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12 Lead ECG Placement Mnemonics helps to remember placement of chest and limb ECG leads. Often the respective leads indicators are marked on chest leads. Limb leads are color coded and marked too. There are three types of ECG leads available: Banana Type Snap Type Pinch/Clip/Grabber Type Banana Type leads are common with old pattern of ECG machines. Chest leads are marked with C1, C2 or like V1, V2. Todays leads also carries a color coding. Snap Type is used very frequently and attached to the connector with a snap or button. Easy to use with disposal type of connectors and these are frequently used in ICU, NICU and Emergency deptts. Apart from color coding, often chest lead numbers are marked as V1, V2.. and Limb leads as RA, RL, LL, LA. The other type is Pinch type ECG lead and it has a clip type mouth to connect to the connector. In most cases, the leads are numbered, so that you dont have to remember them. It is true for both chest leads as well limb leads. The problem arises when the numbers fall off due wear and tear or when not numbered at all. In this case the color coding helps. The 12 ECG chest lead standard color coding are like this: With the help of color coding any lay man can place ECG leads without a mnemonic.
ECG is the mainstay of diagnosing STEMI which is a true medical emergency Making the correct diagnosis promptly is life-saving. That is why when a clinical picture correlates with MI, ECG becomes the first line of Investigation. What is Acute Coronary Syndrome Coronary heart disease is a major cause of death and disability in developed countries and the world •Unstable coronary disease (ACS) is characterized by plaque rupture or erosion with associated thrombosis –STEMI –NSTEMI –Unstable angina •STEMI is a true medical emergency ECG in STEMI •ECG is a mainstay in the initial diagnosis of patients with suspected ACS which will dictate management •In patients with acute STEMI the ECG evolves through a typical sequence •Definition of STEMI –New ST elevation at the J point in two contiguous leads of >0.1 mV in all leads other than leads V2-V3 –For leads V2-V3 the following cut points apply: ≥0.2 mV in men ≥40 years, ≥0.25 mV in men <40 years, or ≥0.15 mV in women •Other conditions which are treated as a STEMI –New or presumed new LBBB –Isolated posterior MI •The presence of reciprocal ST depression helps confirm the diagnosis Examples of ECG Changes in STEMI: What are contiguous leads? Contiguous leads are “next” to one another anatomically speaking. They view the same general area of the heart (specifically the left ventricle).The “inferior” leads (II, III and aVF) view the inferior wall of the left ventricle. Remember that the inerior leads make up the lower-left corner of the 12 lead ECG.The “septal” leads (V1 and V2) view the septal wall of the left ventricle. They are sometimes grouped together with the anterior leads.The “anterior” leads (V3 and V4) view the anterior wall of the left ventricle.The “lateral” leads (I, aVL, V5 and V6) view the lateral wall of the left ventricle. Leads I and aVL are sometimes referred to as the “high lateral” leads, because their positive electrode is on the left shoulder. Leads V5 and V6 are sometimes referred to as the “low lateral” leads because their positive electrodes are on the lateral left chest.
Normal adult 12-lead ECG Normal sinus rhythm each P wave is followed by a QRS P waves normal for the subject P wave rate 60 – 100 bpm with <10% variation rate <60 = sinus bradycardia rate >100 = sinus tachycardia variation >10% = sinus arrhythmia normal QRS axis normal P waves height < 2.5 mm in lead II width < 0.11 s in lead II for abnormal P waves see right atrial hypertrophy, left atrial hypertrophy, atrial premature beat, hyperkalaemia normal PR interval 0.12 to 0.20 s (3 – 5 small squares) for short PR segment consider Wolff-Parkinson-White syndrome or Lown-Ganong-Levine syndrome (other causes – Duchenne muscular dystrophy, type II glycogen storage disease (Pompe’s), HOCM) for long PR interval see first degree heart block and ‘trifasicular’ block normal QRS complex < 0.12 s duration (3 small squares) for abnormally wide QRS consider right or left bundle branch block, ventricular rhythm, hyperkalaemia, etc. no pathological Q waves no evidence of left or right ventricular hypertrophy normal QT interval Calculate the corrected QT interval (QTc) by dividing the QT interval by the square root of the preceeding R – R interval. Normal = 0.42 s. Causes of long QT interval myocardial infarction, myocarditis, diffuse myocardial disease hypocalcaemia, hypothyroidism, subarachnoid haemorrhage, intracerebral haemorrhage, drugs (e.g. sotalol, amiodarone), hereditary, Romano Ward syndrome (autosomal dominant) Jervill + Lange Nielson syndrome (autosomal recessive) associated with sensorineural deafness, normal ST segment,no elevation or depression, causes of elevation include acute MI (e.g. anterior, inferior), left bundle branch block, normal variants (e.g. athletic heart, Edeiken pattern, high-take off), acute pericarditis causes of depression include myocardial ischaemia, digoxin effect, ventricular hypertrophy, acute posterior MI, pulmonary embolus, left bundle branch block normal T wave causes of tall T waves include hyperkalaemia, hyperacute myocardial infarction and left bundle branch block causes of small, flattened or inverted T waves are numerous and include ischaemia, age, race, hyperventilation, anxiety, drinking iced water, LVH, drugs (e.g. digoxin), pericarditis, PE, intraventricular conduction delay (e.g. RBBB)and electrolyte disturbance. normal U wave source:ecglibrary.com