localizing ecg abnormalities

[stoic]

so another thread got me thinking, something i don't really know how to do is look at an ecg and say "ahh, that abnormality is originating in the posterior septum."

i have no real desire to be a true ecg whiz, but i'd like to be able to generally figure the location out from the trace. seeing as how EM docs are practical people, i figure ya'll might have some quick ways of figuring out if something is anterior/posterior/septal/inferior/etc.

thanks in advance,
dave

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[MedicinePowder]

so another thread got me thinking, something i don't really know how to do is look at an ecg and say "ahh, that abnormality is originating in the posterior septum."

i have no real desire to be a true ecg whiz, but i'd like to be able to generally figure the location out from the trace. seeing as how EM docs are practical people, i figure ya'll might have some quick ways of figuring out if something is anterior/posterior/septal/inferior/etc.

thanks in advance,
dave

a few people on here recommended the art of interpretation by garcia to make ekg reading easy--i bought it and gotta say i'm disappointed. it's too long, and doesn't give u a practical way of looking at the whole ekg. instead, stuff like Rbbb and Lbbb and t-waves etc etc are explained in tediously long chapters. someone mentioned rapid interpretation of ekgs, maybe i'll look into that.

 

[DogFaceMedic]

Dubins, "Rapid Interpretation of EKG's". It is easy to read and follow. You can get the 5th edition on line for ~$10. The new 6th Ed is color and $35, but no major difference. An EM attending, an EM resident, and an IM attending all said read Dubins within seconds of me asking an EKG question.

 

[MushieCookie]

a few people on here recommended the art of interpretation by garcia to make ekg reading easy--i bought it and gotta say i'm disappointed. it's too long, and doesn't give u a practical way of looking at the whole ekg. instead, stuff like Rbbb and Lbbb and t-waves etc etc are explained in tediously long chapters. someone mentioned rapid interpretation of ekgs, maybe i'll look into that.

How about Dubins? I've heard good things about this book. I haven't read it yet, but plan on getting it soon.

 

[EM_Rebuilder]

I have been told Dubins over and over as well.

I am no EKG king but I have paid extra attention to them throughout third year since I knew they are important for EM. Things really started coming together for me once I could visulize the lead placement circle diagram that you have seen before. Now, when I see an EKG with some abnromalities, I can think of that picture and usually get the location of infarct right...

 

[SoCuteMD]

Dubin is great, but I bought it before I found he was/is a pedophile...

 

[MushieCookie]

Dubin is great, but I bought it before I found he was/is a pedophile...

Really??

 

[USCDiver]

Really??

Snopes.com

It's still a good book....

 

[Apollyon]

a few people on here recommended the art of interpretation by garcia to make ekg reading easy--i bought it and gotta say i'm disappointed. it's too long, and doesn't give u a practical way of looking at the whole ekg. instead, stuff like Rbbb and Lbbb and t-waves etc etc are explained in tediously long chapters. someone mentioned rapid interpretation of ekgs, maybe i'll look into that.

I think the Garcia book is great, and I recommend it fully as an EM-residency trained physician.

 

[DrQuinn]

I think the Garcia book is great, and I recommend it fully as an EM-residency trained physician.

here here. yearsssssssssss ago on SDN someone recommended it (like when I was an MS2). Bought it and have been tooting its horn for years. It is a LONG book with LONG chapters, but, dude, once you read those chapters you're gonna be an EKG king (or queen).

But to answer the OPs initial question:

septal leads v1 v2
anterior leads v2 v3 v4
lateral leads v5 v6
"high lateral" leads I, avL
inferior leads II III avF

hope this helps.
Q

 

[Jeff698]

septal leads v1 v2
anterior leads v2 v3 v4
lateral leads v5 v6
"high lateral" leads I, avL
inferior leads II III avF

It really helps me to understand this by looking at where the positive electrode is on the patient's body. Think of the positive electrode as the lens of a camera (or your eye) pointed at the center of the heart. The part of the heart your camera (or you) are looking at is the area that lead 'looks' at.

V1 is 4th IC to the right of the sternum. V2 is the same IC but on the left of the sternum. Both are looking at the septum and, therefore, are considered septal leads.

Quinn's 'high' lateral is b/c the positive electrode in I and aVL is on the left arm. It looks 'down' at the lateral wall, thus 'high' lateral.

V5 and V6 have their positive electrodes on the lateral chest wall. They look 'up' at the lateral wall, thus 'low' lateral.

After you learn this, learn which coronary arteries supply these sections of myocardium and what else they supply. Pretty straightforward.

Inferior: RCA
Septal/Anterior: LAD
Lateral: LCx

Obviously there is some anatomic variation but these are decent rules of thumb.

Take care,
Jeff

 

[kungfufishing]

The Garcia book really is as good as advertised. I made the mistake of letting my buddy borrow it, but have since obtained the arrhythmia book and stopped seizing.

Your patients might prefer that you really are an ECG whiz, or at least capable.

In order to do a good job at "seeing the whole EKG" you should learn to systematically break it down into pieces.

Much of the length of Garcia's book is the result of one of its' greatest strengths, multiple ECG examples of each concept. Repetition with well detailed explanations of every practice ECG.

 

[BKN]

here here. yearsssssssssss ago on SDN someone recommended it (like when I was an MS2). Bought it and have been tooting its horn for years. It is a LONG book with LONG chapters, but, dude, once you read those chapters you're gonna be an EKG king (or queen).

But to answer the OPs initial question:

septal leads v1 v2
anterior leads v2 v3 v4
lateral leads v5 v6
"high lateral" leads I, avL
inferior leads II III avF

hope this helps.
Q

And the weird ones on a 18 lead ECG (3 posterior and 3 right sided leads):

1. Posterior v7 v8 v9 - or R wave and st depression in v1 and v2 (upside down and backwards from q wave and elevation since you are looking at it from the other side)

2. right ventricular infarct v4R

BTW OP - if you're an EP, you really do need to be at least a moderate ECG whiz, but you have plenty of time. However if you show up for your tryout rotations able to read one pretty well (MIs, ischemia, Bundle blocks, AV block and basic dysrhythmias), you'll be way ahead of your competition and will impress.

If you buy Garcia, it's long but color coded to be read 3 times, first at basic level then intemediate then advanced. Show up with basic mastered.

p.s. And when you're ready to tackle the mountain, try Chou.

 

[Dr. Will]

As a 4th year, Dubin has served me well. It has given me just enough of a foundation to really start analyzing EKG's. It is more than enough right now, as I do my audition rotations. It's gotten me some points with a few attendings. Bottom line, it's great for just the basics. Best of all, you could read it in a couple days, and come out with enough knowledge as student to impress.

Now that I'm feeling comfortable with just the "basics," I plan on getting Garcia to further expand that knowledge and continue practicing.

 

[12R34Y]

I cannot speak highly enough of Garcia. it makes Dubin look like a monkey smoking pot.

I LOVE GARCIA!!!!!!!!! It is the most high-yield book on EKG's I've ever seen. It has hundreds of practice 12-leads and it covers EVERYTHING.

It's been said on this board a billion times. Garcia is the best. You will be the master if you read that bad boy.

later

 

[mgak07]

Garcias book is great.

I actually had a lecture by him once during an EKG class. Great presentation with one of the best put together powerpoint slide lectures I have ever seen.

After reading this book and doing a bunch of EKGS in practice, you should be golden.

 

[margaritaboy]

I'm with you guys too.

I've read a couple EKG books, but Garcia's is by far the best. I think its scope and depth are appropriate for EM physicians. Quinn is right, by the time you get to the end of that book, you are the EKG Man (or Woman).

EKGs are one skill in medicine that I feel has to be learned through repitition and practice, perhaphs moreso than many other skills.

 

[mfleur]

are we talking about his Art of Interpretation or Arrhythmias book?

Thanks

 

[stoic]

wow, didn't expect to see this thread again.

i eventually ended up with both dubin and garcia (the art of interpretation). dubin was a good primer for garcia, but in the end there is no question: garcia is the best.

we'll see if i actually learned how to read EKG's shortly - starting MS3 in about 4 weeks...

 

[DrMom]

are we talking about his Art of Interpretation or Arrhythmias book?

Thanks

In general folks are talking about his art of interpretation book, although I also like his arrhythmias book. Art of interpretation covers 12 leads and arrhythmias covers rhythm strips, some difference in scope of topics, too.

 

[hyperbaric]

I cannot speak highly enough of Garcia. it makes Dubin look like a monkey smoking pot.
I LOVE GARCIA!!!!!!!!! It is the most high-yield book on EKG's I've ever seen. It has hundreds of practice 12-leads and it covers EVERYTHING.

It's been said on this board a billion times. Garcia is the best. You will be the master if you read that bad boy.

later

Hadn't heard about the pot smoking! The Dubin book is great, but (like others have said) I would not have bought it had I known about the pedophilia.

 

[Magda519]

so another thread got me thinking, something i don't really know how to do is look at an ecg and say "ahh, that abnormality is originating in the posterior septum."

i have no real desire to be a true ecg whiz, but i'd like to be able to generally figure the location out from the trace. seeing as how EM docs are practical people, i figure ya'll might have some quick ways of figuring out if something is anterior/posterior/septal/inferior/etc.

thanks in advance,
dave

I think that the posterior abnormalities usually result from occlusion of the left circumflex coronary artery or the occlusion of the RCA. An extensive EKG using V7,8,9 and right precordial leads are needed.

An easy way to detect an AMI for me was to check for ST elevation or ST depression on the reciprocals leads,

Lead I, AVL, V5 and V6---LATERAL ----Circumflex(LCX)or their branches:Obtuse Marginals arteries
Lead II, III and AVF---INFERIOR-----RCA or LCX
V1 and V2---SEPTAL---Left main- LAD/Diagonals
V3-V4-----ANTERiOR---Left main-LAD/Diagonals

For ischemia changes you have to check the same leads. I hope this helps.