12-Lead ECGs and Electrical Axis

Fast & Easy ECGs, 2nd E – A Self-

Paced Learning Program

Fast & Easy ECGs, 2E 1

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 Heart’s Electrical Activity
• Depolarization and repolarization of the atria
and ventricles are electrical events
• The ECG detects this electrical activity and
displays it on the oscilloscope or prints it

Fast & Easy ECGs, 2E 2

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 Planes of the Heart
• With the 12-lead ECG, electrodes are placed at
specific spots on the patient’s extremities
and/or torso and chest wall to view the heart’s
electrical activity from two distinct planes:
– frontal
– horizontal
• These planes provide a cross-sectional view of
the heart

Fast & Easy ECGs, 2E 3

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 Frontal Plane
• Leads I, II, III and aVR, aVL,
and aVF view the heart
along this plane
– Referred to as limb leads
• Four electrodes are
positioned either on the
extremities or on the
torso
– Can be placed far down on
limbs or close to hips and
shoulders, but they must
be even (right vs. left)

Fast & Easy ECGs, 2E 4

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 Limb Leads - Standard
• Leads I, II, and III form what
is known as Einthoven’s
triangle, which is an
electrically equilateral
triangle based on these
three limb leads’ positions
relative to one another
– leads intersect at angles
of 60 degrees

Fast & Easy ECGs, 2E 5

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 Limb Leads - Lead I
• Positive electrode - left
arm (or left side of chest
below the clavicle in the
midclavicular line)
• Negative electrode - right
arm (or right side of chest
below the clavicle in the
midclavicular line)
• Ground electrodes
– left leg (or left side of
chest in midclavicular
line just beneath last
rib)
– Right leg (or right side
of chest in
midclavicular line just
beneath last rib
• Waveforms are positive

Fast & Easy ECGs, 2E 6

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 Limb Leads - Lead II
• Positive electrode - left leg
(or on left side of chest in
midclavicular line just
beneath last rib)
• Negative electrode - right
arm (or right side of chest
below the right clavicle in
the midclavicular line)
• Ground electrode
– Left arm (or left side of
chest in midclavicular line
just below the left clavicle)
– Right leg (or right side of
chest in midclavicular line
just beneath last rib)
• Waveforms are positive

Fast & Easy ECGs, 2E 7

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 Limb Leads - Lead III
• Positive electrode - left leg
(or left side of the chest in
midclavicular line just
beneath last rib)
• Negative electrode - left arm
(or left side of chest below
the clavicle in the
midclavicular line)
• Ground electrode
– Right arm (or right side
of chest in midclavicular
line just below the
clavicle)
– Right leg (or right side of
chest in midclavicular
line just beneath last rib)
• Waveforms are positive or
biphasic

Fast & Easy ECGs, 2E 8

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 Limb Leads - Augmented Leads
• Includes aVR, aVL and aVF
• Are unipolar
• Enhanced by ECG machine because
waveforms produced by these leads are
normally small

Fast & Easy ECGs, 2E 9

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 Limb Leads - Lead aVR
• Positive
electrode
placed on the
right arm (or
right side of
chest below
the clavicle in
the
midclavicular
line)
• Waveforms
have negative
deflection

Fast & Easy ECGs, 2E 10

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 Limb Leads - Lead aVL
• Positive
electrode
placed on left
arm (or left
side of chest
below the
clavicle in the
midclavicular
line)
• Waveforms
have positive
deflection

Fast & Easy ECGs, 2E 11

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 Limb Leads - Lead aVF
• Positive
electrode
located on left
leg (or left
side of chest
below the last
rib in the
midclavicular
line)
• Waveforms
have a
positive
deflection

Fast & Easy ECGs, 2E 12

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 Precordial Leads
• Includes leads V1, V2,
V3, V4, V5 and V6
• Positioned in order
across the chest
• Unipolar
– Opposing pole is
center of heart as
calculated by ECG
I

Fast & Easy ECGs, 2E 13

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 Lead V1
• Electrode
positioned
in fourth
intercostal
space just to
the right of
the sternum
• Faces and is
close to the
right
ventricle
• Also has a
view of
ventricular
septum

Fast & Easy ECGs, 2E 14

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 Lead V1
• Steps for
positioning the
V1 electrode

Fast & Easy ECGs, 2E 15

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 Lead V2
• Positioned in 4th
intercostal space just
to the left of the
sternum
• Horizontally, it is at the
same level as lead V1
but on the opposite
side the sternum
• Just like lead V1, V2
faces and is close to
the right ventricle
• Although it has a view
of the right ventricle
and anterior wall of
the heart, it is more
recognized for its view
of the ventricular
septum

Fast & Easy ECGs, 2E 16

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 Lead V2
• Steps for positioning the V2 electrode

Fast & Easy ECGs, 2E 17

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 Lead V3
• Located midway
between leads
V2 and V4
• Views anterior
wall of the left
ventricle
• Depolarization
of the left
ventricle moves
perpendicular to
the positive
electrode,
resulting in a
biphasic
waveform
I

Fast & Easy ECGs, 2E 18

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 Lead V4
• Is placed at the
5th intercostal
space n the
midclavicular line
• Views the anterior
wall of left
ventricle
and is close to the
heart’s apex
• Depolarization of
the left ventricle
moves
perpendicular to
the positive
electrode
resulting in a
biphasic
waveform I

Fast & Easy ECGs, 2E 19

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 Lead V4
• Steps for
positioning
the V4
electrode

Fast & Easy ECGs, 2E 20

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 Lead V5
• Placed in 5th
intercostal space at
the anterior axillary
line
• Horizontally, it is even
with V4 but in the
anterior axillary line
• Views lateral wall of
the left ventricle
• Depolarization of left
ventricle moves
toward the positive
electrode, producing
a tall R wave
I

Fast & Easy ECGs, 2E 21

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 Lead V5
• Steps for positioning
the V5 electrode

Fast & Easy ECGs, 2E 22

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 Lead V6
• Located
horizontally level
with V4 and V5 at
the midaxillary
line
• Views lateral wall
of left ventricle
• Depolarization of
left ventricle
moves toward
the positive
electrode
producing a tall R
wave I

Fast & Easy ECGs, 2E 23

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 Lead V6
• Steps for positioning
the V6 electrode

Fast & Easy ECGs, 2E 24

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 12 Lead ECG Waveforms
• Each view provides
different information
• When assessing the 12
lead ECG look for
characteristic normalcy
and changes in all leads

Fast & Easy ECGs, 2E 25

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 Contiguous Leads
• Two leads that look at
neighboring anatomical
areas of the heart are
said to be contiguous

Fast & Easy ECGs, 2E 26

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 Right Ventricular Leads
• View the right
ventricle
• Are in addition to
the 12 lead ECG
and require
relocating the
precordial ECG
electrodes

Fast & Easy ECGs, 2E 27

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 Posterior Leads
• View the posterior
surface of the heart
• Are in addition to the
12 lead ECG and require
relocating the
precordial electrodes

Fast & Easy ECGs, 2E 28

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Conditions Identified by 12-Lead ECG

Fast & Easy ECGs, 2E 29

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Conditions Identified by 12-Lead ECG

Fast & Easy ECGs, 2E 30

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Conditions Identified by 12-Lead ECG

Fast & Easy ECGs, 2E 31

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 Electrical Axis
• The 12-lead ECG can measure the axis of the
electrical flow of energy during the cardiac
cycle

Fast & Easy ECGs, 2E 32

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 Instantaneous Vectors
• Cardiac cell
depolarization and
repolarization produces
many small electrical
currents
– Sum of these currents
called instantaneous
vectors
– Average of
instantaneous vectors
called the mean vector
I

Fast & Easy ECGs, 2E 33

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 Mean Electrical Axis
• Direction of the
mean vector called
the mean electrical
axis
• Axis is defined in the
frontal plane only

Fast & Easy ECGs, 2E 34

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 ECG Deflection
• Wave of
depolarization
and its affect
on the ECG

Fast & Easy ECGs, 2E 35

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 QRS Axis
• Most important and
frequently
determined axis

Fast & Easy ECGs, 2E 36

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 Ventricular Depolarization and Mean
QRS Axis
• Interventricular septum depolarization
represents the first cardiac vector associated
with ventricular depolarization
• A sequence of vectors is produced as the
Purkinje fibers carry the impulse from the
endocardial lining of the RV and LV through
the ventricular wall toward the epicardium

Fast & Easy ECGs, 2E 37

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 Ventricular Depolarization and Mean
QRS Axis
• Completion of right
ventricular activation
occurs first
• The thinner wall of
the RV transmits
impulse quicker than
the thicker wall of LV

Fast & Easy ECGs, 2E 38

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 Mean QRS Axis
• The small
depolarization
vectors of the thicker
LV are larger
• Therefore, the mean
QRS axis points more
to the left

Fast & Easy ECGs, 2E 39

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 Position of Mean QRS Axis
• Limb leads provide information about the
frontal plane and are used to determine the
position of the mean QRS axis
• Described in degrees within an imaginary
circle drawn over the patient’s chest

Fast & Easy ECGs, 2E 40

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 Position of Mean QRS Axis
• AV node is center of
circle
• Intersection of all lines
divides circle into
equal, 30-degree
segments
• Lead I starts at +0
degrees and is located
at the three o’clock
position
• Lead aVF starts at +90
degrees and is located
at the six o’clock
position
Fast & Easy ECGs, 2E 41
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 Position of Mean QRS Axis
• Mean QRS axis
normally points
downward and
to patient’s left
(between 0 and
+90 degrees)

Fast & Easy ECGs, 2E 42

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 Determining Electrical Axis
• Use leads I and aVF
– These two leads can best detect variations in the
heart’s electrical axis

Fast & Easy ECGs, 2E 43

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 Determining Electrical Axis
• If the mean
QRS vector
directed
anywhere
between -
90º and
+90º,
positive QRS
complex in
lead I I

Fast & Easy ECGs, 2E 44

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 Determining Electrical Axis
• If mean QRS
vector directed
between 0º and
+180º, positive
QRS complex in
lead aVF

Fast & Easy ECGs, 2E 45

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 Right Axis Deviation
• An axis
between +90
and
±180 degrees
indicates right
axis deviation

Fast & Easy ECGs, 2E 46

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 Left Axis Deviation
• An axis between 0 and
−90 degrees indicates
left axis deviation

Fast & Easy ECGs, 2E 47

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 Determining Electrical Axis
• The
deflection of
the QRS
complexes in
leads I and
aVF help
identify
electrical
axis I

Fast & Easy ECGs, 2E 48

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 Determining Electrical Axis
• Location of axis
influenced by:
– Heart’s position in the
chest
– Heart size
– Patient’s body size
– Conduction pathways
– Force of electrical
impulses being
generated

Fast & Easy ECGs, 2E 49

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 Practice Makes Perfect
• Determine
if the
mean QRS
is normal
or if there
is axis
deviation

Fast & Easy ECGs, 2E 50

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 Practice Makes Perfect
• Determine
if the mean
QRS is
normal or
if there is
axis
deviation

Fast & Easy ECGs, 2E 51

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 Practice Makes Perfect
• Determine
if the mean
QRS is
normal or
if there is
axis
deviation

Fast & Easy ECGs, 2E 52

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 Practice Makes Perfect
• Determine
if the mean
QRS is
normal or if
there is axis
deviation

53
Fast & Easy ECGs, 2E
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 Summary
• Because the electrodes positioned on the
patient’s skin detect the heart’s electrical activity,
placing them in a different location changes the
lead or view.
• The shape of the waveform is described from the
perspective of the positive electrode of the
selected lead.
• Bipolar leads include leads I, II, and III.
• Unipolar leads include leads aVR, aVL , and aVF
and the precordial leads V1, V2, V3, V4, V5, and V6.

Fast & Easy ECGs, 2E 54

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 Summary
• Limb leads are produced by placing electrodes on the
right arm (RA), left arm (LA), left leg (LL), and right leg
(RL).
• The limb leads include leads I, II, and III; augmented
voltage right (aVR); augmented voltage left (aVL); and
augmented voltage foot (aVF).
– They provide a view of the electrical activity along the
heart’s frontal plane.
• The precordial leads include leads V1, V2, V3, V4, V5, and
V6.
– They provide information about the electrical activity
along the horizontal plane of the heart.

Fast & Easy ECGs, 2E 55

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 Summary
• The mean or average of all the instantaneous
vectors which the ECG detects is called the mean
vector.
• The direction of the mean vector is called the
mean electrical axis.
• When the electrical current traveling through the
heart is moving toward a positive ECG electrode
on a person’s chest or extremity the ECG machine
records it as a positive or upright waveform.

Fast & Easy ECGs, 2E 56

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 Summary
• The mean of all vectors that result from ventricular
depolarization is called the QRS axis.
• Completion of right ventricle activation occurs first as
the thinner wall of the right ventricle transmits the
impulse in a fraction of the time it takes the impulse
to travel through the thick lateral wall of the left
ventricle.
• Sum of all the small vectors of ventricular
depolarization is called the mean QRS vector.

Fast & Easy ECGs, 2E 57

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 Summary
• Because the small depolarization vectors of the
thicker left ventricle are larger, the mean QRS axis
points more to the left.
• The limb leads are used to determine the position
(axis) of the mean QRS vector which is described
in degrees within an imaginary circle drawn over
the patient’s chest.
• Lead I starts at +0 degrees and is located at the
three o’clock position.
• Lead aVF starts at +90 degrees and is located at
the six o’clock position.

Fast & Easy ECGs, 2E 58

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 Summary
• The mean QRS axis normally points downward
and to the patient’s left, between 0 and +90
degrees.
• An axis between +90 and +180 degrees indicates
right axis deviation, and one between 0 and -90
degrees indicates left axis deviation.
• An axis deviation between -180 and -90 degrees
indicates extreme axis deviation and is called an
indeterminate axis.

Fast & Easy ECGs, 2E 59

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 Summary
• Leads I and aVF can be used to quickly
determine whether the mean QRS axis on any
ECG is normal.
• If the QRS complex is positive in leads I and
aVF, the QRS axis must be normal.

Fast & Easy ECGs, 2E 60

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 Summary
• If the QRS complex is upright in lead I and
negative in lead aVF then left axis deviation
exists.
• If the QRS complex is negative in lead I and
positive in lead aVF then right axis deviation
exists.
• If the QRS complex is negative in both leads
extreme right axis deviation exists.

Fast & Easy ECGs, 2E 61

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 Summary
• Electrodes placed on patient’s skin detect
heart’s electrical activity.
• Graphic record or tracing is called an
electrocardiogram.
• Abnormalities in cardiac rate and/or rhythm
are called dysrhythmias.

Fast & Easy ECGs, 2E 62

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 Summary
• ECG paper consists of horizontal and vertical
lines that form a grid.
• Horizontal measurements used to determine
heart rate and duration of various waveforms,
segments and intervals.
• Vertically on ECG paper, distance between
lines, or boxes, represents amplitude in
millimeters (mm) or electrical voltage in
millivolts (mV).

Fast & Easy ECGs, 2E 63

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 Summary
• Conduction of electrical impulse through the
heart can be seen on ECG as P wave, PR
interval, QRS complex, ST segment and T
wave.
• Artifact is markings on ECG tracing that have
no relationship to electrical activity of the
heart.

Fast & Easy ECGs, 2E 64

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 Summary
• Each lead provides a different view of heart.
• Impulses traveling toward a positive electrode
are recorded on ECG as upward deflections.
• Impulses traveling away from a positive
electrode or toward a negative electrode are
recorded as downward deflections.

Fast & Easy ECGs, 2E 65

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 Summary
• Limb leads are produced by placing electrodes
on right arm (RA), left arm (LA) and left leg
(LL).
– Include leads I, II, III, augmented vector right
(aVR), augmented vector left (aVL) and
augmented vector foot (aVF).
• Precordial leads include leads V1, V2, V3, V4,
V5, and V6.

Fast & Easy ECGs, 2E 66

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