Right Sided MI - How Do I Tell The Difference

[spenac]

So I move v1-6 over to right side how will that change the things seen on my 12 lead? Will it change my QRS, etc? What does it actually tell me?

[croaker260]

So I move v1-6 over to right side how will that change the things seen on my 12 lead? Will it change my QRS, etc? What does it actually tell me?

Actually you leave V1 and v2 in place, moving just V3-V6 (although I recently saw a text that just moved V4-V6...not sure if there is any real difference there).

This gives you views of the right side of the heart through the right side of the chest. Similar to moving your leads around for V7 through V15 will give you your posterior view instead of hoping for riciprocal changes in V1-V2.

Remember your precordial (V) leads are UNIPOLAR, looking only from their specific locaion, where your "limb Leads" (I, II, III, AVL, AVR, AVF) are BiPolar, meaning they need two leads to assess their "view". This is why moving your V leads can be useful.

Any-who....Moving your V3-V6 over to look at V3r thu V6r will enable you to assess for ST elevation or other signs of Ishemia/infarction specific in location to the right side of the heart.

Just a thought, but with out going back to the OP, you do understand your lead groupings, vectors, and such in 12 leads?

I know you said something about having the "basics" down, but different people view the "basics" as different things....no offense intended....

[kevkei]

To check for RVI, do a 15 lead. Move V4 to the contralateral position on the right side (V4r) and move V5 and V6 to the posterior (=V8, V9), these three new leads now complete the 15 lead.

As for moving V4-V6 to the right, you can accomplish as much by only moving V4 as it has 90% sesitivity and 90% specificity.

The mention of ST elevation in II, II, and aVf is inaccurate as only ~40% of inferior STEMI involves the right ventricle.

Some hints in a standard 12 lead:

- if there is elevation in V1 only, especially with inferior changes, be suspicious of RVI (proximity to V4r).

- If there is ST depression in V1,V2, be alert it may be reciprocal changes from V8,V9.

Clinically, there is a triad that is common with RVI, this is hypotension, JVD and dry lung sounds, signs common with right heart failure.

As for the comment of treat the patient and not the monitor, that is horrible advice. STEMI is one clinical acumen that is quite definitive with specificity. How else would we give tNK if not for a positive 12 lead in addition to history and clinical findings?

[croaker260]

As for moving V4-V6 to the right, you can accomplish as much by only moving V4 as it has 90% sesitivity and 90% specificity.

Thats a very specific staement.

Do you have a reference?

Not that I disagree...just want to be "solid"....

[fiznat]

Yeah I think those numbers are a bit fudged. ...Either that or they need to be qualified. I know that the entire 12 lead is not that sensitive for ACS, so I have a hard time believing that a single lead is such a great indicator of RVI.

What MIGHT be true is IF there is a STEMI on the right side, there is a high chance it will show up in V4R. That much is possible. You still ought to post your source if you are going to quote stats like that though.

[akroeze]

I've never understood why just V4R is sufficient. Any other time you need TWO leads to say anything... why is it the right side only needs one?

[JakeEMTP]

Here is a good article on Right-sided Infarction. It's a little long, but lot's of info.

http://ccn.aacnjournals.org/cgi/content/full/25/2/52#F3

They also suggest moving all leads, including switching V1 and V2.

[mshow00]

You can check out Bob Page's book that he uses to supplament his lecture. It is at http://www.multileadmedics.com/seminarhandouts.htm click the MLM 05 Master link. He explains not only how to read 12 leads, but 15 leads, and the right sided MI.

[Niftymedi911]

And don't give Fentanyl to them (MS is contraindicated) without MD's orders... like me and get QA'd........ Bad Fred.... (slaps hand for thinking outside of the box).

[WolfmanHarris]

I've never understood why just V4R is sufficient. Any other time you need TWO leads to say anything... why is it the right side only needs one?

Provincial ALS standards say RVI indicated by V4R with any TWO of II, III and avF.

According to my book approximately half of inferior MI's have right ventricular involvement and that "right ventricular MI's rarely occur independently on inferior wall MI's." (from Ontario Base Hospital Group ALS Pre-course. I'd check my Bledsoe or ECG book but don't have either at the base tonight.)