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12 Lead ECG Interpretation
12 Lead ECG Interpretation

McHenry Western Lake County EMS System

Topics
Topics

Anatomy revisited

The 12 Lead ECG device

The 12 Lead ECG format

Waveform components Lead views

 Anatomy revisited  The 12 Lead ECG device  The 12 Lead ECG format Waveform
Anatomy Revisited
Anatomy Revisited

RCA (Right Coronary Artery)

Right ventricle

Inferior wall of LV

Posterior wall of LV (75%)

SA Node (60%)

AV Node (>80%)

LCA (Left Coronary Artery)

Septal wall of LV

Anterior wall of LV

Inferior wall of LV

Posterior wall of LV (10%)

Coronary Artery)  Septal wall of LV  Anterior wall of LV  Inferior wall of
Anatomy Revisited
Anatomy Revisited

SA node

Intra-atrial pathways

AV node

Bundle of His

Left and Right bundle branches

Left anterior fascicle

Left posterior fascicle

Purkinje fibers

of His  Left and Right bundle branches  Left anterior fascicle  Left posterior fascicle
12 Lead ECG Device
12 Lead ECG Device

Device serves as a voltmeter

-measures the flow of electricity

Unipolar vs. Bipolar Leads

Bipolar Leads
Bipolar Leads
Bipolar Leads  1 positive and 1 negative electrode  RA always negative  LL always

1 positive and 1 negative electrode

RA always negative

LL always positive

Traditional limb leads are examples of these

Lead I

Lead II

Lead III

View from a vertical plane

Unipolar Leads
Unipolar Leads
Unipolar Leads  1 positive electrode & 1 negative “reference point”  Calculated by using summation

1 positive electrode & 1 negative “reference point”

Calculated by using summation of 2 negative leads

Augmented limb leads

aVR, aFV, aVL

View from a vertical plane

Precordial or chest leads

V1-V6

View from a horizontal plane

12 lead ECG Format
12 lead ECG Format
12 lead ECG Format Leads that are produced by devices used in the Pre Hospital setting
12 lead ECG Format Leads that are produced by devices used in the Pre Hospital setting

Leads that are produced by devices used in the Pre Hospital setting

12 Lead ECG Format
12 Lead ECG Format
12 Lead ECG Format These typically are not seen Pre Hospital

These typically are not seen Pre Hospital

12 Lead ECG Format These typically are not seen Pre Hospital
12 Lead ECG Format  Device prints out 2.5 sec of each lead.  The
12 Lead ECG Format
 Device prints out
2.5 sec of each
lead.
 The device
computer then
analyzes all 10 sec
of all 12 leads, but
only prints 2.5 sec
of each group
12 Lead ECG Format The computer diagnosis is not always accurate! Look at your ECG!
12 Lead ECG Format
The computer
diagnosis
is not always
accurate!
Look at your ECG!
12 Lead ECG Format The computer is very accurate at measuring intervals and durations
12 Lead ECG Format
The computer is
very
accurate at
measuring
intervals
and durations

Waveform Components R Wave

Waveform Components R Wave  First positive deflection  R wave includes the down stroke returning

First positive deflection

R wave includes the down stroke returning to the baseline

Waveform Components R Wave  First positive deflection  R wave includes the down stroke returning
Waveform Components R Wave  First positive deflection  R wave includes the down stroke returning

Waveform Components Q Wave

Waveform Components Q Wave  First negative deflection before the R wave  Q wave includes
Waveform Components Q Wave  First negative deflection before the R wave  Q wave includes

First negative deflection before the R wave

Q wave includes the negative down stroke and return to baseline

Waveform Components S Wave

Waveform Components S Wave  Negative deflection following the R wave  S wave includes departure

Negative deflection following the R wave

S wave includes departure from and return to baseline

Components S Wave  Negative deflection following the R wave  S wave includes departure from
Components S Wave  Negative deflection following the R wave  S wave includes departure from

Waveform Components QRS

Waveform Components QRS  Q waves  Can occur normally in several leads  Normal Q

Q waves

Can occur normally in several leads

Normal Q waves called physiologic

Physiologic Q waves

< .04 sec (40ms)

Pathologic Q

>.04 sec (40ms)

Waveform Components QRS

Waveform Components QRS  Q wave  Measure width  Pathologic if greater than or equal

Q wave

Measure width

Pathologic if greater than or equal to 0.04 seconds (1 small box)

Components QRS  Q wave  Measure width  Pathologic if greater than or equal to
Components QRS  Q wave  Measure width  Pathologic if greater than or equal to

Waveform Components QS Complex

Waveform Components QS Complex  Entire complex is negatively deflected  No R wave is present
Waveform Components QS Complex  Entire complex is negatively deflected  No R wave is present

Entire complex is negatively deflected

No R wave is present

Waveform Components J-Point

Waveform Components J-Point  Junction between the end of QRS and beginning of ST segment 
Waveform Components J-Point  Junction between the end of QRS and beginning of ST segment 

Junction between the end of QRS and beginning of ST segment

Where QRS stops and makes a sudden sharp change in direction

Waveform Components ST Segment

Waveform Components ST Segment  Segment between J-Point and beginning of T wave

Segment between J-Point and beginning of T wave

Waveform Components ST Segment  Segment between J-Point and beginning of T wave

Waveform Components ST Segment

Waveform Components ST Segment  Need reference point  Compare to TP segment  DO NOT

Need reference point

Compare to TP segment

DO NOT use PR segment as reference!

Components ST Segment  Need reference point  Compare to TP segment  DO NOT use

Waveform Components Practice

Waveform Components Practice Find the J Point and ST segment
Waveform Components Practice Find the J Point and ST segment
Waveform Components Practice Find the J Point and ST segment
Waveform Components Practice Find the J Point and ST segment

Find the J Point and ST segment

Waveform Components Practice

Waveform Components Practice J POINTS ST SEGMENT
Waveform Components Practice J POINTS ST SEGMENT
Waveform Components Practice J POINTS ST SEGMENT
Waveform Components Practice J POINTS ST SEGMENT

J

POINTS

ST

SEGMENT

Waveform Components Practice

Waveform Components Practice Find the J Point and ST segment
Waveform Components Practice Find the J Point and ST segment
Waveform Components Practice Find the J Point and ST segment
Waveform Components Practice Find the J Point and ST segment

Find the J Point and ST segment

Waveform Components Practice

Waveform Components Practice J POINTS ST SEGMENT
Waveform Components Practice J POINTS ST SEGMENT
Waveform Components Practice J POINTS ST SEGMENT
Waveform Components Practice J POINTS ST SEGMENT

J

POINTS

ST

SEGMENT

Lead Views
Lead Views
Lead Views
Lead Views
Lead Groups
Lead Groups

I

aVR

VI

V4

II

aVL

V2

V5

III

aVF

V3

V6

Limb Leads

Chest Leads

Inferior Wall MI

Inferior Wall MI  II, III, aVF  View from Left Leg ⊕  inferior wall

II, III, aVF

View from Left Leg

inferior wall of left ventricle

View from Left Leg ⊕  inferior wall of left ventricle I aVR VI V4 II

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

Inferior Wall MI
Inferior Wall MI
Inferior Wall MI  Posterior View  Portion resting on diaphragm  ST elevation….suspect inferior injury

Posterior View

Portion resting on diaphragm

ST elevation….suspect inferior injury

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

Lateral Wall MI
Lateral Wall MI

1 and AVL

View from Left Arm

Lateral wall of left ventricle

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

from Left Arm ⊕  Lateral wall of left ventricle I aVR VI V4 II aVL
Lateral Wall MI
Lateral Wall MI
Lateral Wall MI  V5 and V6  Left lateral chest  Lateral wall of left

V5 and V6

Left lateral chest

Lateral wall of left ventricle

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

Lateral Wall MI  I, aVL, V5, V6 I aVR VI V4 II aVL V2
Lateral Wall MI
 I, aVL, V5, V6
I aVR
VI
V4
II aVL
V2
V5
III aVF
V3
V6

ST elevation… suspect lateral wall injury

aVL, V5, V6 I aVR VI V4 II aVL V2 V5 III aVF V3 V6 

Lateral Wall

aVL, V5, V6 I aVR VI V4 II aVL V2 V5 III aVF V3 V6 
Anterior Wall MI
Anterior Wall MI

V3, V4

Lateral anterior chest

+ electrode on anterior chest

Lateral anterior chest  + electrode on anterior chest I aVR VI V4 II aVL V2

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

Anterior Wall MI
Anterior Wall MI

V3, V4

ST segment elevation….suspect anterior wall injury

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

 ST segment elevation….suspect anterior wall injury I aVR VI V4 II aVL V2 V5 III
Septal Wall MI
Septal Wall MI
Septal Wall MI  V1, V2  Along sternal borders  Look through right ventricle and

V1, V2

Along sternal borders

Look through right ventricle and see septal wall

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

Septal Wall MI
Septal Wall MI

V1, V2

Septum is left ventricular tissue

I aVR

VI

V4

II aVL

V2

V5

III aVF

V3

V6

MI  V1, V2  Septum is left ventricular tissue I aVR VI V4 II aVL
ST Segment Analysis
ST Segment Analysis
ST Segment Analysis For each complex, determine whether the ST segment is elevated one millimeter or
ST Segment Analysis For each complex, determine whether the ST segment is elevated one millimeter or
ST Segment Analysis For each complex, determine whether the ST segment is elevated one millimeter or
ST Segment Analysis For each complex, determine whether the ST segment is elevated one millimeter or
ST Segment Analysis For each complex, determine whether the ST segment is elevated one millimeter or
ST Segment Analysis For each complex, determine whether the ST segment is elevated one millimeter or

For each complex, determine whether the ST segment is elevated one millimeter or more above the TP segment

ST Segment Analysis
ST Segment Analysis
ST Segment Analysis YES YES YES NO YES NO

YES

ST Segment Analysis YES YES YES NO YES NO

YES

ST Segment Analysis YES YES YES NO YES NO

YES

ST Segment Analysis YES YES YES NO YES NO

NO

ST Segment Analysis YES YES YES NO YES NO

YES

ST Segment Analysis YES YES YES NO YES NO

NO

12 Lead ECG
12 Lead ECG

AMI recognition

Two things to know

What to look for

Where you are looking

AMI Recognition
AMI Recognition

What to look for

ST segment elevation

One millimeter or more (one small box)

Present in two anatomically contiguous leads

Summary
Summary

The key to 12 lead ECG interpretation for AMI are Q wave, R wave, S wave and pathologic Q wave, the J point and ST segment. Each lead looks at a specific portion of the heart through the + electrode

Summary
Summary

Specific changes must appear in two contiguous leads

Changes seen in AMI are: tall, peaked T wave, elevated ST segment and a widened Q wave

A normal 12 lead ECG does NOT rule out AMI

Special Thanks!

Special Thanks! To Acute Coronary Syndrome Consultants, Inc. Tim Phalen, Gary Denton and Assoc. and Temple

To Acute Coronary Syndrome Consultants, Inc. Tim Phalen, Gary Denton and Assoc. and Temple College for the use of their materials in this presentation