Dr. Fowler's 12 Lead EKG Interpretation Part 1

12 Lead EKG Interpretation
Ess e spe ntially akin g...
Copyright 2002, Ray Fowler, M.D., FACEP
Ray Fowler, M.D., FACEP

Assistant Professor of Emergency Medicine The University of Texas Southwestern
drray@doctorfowler.com
Objectives of this program:

1. Become familiar with cardiac anatomy as it relates to the electrocardiogram 2. Develop an initial understanding of Axis 3. Understand how to interpret hypertrophy 4. Recognize Bundle Branch Blocks 5. Understand how to interpret EKGs for signs of myocardial infarction 6. Understand the grouped leads concept
12-lead EKG interpretation is a relative newcomer in the field evaluation of the emergency patient
Many, perhaps most medics are not adept at 12 lead EKG interpretation
WHY?????
Because many EKG courses are too long, too boring, and teach absolutely unnecessary and unrememberable stuff to medics who will never use that information
Fowlers handy and dandy program will give you ALL you need to know about 12 lead EKGs in an absolutely rememberable format (GOOD LUCK, right?!?!?)
What am I NOT talking about?

Advanced rhythm assessment Ventricular tachycardia assessment Vtach vs. SVT assessment Block
This EKG is the REASON that 12 EKG Machines are in the field
Acute Anterior Myocardial Infarction
Rhythm strip interpretation has been a standard since almost the beginning of EMS
Basic Rhythm Strip Interpretation

Rate ST Segment Rhythm T Wave P Waves U Wave PR Interval Summary QRS Complex
Rate Rhythm P Axis Hypertrophy Infarction PR QRS ST T U Assessment

Since serious rhythm disturbances are the most important issue (like VF, VT, asystole), then if you see a serious rhythm disturbance proceed with rhythm strip interpretation FIRST
Fowlers Prime Directive of Cardiac Emergencies:
Some systole is better than no systole at all!

Pulseless Rhythms
Shock x 3, Intubate with CPR, Epi q 3, Shock, Lidocaine then Who Knows
Pulseless Rhythms
Shock x 3, Intubate with CPR, Epi q 3, Shock, Lidocaine then Who Knows Shock x 3, Intubate with CPR, Epi q 3, Shock, Lidocaine then Who Knows
Pulseless Rhythms
Shock x 3, Intubate with CPR, Epi q 3, Shock, Lidocaine then Who Knows Shock x 3, Intubate with CPR, Epi q 3, Shock, Lidocaine then Who Knows Intubate, IV, Epi q 3, Consider Atropine, Look for cause
Second point:
Much of what we call 12 lead interpretation is in fact actually rhythm strip interpretation.
such as, for example, the evaluation of AV block, which can usually be done in one, or at most, two leads
Third point:
AXIS INTERPRETATION He IS BORING!! n
ce,
Iw ill m ake
it V
ER Ys hor
t!
Positive
As the lead sees the impulse growing (or coming toward it), the machine records an upward deflection Positive
As the lead sees the impulse growing (or coming toward it), the machine records an upward deflection Positive Positive
As the lead sees the impulse growing (or coming toward it), the machine records an upward deflection Positive Positive
Positive
As the lead sees the impulse coming then going (or going by the lead), the machine records an isoelectric deflection Positive Positive
As the lead sees the impulse coming then going (or going by the lead), the machine records an isoelectric deflection Positive Positive
The EKG Basic Limb Leads

+ I
II
III
+
Lead I is horizontal, and is arbitrarily established at 0 Degrees
+
Lead III is 120 degrees from Lead I, and is arbitrarily established at Positive 120 Degrees
Lead II is 60 degrees down from Lead 1 + and is arbitrarily established at Positive 60 Degrees
The Leads may be moved to the center of the chest

I +
I II + + + III III II +
Axis is based on the direction of the hearts depolarization

+ I
II
III
+
I + I II
II
III
III
+
I + I II
II
III
III
+
I + I II II III III
+
Is this a Normal EKG???
Left Axis Deviation
Ventricular Hypertrophy
Enlargement of ventricles
Left Ventricular Hypertrophy

Left Axis Deviation Deep S wave in V1 Large R wave in V5

Left Axis Deviation Deep S wave in V1 Large R wave in V5 V1 plus V5 adds up to more than 35 millimeters

Left Axis Deviation Left Axis Deviation Deep S wave in V1 Deep S wave in V1 Large R wave in V5 Large R wave in V5 V1 plus V5 adds up V1 plus V5 adds up to more than 35 millimeters to more than 35 millimeters
Right Ventricular Hypertrophy

Look to the RIGHT side of the heart to find it, namely V1

Look to the RIGHT side Look to the RIGHT side of the heart to find it, of the heart to find it, namely V1 namely V1
Finding Ventricular Hypertrophy
Always look at Lead V1


Large R wave in V1 = RVH Deep S wave in V1 = LVH

Large R wave in V1 = RVH Deep S wave in V1 = LVH Corollary: If the complex is wider than 0.12 seconds, this is probably a bundle branch block and not ventricular hypertrophy
Bundle Branch Block

Positive Deflection Rabbit Ears in V1 with wide complex Positive Deflection in V6 with wide complex
Right Bundle Branch Block
Left Bundle Branch Block

Left Anterior Hemiblock
This is the END of
Part 1
of 12 Lead EKG Interpretation! Please join us for part 2!

Dr. Fowler&#39;s 12 Lead EKG Interpretation Part 1

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12 Lead EKG Interpretation

Ess e spe ntially akin g...

Copyright 2002, Ray Fowler, M.D., FACEP

Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Objectives of this program:

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

What am I NOT talking about?

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Acute Anterior Myocardial Infarction

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Basic Rhythm Strip Interpretation

Rate Rhythm P Axis Hypertrophy Infarction PR QRS ST T U Assessment

Fowlers Prime Directive of Cardiac Emergencies:

Some systole is better than no systole at all!

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

Copyright 2002, Ray Fowler, M.D., FACEP

The EKG Basic Limb Leads

Lead I is horizontal, and is arbitrarily established at 0 Degrees

The Leads may be moved to the center of the chest

Copyright 2002, Ray Fowler, M.D., FACEP

Axis is based on the direction of the hearts depolarization

Is this a Normal EKG???

Copyright 2002, Ray Fowler, M.D., FACEP

Left Axis Deviation

Copyright 2002, Ray Fowler, M.D., FACEP

Left Ventricular Hypertrophy

Copyright 2002, Ray Fowler, M.D., FACEP

Left Ventricular Hypertrophy

Copyright 2002, Ray Fowler, M.D., FACEP

Left Ventricular Hypertrophy

Left Ventricular Hypertrophy

Right Ventricular Hypertrophy

Copyright 2002, Ray Fowler, M.D., FACEP

Right Ventricular Hypertrophy

Dr. Fowler's 12 Lead EKG Interpretation Part 1

Dr. Fowler's 12 Lead EKG Interpretation Part 1