspected okay and we see that terminology like on the physio control the life pack 12 the life pack 15 print outs when it says acute am i suspected there is an mi okay you can be pretty sure that there is a stemi somewhere on that paper when it prints out and says normal sinus no st change noted whatever no acute am i suspected there is a very high percentage and very high likelihood that that is incorrect information okay so the monitors are very good of saying when there's a stemi you know and they tell you there's a stemi it's probably a stemi but do not get used to falling back on that information because there have been multiple studies done that says when it tells you it's a good 12-lead ekg it's normal findings there's nothing to be alerted about it's probably wrong okay so just keep that in the back of your mind as you're practicing paramedic in the back of the medic unit and then down at the bottom um you these are just our continuous leads that we see that we can use for rhythm interpretation and rhythm identification those can be changed from monitor for monitor it's it's truly whoever's at your agency and responsible for the cardiac monitors they can pick and choose which leads that we get that full six second strip on at the bottom of the 12 lead ekg all right so now let's talk about st segment elevation and st segment identification so before we can find the st segment we have to be able to find the j point and the j point ironically enough is the junction between the end of the qrs complex and the beginning of the st segment so remember that j point is the junction of where that qrs complex is ending and that st segment is beginning so every time you measure the qrs complex for its width right to determine is it narrow or normal or wide is it greater than 0.12 or is it less than 0.12 every time you measure that qrs complex you're finding the j point it's the end of the qrs complex we have to be able to find that so that we can identify what is our st segment so that we can then make the determination is it elevated is it even with the isoelectric line or do we have some depression the st segment itself is the area between the s wave which is the end of the qrs and the t wave so it should be a somewhat flat isoelectric line that's that time between our ventricular depolarization that we see in our qrs complex and our ventricular repolarization of what we see in our t wave so that st segment is what we're actually looking at to be able to determine is it elevated which would be a stemi is it even with the isoelectric line or is it actually a little bit depressed telling me that i have some ischemia so what we are doing is we are identifying the j point so that we can see the beginning of our st segment and we are comparing that st segment's height to the preceding tp segment okay so find your st segment and then look at that tp segment right next to it right down the line right on the other side of the t wave you're going to use those two lines or those two landmarks to make your determination is this patient having a stemi or not is your st segment elevated above the tp segment or is it depressed below the tp segment or is it essentially at the same level as the tp segment so make sure that you know that i find a lot of paramedic students who don't know that and they just kind of look broadly across the strip to say yeah it looks tall to me it looks a little bit elevated but if you don't actually know what you're comparing it to it's difficult to make that determination of yep this is elevated by two millimeters or it's elevated by three millimeters or it's not elevated at all so we're comparing the st segment to the preceding tp segment in terms of the height comparison hey brandon sure let me go back for just a second there just terminology purposes i want to make sure they understand you're saying preceding it would actually be the next the following oh i'm sorry yes so i just want to make sure that they're clear on that that when brandon's looking at that j point in the sp segment he is comparing it to the tp segment to the right not the one for it correct sorry about that thank you no i know what you meant but i just wanted to clear that up all right so let's um take a few minutes and look to make sure that we can all find the j point so that we can all find the st segment and we can make a determination is it elevated is it even with the isoelectric liner or is it even a little bit depressed so uh let's look at this first one here this okay so let's look at number one so i want you all to find the j point and i know it's hard to do on your computer screen and i know it's hard to kind of make a mental note of where it's at and i'm going to give you a few seconds to find the j point and then i'm going to highlight um where it would be so the j point for number one will be about right there okay right where i play that red circle and again it's a little bit hard to place it exactly where it's at right and the red circle is a little bit larger so that you all can actually see it but hopefully you kind of get the adjust of it there so that would be about where my qrs complex ends and my st segment begins and then i have to look at the following tp segment to make the determination is it elevated is it even with or is it below so if i draw a straight line from that j point you see that we're pretty even with that following tp segment so we're iso electric with it i don't see any elevation there which would make me say that i don't see a stemi or st segment elevation i should say in that one picture now we're gonna jump over to number two all right there's my j point and as i draw a straight line over there may be a little bit of elevation there and we haven't talked about how much elevation is elevation to be concerned with um but there might be about one millimeter of elevation there about one small box there again it's kind of hard because i i drew the line um pretty wide pretty thick so that you can actually see it on your screen the j point for number three would be where that dot is as i go a straight line over i'd say i definitely have st segment elevation that's greater than one millimeter in height we drop down to number four so this is kind of a tricky one um number four the j point is actually down near the bottom of it and if we get into imitators tonight we'll actually kind of talk about what's going on there in number four um it's called an rsr prime configuration probably a right bundle branch block we need a lot more information to go off than that but that's just kind of what that looks like to me what how it stands out to me um so remember we're going off the end of the complex end of the s wave okay and the end that would actually be one entire complex of what we're looking at there as we bring our line straight over from the j point we're isoelectric so there's nothing concerning there as we jump over to number five my j point would be where that red dot is as i draw a straight line off of that again i'm basically right on the iso electric line and as i jump over to number six my j points are probably a little bit lower down than where that circle is but not by much and as i come over i doubt i'm definitely a little bit lower than that following tp segments i have a little bit of depression there which could clue me in if you have this patient's having a little bit of ischemia so hopefully that helps in j point identification right and the more that you do 12 lead ekgs the more comfortable you will become with them and being able to pick these things out and there's definitely some tricky ones number four is a tricky one um but for the most part once you're able to find the j point and you're able to find the end of that qrs complex um you know you'll fly through that exercise if you weren't already flying through that exercise as we just did it i'm sure i had we probably have people um with us today that are kind of all you know both ends of the spectrum here so stimmy or not um what are we looking for to actually call something a stemi so we're looking for st segment elevation i think we've discussed that enough and we're looking for one millimeter or more of elevation and one millimeter is one small box on the ekg paper so not only are we looking for one millimeter of elevation or more but we're looking for it in two or more anatomic contiguous or numerically consecutive leads that's the big part here everyone knows that a stemi is an st segment elevated myocardial infarction right so just by the name of it we can pick up on the fact that the st segment is elevated in order to be a stemi but we also have to remember that it must be elevated and two or more anatomically contiguous or numerically consecutive leads and we're going to look at what that actually means so one more thing about the actual some of the findings that we can find on a 12-lead ekg before we jump into into some practice strips is uh when we get this message and this is off a off a life pack 12 or a life pack 15 monitor it's a physio control strip that we're looking at if you get the message that says um cannot rule out anterior infarct possibly acute or if we get a message that says um inferior wall am i suspected age undetermined what that's actually telling us when we get that age undetermined message um it's actually telling us that it's picking up on pathological q waves and those pathological q waves are q waves that are greater than point zero four seconds or one small box so there's physiologic q waves and those are normal findings right if we did a 12-lead ekg on any of us we would probably have physiological q waves and those are q waves that are less than one small box in width or less than .04 seconds when we get wide q waves on a 12 lead ekg those are called pathological q waves and that tells us that this patient has had a previous infarction in that area so again if you get a 12 lead ekg strip and it says you know anterior wall mi age undetermined or inferior wall am i age undetermined when we get that language that is telling us that it is picking up on pathological q waves and a lot of times when we see that we're not able to see those really wide q waves but that machine was able to measure and remember the machine is really good at taking measurements like i said a few slides ago so if you get that message doesn't mean that they're having a heart attack right now it's just telling you that they're picking up on some wide pathological keyways and that they've probably had an mi in that area before now real quick um you know again we have we have students kind of all over the spectrum i think in terms of where they're at in their program um there are two types of mis right and i'm not talking about stemi and non-stemi but i'm talking about the level of the myocardium or the depth of the myocardium that's affected so you have a sub endocardial mi and you have a transmural mi a sub endocardial mi is when a partial thickness of that myocardium hasn't been infarcted so it's hasn't made its way through the entire thickness of the myocardium the entire thickness of that left ventricular wall only a partial thickness of the left ventricular wall that is called a sub endocardial mi the transmural mi is a full thickness myocardial infarction when a patient has a transmural mi they have that full wall thickness myocardial infarction that patient will be left with pathological q waves okay if they have a sub-endocardial infarction they may or may not have pathological q waves on 12-lead ekgs down the line so if we come up with pathological cue waves and the anterior leads or inferior leads or wherever that doesn't only tell you that yep this patient has had an mi there before but it also tells you that it was probably transmural in nature meaning that the entire thickness of that section of the myocardium was actually infected so let's talk about anatomically contiguous leads or numerically consecutive leads so i said that we're looking for st segment elevation that is one millimeter in height or greater than two or more anatomically contiguous leads or numerically consecutive leads so uh anatomically contiguous leads we are looking at what are the actual lead groupings of the 12 lead right meaning 1 avl v5 and v6 those are my lateral leads 2 3 and avf my inferior leads v1 and v2 my septal leads and v3 v4 my anterior leads those are my anatomically contiguous lead groupings okay so if i have st segment elevation and lead two and i have st segment elevation in lead three those are both um anatomically contiguous change this so let's say i have elevation here and i have elevation here those are anatomically contiguous to one another they belong to the same lead grouping so therefore in that scenario i would have an inferior wall mi okay if i have st segment elevation in v1 and i have sc segment elevation and v2 those belong to the same grouping anatomically that is a septal wall am i and the same with v3 and v4 those are my anterior leads and i already said 1 avl v5 and v6 so those are my lateral leads so that is the anatomically contiguous part of that 12 lead ekg interpretation uh is the lead groupings themselves so if they have one millimeter of st segment elevation and two or more of those anatomically contiguous leads the other way that i can hand it is and numerically consecutive leads and primarily we look at our precordial leads for this my chest leads so numerically consecutive meaning just the way that we count one two three four five six okay so not necessarily that they're touching one another okay not that they're butting up against one another but that they're numerically consecutive so we already said if we had elevation in v1 and v2 that would be a septal wall mi those are anatomically contiguous to one another but let's say i also have elevation in v3 but i don't and v4 i don't in v5 and i don't in v6 so i only have elevation and leads v1 v2 and v3 well i know i definitely have a septal wall in my because v1 and v2 they belong together but i also have elevation in v3 so v2 and v3 those are numerically consecutive to one another when we count we count one two three four and so on right so if i have elevation in v2 and i also have elevation in v3 that becomes a stemi so that would become the new name for this with the three leads of elevation would be an anterior septal wall mi it's a little hard to write on a computer screen so please forgive me here so let's go over another scenario real quick if i have elevation in v4 and i have elevation in v5 but i don't have elevation anywhere else do i have st segment elevation and two or more numerically consecutive leads i do i have it in v4 and i have it in v5 so this is an anterior lateral wall am i let me throw one more thing at you let's say i have elevation in v 3 and v 6 but i don't have it anywhere else is that a stemi it is not okay they are not numeric they're next to each other don't get that confused they are next to one another but they're not numerically consecutive okay so just because i have elevation in v3 and i have elevation in v6 that by itself is not a stemi if i had elevation in v2 or fight elevation in v4 then i have something or if i had elevation in v5 next to v6 numerically consecutive then i would have something but at this point i only have st segment elevation and two different leads certainly concerning i want to keep an eye on it to see if it develops and if the leads that are numerically consecutive to it start to become elevated so i'm definitely going to keep an eye on it but in and of itself just in that scenario i do not have st or i do not have a stemi so let's look at this real quick and i'm going to give you all a few seconds to work your way through this i want you to see if you see any elevation in any of the leads and if you do are they anatomically contiguous to one another or are they numerically consecutive to one another doesn't mean anything i'll give you a few seconds so as you're working your way through this strip the way that i always look at every single strip is left to right just like we read okay and there's a little bit of a caveat to this and i think adam will hit on near the end but just for starting purposes so we're all on the same page the way that i read 12 lead ekg is i start from the left and i read to the right okay so in this scenario oops sorry in this scenario i start with lead one okay it's on my left side and then i go to avl v5 and v6 so i'm looking at my lateral leads and i'm only looking at one avl v5 v6 just because one is my first lead at the top left so i am looking at this 12 lead ekg and i'm interpreting this 12 lead ekg in a systematic approach but n is a grouping okay i work with a lot of students who look at lead one and then two and then three and then avl then evf and they work their way up and down through the strip my problem with that is how do you know by the time you've looked at one and you look at two you look at three and you get the avl you kind of already forgot what what did i have in lead one right an avl and lead one are there are the two leads that correspond with one another so when you start with lead one i encourage you to then go to avl and then go to v5 and v6 and just knock out your lateral leads altogether okay it's much easier to pick up on on any trends when you approach it that way so as i look in lead one and we're going to do a lot of review strips at the end so it might seem like i'm going through this a little quick but we're going to do a lot of review strips at the end so when i look at lead one i do not see any st segment elevation i see a little bit of a flipped t wave or some depression there when i look at avl i definitely have depression and inverted t waves when i look in v5 and v6 i don't see anything concerning next i'm going to look at lead 2 3 and avf so my inferior leads when i look at lead 2 i definitely see some elevation that looks about to be 1 or 2 millimeters lead 3 i see elevation that's probably 2 or 3 in height so just right there i have elevation in lead two i have elevation and lead three without even looking at avf i know i have an inferior wall am i because i have elevation in two or more anatomically contiguous leads at this point i look at lead avf i also have elevation there so yep i have an inferior wall of mine i already knew that a little girl but i definitely have an inferior wall am i next i'm going to go to v1 and v2 my septal leads i don't see any st segment elevation there i don't see any st segment depression and then finally i'm going to go to my anterior leads v3 and v4 i don't see any depression there i don't see any elevation there so the only thing that i see that's really alarming to me in terms of st segment elevation at this point excuse me is elevation in 2 3 and avf are my inferior leads so i know i have an inferior wall am i but also keep in mind that one of the things we saw as we worked our way through here was inverted t waves and depression and one in avl okay so this is an inferior wall of my with reciprocal changes in my in leads one in avl okay inferior wall mi with reciprocal changes and lead one in avl and we're going to talk about what reciprocal changes are in the next two slides so when you're talking about reciprocal changes think about a teeter-totter think about on one side of the teeter-totter you have your inferior leads you have 2 3 and avf on the other side of the teeter totter you have one avl v5 and v6 and really all leads on the other side okay so you have this teeter totter well it's common to see when we have we don't have to see it but it's common to see when we have elevation and 2 3 and avf we get depression and our lateral leads we can get it in all leads but most commonly we see them in our lateral leads even more specifically leads 1 and avl on the flip side of that when we get elevation in our lateral leads we can see inversion or flip t waves uh and are inferior leads 2 3 and avf okay so it's a teeter-totter as one becomes elevated the other one is commonly found to be depressed or inverted um and that is with your inferior leads versus mainly your lateral leads but you can have reciprocal changes in your v leads as well so why is that so if you think about think about looking at the left ventricle or a ventricle or section of your heart it really doesn't matter think about looking at it from one side okay so let's say that we're looking at it from the left side which is uh the inferior side in this picture so let's say we're looking at it from this side okay when i'm looking at it from my inferior leads let's say i'm getting st segment elevation well if i'm looking at it from this opposite side and in this scenario it's my lateral leads i'm going to see depression right it's kind of a mirrored effect if i see elevation from this side if i go around the other side and look at it well now it appears to be depressed to me or inverted okay and that's essentially what reciprocal changes are it's just showing you this mirrored effect and other leads across the 12-lead ekg strip you don't have to have reciprocal changes for that to be an mi all it is is just kind of extra evidence that yep um we're definitely having an mi in our inferior wall we have reciprocal changes so which is telling me my lateral leads are even seeing this thing is inverted okay it's just kind of extra evidence i don't need it to call it in my am but it's there okay that's all reciprocal changes are so remember inferior leads on one side and really all other leads on the other side of that teeter totter but primarily we see it in our lateral leads just because of where these two um leads are actually looking at the left ventricle from what angle they're looking at it from so if we look at this strip again uh i think this might be the the identical shrimp or it's a very similar strip so looking at reciprocal changes i have st sec oops i have sc segment elevation in leads 2 3 and avf so i have an inferior wall mi okay if we look in lead 1 we look in lead avl we have inversion okay those that is my reciprocal change i don't have it anywhere else on this strip and that's fine i would just say i have an inferior wall of mine with reciprocal changes in my lateral leads at least one in adl again i don't have to have those reciprocal changes in order to call this an mi it's just kind of extra evidence okay we already caught you red-handed but we also got video we also got it on video okay it's just extra evidence to have for the crime that's being committed here and then i'll only a few more slides of cover and i'll turn it over to adam there's two types of mi that i want to talk a little bit more in depth on um and and just kind of cover for the anatomy and then why their signa and their significance so an extensive anterior wall mi so this is when we have st segment elevation in our septal leads anterior leads and our lateral leads so we have st segment elevation in v1 through v6 okay now remember it doesn't have to be v1 through v6 but it's at least got to be v2 through v5 to get that numerically consecutive st segment elevation right so that is called an extensive anterior wall mi um and that's also termed and this is pretty consistent across the country from my experience of widowmaker and the reason that's called the widow makers it has about an 80 to 90 percent mortality rate associated with it and when we get an extensive anterior wall of mi or sc segment elevation and all of our precordial leads our septal leads down through our lateral leads this is telling us that we have a block high in that left main coronary artery so in this gray arrows kind of pointing to it we have a blockage that's high up in that left main coronary artery so remember when we have a blockage that is occurring anywhere that's downstream of that blockage is not getting perfused like it needs to be it's not getting oxygenated blood flow like it needs to be so when we get that blockage everything else that's downstream of that is going to become ischemic injured and infarcted so when we get this st segment elevation that goes from my septal leads all the way down to my anterior and my lateral leads that's telling us we have a left main coronary artery occlusion and that is very significant because we are cutting off fusion for really to everything below that which is my entire left ventricle which we know is the workhorse and the true pump of our cardiac system okay so this person needs to be opened up and they need to be on the table 10 minutes ago so when we get that extensive anterior wall of my that significant st segment elevation know that pathophysiology of what's actually happening behind that a clot high up in that left main coronary artery which is subsequently cutting off blood flow down to that left circumflex and down to that left anterior descending so and here's an example of what that would look like so if we look at this and obviously i kind of just gave it away right i told you all what to look for but when we look at this do we have any elevation in v1 and i don't think so there's not there's nothing there that i would say that i could definitively say yes there is elevation in v1 okay so i'm going to rule it out do i have elevation in v2 yes um i definitely have elevation in v2 do i have elevation in v3 yes so right there alone i have an anterior septal wall am i because i have st segment elevation and two numerically consecutive leads i'm going to continue looking do i have sc segment elevation in v4 yes do i have st segment elevation in v5 yes i do do i have it in v6 i don't see any elevation there so i have st segment elevation and v2 v3 v4 and v5 that is one septal lead both anterior leads and one lateral lead that are all numerically consecutive to one another this would be called an extensive anterior wall mi also called a widowmaker again has about an 80 to 90 percent mortality rate associated with it because of that huge occlusion in that left main coronary artery cutting off perfusion um downstream to it wiping out our left ventricle entirely and what i'd be willing to bet is because of that huge occlusion in that left main coronary artery if we take a repeat 12 lead ekg on this patient 5 10 15 minutes down the road we're going to see elevation in v6 we're probably going to see elevation in b1 okay it just hasn't extended all the way to the areas that those leads are looking at at this point an inferior wall am i so from the inferior wall um is primarily supplied by the right coronary artery um and there's there's a um i guess a phenomenon that that we i won't dive into tonight called coronary artery um dominance some people are right coronary artery dominant and some people are left coronary artery dominant the majority of the population about 70 to 80 percent of people are right coronary artery dominant meaning their right coronary artery supplies the majority of um not only the right ventricle but also their interventricular septum and their portion of their their left ventricle as well so the posterior descending artery if you remember from going back to one of our first slides that posterior descending artery comes off of our right mane this would be our right mane okay our posterior descending comes off and wraps around conveniently enough the posterior side of the heart and then travels downwards or descending okay it supplies the inferior wall our proximal right coronary artery to this section right here okay our right main it supplies our right ventricle our posterior wall and also a portion of our inferior wall so our right coronary artery it has a pretty significant workload and especially in our right coronary dominant patients so i cover that because if we have an inferior wall of mine i'm sure you're depending on where you're at in your program if you have an inferior wall am i hopefully you were taught that once you see that inferior wall am i your job's not over yet you need to check for a right ventricular infarction and the reason we do that is because of that coronary artery anatomy that i just showed you so remember our right coronary artery supplies a portion of our inferior wall okay it also supplies a uh our right ventricle well if i'm having an inferior wall in my or an inferior wall infarction there's a chance that that occlusion is high enough that it's also infarcting my right ventricle okay because ultimately they're supplied by the same vessel it just depends on the location of that occlusion as to is it just an inferior wall of mine or is it a right ventricular infarction and an inferior wall of mine so a in order to appropriately check for a right ventricular infarction what we're going to do when we see elevation in leads 2 3 and avf we're going to take v4 okay and i'm fine with you only moving v4 you're going to move v4 from the left side over to the right side and the same area okay that fourth intercostal space underneath the right nipple and you're gonna rerun your 12 lead ekg with your new printout you're going to you are going to mark v4 r okay it does not automatically do it for you like it shows here in this strip this is just computer generated okay so when you get that new print out i want you to take a pin and buy that v4 you need to ride an r and you need to circle it so you know which 12 lead was your normal left side of 12 lead ekg and which 12 lead was your right sided 12 lead ekg okay so we get an inferior wall of mi we move v4 over to the right we do another 12 lead as it prints out we mark v4 r that is my right sided 12 lead ekg what i am looking at is do i have elevation in v4 r okay if i have elevation in v4 r that is telling me this patient is also having a right ventricular infarct okay when i when i say you can just move v4 over to the right side that has about a 97 accuracy rate okay so uh it is 97 correct i'll i'll take those odds any day so move v4 over to the right side if i have elevation in v4 which i do have elevation and v4 in this picture see if how straight of the line i can draw not very i do have elevation in v4r and this 12-lead ekg so not only do i have an inferior wall in my because of my elevation but i also have a right ventricular infarction why is that important so what is our treatment plan for patient for cardiac patients having a stemi right mona if you've heard that that acronym not necessarily in that order right we give oxygen we give aspirin we get nitro if we need to control their pain um then we can get morphine or we can get fentanyl it you know depends on how you're taught the program in there you're in the the fire department you work for whatever but the problem is we can give oxygen we can give aspirin okay the problem comes with nitrile so if this person's having a right ventricular infarct and we end up giving them nitroglycerin we're going to vasodilate okay remember nitroglycerin it turns into nitrous oxide in your blood and it ends up vasodilating okay so as i vasodilate i am going to drop the preload in that patient and that right ventricle is going to have even a more difficult time pumping blood than what it was okay it's already infarcting it's already having a hard time doing its job because it's got decreased perfusion to it well now what we've done is we've taken that right ventricle that was already failing and already struggling and we've given this patient nitro and now the pressure that or in their vessel that was this diameter that was already struggling now we've made it this diameter we've vasodilated that patient and we've dropped their preload so now the right the right ventricle has practically no chance of pumping blood into the lungs and getting it to the left side for perfusion okay so remember that inferior wall am i we need to do a right sided 12 lead ekg look at v4 r okay if it's elevated that patient's having a right ventricular infarction we need to certainly um be cautious with nitro depending on blood pressure depending on protocol you can still give it i'm really not going to dive into that tonight but i certainly wouldn't just go and give them nitro without making sure i'm following my protocol their blood pressure is adequate enough to support it and so forth if v4 r comes back and it is not elevated treat them as you would any other cardiac patient give them nitro okay they're not having a right ventricular infarction if v4r does not come back elevated give them nitro okay just as you would with any other type of mi patient adam all right thank you all right guys so we're going to go ahead and jump directly into some of the imitators brandon did a great job as far as the anatomy and physiology that as with regards to the coronary vessels um and then how to look at the j point and compare so we need to also talk tonight about some of the different things that can imitate um or make you think that the patient is in fact having a semi or an infarction pattern when in reality they may or may not be um and some of those that we'll talk about tonight are bundle branch blocks both left and right bundle branch of ventricular beats lvh which is also known as left ventricular hypertrophy pericarditis early repolarization and a few others the ones that typically um kind of jump out at you for from a national registry standpoint um are the bundle branch blocks ventricular beats uh left ventricular hypertrophy i don't think that they're going to throw any curveballs at you as far as pericarditis or early repolarization but we'll certainly talk about what those are so with bundle branch blocks where you're going to end up looking for your bundle branch block when you're looking at your ekg and brandon said that he generally reads the ekg from left to right and i do too um in fact i read it the exact same way that brandon does as far as looking at one and then going to abl and then v5 and v6 because at that point now i have covered all of my lateral leads a few things that i think that we should do and brandon and i agree on this prior to even going to lead one though we should probably take a quick look in v1 so v1 if you can remember will never lie to you so what you are actually seeing in v1 is an accurate depiction of what is actually going on in your patient as far as the ekg is concerned so when you do your 12-lead ekg we're going to go to v1 first and we'll practice this we go to v1 and we find our j point let me i don't have a touch screen so i actually have to kind of draw and click on some things here so when i go to my j point which for me here i'm going to draw this little circle here is my j point what you need to do after you have located the j point is we are actually going to go backwards we're going to go backwards one small block or .04 seconds and when we go back that one small block where 0.4 is that .04 seconds i'm sorry we're gonna look at the terminal deflection and see which direction it is headed so if i go back and look at this terminal deflection you can see that the terminal deflection in this particular scenario is going up so then we relate to what is called the turn signal theory and some of you may be familiar with this maybe your instructors have talked to you about it but if you can envision that you're in a car and you are driving and you are getting ready to turn you have to hit your turn signal if you hit your turn signal and you push it up hopefully you are making a right-handed turn if you are driving your vehicle and you press your turn signal down you are likely making a left-handed turn and it's the same thing when we talk about bundle branch blocks so we go to v1 we find the j point you back up one small block and you determine which way the terminal deflection or the electrical impulse is headed if it's going up as it is in this particular situation if i'm driving and i put my turn signal up i am making a right-handed turn so this would be a right bundle branch block if i am driving my car i find my j point here i back up 0.04 i can see that the terminal deflection is heading down when i'm in my car and i press that turn signal down i am making a left-handed turn so that gives me in this situation a left bundle branch block a few things to keep in mind and that are important you notice that both the right and left bundle branch block are both located in v1 and you notice that you find the j point exactly as brandon described to you before so if you can just simply remember to look in v1 first find your j point back up one small block and look to see which way it's headed i think that it'll help you out tremendously as far as the right and left bundle branch block now what is the inclusive criteria in order for us to even call it a bundle branch block you have to have a wide qrs so if you go to leave v1 and you look and your qrs is within normal limits meaning less than 0.12 seconds in duration you do not have a bundle range block the only time that we have to find that j point and determine if it is a left or a right bundle branch block is when we go to v1 and we look at our qrs is greater than 0.12 so if you look and you have a wide complex and v1 that is when you should start thinking that it's a bundle branch block now one final thing here as far as the bundle branch blocks are concerned a right bundle branch block you can still read your ekg appropriately so you're riding into the hospital you do an ekg and you've determined that the patient has a right bundle branch block you can still interpret the underlying 12-lead ekg and call that into the hospital or send it in through an electronic mechanism if you have that ability if you are doing a 12-lead ekg and the patient is having a left bundle branch block that is a true imitator of an infarction and you cannot read that ekg as far as a stemi is concerned so what i would do is call into your base physician or however you guys normally do that in your normal practice and say hey you know i'm coming in i have a patient this age we've done a 12 lead and they have a left bundle branch block and that will alert the the physician at the receiving hospital that you've done your job you've done the ekg but you're just simply not able to read that that information at this point because of that left thermal branch block so bundle branch blocks may produce st elevation st depression they can give you tall t waves inverted t waves y qrs or i'm sorry wide q waves uh that brandon talked about as far as a pathologic q wave telling you that the patient potentially had a previous infarct they may also hide st elevation depression those t-wave issues and then that wide qrs as well so you can see with bundle branch blocks it's really all over the board but if they have a right on the range block you can still read the ekg a left you cannot is there anything you want to add to that brandon no okay sorry all right so with ventricular rhythms uh we talk about paste rhythms idioventricular ventricular tachycardia pvcs and you guys know that if you have a couple of pvcs in a row that that turns into v-pack um and these also can mask or mimic every ecg change suggestive of an acute coronary syndrome so when you look at this ekg in particular based on what we just talked about i'm going to look and leave v1 and hopefully you guys can see that it ends up having a pacer spike so the pacer spike that i have on this particular ekg as far as v1 is telling me that it is a paste ventricular rhythm i don't see that it has a pacemaker prior to the atria firing as far as p waves are concerned so this is a paste ventricular rhythm and again all bets are off so as far as the interpretation this would just be interpreted as a paste ventricular rhythm and as you call into your hospital or send your ekg in to let them know that you're transporting a patient to them i would just let them know that as such that you're transporting a patient and you've done your 12 lead ekg and it's showing a paste rhythm so basically what that is going to do is tell the physician that you're not sure if the patient is in fact having a stemming or not because there is a mimicker on the ekg now for several years actually when i was new and had gone through training i was always told that you can't read the ekg i do want to kind of give a little disclaimer you can there is a criteria out there that allows you to read past that information but it is very complex i do not know paramedics that do that and in fact i have challenged and asked several er physicians and they're familiar with the criteria to be able to do that however most of them end up using an application on their on their cell phone or contacting cardiology to have them read past it so it is possible to read if they have one of these imitators we just don't do it at the paramedic clip all right so what is this um and i know that most of you guys are muted and not necessarily interacting at this point um and that hopefully we can get that to change here in a few minutes when we get into some of the practice strips but when you look at this you can look and and very quickly determine that there is obviously something that looks a little funky with this particular ekg so if you're looking at this and you're thinking okay well i remember this from class or i had a 12-lead ekg course years ago and i kind of remember this information and you're thinking that it's left ventricular hypertrophy you are absolutely correct so remember that lvh much like a bundle brain's block either left or right or much like the ventricular rhythms like ventricular tachycardia or paste ventricular rhythms it will mimic what a stemming looks like so if you're not paying attention as far as the lvh and these other mimickers you're going to probably end up calling this um an anterior septal wall mi in which case that would not be correct so we look at lead v1 um and that measures less than 0.12 so we don't think that we end up having a bundle branch block so then we would go through and we would look at our other criteria here as far as 1 avl v5 and v6 2 3 and avf v1 and v2 and then b3 and b4 as far as rating your normal 12 lead ekg as far as lvh the criteria is this you look at lead v1 and v2 and you pick the lead that has the most negative deflection so when we're talking about the most negative deflection what i mean is from this point to the bottom and it's kind of overlapped down here in v3 but you can appreciate i'm just going to kind of draw this in a little bit to kind of give you an idea so here is the most negative deflection and we're looking to determine between v1 and v2 which one has the deeper negative deflection and you can tell that that's obviously going to be v2 it's much deeper and like i said it overlaps in v3 so it's a little bit hard to count it for sure but what we would need to do is we need to count these boxes up so if you can just recall that as we're going down each one of these big blocks is five millimeters so as we continue to go down and again i'm gonna have to kind of guess a little bit here we're going to end up just counting this down so i've got 5 10 15 20 25 30. and as an example we'll call the negative deflection on this ekg 30. the second step that we're going to end up doing is we go to v5 and v6 and we look to see which one has the most positive deflection and we do the same thing and i think that we can agree that between v5 and v6 v5 has the highest positive deflection so if i started there and i ended there i'm going to count these boxes in between 5 10 15 we'll call it 16. so if i had 30 over here and i had 16 over here the total there would end up becoming 36 and that would actually meet the criteria for left ventricular hypertrophy and i'll show you why let me clear this off so what we do as i mentioned we look in v1 and v2 we pick the negatives or the the deepest negative deflection and count it up and then remember that number then you go to v5 and v6 you find the most positive deflection you counted up and remember that number and you add the two numbers together if the sum of those two numbers when added together so for example 30 and 16 would end up becoming 46 um that is obviously more than 35 so that patient would be suspected of having left ventricular hypertrophy again that is a true mimicker call into the hospital tell the doc hey we're bringing a patient and it has lvh therefore i can't tell you what's going on as far as their 12-lead ekg is concerned and again this is just another picture of the same ekg that we just talked about with lvh um every one of your lvh ekgs that you guys will run into they will look very characteristic of this you should be able to look at a patient that has lvh on 12 lead ekg and pick that out very quickly they will all have these very long um negative deflections and then oftentimes they will have much taller positive deflections but again when you add those two numbers up it should equate to being over 35 and if it does then the patient is going to have left ventricular hypertrophy what causes lvh it's hypertension so chronic hypertension the left ventricle is having to work hard to pump blood out from the left ventricle through systemic circulation and because of that the left ventricle becomes enlarged hence the hypertrophy so it changes the electrical impulse because of that enlarged heart as far as the left ventricle not necessarily an enlarged heart systemically excuse me some medications uh hypothermia and wpw concerns that we think are important for you guys to know when you're looking at an ekg on the far left is something called a digitalis effect so with did is a cardiac glycoside um and it is used to basically strengthen the contraction for a patient that has atrial fib they also use them in patients that have congestive heart failure etc so what you'll end up getting there is something called a sag a characteristic sag and you can see it's in red and it's basically because of the repolarization of the ventricles and if you kind of think back a p wave is depolarization of the atria it repolarizes somewhere in the qrs complex the qrs is depolarization of the ventricle and then it has to repolarize so it is ready to fire again so it kind of um it deals with the ventricles trying to repolarize and that is why that characteristic sag a lot of times you'll hear people talk that it'll end up being flattened or notched and that is known as a digitalis effect so the patient is on dig and they're therapeutic the one in the middle is called a delta wave and that is found in a patient that has wolf parkinson white syndrome and what actually happens here um you end up with what's called a delta wave so if you look there you find your iso electric line you find your p wave that p wave that pr interval should come all the way over to where the dotted line is and then go up making it an r wave there would not be a q in this particular example what happens though in a patient that has wolf parkinson white is because of the re-entry pathways the electrical impulse can get from the sa node down to the ventricles quicker than it should um and it's it's done through those accessory pathways so that accessory pathway allows the firing of the ventricle to happen prematurely and that's where that delta wave comes in and again you can see there from the depiction that it comes over um as a delta wave and then the third one here is um is shown as hypothermia and that's known as an osborne wave or a j wave they don't really know what causes this there are other things other than hypothermia patients that have hypocalcemia head injured patients can sometimes uh present with an osborne wave or a j wave um but it's really unknown as to what causes it and where it comes from unlike the delta wave in the ditch effect uh where they know where where it's actually coming from and the cause for that the os form wave doesn't have a real known cost but that's what it looks like and some people will say it's kind of like a camelback or a humpback um but it's always going to be on the right side of your qrs complex so brandon and i have talked about this a lot and in my paramedic class you know i talked to our students and kind of tell them i don't think that you guys if you're looking to take the national registry you have not yet taken the examination i don't think that they will give you a delta wave and ask you to interpret it what i think that they will do though is they will tell you that you have a patient that has a delta wave and they want to know what causes that um and the answer in that situation would be wolf parkinson white same thing with an osborne wave or a j wave that would be hypothermia so be familiar with what the waves look like and what they mean more so than being able to pick them out in an ekg all right so let's practice a few of these brandon can you how many do we have on uh i think we only have eight out of the by all means we can definitely open them all up okay so what i'd like to do is take a second to interpret one or two of these ekgs and then kind of turn it over and walk through it with you guys if you want to do that uh with with having a smaller group i think that we're able to do that and still kind of come in under our time um if you guys don't necessarily want to have to interpret them in a group setting that's okay too um and some of you may not have the ability to have audio we may not be able to hear you but um what we can do is i will time it and give everybody a minute or so to do your own interpretation of the ekg and then i'll go through and interpret it at the end so that you guys can see you know if you're on the right path or you are not so yeah yeah i think i think if someone wants to jump in well we'll just we'll just give everyone 30 to 60 seconds to kind of look at it make your interpretation and then before adam goes through with what he sees if somebody wants to jump in and say hey this is you know you can unmute yourself hey this is what i see um i think that'll be a good way to get through to give everyone an opportunity to jump in and and do an interpretation but also not to force anyone's hand in it either yeah that's fine brain so for this first one i'm going to do the first one just to kind of show you again the formatting of how brandon and i both approach these ekgs um and then starting with the next one our number two again like brandon said feel free to jump in if not then we'll time it we'll give everybody a minute or so to interpret each one of the ekgs that we have and then i'll go through it at the end of that minute so that you can tell if you're on the right path or not so in this situation here we're going to look at lead v1 and when i'm looking in lead v1 all i am looking for is to see if the patient if that ekg is wide or narrow and you can see that in this particular situation it is narrow it is less than 0.12 so we do not have to worry about this patient having a bundle branch block then i'm going to come over and i'm looking at lead one i'm finding the j point i'm looking at that as compared to the um st i'm sorry yeah that the tp segment of the next complex i don't have elevation in one i'm looking at avl i have no elevation and abl i'm looking in lead v5 i don't i may have a little bit of elevation in v5 but i don't necessarily think so and then i look at v6 and again i don't think that i have a millimeter of elevation in v5 or v6 i go to lead two i find my j point i compare that to the tp segment it looks even to me i go to lead three i find my j point i compare it to the tp segment it looks normal to me and i go to avf i find my j point i compare it to the tp segment and it looks normal to me the next lead that i would go to is lead v1 which was kind of where we started to see if it was wide or narrow i find my j point i compare it to the tp that is equal i go to lead v2 i find my j point i compare that to the tp that is equal i go to v3 here's my j point compare it to a tp it is normal i go to lead v4 i find my j point and i compare that to my tp segment and you can see it may be a little bit higher there but it is not a full millimeter and remember brandon told you in order to call it an elevation it has to be one small block or bigger and it has to be into either anatomically contiguous or numerically consecutive so this particular ekg that we're looking at here i do not have any elevation there i would call that a normal finding on my 12 lead ekg so this is just the answer to 12 lead number one the interpretation sinus tachycardia which we didn't count the rate in particular but otherwise it is a normal ecg there is no elevation there there's no significant t wave changes or anything else that we need to be concerned with all right so looking at this one this is actually a really good ekg because it's very clean and very crisp so if you are truly new at reading 12 lead ekgs this is a very good ekg to practice with and again if anybody wants to shout out and take take control of this one that's fine if you want to do it on your own that's fine too we'll give you about a minute or so uh all right so if we start in lead v1 i can look and leave v1 and determine that that is not wider than 0.12 so i don't think that i have to worry about it being a bundle branch block so then i'm going to go to v i'm sorry lead one brandon feel free to argue with me or tell me what you normally do but when for the group when i was taught during ekgs i was always told to move over one if you have the ability to do that um so for instance let's look at avf real quick if you're looking at avf and it's really close to the 8bf that's actually a potential that it's still in transition so that that particular beat might be a little funky and it may give you some false information so if you can try to move over one beat before you actually look at your ekg no that's absolutely correct and i'm late i'm glad you uh remembered to mention that today yeah that's i i always look at the second or third beat if your second and third beats are kind of crappy looking there's a lot of artifact they're moving up or down on the paper and that first beat is the best beat you have in that then sure use it um but if you if you have a good beat in that second or third beat that you're seeing there in that two and a half second window of time that these leads show us and by all means i would i would certainly recommend using that second or third beat and staying away from that first one uh in the lead all right so we've looked at v1 we don't think we have a bundle branch block so i'm going to find my j point um and my j point is compared to the tp is iso electric or even so there's no elevation that's a good thing on the next one abl i find my j point i compare it to the tp it looks equal and v5 i end up finding my j point i compare it to the tp isoelectric j point and v6 to the tp segment is isoelectric in lead 2 j point tp isoelectric 3 j point isoelectric avf i have my j point and that is also isoelectric let's go to v1 v1 i find my j point tp it's even b2 i found my j point i compared to the tp it is even b3 j point isoelectric that is even and then v4 i find my j point i compare it to my tp segment it is even now you all are probably wondering why are these guys giving us all these normal ekgs so it's important to remember that you are going to do a lot of ekgs in practice and you're going to find a lot of your ekgs are completely normal it is important to do them if they're having complaints elderly female diabetic chronic hypertensive patients they don't present typically so if they tell you that they have a problem you should really be doing a 12-lead ekg in addition to that if you are a paramedic student um as faculty we sometimes like to throw curveballs at you um i'll give my students a normal ekg just to build their confidence because i want them to be able to look at that and go that is normal there is nothing there so just because you're in a 12-lead class or you're in paramedic school doesn't mean that you have to find something on the ekg yeah in the same sense that just because you're sitting at a static or a dynamic cardiology station doesn't mean there's something wrong with that stripper or something don't let your mind take you down this pathway of oh they're giving me this 12 lead on an exam or i'm sitting in the dynamic cardiology station and they have a strip in front of me i have to treat it right so don't don't forget about normal correct and then this is just the answer to the second 12 lead that we just looked at there's really no artifact or anything underlying it was a beautiful ekg it's a sinus rhythm there's no st elevation there's nothing funky with the t-wave so there's just a straightforward 12-lead ekg looking at the next one again we'll give you a minute here to interpret it kind of go through sorry you guys all right so looking in v1 again it's narrow so we don't have a bundle branch block that we're concerned with i end up going to leave v i'm sorry lead one i keep saying v1 and i apologize for that i go to one i find my j point it is even i go to abl i find my j point it is even i go to v five i find my j point it is even b six j point is also even i go to two fungi it's even with my tp i go to lead three i find my j point it is even i go to avf i find my j point and it is even i go to v one i find my j point it is even although i do have a flip t wave in v1 i go to v2 i find my j point it is even i go to v3 j point it is even v4 i find my j point and it is also even now one thing looking at this ekg i don't have a stemi i feel confident saying yeah i don't see anything as far as stemming is concerned not that they're not having an infarction such as a non-stemi but looking at this ekg you can see that there are some irregularities to it so when you look at the base uh ekg as far as like lead 2 if that's what you're normally monitoring in you're probably going to pick up on the fact that this is in atrial fibrillation so there there appears to be some p waves but i don't know that they're necessarily great uh they're definitely not consistent but from a 12 lead perspective there is nothing on this 12-week ekg that would make me be concerned to call into the hospital and tell them hey we're bringing this particular patient in so it's atrial fib non-specific st and t-wave changes and that's the flip t waves that we're talking about so v1 v2 and v3 i'm going backwards so these this is the same ekg you can see that v1 has flipped v2 has flipped and v3 has flipped t waves so for all intents and purposes that is an ischemic finding until proven otherwise and the patient should be evaluated but there is not an actual injury pattern on the ckg all right number four give you guys about 30 seconds or so to interpret this one we'll try to pick up the piece a little bit for you uh all right so starting in v1 phil does anyone does anyone want to take a stand about it philip s raised his hand brandon so all right i don't know if that means he wants to take a stab or maybe he has a question we should probably ask him either way i feel like he's about to be put on the spot all right so phil let me uh find you here in the list adam will unmute yeah okay phil you should have the ability to talk you can't hear me how are you i'm well yourself good thanks for joining us for sure thanks for having me did you have a question or did you want to try this one um i was gonna try it okay go for it yeah um so um looking in you know starting in uh lead one um there's a lot of artifact in it all right it looks um you know from the j point i can kind of make out it looks like it just slightly um going over from there uh abl though okay that doesn't appear to be any um when i move down to lead two uh there is there from the j point i kind of make out from the artifact it appears to be slightly elevated are you saying lead to at this point uh yes all right so if you're comfortable reading these do it with your way i don't want to turn you against that if you are new to reading these i would recommend that since you have started with one in avl go ahead and look at v5 and v6 and we have looked at all of our lateral leads gotcha let's see that makes sense okay um so yeah so if we go to v5 yeah um then if we find on that j point um it's definitely uh elevated yes and when we go to v6 uh is also elevated as well so right right now philip just without looking at anything else at a minimum what do you have thus far uh a lateral uh infarct to a lateral injury good we have sc segment elevation greater than one millimeter and at least two anatomically contiguous leads right v5 and v6 my two lateral leads on my right side good all right continue on there all right so uh so we go to lead two um you know it looks like there's some slight elevation there uh even in that artifact there okay v3 doesn't appear to have uh as much elevation and avf also looks to be uh you know even there okay um then we move to v1 um that j point yeah pretty even i would say i agree um but once we get to v2 i would definitely say elevation there agree v3 elevation for sure as well as v4 very good so we have elevation in two three four five and six what do you think that is well um would that that would be a qualifier for the uh for the widowmaker the uh with the uh the fact that it reaches all four of those or at least four consecutive okay very good yup so that the way that that would be turned if you're calling this in would be an extensive anterior mi so we have elevation or an infarction in our lateral our anterior and our septal leaves so it is basically wiping out the entire left side that left mean coronary artery is occluded proximally so you have a very high occlusion which is now causing a blockage in diminished blood flow to the anterior wall the septal wall and that lateral wall so that is very very good it's good for you you interpret it is bad for the patient i should say absolutely is terrible for the patient for sure good job thank you so let me ask you a question for the group um let's just say for argument's sake that we do have a little bit of elevation and lead to because you kind of were saying ah maybe it's a little elevated but when you got to three it was not and when you got the avf it was not so if that's the case does lead to really even mean anything uh um if i would say no since uh you know if it was again just being slightly and since it's not you know consecutive so it is not in through three and it's not an abf um you know yeah so yeah it would have to be more than a millimeter and if it was elevated in two it would also need to be elevated in three and avf or avf in order to be called a stem because you would have to have it in two or more so very good on that good job thank you all right so let's look and see if we got it right yep the interpretation is an extensive anterior infarction you have elevation in v2 through v6 that is very very good all right let's take a look at the next one if anybody else wants to join go ahead and raise your hand or unmute yourself and if nobody does fill up and you want to take the next one that's fine too all right let's go ahead and take a look at this so we'll start in v1 does anyone else want to take a stay about it you don't see anything brandon nope all right so looking in v1 it's narrow so we don't have a bundle branch block that we're dealing with i go to lead one i find my j point it's isoelectric even though there is a little bit of artifact and i wish i had a perfect way to tell you guys how to get around that that is simply just an experience thing so if you're looking in lead one you can see that it's kind of running away from you a little bit to the right you're just going to have to learn how to read through some of that stuff and experience will allow you to be able to do that but i don't see anything that's worth worth calling in for i go to avl i definitely have flipped t waves and abl which tells me that i probably have a little bit of ischemia i go to v5 it is normal i go to v6 it is normal i look at lead two it appears to me that i have maybe a little bit of elevation there but again it's kind of running away from me making it a little bit difficult to to tell if there's elevation or not so let's look at the other two that are in that grouping if i go to lead three and find my j point i think i definitely have some elevation in lead three and then i look at avf when i find my j point in abf i think that i definitely have a millimeter of elevation in evf as well i go to v1 i have flipped t waves v2 i have a flip t wave v3 appears to me to be isoelectric v4 is isoelectric and we've already looked at v5 and v6 when we were looking at our lateral grouping so what i would call this in as is an inferior wall mi with reciprocal changes and you really have reciprocal changes kind of all over the place you have them in avl you have them in your septal leagues so flip t waves or reciprocal changes in my lateral and septal leads but this is an inferior wall am i and to just kind of put it on your radar brandon i did already talk about this if i have an inferior wall am i i should be thinking of doing what i'll give you a second to answer your own question or answer my question what should you be considering doing for this patient if you're saying that you should be doing a right sided ekg you are absolutely correct remember these patients if they have elevation in v4r we do not want to use nitrates right away we need to make sure that the tank is full so we have to give them fluids so we would simply move that v4r over redo our 12 lead ekg and if i have elevation in v4r then i would be thinking about giving fluids and not nitrates if it is not elevated in b4r then you can proceed with your typical mono as long as they meet all the other criteria so the interpretation here and inferior infarction and i should be doing a right-sided ekg to determine if there is right-sided involvement or not all right looking at the next one i go to v1 and as you can tell here v1 looks to be a little funky it looks wider than the other ekgs that we have been looking at so let me get my tool here to draw if i find the beginning of my qrs complex which i'm going to say is right here and i find the end of that qrs complex which is right here if i measure that out that is going to be greater than 0.12 seconds in nature so then what i need to do is i need to find my j point and back up 0.04 when i back up one small block you can tell that the terminal deflection is facing down so remember you're driving your car you push your turn signal down hopefully you are turning left and remember that what we talked about before with a left bundle branch block that is a true imitator of your ekg meaning that you're no longer able to read this as a semi or a non-semi basically you would just call in hey i've got a patient with a left bundle branch block and hopefully the hospital will have an old ekg that they can refer to other than that you're not able to read this ekg so you can see that starting in v1 has saved me a lot of time because i'm not necessarily going to go through and read one avl v5 and v6 2 3 and abf because i already know with the left bundle branch block i'm not able to interpret that ekg anyway so the interpretation this is a left bundle branch block here's the next one i look in v1 it appears narrow or less than 0.12 so i'm going to just read it as normal i go to my lead 1 j point is depressed below so it's underneath the isoelectric line so that tells me that i have some ischemia there avl is obviously depressed v5 and this is an important thing here so when we talked about transitioning that lead if you look at the very first beat in v5 it looks kind of funky as compared to the next two i think that's just part of that transition so if i'm in v5 the second b it looks pretty normal v6 the second beat it looks pretty normal i go to two i have elevation three i have elevation abf i have elevation so i know that i have an inferior wall mi at this point i go to v1 again there's some artifact here but i can still appreciate that there is a flip t wave i go to v2 i have a flipped t wave i go to v3 i have a flip t wave and i go to v4 i also have a flip t wave now one thing that we haven't really hammered on and i don't know that we're going to in depth tonight but this is an inferior wall infarction and another thing that you guys can kind of keep in mind is if you have st segment depression or flip t waves and v1 through v4 you need to think that it could end up being that the patient also has a posterior wall mi so we don't touch on that a lot as far as this particular course but you may need to end up taking leaves off and wrapping them around the back and doing a seven eight and nine so if this was just truly a straightforward inferior wall mi hopefully you guys are thinking to move that v4r over redo your 12 lead to see if there's elevation or not remember if there is elevation in v4r then fluids is the treatment and withhold your nitro if it is not elevated in v4r then nitroglycerin would be appropriate as long as their pressure will allow for it so the interpretation and inferior infarct possible posterior wall and that's because you have that depression in v1 through b4 all right v1 narrow one iso electric maybe a flip t wave avl flip t's v5 that actually looks it's kind of funky looking but i think there's some elevation there in v5 v6 looks isoelectric lead 2 looks normal lead 3 looks normal avf looks normal so then i go to v1 v1 looks normal to me lead 2 looks elevated if i find that j point and draw a line over it's going to be above the tp segment so i have elevation in v2 i have elevation v3 i have elevation and b4 and i've already called elevation and b5 so much like philip was just talking about if i have elevation and v two three four and five that tells me that i have an extensive anterior mi and i have a proximal occlusion of the left knee coronary artery do a few more of these we got a few more minutes here looking at this one um the qrs segment in v1 it looks wide but if you actually take the time to measure that out it is less than 0.12 seconds it's probably right on the money as far as 0.08 so it's not a bundle branch block i've got maybe a little st depression in lead one maybe a little bit of depression and avl v5 maybe a little depression and v6 maybe a little bit of a depression so i think i probably have some ischemia going on here for sure i get the lead two um lead two actually looks okay lead three when i find my j point i have elevation and lead three and i have elevation and avf so i have elevation into or i'm sorry three in abf telling me that i have an inferior wall mi lead v1 appears to be isoelectric v2 is isoelectric v3 is isoelectric and v4 is isoelectric so it's an inferior wall mi this one's a little bit more difficult as far as trying to figure out where that tp segment is there is some elevation there remember that this is going to end up being a right-sided 12 lead that needs to happen i have a narrow v1 depression in one depression and adl isoelectric and v5 and v6 i have elevation in 2 3 and avf lead v1 is isoelectric v2 there is actually some depression there from your j point to your tp v3 appears to be isoelectric and v4 uh appears to be closed isoelectric as well so i have an inferior wall mi lee 2 3 and abf and i have some reciprocal changes as far as those flip t waves and my lateral leads for sure notice there on v4 v5 and v6 at pvc so in addition to the patient having an inferior wall of my they're also having premature ventricular contractions and that's why that looks funky again as we mentioned before just kind of move over a beat and then do your interpretation so it's an inferior infarct do the right side of 12 lead that we've been talking about all right just a couple more here um v1 is narrow there is a quite a bit of artifact in this particular ekg but one is isoelectric abl is isoelectric v5 there is depression v6 there is depression so i definitely have some ischemia in my lateral leads two looks normal three i don't see any elevation abf i don't see any elevation v1 um it looks like there might be a little bit of elevation in v1 i think there definitely is in v2 v3 appears to be elevated to me and v4 actually looks to be a little bit depressed so i have elevation in v1 and v2 remember that those go together anatomically and they touch each other numerically so i have a septal wall infarction when i add v3 into that it also brings in my anterior wall so this is an anterior septal and your treatment modality here is going to be ammonia i'll do one more brand and then take some time for questions if they have yeah let's see let's just knock this one out and then we'll see if they have any questions as they're still hanging in there okay so v1 narrow one depression avl flip t so hypoxia or ischemia v5 is flipped v6 is flipped so we know this this patient definitely needs to be on some oxygen i look at lead 2 i have maybe a little bit of elevation if i'm comparing the j to the tp but i definitely have it in three and i definitely have it in abf so i know this is an inferior wall infarction uh v1 i have flipped t waves v2 i have depression with flip t waves v3 i have depression with flip t waves v4 depression flip t waves so this is a very irritable heart this patient is in fact having an inferior wall mi and they have basically reciprocal changes in all of their other leads so what do you do move v4r over reprint your ekg to see if you have elevation or not and then make your determination on whether or not mona or fluids is the appropriate treatment all right so just for the sake of time and getting you guys out on time there are three more ekgs but if you guys are okay with it we'll kind of open it up to questions that any of you may have you can unmute yourself you should be able to unmute yourself uh or if you want to send it in the chat either one's completely fine or if you don't have any questions that's fine too if there are no questions i'm totally happy to go ahead and interpret that the next three ekgs only take a minute to do it i don't want to shortchange it but i wanted to make sure that we respected your time and had an opportunity for you to ask questions if you needed to i'm done with that okay thanks phillip all right i'll go ahead and just knock these next three out and if you guys have questions just raise your hand or unmute yourself alright so v1 narrow so it's not a bundle branch i look at one it's isoelectric avl is definitely flipped v5 is isoelectric v6 is isoelectric two is elevated three is elevated avf is elevated so i have an inferior wall am i for sure v1 i have flipped t waves v2 is flipped v3 is flipped v4 is depressed with flip t and v5 i have depression i've already looked at that and then v6 we've already looked at as well so in this situation here i have an inferior wall mi with reciprocal changes in my lateral and my anterior and septal leads so you basically have widespread reciprocal changes but the inferior wall mi is what you should be paying attention to remember to do that v4r all right v1 narrow i look at one it's isoelectric abl is maybe a little elevated v5 is isoelectric v6 is isoelectric i look at lead 2 it appears to be normal actually it appears to be depressed 3 is depression abf is depression v1 i have elevation v2 i have elevation b3 i have elevation v4 i have elevation what this is here is an anterior septal mi because i have elevation in my v1 and v2 and my v3 and v4 remember that because they touch that is an anterior and septal mi so both of those are brought into that your treatment is going to be nitrates and oxygen morphine so you're mono-pneumonic 15 it's a narrow and v1 one is isoelectric avl is isoelectric maybe a little elevated but probably not enough to call it v5 is isoelectric v6 is actually depressed two is depressed three is depressed avf is depressed v1 is elevated v2 elevated b3 elevated b4 elevated much like the one we just looked at this is an anterior septal mi