1. BASE HOSPITAL GROUP ONTARIO Chapter 8 for 12 Lead Training -The 15 Lead ECG- Ontario Base Hospital Group Education Subcommittee 2008 TIME IS MUSCLE

2. OBHG Education Subcommittee The 15 Lead ECG 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 AUTHOR Greg Soto, BEd, BA, ACP Niagara Base Hospital

3. 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

4. OBHG Education Subcommittee 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

5. OBHG Education Subcommittee 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

6. OBHG Education Subcommittee 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

7. OBHG Education Subcommittee 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

8. OBHG Education Subcommittee Clinical Signs of RVI The TRIAD:  Jugular vein distention (JVD)  Hypotension, either presenting or following nitro administration  Clear lung sounds

9. OBHG Education Subcommittee Right Coronary Artery  Inferior wall of LV  Right ventricle  Posterior LV  Posterior fascicle of LBB  SA and AV node  2 nd deg I common

10. OBHG Education Subcommittee Posterior view

11. OBHG Education Subcommittee 15-Lead ECG

12. BASE HOSPITAL GROUP ONTARIO 15 Lead Practice Cases

13. OBHG Education Subcommittee Inferior/Posterior/RVI

14. OBHG Education Subcommittee Inferior

15. OBHG Education Subcommittee Inferior - Posterior

16. OBHG Education Subcommittee None

17. OBHG Education Subcommittee Inferior/Posterior

18. OBHG Education Subcommittee None

19. OBHG Education Subcommittee 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

20. BASE HOSPITAL GROUP ONTARIO QUESTIONS?

21. BASE HOSPITAL GROUP ONTARIO Well Done! Education Subcommittee STARTQUIT