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Chapter 8 for 12 Lead Training

-The 15 Lead ECGOntario Base Hospital Group Education Subcommittee 2008 TIME IS MUSCLE

The 15 Lead ECG

AUTHOR Greg Soto, BEd, BA, ACP
Niagara Base Hospital

REVIEWERS/CONTRIBUTORS
Neil Freckleton, AEMCA, ACP Hamilton Base Hospital Jim Scott, AEMCA, PCP Sault Area Hospital Ed Ouston, AEMCA, ACP Ottawa Base Hospital Laura McCleary, AEMCA, ACP SOCPC Tim Dodd, AEMCA, ACP Hamilton Base Hospital Dr. Rick Verbeek, Medical Director SOCPC

2008 Ontario Base Hospital Group

OBHG Education Subcommittee

Chapter 8 - Objectives
Describe

the benefits of acquiring a 15-lead

ECG Describe the proper lead placement for Leads V4R, V8, and V9 Describe the hemodynamic problems associated with a right ventricular infarction List 3 clinical signs of RVI On a 15-lead ECG, recognize ECG changes for a posterior and right ventricular MI
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Why a 15-Lead ECG?

Used

when a patient has an Inferior STEMI or suspected Posterior STEMI (reciprocal changes with ST depression in V1/V2) Can confirm Posterior MI (usually associated with an Inferior MI Can suggest RVMI which is a larger and more complicated Inferior MI

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Acquiring the 15-Lead (V4R)

Run

standard 12-lead Lead V4R: 5th IC space midclavicular on right side Same as left side V4 Attach V4 wire to the V4R position

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Acquiring a 15-Lead (V8, V9)

Posterior leads V8: 5th IC space midscapular line V9 goes between V8 and the spine Place Lead V5 wire on V8 and V6 wire on V9 Acquire the second 12-lead Re-label the new leads

Note: A 16-lead ECG can also be utilized to examine the posterior myocardium, and differs from the 15-lead ECG in that V4 becomes V7.

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Right Ventricular Infarction

RV

gets blood supply from the RCA Up to 50% of inferior MI will have RVI RV is preload dependant for Cardiac Output Nitrates cause preload reduction; thus use nitrates with extreme caution Hypotension in RVMI often responds well to IV fluid bolus (increase in preload) May require 1 liter or more IV fluid bolus for hypotension
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Clinical Signs of RVI

The TRIAD: Jugular vein distention (JVD) Hypotension, either presenting or following nitro administration Clear lung sounds

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Right Coronary Artery

Inferior

wall of LV Right ventricle Posterior LV Posterior fascicle of LBB SA and AV node 2nd deg I common

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Posterior view

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15-Lead ECG

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15 Lead Practice Cases

Inferior/Posterior/RVI

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Inferior

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Inferior - Posterior

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None

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Inferior/Posterior

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None

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Indications - 15 Lead ECG

Any

Inferior AMI (but especially accompanied by ST-depression in V1 to V3) ST-depression in V1 V3 on its own in symptomatic ACS patient

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QUESTIONS?

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START

QUIT

Well Done!
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