12 leads: where do you feel weak?

[ccmedoc]

This is the typical pattern I follow when I look at any XII lead:

Rate:

Rhythm:

P for every QRS:

QRS:

PRI:

QTc:

Axis Deviation:

Q waves:

Localized Changes:

II, III, AVF:

V1, V2:

V3, V4:

V5, V6, I, AVL:

Right Ventricle:

Posterior:

Additional Notes:

Impression:

Take care,

chbare.

This is exactly how I read them..every time. If you develop a system, and note changes along the way, you tend not to get caught on the small stuff and see the big picture. Analyze all the above and then scrutinize the changes.

The fact of the matter is, you don't need to know anything in the prehospital setting, other than the fact that the person is having a STEM

I or not. Don't try to misinterpret me, follow your protocols for MONA and don't waste any time. There is no pt care that is more important than getting this pt to a cath lab. Additionally, even if the pt has no STEMI and s till having chest discomfort, they still may require intervention such as angiogram. I teach all EMTs how to recognize a STEMI and the reason why it is so important to get this pt to a cath lab.

There is something seriously wrong with this web page. Nothing personel but type doesn't stay in lines > ????

Very simplistic thinking, if not a bit contradictory. Progressive systems are not in the future here...

How do we propose to decrease door to balloon times if you don't know anything prehospital? It starts there, and the sooner the better.

As chbare says, there are a plethora of other problems that can be caught with a well educated eye, and a remedy can be initiated, or a wrong treatment avoided. Simply throwing MS, O₂, Nitro, and ASA at every chest pain is bush league and potentially very harmful..IMHO

-For what its worth

[fiznat]

Fiz, this is a great idea. When you get this educational piece put together any chance to get a copy in the hands of those in the EMTCity land? That would be a wonderful educational tool that we could all use, basic or advanced.

Thank you! Sure I can, although I think just because of the nature of the material most of the value will be in the class discussion. Still, I can definitely upload whatever powerpoint and example strips I come up with.

[itxtme]

The fact of the matter is, you don't need to know anything in the prehospital setting, other than the fact that the person is having a STEM

I or not. Don't try to misinterpret me, follow your protocols for MONA and don't waste any time. There is no pt care that is more important than getting this pt to a cath lab. Additionally, even if the pt has no STEMI and s till having chest discomfort, they still may require intervention such as angiogram. I teach all EMTs how to recognize a STEMI and the reason why it is so important to get this pt to a cath lab.

There is something seriously wrong with this web page. Nothing personel but type doesn't stay in lines > ????

I disagree. 12 leads are average indicators of AMI (well maybe above average) but certainly not the gold standard. Step away from AMI's for a moment and a 12 lead is absolutely invaluable. For example we have a pt with possible CHF but differentials of double pneumonia we can use 12 leads such as axis deviation and R wave progression to help in choosing a more definite treatment plan. Merely a piece of the puzzle but if you use 12 leads for AMI recognition only you will have EMT's soon calling the cath lab for a LBBB (old onset) because they don’t know how to spot one (and we all know how ST elevated a LBBB appears!)

edit sp.

[celticcare]

The fact of the matter is, you don't need to know anything in the prehospital setting, other than the fact that the person is having a STEM

I or not. Don't try to misinterpret me, follow your protocols for MONA and don't waste any time. There is no pt care that is more important than getting this pt to a cath lab. Additionally, even if the pt has no STEMI and s till having chest discomfort, they still may require intervention such as angiogram. I teach all EMTs how to recognize a STEMI and the reason why it is so important to get this pt to a cath lab.

As a coronary care unit nurse, I have to totally disagree with you and having those bits of information from EMS, even if it is at least an educated guess, is a gauge to understanding if a potential condition has gotten worse or even rectified to an extent. There is more to a patient than a STEMI and a developing LBBB or RBBB is just as important for me to know as a STEMI and how am I going to see that.... via lead 1 mainly.

How am I going to clearly get an image of axis? via 12 lead. How am I going to locate ST depression and T wave inversion, which I think at times are just as if not more important than a STEMI due to the fact this is ischemia, this is myocardium we can save. STEMI is infarct, that is dead tissue we have already lost, if a patient is showing t wave inversion or segment depression, I would want them hauled ass for potential revascularisation or reperfusion therapy.

Just my two cents, but I notice a big continium of care when a pre-hospital 12 lead is done and its a guiding baseline. So even if you don't fully know how to read them *heck I don't know all the facts either, it takes time*, just print one for us, please, it does actually make treatment options more clear and that baseline vital trend, 12 lead the other vital sign.

Scotty

[FL_Medic]

12-leads are much more important than just a diagnostic tool for STEMI as above posters mentioned.

Consider that A-fib RVR you want to treat with C+ channel blocker. What if they have WPW and don't know it? A 12-lead would be much easier to diagnose that. (not advocationg 12-leads on all rapid a-fib patients)

You can see brugada, or hypertorphic cardiomyopathy which may indicate why your patient had a syncopal episode.

You may see more defined flutter waves in other leads(although they are usually most prevelant in inferior leads).

You could have a better understanding of your patients condition if they have an electrolyte imballance, ie hyperkalemia (peaked T-waves)

Maybe your p-waves are hard to define, and you need to look at other leads to be sure.

Those wide QRS complexes may just be a BBB.

Axis deviation could indicate a chronic problem for your differential Dx.

R-axis deviation:

-May be abnormal in peolpe who have a block in the posterior division of the left bundle.

-Can imply delayed activation of the right ventricle ( as seen in RBBB ) or Right Ventricular enlargement.

-Pathology: Right Ventricular enlargemnet and hypertrophy. C.O.P.D. Pulmonary Embolism, Congenital heart Disease, Inferior wall MI.

L-axis deviation:

-Can be normal in the presence of acites, abdominal tumors, pregnancy or obesity.

-Abnormalities are due to Left Ventricular enlargement or a Left anterior hemiblock.

-Pathology: Left ventricular enlargement, and hypertrophy, Hypertension, Aortic Stenosis. Ischemic Heart Disease. Inferior wall MI.

There are 12-lead changes that may indicate a pericardial effusion or tamponade

Q-waves may indicate a silent MI the patient didn't know they had.

Edited March 16, 2009 by FL_Medic

[FireMedic65]

Reading over all of these, made me realize I really need to take a course on this. If not that, at least get a good book on it. When I was in medic school, our 12 lead lecture was very basic. Pretty much how to attach the electrodes in the right spot, and to look for ST elevations or depressions and to named what lead they came from.

I feel this is a excellent idea for EVERY service using 12 lead capable monitors to do. Great thinking!

[FL_Medic]

Reading over all of these, made me realize I really need to take a course on this. If not that, at least get a good book on it. When I was in medic school, our 12 lead lecture was very basic. Pretty much how to attach the electrodes in the right spot, and to look for ST elevations or depressions and to named what lead they came from.

I feel this is a excellent idea for EVERY service using 12 lead capable monitors to do. Great thinking!

If you're lucky enough to live near a big city where they do medical conferences you could get a good class at one of them. Also, there's a ton of information on the web, including videos from conferences. I like the medical podcasts on iTunes. They are short, but you can get some useful information.

Some of the stuff I mentioned may not change your treatment, but end up helping the patient in the long run if you find something early. I like to know what's going on, even if it wont change my Tx. So that's why I look for some of this more advanced stuff. I think there are a lot of us that do though.

The first thing I would look up would be MI mimickers, ie. early repol, brugada, cardiomyopathy... That would help anyone. Just keeps you from misdiagnosing, ya know? The more advanced stuff is cool too though.

[swn919]

Okay I'll be more specific:

1. Do you routinely determine the mean QRS Axis and can you apply that information practically?

2. Are you aware of the Sgarbossa Criteria and have you used it before?

3. Do you routinely check for Cor (or P) Pulmonale?

4. Do you look for LVH, BER, and BBB on every STEMI?

5. Do you systematically interpret every 12 lead you read in the same order every time?

6. How familiar are you with syndromes like Brugada, Pericarditis, Wellen's, WPW, hyper/hypo K, and long QT?

Others....?

1. I wouldn't say routinely only if something looks out of whack.

2. No, I was not until I googled it thanks for pointing me to something new, and usefull

3. Unfortunately, no

4. BBB, yes the rest no

5. Yes same order each time to make sure I don't miss any thing.

6. Familiar enough to interpret each one except Wellen's