15

17

12 Lead ECG Interpretation

PART IV
AMI ImitatorsBeware!

Dana Yost, Senior Paramedic

Paramedic Training
King County, WA

MI Imitators
LBBB

Pericarditis

LVH

Cardiomyopathy

Paced

Acute Myocarditis

Ventricular Rhythms

WPW

Benign Early
Depolarization

Hyperkalemia

Left Ventricular
Aneurysm

Hypothermia

Bundle Branch Block

Delayed depolarization
Can be pre-existing condition

Can be caused by MI

Bundle Branch Block

BBB caused by MI
60%-70% association with pump failure
40%-60% mortality without reperfusion

Bundle Branch Block

Can mimic MI
Can hide evidence of MI

Bundle Branch Block

May Produce
ST elevation
ST depression
Tall T waves
Inverted T waves

May Hide
ST elevation
ST depression
Tall T waves
Inverted T waves

The Problem
Critical to re-perfuse patients with BBB produced by MI
MI harder to identify on ECG when BBB present

BBB Recognition

Forget About the Notch!

BBB Recognition
Wide QRS
> 120ms
Supraventricular rhythm

RBBB vs. LBBB

Use V1
Identify direction of
terminal force

Bundle Branch Block

V1

Right

Left

BBB Recognition

BBB Recognition

18

Left Ventricular
Hypertrophy
Enlarged left ventricle
Pumping against increased resistance
Chronic overfilling

LVH
May Produce
ST elevation
ST depression
Tall T waves
Inverted T waves

May Hide
ST elevation
ST depression
Tall T waves
Inverted T waves

LVH
Does not abnormally widen QRS
Increases height and depth of QRS
Recognized by this increase
Three step recognition formula

LVH Recognition
Step 1
Look in V1 and V2
Pick the deepest negative deflection
Count small boxes of negative deflection in
that lead
Remember that number

LVH Recognition
Step 2
Look in V5 and V6
Pick the tallest positive deflection
Count small boxes of positive
deflection
Remember that number

LVH Recognition
Step 3
Add the two numbers together
Suspect LVH if the sum equals 35 or
more

LVH
(V1 or V2) + (V5 or V6) = _____mm

11

Paced Rhythms
Present like a LBBB
Pacer spikes

Summary
Most Common Imitators

LVH
LBBB
PACED

Summary
Imitators can produce

ST elevation

ST depression
Inverted T waves