Diagnostic ECGThe 12-Lead (Clinical Essentials) (Paramedic

Care) Part 6
12-Lead ECG Interpretation
Like the approach to a 12-lead ECG analysis, the approach to the 12-lead ECG interpretation
must likewise be disciplined. First, the Paramedic should assemble the list of abnormalities (i.e.,
presence and location of Q waves, R wave progression, ST changes, and T wave abnormalities).
Reflecting on these changes, the Paramedic should assess for lead groupings. Lead groupings are ECG
changes in contiguous leads that are suggestive of involvement of a specific ventricular wall.
Armed with this information, the Paramedic can attempt to identify the culprit artery that is
involved. Understanding coronary artery involvement can help the Paramedic predict the progression
of the acute coronary event and prepare for these predictable events. For example, the right coronary
artery (RCA) supplies the AV node in the vast majority of patients.44 ECG changes suggestive of an
inferior wall myocardial infarction (IWMI) implicate the right coronary artery (RCA) and vis-a-vis the
AV node ischemia. This AV node ischemia can manifest as type I heart block. The first indication of a
type I heart block is a prolonged PR interval (PRI). Therefore, a Paramedic confronted with a possible
IWMI would monitor the PRI in an IWMI for a possible heart block.
Finally, the Paramedic should consider the 12-lead ECG as a whole. ECG changes in adjoining walls
may be suggestive of the extent and the evolution of the AMI. For example, ST changes and T wave
abnormalities across all of the pre-cordial leads, from V1 to V6, are suggestive of an extensive AMI.
Such a pattern of ischemia could be suggestive of a left main coronary artery occlusion.45 The
implications of left main coronary artery occlusion include acute pulmonary edema (backward failure),
cardiogenic shock (forward failure), and sudden cardiac death (cardiac arrest).
A combination of Q waves, ST changes, and T wave abnormalities across one or more ventricular
walls may be suggestive of an AMI later in its evolution. While every STEMI has the potential for
reversal, the prognosis in a late evolution AMI is poorer and the morbidity higher.
Paramedic Prognosis
If the AV node is suffering from a lack of oxygenated blood, it will malfunction. As noted in
previous topics, the AV node is responsible for delaying the impulse and allowing the atria to contract
and push blood into the ventricles. The node is also the electrical connection between the atria and the
ventricles. The artery that serves the AV node is the right coronary artery. If ischemic or injury patterns
in the ECG leads which look at the area served by the RCA occur, the Paramedic can anticipate
conduction abnormalities in the monitoring strip. The conduction abnormalities may lead to a
decrease in coronary output sufficient to decrease preload and drop the blood pressure. Concurrently,
blood may back up into the venous system, leading to distention in the neck veins. Also associated with
RCA occlusions are bradycardias.
With LAD occlusions, the conduction is affected at the bundle of His, making for more serious
conduction abnormalities and unreliable escape mechanisms. The anterior wall is the largest portion of
the left ventricle and is responsible for ejecting blood into the high pressure system. Damage to the
anterior wall may lead to the inability to eject the blood delivered to it and the backup of blood to the
lungs. Anterior wall damage caused by occlusion of the LAD may lead to pump failure. Treatment
options for anterior wall damage include anticipation of cardiogenic shock, gross irritability of the
muscle cells leading to ventricular fibrillation, and reduction of heart rate and workload, leading to a
reduction in myo-cardial oxygen demand.
Further 12-Lead ECG Interpretation
As the hearts muscle depolarizes, the energy moves down the electrical pathway from the
sinoatrial node (SA node) to the atrioventricular node (AV node) as a wave front. The electrical wave
front then moves across the septum in a left-to-right fashion, then to the bundle branches, and finally
the wave front radiates outward across the ventricular mass. Each of these electrical events can be
recorded, over time, on an ECG. The graphic representation of these events is the traditional PQRS
complexes seen on an ECG.
There is another way to look at the electrical event. Instead of looking at depolarization in
fragments of P, Q, R, and S, the Paramedic could look at the sum of these events. The sum of these
electrical events would be the common direction of the electrical wave front called the mean electrical
vector (Figure 34-23).
To explain vectorography in another way, these electrical events could be likened to a battle
front during a war. While an army may send out many patrols, some going in different directions, the
main objective of the army is to move the front forward. This common direction would be the armys
vector. Similarly, while there may be minor deflections on the ECG, the major direction of the energy
during depolarization is toward the apex of the heart. This common direction, or vector, of the energy
of depolarization is called the hearts electrical axis. Any aberration from a normal electrical axis could
be indicative of disease (which is explained in more detail shortly).
Figure 34-23 Electrical vector.
Figure 34-24 Hexaxial reference system.
To help conceptualize the hearts normal axis, and to help determine if there is any axis
deviation, an artificial construct called the hexaxial reference system was created. To create the
hexaxial system, the limb leads were drawn around the heart and Lead I, the lead that is horizontal and
on the right side, was assigned zero degrees and the left side 180 degrees. As the limb leads are part of
Einthovens Triangle (an equilateral triangle), then Lead II would be at 60 degrees and negative 120
degrees and Lead III would be at 120 degrees and negative. The three axes are then all drawn into the
middle of the heart and the three augmented leads overlaid with aVF at 90 degrees, aVL at negative 30
degrees, and aVR at 30 degrees and negative 150 degrees. The resulting construct shows the heart
divided into equal 30-degree segments (Figure 34-24).
The traditional method of calculating the mean electrical axis was to find the most equiphasic
lead of the frontal leads (I, II, III, aVR, aVL, and aVF). An equiphasic lead is an QRS complex with an R
wave that is equal in height to the depth of the S wave. An equiphasic wave would be neither going
toward the vector nor away from it, but would be perpendicular to it. Using that lead, the Paramedic
would plot it on the hexaxial reference system (Figure 34-25). The lead represented on the
perpendicular spoke would be the hearts mean electrical axis in degrees. For example, if the equipha-
sic QRS was Lead I, then the perpendicular axis would be 90 degrees.
Figure 34-25 Axis determination using the hexaxial reference system.
This method of axis determination, while very accurate, is cumbersome in the field. An
acceptable alternative is the Grant method. With the Grant method, the Paramedic would refer to Lead
I and Lead II only (Figure 34-26). If both leads are upright, then there is a normal axis deviation. If
Lead I is upright but Lead II is primarily downward in deflection, then a left axis deviation is assumed.
Alternatively, if Lead I is primarily downward but the QRS in Lead II is upright, then it can be assumed
it is a right axis deviation. If the QRS for both Lead I and Lead II is negatively deflected, then the axis is
called an extreme left axis deviation; nicknamed "no mans land" because it represents extreme
abnormal depolarization.
Figure 34-26 Determination of axis using Lead I and Lead II.
STREET SMART
Many 12-lead ECGs provide a reading of the axis, listed as P-R-T axes. The Paramedic need only read
the R axis and compare it to the hexaxial reference to determine the axis.
To reduce confusion, some Paramedics use their thumbs to represent the QRS deflection-Lead I on
the right hand and Lead II on the left hand. If Lead I is upright (i.e., the right thumb is up and the left
thumb is down), then there is a left axis deviation. If both Lead I and Lead II are negative, then both
thumbs are down.
Axis Deviation
Axis deviation is any time the hearts axis is not normal. Determining axis deviation is another means
of observing many pathological conditions. Coupled with other physical findings, axis determination
can help the Paramedic establish a diagnosis. For example, a right axis deviation which is abnormal
can often suggest pulmonary pathologies such as pulmonary embolism and chronic obstructive
pulmonary disease.46
A slight left axis deviation, from 0 to (-) 30 degrees, may be physiologic and seen in obese patients
or women who are in their third trimester of pregnancy. A larger left axis deviation, from (-) 30 to (-)
90 degrees, is often associated with left ventricular hypertrophy, secondary to heart failure, inferior
wall MI, or (in some cases) Wolff Parkinson White syndrome.47
Of greater concern to the Paramedic is an extreme left axis deviation (>180 degrees) into "no
mans land." While conditions such as congenital transposition of the great vessels and dextrocardia
can produce this, extreme left axis deviation in the normal heart is suggestive of ventricular
tachycardia. During ventricular tachycardia, the electrical source is in the ventricle and the wave front
runs backward through the conduction system.
Differentiating VT from SVT with Aberrant Conduction
Paramedics (and other practitioners) often have difficulty determining whether a fast rhythm
with a wide QRS complex is ventricular tachycardia or supraventricular tachycardia with aberrant
conduction. Some patients can tolerate a sustained monomorphic ventricular tachycardia for a
prolonged period of time, despite opinion that patients cannot tolerate ventricular tachycardia (VT).
Because the patient is tolerating what appears to be a wide complex tachycardia of unknown etiology,
the assumption is it must be supraventricular tachycardia (SVT) with aberrant conduction. Some
patients do develop a rate-related bundle branch block.
The determination is important as treatments for SVT, such as calcium channel blockers, can lead
to rapid patient deterioration if the rhythm is actually VT. Instead of trialing a medication to "see if it
works," at the risk of patient discomfort and wasted time, a 12-lead ECG can provide the necessary
information.
Ventricular tachycardia occurs most often in patients with acute cardiac ischemia or those with a
cardiac history. The Paramedic should first obtain a quick patient history, paying attention to
antiarrythmic medications that indicate a previous history of cardiac dysrhythmia or medications that
may predispose the patient to arrhythmias (proarrhythmic medications).
Alternatively, supraventricular tachycardias often occur in otherwise healthy individuals. Some of
these patients may have a history of SVT or a diagnosis of WPW or LGL syndromes.
Next, the Paramedic should obtain a 12-lead ECG, paying particular attention to axis deviation and R
wave progression. The first step is to determine if the rhythm is regular. Ventricular tachycardia is
usually very regular. SVT with aberrancy is also usually regular unless the underlying cause is an atrial
fibrillation with a rapid ventricular response. If the rhythm is atrial fibrillation, then the ventricular
response will be irregularly irregular. While regularity will not help differentiate an interpretation of
either VT or SVT, an irregularly irregular rhythm is suggestive of atrial fibrillation.48
Next, the Paramedic should examine the QRS morphology in V1. In ventricular tachycardia, the V1
lead will be an R wave, where typically there is no R wave. Looking across the chest leads, the
Paramedic may also observe an S wave where typically there is no S wave.
In fact, if all of the QRS complexes in the chest Leads V1 through V6 are in the same direction (a
phenomena called concordance), the ECG interpretation favors VT. The direction of the QRS (the
polarity) can be either positive or negative but should be in the same direction.
Next, the Paramedic should look at Lead I and Lead II. If both leads are negative, or the R vector on the
12-lead ECG reads between (-) 90 degrees and (-) 180 degrees (i.e., extreme left axis deviation), then
the interpretation of VT is supported.
Table 34-8 Comparison of VT vs. SVT with Aberrancy
Ventricular Tachycardia Supraventricular Tachycardia
History of ischemia Healthy individual
Proarrythmic medications History of SVT
Regular or irregular rhythm Regular or irregular rhythm
Dissociated P wave activity P waves before each QRS
Concordance in the chest leads R wave progression
In V1 ( MCL1), R wave, Rr, QR, RS In V1 (MCL1), rSR
In V6 (MCL6), rS, QS, QR In V6 (MCL6), qRs

QRS duration of 0.16 sec or more QRS duration > 0.12 but < 0.16 sec

Initial notching or slurring of QRS Absent or ending slurring of QRS

Axis of -90 to -180 degrees Axis of -90 to +180
Finally, the Paramedic should observe the 12-lead ECG for the presence of P waves. Atrial
depolarization still occurs in VT, independent of the ectopic ventricular pacemaker. Because of the
independent atrial and ventricular activity (i.e., atrial-ventricular dissociation), P waves will randomly
appear throughout the 12-lead ECG. P waves that appear regularly in front of a QRS suggest a
supraventricular ectopic pacemaker (Table 34-8).
Miscellaneous Effects on the ECG
Electrolyte abnormalities, particularly potassium, can cause changes in the appearance of the 12-
lead ECG. While the Paramedic does not usually have access to lab results, the patients history may
suggest the potential for electrolyte disturbances. For example, patients in end-stage renal disease may
experience elevation of potassium levels while those patients receiving diuretics may have a decreased
level of potassium unless they receive potassium supplementation.
A normal potassium level, between 3.5 mEq/L and 4.5 mEq/L, is important for optimum cardiac
cell function. If the patient is hypokalemic (i.e., serum potassium less than 3.5 mEq/L), then the
patient may be prone to decreased inotropy. This can lead to generalized weakness or malaise, and/or
dys-rhythmias such as atrial flutter and bradycardia.
Causes of hypokalemia are numerous and include vomiting, aggressive gastric suctioning, diarrhea
(secondary to infectious diseases), or abuse of potassium-wasting diuretics such as furosemide. With
hypokalemia, the 12-lead ECG may show T wave flattening, ST-segment depression, and/or U wave
development.49,50
Hypokalemia is often associated with low magnesium levels or hypomagnesemia (Figure 34-27).
Hypomagnesemia may predispose the patient to a form of polymorphic ventricular tachycardia called
torsades de pointes.51
Albuterol is a bronchodilator but also drives potassium into the cells. Aggressive use of albuterol
(i.e., stacked treatments) may cause changes in cellular uptake of potassium, putting the patient at risk
for low potassium levels and dysrhythmias.
Perhaps more problematic for the Paramedic may be hyperkalemia. A serum potassium level
above 4.5 mEq/L is considered hyperkalemia. One of the most common causes of hyperkalemia is
kidney failure. Patients who are on kidney dialysis are at obvious risk of hyperkalemia prior to dialysis.
Other at-risk patients include patients with diabetes who are experiencing diabetic ketoacidosis,
patients with severe burns, patients with crush injury, and those patients with acute tubular necrosis
secondary to shock.
Figure 34-27 ECG changes associated with hypokalemia and hyperkalemia.
The common ECG alterations seen in hyperkalemia are changes in the T wave. At potassium
levels greater than 4.5 mEq/L but less than 6.5 mEq/L, the T wave appears tall and peaked and is best
seen in inferior leads (Lead II and Lead III). As the potassium level continues to climb toward 8 Eq/L,
the QRS starts to widen and a left axis deviation may be appreciated. Finally, as the potassium level
climbs above 8 mEq/L, the P waves all but disappear and the QRS starts to flatten into a sine wave
configuration. It is at this time the patients cardiac output has dropped precipitously and the patient is
at risk for ventricular fibrillation or asystole.
Arrhythmias caused by hyperkalemia are very difficult to treat with defibrillation or the usual
emergency drugs without lowering the serum potassium level. Calcium chloride, calcium gluconate, or
sodium bicarbonate, all competitive electrolytes, may be used to lower potassium levels. Alternatively,
serial treatments with Albuterol may help to treat mild to moderate hyperkalemia. In severe cases, it
may be necessary to administer 50% dextrose with short-acting insulin.52 The insulin helps to drive
both glucose and potassium into the cells.
STREET SMART
Calcium is needed for regular cell function. Loss of calcium (serum calcium levels less than 8.5 mg/dL)
or hypocalcemia is rare. Typical causes of calcium disturbances are chronic diseases. The effect of
calcium is seen on the QT interval. Hypocalcemia causes a widened QT interval whereas an elevated
serum calcium causes a short QT interval. To remember that calcium is related to QT, the Paramedic
need only remember that QT interval is corrected for heart rate and recorded on the 12-lead ECG as
such (i.e., QTc). The little c could represent calcium, to remind the Paramedic of other causes of
prolonged/shortened QT intervals.
Extra-Cardiac Causes of ECG Changes
Potentially devastating extra-cardiac pathologies, such as intracranial hemorrhage,
hypothermia, and pericarditis, can also cause changes on the 12-lead ECG. While not pathognomonic
for these pathologies, they are another sign to be added to the symptom complex for diagnosis.
An acute rise in intracranial pressure secondary to sub-arachnoid hemorrhage, intracerebral bleed, or
an epidural bleed may lead to wide and deeply inverted T waves in the chest leads.53-55 The
Paramedics attention is likely focused on other more urgent matters during one of these events.
However, 12-lead ECG evidence, if obtained, may be useful at the emergency department.
Hypothermia affects all cellular functions and can also cause changes in the ECG. When a
patient is hypothermic, all of the interval durations (i.e., PR, QRS, and QT) lengthen and positive
deflections at the J point, or point where the ventricular complex ends and the ST segment begins,
become noticeable. These deflections are in the same direction (polarity) as the QRS and are termed
Osborn waves (sometimes called the camel-hump sign). The Osborn wave is seen in all leads, but is
more prominent in the inferior limb leads. The size of the Osborn waves correlates directly with the
degree of hypothermia. Osborn waves are often difficult to discern because of artifact from muscle
tremors (Figure 34-28), but are seen in 80% of patients with hypothermia (below 33C/91.4F).56
Finally, pericarditis, an inflammation between the pericardium and the epicardium, can cause
chest pain and 12-lead ECG abnormalities. Initially, the Paramedic may be led to believe that the chest
pain is secondary to acute coronary syndrome. However, nitrates are not useful in treating the pain of
pericarditis, so it is important for the Paramedic to seek historical clues to the diagnosis of pericarditis
(i.e., fevers, etc.) as well as ECG evidence.
The inflammation that occurs between the sac surrounding the heart and the epicardium leads to
swelling which puts some pressure on the myocardium. The myocardium cannot repolarize as it
normally does due to the swelling, so there are T wave changes. The T will become pointed and tall
(similar to a hyperacute T wave found in an MI). However, the changes tend to occur in all leads rather
than within contiguous leads only, leading the Paramedic to suspect other causes for the chest pain,
such as pericarditis.
Evaluation
One of the advantages of the 12-lead ECG is its ability to predict the clinical progression of the
patients disease if left unchecked. For example, in the case of a patient with an anterior wall
myocardial infarction (AWMI), the patient may eventually develop cardiogenic shock secondary to lost
myo-cardial function. In this case, the patient had an IWMI that could, predictably, either extend to
the mitral valve (causing mitral valve regurgitation) or extend into the right ventricle. It is estimated
that 50% of IWMI extend into the right ventricle, with a resultant loss of preload.
Figure 34-28 Osborn wave secondary to hypothermia.
Figure 34-29 Lead placement for a 15-lead ECG, which is helpful in assessing the right
ventricle.
STREET SMART
The right ventricle essentially primes the pump (the left ventricle). Loss of right ventricular function,
secondary to myocardial injury, can lead to profound hypotension. For this reason, some Paramedics
perform a 15-lead ECG to identify right ventricular involvement before administering vasodilators such
as nitroglycerin.
15-Lead ECG
An additional diagnostic test available to the Paramedic if the Paramedic suspects right ventricular
involvement is the 15-lead ECG.57 The electrode placement for a 15-lead ECG will place positive
electrodes onto the right side of the chest and view the right ventricle.
Locations for these electrodes are the 5th right intercostal space at the midclavicular line, 5th
right intercostal space anterior axillary line, and 5th right intercostal space at midaxillary. The
corresponding V4 to V6 wires from the left chest electrodes are switched over to the right electrodes
and the ECG is rerecorded (Figure 34-29). The repeated ECG is marked right chest leads or V4R, V5R,
and V6R.
Conclusion
The diagnostic 12-lead electrocardiogram is a useful tool in the Paramedics assessment tool box with
the potential to improve patient outcome by early detection of cardiac abnormalities. This is especially
true in situations where the patient presents with an acute ST elevation myocardial infarction, where
the patient can be triaged to the appropriate hospital, or in cases of dynamic changes in the ECG that
change with treatment, uncovering underlying cardiovascular disease.
key points:
Death from AMI remains a national health problem.
Aggressive prehospital treatment including obtaining and interpreting a 12-lead ECG can
favorably impact patient mortality and morbidity.
Paramedics must have a higher index of suspicion with patient populations that may present
with atypical cardiac symptoms.
A regular ECG uses standard limb leads, augmented limb leads, and precordial leads.
The regular ECG allows for inferior, anterior, and lateral views of the left ventricle, as well as
combinations.
Accurate 12-lead ECG requires proper patient preparation including standardized electrode
placement.
A 12-lead ECG is printed in a standard configuration.
Viewing a specific combination of leads, called contiguous leads, allows correlation to specific
ventricular walls.
Based upon coronary artery anatomy, ECG changes in contiguous leads permit Paramedics to
estimate damage in specific arteries.
Estimation of damage in specific arteries permits prognosis and planning.
Understanding an acute myocardial infarction requires an understanding of penumbra.
Additional ECG evidence, such as new onset left bundle branch block (LBBB) and reverse R wave
progression (RRWP), are important in supporting the diagnosis of myocardial infarction.
Some 12-lead ECGs do not show acute changes. The Paramedic should focus on treating the
patient based on history.
There are numerous extra-cardiac causes to ECG abnormalities.
12-lead ECG interpretation takes a disciplined approach that gathers all the pertinent
information to prevent premature interpretation.
Based on the 12-lead ECG interpretation and the patient history, the Paramedic can make a field
diagnosis.
Additional information is also available from the 12-lead ECG that can lend insight into other
health conditions.
The 12-lead ECG can help differentiate ventricular tachycardia (VT) from supraventricular
tachycardia.
The addition of three right-sided leads can help identify right ventricular AMI.
Early detection of MI, via 12-lead ECG, and rapid transportation to an interventional cardiac care
center can lead to better patient outcomes.