Transcript Chapter 8 for 12 Lead Training -The 15 Lead ECG-

ONTARIO
BASE HOSPITAL GROUP
Chapter 8
for 12 Lead Training
-The 15 Lead ECGOntario Base Hospital Group
Education Subcommittee
2008
TIME IS
MUSCLE
The 15 Lead ECG
AUTHOR
REVIEWERS/CONTRIBUTORS
Greg Soto, BEd, BA, ACP
Neil Freckleton, AEMCA, ACP
Hamilton Base Hospital
Niagara 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
2008 Ontario Base Hospital Group
Dr. Rick Verbeek, Medical Director
SOCPC
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

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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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BASE HOSPITAL GROUP
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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BASE HOSPITAL GROUP
Well Done!
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