12 Lead ECG Interpretation: Color Coding for MI s
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1 12 Lead ECG Interpretation: Color Coding for MI s Anna E. Story, RN, MS Director, Continuing Professional Education Critical Care Nurse Online Instructional Designer 2004 Anna Story 1
2 Objectives review the ECG waveform and intervals Define myocardial ischemia, injury and infarction Identify the 5 major infarct areas on the 12 lead Name occluded arteries common to the area Differentiate ECG changes reflecting ischemia, injury and infarction Identify cardiac enzymes associated with ACS 2004 Anna Story 2
3 MI Definition A result of occlusion of arterial flow to the myocardium. Ischemia, injury and necrosis is result Occlusion occurs via spasm, blood clot or stenosis 2004 Anna Story 3
4 The 12-Lead view Each limb lead I, II, III, AVR, AVL, AVF records from a different angle All six limb leads intersect and visualize a frontal plane The six chest leads (precordial) V1, V2, V3, V4, V5, V6 view the body in the horizontal plane to the AV node The 12 lead ECG forms a camera view from 12 angles 2004 Anna Story 4
5 Views from Augmented and Limb Leads- Frontal 2004 Anna Story 5
6 Precordial lead snapshots Think of each precordial lead as a horizontal view of the heart at the AV node With the limb leads and the precordial leads you have a snapshot of heart portions 2004 Anna Story 6
7 Unipolar and Bipolar Limb leads I, II, III are bipolar and have a negative and positive pole Electrical potential differences are measured between the poles AVR, AVL and AVF are unipolar No negative lead The heart is the negative pole Electrical potential difference is measured betweeen the lead and the heart Chest leads are unipolar The heart also is the negative pole 2004 Anna Story 7
8 Lead Placement is Important Each positive electrode acts as a camera looking at the heart Ten leads attached for twelve lead diagnostics. The monitor combines 2 leads. Mnemonic for limb leads White on right Smoke(black) over fire(red) Snow(white) on grass(green) 2004 Anna Story 8
9 Precordial Leads 2004 Anna Story 9
10 I and AVL V3 & v4 V1 & v2 II, III and AVF V5 & v6 Where the positive electrode is positioned, determines what part of the heart is seen! 2004 Anna Story 10
11 The ECG Tracing: Waves P- wave Marks the beginning of the cardiac cycle and measures the electrical impulse that causes atrial depolarization and mechanical contraction QRS- Complex Measures the impulse that causes ventricular depolarization Q-wave- may or may not be evident on the ECG R-wave- first upward deflection following P wave S-wave- the first downward deflection following the R- wave T- wave Marks ventricular repolarization that ends the cardiac cycle 2004 Anna Story 11
12 Intervals and Segments P-R interval- Time interval for impulse to go from the SA to the AV node normal secs QRS Interval Time interval for impulse to go from AV node to stimulate Purkinjie fibers Less than 0.12 secs QT Interval Time interval from beginning of depolarization to the end of repolarization Should not exceed ½ the length of the R-R ST segment end of the S to the beginning of the T 2004 Anna Story 12
13 The ECG Tracing 2004 Anna Story 13
14 ECG Changes : Ischemia T-wave inversion ( flipped T) ST segment depression T wave flattening Biphasic T-waves Baseline 2004 Anna Story 14
15 ECG Changes: Injury ST segment elevation of greater than 1mm in at least 2 contiguous leads Heightened or peaked T waves Directly related to portions of myocardium rendered electrically inactive Baseline 2004 Anna Story 15
16 ECG Changes: Infarct Significant Q-wave where none previously existed Why? Impulse traveling away from the positive lead Necrotic tissue is electrically dead No Q-wave in Subendocardial infarcts Why? Not full thickness dead tissue But will see a ST depression Often a precursor to full thickness MI Criteria Depth of Q wave should be 25% the height of the R wave Width of Q wave is 0.04 secs Diminished height of the R wave 2004 Anna Story 16
17 Evolving MI and Hallmarks of AMI Q wave 1 year ST Elevation T wave inversion 2004 Anna Story 17
18 Dissecting the 12 Lead ECG Horizontal marks time Vertical marks amplitude 6 limb leads 6 precordial leads Positioning measures 12 perspectives or views of the heart The 12 perspectives are arranged in vertical columns Limb leads are I, II, III, AVR, AVL, AVF Precordial leads are V1, V2, V3, V4, V5, V Anna Story 18
19 A Normal 12 Lead ECG 2004 Anna Story 19
20 A Normal 12 Lead ECG 2004 Anna Story 20
21 Color Coding ECG s Anterior Yellow indicates V1, V2, V3, V4 Anterior infarct with ST elevation Left Anterior Descending Artery (LAD) V1 and V2 may also indicate septal involvement which extends from front to the back of the heart along the septum Left bundle branch block Right bundle branch block 2 nd Degree Type2 Complete Heart Block 2004 Anna Story 21
22 Anterior MI 2004 Anna Story 22
23 Color Coding ECG- Inferior Blue indicates leads II, III, AVF Inferior Infarct with ST elevations Right Coronary Artery (RCA) 1 st degree Heart Block 2 nd degree Type 1, 2 3 rd degree Block N/V common, Brady 2004 Anna Story 23
24 Inferior MI 2004 Anna Story 24
25 As an aside. Right sided EKG Ever heard of it? Ever done one? Think about it.. For your cases that are clearly inferior MI s Obtain a dextrocardiogram whenever ST segment elevation is noted in Inferior leads 2004 Anna Story 25
26 Right Sided EKG???? The single most accurate tool used in measuring RVI. 90% sensitive and specific RVI occurs around 40% in inferior MI s Significance Larger area of infarct Both ventricles Different treatment Right leads look directly at Right Ventricle and can show ST elevations in leads II. III. AVF, V4R, V5R and V6R Occlusion in RCA and proximal enough to involve the RV 2004 Anna Story 26
27 Clinical Triad of RVI Hypotension Jugular vein distention Dry lung sounds 2004 Anna Story 27
28 Color Coding ECG- Lateral Red indicates leads I, AVL, V5, V6 Lateral Infarct with ST elevations Left Circumflex Artery Rarely by itself Usually in combo 2004 Anna Story 28
29 Lateral MI 2004 Anna Story 29
30 Color Coding ECG- Posterior Green indicates leads V1, V2 Posterior Infarct with ST Depressions and/ tall R wave RCA and/or LCX Artery Understand Reciprocal changes The posterior aspect of the heart is viewed as a mirror image and therefore depressions versus elevations indicate MI Rarely by itself usually in combo 2004 Anna Story 30
31 Posterior MI 2004 Anna Story 31
32 Color Coding ECG- SubEndo No color for SubEndocardial infarcts since they are not transmural Look for diffuse or localized changes and non Q wave abnormalities T-wave inversions ST segment depression 2004 Anna Story 32
33 SubEndo MI 2004 Anna Story 33
34 More than one color shows abnormality A combination of infarcts such as: Anterolateral yellow and red Inferoposterior blue and green Anteroseptal yellow and green 2004 Anna Story 34
35 Putting it ALL together 2004 Anna Story 35
36 2004 Anna Story 36
37 Practice 1 Anterior MI with lateral involvement ST elevations V2, V3, V4 ST elevations II, AVL, V Anna Story 37
38 Practice 2 Anteroseptal MI ST elevations V1, V2, V3, V Anna Story 38
39 Practice 3 Inferior MI ST elevation 2,3 AVF 2004 Anna Story 39
40 Practice 4 Inferior lateral MI ST elevations 2, 3, AVF ST elevations V Anna Story 40
41 Practice 5 Acute inferior MI Lateral ischemia 2004 Anna Story 41
42 Cardiac Enzymes Indicating Infarct Troponins- Now the Gold Standard! Rises after 3-6 hours Negative Troponin within 6 hours of onset of S&S rules out the MI Peaks at about 20 hours May be raised for 14 days 2004 Anna Story 42
43 Cardiac Enzymes Indicating Infarct Troponin T 84% sensitivity for MI 8 hours after onset of symptoms 22% for unstable angina Advantages Highly sensitive for detecting myocardial ischemia Levels may help to stratify risks Disadvantages Less specific than Troponin I Increased in angina Increased in chronic renal failure 2004 Anna Story 43
44 Cardiac Enzymes Indicating Infarct Troponin I 90% sensitivity for MI 8 hours after onset of S&S and 95% specificity Level greater than 1.2 suggest MI Negative rules out MI Obtain two negative troponin values 4 hours apart Normally exceedingly low Even a small elevation indicates myocardial damage 2004 Anna Story 44
45 References Twelve Lead Electrocardiography for ACLS Providers, D. Bruce Foster, D.O. W.B. Saunders Company Rapid Interpretation of EKG s, Dale Dubin, M.D., Cover Publishing Co ECG s Made Easy, Barbara Aehlert, RN, Mosby, 1995 The 12 Lead ECG in Acute Myocardial Infarction, Tim Phalen, Mosby, 1996 Color Coding EKG s, Tim Carrick, RN, H &H Publishing, Drawings by Jill Gregory, Medical Illustrator, CGEY 2004 Anna Story 45
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