# 15 lead ecg



## Hunter (Jan 11, 2014)

So I recentlt had the privilidge of attendnig a class by Bob page where we covered a ton of materials but one of the bigger things he discussed was that "every normal 12 lead EKG should get a 15 lead EKG consisting of v4R, v8 and v9." We were showed evidence of long term diagnosis that were made possible by crews running 12 and 15 leads on patients who some of us amy have brushed off as "BS" calls. About how monitoring a patient in Lead II is dangerous if not negligent and that a MCL1 or V1 have a much higher sensitivity to dectecting changes in a heart rhythm earlier than Lead II. Also discussed about using a 12 lead to differentiate between Wide complex Tachycardia and A-Fib with RVR, determining Hypo/hyperkalemia, and a ton of other information that I'm still trying to condense and process by reading through his book.
So my questions to you guys and glass are; how many on here routinely do 15 lead EKGs on patients who get a 12 lead? What do you concider to be a qualifier for a patient to need a 12 lead. Does anyone monitor in V1 or use a Modified Chest lead to monitor patients? How many people have never even heard of using a 15 lead? I know there was a few in the class that it was the first time hearing of it.


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## NomadicMedic (Jan 11, 2014)

I do v4r if I see an inferior STEMI. I do a posterior when indicated. Neither as a regular course of action.


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## chaz90 (Jan 11, 2014)

I'll do a right 15 or 18 lead if I'm really suspicious of something cardiac going on but can't immediately find it on a 12 lead or if I see an inferior wall MI. The last time I did a posterior EKG was on a guy who told me he last had a posterior wall MI with stent placement and this felt the same. I've heard a bit about not monitoring in lead II, but to be perfectly honest I don't typically monitor in other leads. My default monitor setting most of the time for monitoring is II, III, and EtCO2 or SpO2. I'll try to remember about monitoring other leads and think about switching it up.


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## DrankTheKoolaid (Jan 11, 2014)

Automatic on any patient I do a 12 lead on and it takes less then a minute


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## 46Young (Jan 11, 2014)

I've had Bob Page's presentation, and I've also had Tom Bouthillet's STEMI Equivalents and STEMI mimics presentation at the 2013 Virginia EMS Symposium. You can find the presentation at slideshare.net

http://www.slideshare.net/tbouthillet/stemi-equivalents-and-mimics

Doing a V4R is obvious if you have inferior changes. I do posterior leads when the patient is symptomatic with a clean 12 lead, and also for a patient with antero-septal depressions, particularly with a "pony-saddle" STD in V2, which is found on slide #41 of Tom's presentation.


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## VFlutter (Jan 11, 2014)

I was at a Bob Page lecture a few months ago. It was great. I also do V4R on inferior MIs but rarely do 15 leads. Most of our cardiologists don't really care much for them. I have never had one ask for a 15 lead.


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## Hunter (Jan 11, 2014)

DEmedic said:


> I do v4r if I see an inferior STEMI. I do a posterior when indicated. Neither as a regular course of action.



What indicates a 12 lead for you but not a posterior?






Chase said:


> I was at a Bob Page lecture a few months ago. It was great. I also do V4R on inferior MIs but rarely do 15 leads. Most of our cardiologists don't really care much for them. I have never had one ask for a 15 lead.



Part of the class when I attended was that while the information has been around for years it hasn't been implemented by everyone.


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## NomadicMedic (Jan 11, 2014)

Hunter said:


> What indicates a 12 lead for you but not a posterior?




Not every chest pain needs a posterior ECG, but every chest pain gets a 12 lead. Does that help?

More specifically, if I see ST depression in V1-V3, I'll get a posterior.


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## 18leadECG (Jan 11, 2014)

I am a fan of the 18 lead ECG, if you couldn't tell.


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## triemal04 (Jan 12, 2014)

So...while it is rare, patient's can have isolated right ventricular and posterior MI's...if you are doing a 12-lead because you are concerned about potential cardiac involvement, shouldn't a right-sided and posterior ekg ALWAYS be done to check for early ischemic changes?

Admittedly, I don't do this either, but technically, if you are looking for ischemia in the standard leads, you should probably be looking at all of them.


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## chaz90 (Jan 12, 2014)

triemal04 said:


> So...while it is rare, patient's can have isolated right ventricular and posterior MI's...if you are doing a 12-lead because you are concerned about potential cardiac involvement, shouldn't a right-sided and posterior ekg ALWAYS be done to check for early ischemic changes?
> 
> Admittedly, I don't do this either, but technically, if you are looking for ischemia in the standard leads, you should probably be looking at all of them.



While I admittedly don't know any numbers, I would imagine that the majority of this already small subset of patients experiencing isolated right sided or posterior wall infarcts would also have some characteristic changes in the 12 lead. If I see reciprocal changes absent any visible elevation, you can bet I'm going hunting for the origin. Anyone with more knowledge about this have any input?


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## triemal04 (Jan 12, 2014)

There are other changes that can be seen on an ekg other than ST-elevation, and that won't cause reciprocal changes, especially in early stages.

So the question remains:  if you have someone with typical cardiac chest pain and a normal 12-lead ekg, should you be doing a 15 or 18 lead ekg to check for problems with the right side and posterior?


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## fma08 (Jan 12, 2014)

Curious as to what the rationale is for not monitoring in lead II. I personally hadn't heard anything about how we shouldn't be doing that.


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## Hunter (Jan 12, 2014)

fma08 said:


> Curious as to what the rationale is for not monitoring in lead II. I personally hadn't heard anything about how we shouldn't be doing that.



Lead II isn't as sensitive, the short version is that lead II might show nsr when the person goes into vtach, develops a heart block or other dangerous rhythms.


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## chaz90 (Jan 13, 2014)

Hunter said:


> Lead II isn't as sensitive, the short version is that lead II might show nsr when the person goes into vtach, develops a heart block or other dangerous rhythms.



I can believe certain heart blocks, early ischemic changes or QRS widening might be harder to see in II, but I think most of us should be able to differentiate V Tach and a sinus rhythm at a normal rate regardless of what lead we're monitoring.


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## Hunter (Jan 13, 2014)

chaz90 said:


> I can believe certain heart blocks, early ischemic changes or QRS widening might be harder to see in II, but I think most of us should be able to differentiate V Tach and a sinus rhythm at a normal rate regardless of what lead we're monitoring.



I'll find the EKGs that were presented to us in the class. where Lead II showed a narrow rhythm and v1 shows a wide Rhythm. It's not about your ability to differentiate but about the EKG picking up the changes earlier


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## NomadicMedic (Jan 13, 2014)

You can configure an LP15 to monitor  up to 3 leads (or other monitor channels) of your choice, in real time. Our standard is II, III and CO2, but if you were worried about sporting VT, you could select any leads you wanted. Also, if you had the 12 leads cables on, the monitor will detect and print a strip when there is a rhythm change and the VT alarm should sound. 

Frankly, if I'm concerned about VT, I'm already a little more diligent in my patient monitoring, because I've already seen those frequent PVCs and couplets.


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## chaz90 (Jan 13, 2014)

Hunter said:


> I'll find the EKGs that were presented to us in the class. where Lead II showed a narrow rhythm and v1 shows a wide Rhythm. It's not about your ability to differentiate but about the EKG picking up the changes earlier



I agree there are times where some leads can show much narrower appearing complexes than they are in reality. I was just saying V Tach and a "normal sinus rhythm" are always going to look different enough that you should even notice it in lead II. I've certainly seen the bundle branch blocks and other variances with what look to be fairly narrow complexes in lead II.


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## TheLocalMedic (Jan 17, 2014)

V4R is a no-brainer if you have an inferior infarct, and ST depression in V1-V4 should warrant a look a posterior leads.  Honestly though, if someone is presenting with suspicious symptoms or anginal equivalents, I'm generally already en route to a cardiac receiving facility.  I can do these extra strips en route, but I wouldn't waste time screwing around at scene figuring out all the creative ways I can stick dots on my patient.  

It seems like people often forget about non-STEMIs and think, "oh well, the EKG is clean, so I don't need to go to a cardiac capable hospital".  I may not transport emergently, but anyone presenting with MI symptoms really ought to go somewhere where there's a cath lab.  

As far as not monitoring in lead II, I haven't seen any evidence that monitoring other leads provides you with more sensitive information.  If you know your cardiology and bear in mind that your EKG can evolve with time, monitoring lead II should be fine.  And it's not like a change won't be detected in lead II if it's happening in other leads...


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