# Reverse 12-lead



## jedirye (May 1, 2009)

Hello all,
I've got a couple of questions regarding the reverse 12-lead. I understand the implications, however, I am a bit unfamiliar with exactly how it is executed. A recent article I read (located here) states to move v5 and v6 to lead placement v3r and v4r.

 "_The right ventricle can be rapidly and effectively evaluated by moving leads V5 and V6 from the conventional 12-lead placement to the positions of V3R and V4R respectively. These two unique positions are mirror images of the placement of V3 and V4 on the standard 12-lead EKG (Figure 4). V3R and V4R are considered contiguous leads, and if the standard criteria are met for STEMI, then the patient is considered to have either an isolated right ventricular STEMI or an associated right ventricular STEMI, depending on the other 12-lead findings. These patients should not be administered nitroglycerin and are at increased risk of cardiogenic shock if preload is reduced._"

To be perfectly honest with you, before this article, I was familiar with just moving lead V4 to lead V4r. In researching this more, I have actually read several other lead placements. I am curious which everyone uses, their effectiveness, and also any interesting findings when this was performed (curious as to the sporadicity).

Thanks for your time!

-rye


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## HotelCo (May 1, 2009)

The only thing I've ever done past a 12 lead is a 15 lead. Reverse 12 lead sounds interesting though.


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## 8jimi8 (May 1, 2009)

its diagnostic for right sided

and the main reason that moNa does NOT greet everyone at the door.


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## marineman (May 2, 2009)

We talked about this and were taught in class the reasoning and such but someone like Rid or TomB will be much better suited for this


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## jedirye (May 2, 2009)

marineman said:


> We talked about this and were taught in class the reasoning and such but someone like Rid or TomB will be much better suited for this



I am familiar with the diagnostic significance, however how a reverse 12-lead is executed is what I was questioning as I have read several different methods.


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## reaper (May 2, 2009)

If you are doing a full reverse 12 lead, then just reverse it! Put the 12 lead on the right side, just like you would on the left.

Always make sure you mark the 12 lead as a reverse!


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## vquintessence (May 2, 2009)

jedirye said:


> Hello all,
> I've got a couple of questions regarding the reverse 12-lead. I understand the implications, however, I am a bit unfamiliar with exactly how it is executed. A recent article I read (located here) states to move v5 and v6 to lead placement v3r and v4r.



Looked over the article, and your confusions seems to be because the article was poorly worded, or edited.  Where you place the R sided leads is the same; 3VR, 4vR, 5vR, 6vR... like reaper said the important thing is marking the EKG strip be it right sided or posterior!

_Someone point me in the right direction if I'm misled_, but there is no difference (in the numerical sense) of which electrode you hook up when placing leads, it would just be a pain in the auss to have a non-standard EKG... so why deviate 

Back to point, 4vR like you learned, is the make or break with some degree of certainty, whether or not there is RV involvement.  I personally do the full R sided EKG, but *CANNOT* defend whether or not the views provided by 3vR, 5vR, 6vR give any benefit to you or a receiving cardiologist.  (Have found no info one way or the other in texts).  Focus more on the reciprocal signs as well, and what extent of the RCA or LCx is occluded depending on EKG findings! (ex:  lead I & aVL depression; ex2: inferior AMI with anterior depression indicative of proximal LCx occlusion)  "Time is muscle" doesn't mean diesel bolus... it means giving the receiving facility the faith towards your field diagnostics and potentially reducing door to balloon time.

Check out:  It isn't directly related but points (in an undetermined way) to posterior importance.
http://circ.ahajournals.org/cgi/content/meeting_abstract/118/18_MeetingAbstracts/S_578-c


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## TomB (May 5, 2009)

For acute inferior STEMI where STE in lead III is > STE in lead II and there is a downsloping ST segment in lead aVL (reciprocal change) you can isolate the culprit artery to the RCA which should increase your suspicion of RV involvement. You can throw in a right sided ECG for fun, but at this point in the game the physical exam is more relevant. Is the patient bradycardic with a borderline BP? Suspect RV involvement and treat accordingly! In other words, start an IV and give a preemptive fluid bolus (at least 500 ml) before the first NTG.


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## Dominion (May 6, 2009)

TomB said:


> For acute inferior STEMI where STE in lead III is > STE in lead II and there is a downsloping ST segment in lead aVL (reciprocal change) you can isolate the culprit artery to the RCA which should increase your suspicion of RV involvement. You can throw in a right sided ECG for fun, but at this point in the game the physical exam is more relevant. Is the patient bradycardic with a borderline BP? Suspect RV involvement and treat accordingly! In other words, start an IV and give a preemptive fluid bolus (at least 500 ml) before the first NTG.




Take this for what it's worth as I'm still in classes but we were taught the following as well.  Give preemptive bolus of 500cc before first NTG.  This is something that is a bit debated in our system, some med control will tell you not to give NTG while the medical director for our class and the director for the Level 1 Trauma center says fluid bolus before first NTG.  In the above case.


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## reaper (May 7, 2009)

If you have an acute Inferior STEMI, with RVI. 500cc bolus is just a drop in the bucket. These are Pt's that will end up needing Liters of fluid. Yes, NTG can be given, but you must be very careful. This is a huge balancing act and needs to be monitored closely. I have seen theses Pt's get 8-10 liters of NS in the first 24 hours, just to stabilize them for the cath lab.

Most of these Pt's will have BP's in the toilet, to start with. So NTG is not much of an option with them.

If this is something that you are wanting to learn more about, I would suggest observation in the cath lab. Some hospitals do allow this and it is a great learning experience.


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## TomB (May 8, 2009)

reaper said:


> If you have an acute Inferior STEMI, with RVI. 500cc bolus is just a drop in the bucket. These are Pt's that will end up needing Liters of fluid. Yes, NTG can be given, but you must be very careful. This is a huge balancing act and needs to be monitored closely. I have seen theses Pt's get 8-10 liters of NS in the first 24 hours, just to stabilize them for the cath lab.
> 
> Most of these Pt's will have BP's in the toilet, to start with. So NTG is not much of an option with them.
> 
> If this is something that you are wanting to learn more about, I would suggest observation in the cath lab. Some hospitals do allow this and it is a great learning experience.



I certainly hope these patients aren't waiting 24 hours to get cathed! You have to use common sense. I start with 500 ml of 0.9% NS. If it increases the pressure from 105/55 to 128/60, then I'll consider a trial dose of NTG. If it drops the pressure too much, I'll continue with the fluid loading and hold off on NTG. Consider that sometimes, the STEMI is secondary to coronary vasospasm which NTG can reverse. It boils down to clinical judgment and experience. Not all patients with RV involvement will develop the hypotensive syndrome, and some patients without RV involvement will bottom out with NTG.

Tom


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## mycrofft (May 8, 2009)

*One word:*

Dextrocardia.


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## reaper (May 8, 2009)

TomB said:


> I certainly hope these patients aren't waiting 24 hours to get cathed! You have to use common sense. I start with 500 ml of 0.9% NS. If it increases the pressure from 105/55 to 128/60, then I'll consider a trial dose of NTG. If it drops the pressure too much, I'll continue with the fluid loading and hold off on NTG. Consider that sometimes, the STEMI is secondary to coronary vasospasm which NTG can reverse. It boils down to clinical judgment and experience. Not all patients with RV involvement will develop the hypotensive syndrome, and some patients without RV involvement will bottom out with NTG.
> 
> Tom



Yes, some of them are waiting to be cathed. They have to wait until they are stable enough to survive the procedure.


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## TomB (May 8, 2009)

That's a Catch-22, isn't it?


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## omak42 (May 8, 2009)

Guess it depends on how risky your cardiologist in the Cath Lab are.....Ive seen patients go straight from ROSC to the cath lab.....I would say you cant get anymore unstable than that.  I was there for the procedure and the guy went into VT/VF about 25 different times but eventually made it out of the procedure alive....


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