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2.5
ANCC
CONTACT HOURS

12-lead ECGs

PART I: RECOGNIZING NORMAL FINDINGS

By Guy Goldich, MSN, RN, CCRN

EARLIER TODAY, Mr. S, 67, was admitted to receive I.V. antibiotics to treat
a significant case of lower extremity cellulitis secondary to a cut he sustained
fishing. Responding to the call bell, his nurse finds him sitting up in bed and
complaining of chest discomfort. The nurse takes his vital signs and performs
a pain assessment, which includes documenting the onset, location, quality,
intensity, duration, and any radiation of the discomfort. The nurse asks about
associated signs and symptoms and factors that aggravate or relieve the pain.
Following facility protocol, the nurse administers supplemental oxygen at
4 L/minute via nasal cannula and pages the physician on call, who orders stat
serum cardiac biomarkers, a 12-lead ECG, and sublingual nitroglycerin.
A nurse who can independently interpret a 12-lead ECG can anticipate
and prepare for any emergency care the patient may need. This article explains the basics of 12-lead ECG interpretation, focusing on a normal ECG.
Next month, the second part of this article will discuss ECG abnormalities.

C AROL AND M IKE WERNER /P HOTOTAKE

Whats happening in the heart

The hearts internal conduction system initiates each heartbeat and coordinates all parts of the heart to contract at the proper time. A normal heartbeat
is initiated in the sinoatrial (SA) node, a specialized group of cells in the right
atrium. (See Taking anatomy to heart.) The SA node depolarizes at a rate of 60
to 100 times/minute, causing the atria to contract and propel blood into the
ventricles.
Atrial depolarization produces the first element on the ECG waveform:
the P wave. The first part of the cardiac cycle, the P wave appears as a small,
semicircular bump (see Tracing a normal ECG waveform).
The wave of depolarization continues through the atria until it encounters
the next important structure, the atrioventricular (AV) node, which receives
the atrial impulse. After a brief pause to let the ventricles fill, the AV node
transmits the impulse to the ventricles via the bundle of His. A collection of
cardiac conduction fibers, the bundle of His splits into the right and left
bundle branches.

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The bundle branches are highspeed conducting fibers that run

down the intraventricular septum
and transmit the cardiac impulse
to the Purkinje fibers, which form a
complex network that mingles with
ventricular myocardial cells. The
function of the Purkinje fibers is to
rapidly stimulate ventricular muscle
fibers, resulting in the next major
event in the cardiac cycle: ventricular
depolarization.
Ventricular depolarization generates the QRS complex, the electrical
equivalent of ventricular systole.
(Remember that electrical activity
precedes mechanical activity, and the
ECG shows only electrical activity.) If
you palpate a carotid or radial pulse
while looking at a cardiac monitor,
you should feel a pulse with each
QRS complex on the monitor.
The QRS complex normally has
a duration of 0.06 to 0.1 second.
A duration of 0.12 second or more
usually indicates prolonged ventricular conduction caused by a bundlebranch block. The QRS complex
is variable in appearance and may
have a different shape (morphology)
in different patients or even look

Taking anatomy to
SA node

different in various
Tracing a normal ECG waveform
ECG leads in the
same patient. The
QRS complex may
QRS complex
have one, two, or
T wave
PR
three wave compoP wave
segment
nents, depending
on the lead and
your patients clinical status.
PR interval
QRS
ST
The last major
interval segment
wave component
of the ECG is the
QT interval
T wave, which is
larger than the
P wave and rounded or slightly
The PR interval is the period from
peaked. Immediately following the
the beginning of the P wave to the
QRS complex, it represents venbeginning of the QRS complex. It
tricular repolarization or a metabolic consists of the P wave plus the short
rest period between heartbeats. Deisoelectric segment that terminates
polarization and repolarization are
at the start of the QRS complex.
caused by the movement of cations,
The normal PR interval lasts 0.12
including sodium, potassium, and
to 0.2 second; this represents the
calcium, across the myocardial cell
time from SA node depolarization to
membrane.
ventricular depolarization. If the PR
Besides the three waveforms, the
interval is less than 0.12 second, then
normal ECG cardiac cycle tracing has the cardiac impulse didnt follow the
two important segments, or flat (isonormal conduction pathway. If the
electric) parts of the tracing between
PR interval is longer than 0.2 second,
the waveforms: the PR interval and
then a disease process may be affectthe ST segment.
ing the cardiac conduction pathway,
keeping it from functioning properly.
The ST segment consists of the
heart
isoelectric line between the end of
the QRS complex and the beginBundle of
AV
ning of the T wave. The ST segment
Left
His
node
reveals information about the hearts
posterior
oxygenation status. For example,
fascicle
myocardial ischemia (a temporary,
reversible decrease in oxygenation)
Left
often results in an ST segment beanterior
low the baseline of the ECG tracing.
fascicle
When myocardial cells are injured
(reversible physical damage from
lack of oxygen), the ST segment
often is elevated above the baseline.
Purkinje
So ST-segment elevation is a key
fibers
indicator of myocardial infarction.
For tips on how to use the ECG to
calculate heart rates and more, see
Paper training.

Right bundle
branch
Left bundle
branch

Catching the wave

Examination of a 12-lead ECG
reveals that some QRS complexes

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have upward (positive) deflections

and others have downward (negative) deflections. Heres why.
Each ECG lead has a positive (or
sensing) electrode and a negative
electrode, which acts as an anchor. The positive electrode looks
toward its negative electrode and
senses whether electrical energy
is being directed toward or away
from the positive electrode.
When electrical energy is directed
toward the positive monitoring
electrode, the QRS complex has
an upward deflection. When the
electrical energy is directed away
from the positive monitoring
electrode, the QRS complex has a
downward deflection. The more
directly aligned the direction of the
electrical energy with the positive
electrode, the more upright the
complex. If the electrical energy
approaches the positive monitoring electrode at a slight angle, the
complex will still be upright, but
less upright than if the energy were
directly aligned with the positive
electrode.
Energy arriving at a perpendicular angle to the positive electrode
results in either a waveform with
little deflection (isoelectric) or equal
amounts of positive and negative
deflection.
As energy is directed away from
the positive electrode, the QRS
complex becomes progressively
more negative. When energy flow is
directed totally away from the positive electrode, the QRS complex is
deflected directly downward.
Going with the flow:
A look at vectors
All cardiac cells are electrochemical, meaning they generate electrical
energy during depolarization. This
electrical energy, called a vector, has
strength (measured in millivolts)
and direction (measured in degrees
from an arbitrary zero point called
the electrical axis). Each cardiac
cell generates its own microvector.
The mathematical average of these
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Paper training
Use the markings on ECG paper to
calculate events within the cardiac
cycle. The ECG paper is a grid of large
and small blocks. On the horizontal
axis, a large block is equal to 0.2
second and a small block is equal to
0.04 second. The vertical axis represents voltage or electrical energy, with
each vertical millimeter (small block)
being 0.1 millivolt of electrical energy.
However, in practice, deflections are
typically described in millimeters, not
millivolts.
Count the number of small squares
and multiply by 0.04 to calculate the
duration of any event in the ECG tracing. A QRS complex thats 2.5 small
squares wide is 0.1 second. The ECG
paper can also be used to calculate
heart rates, using one of two methods. In the 6-second method, look

vertical
axis
(millivolts)

for the markings (usually short vertical

lines) at the top of the rhythm strip
or ECG paper. These markings divide
the ECG paper into 3-second intervals.
Count the number of QRS complexes
contained in two intervals (6 seconds)
and multiply by 10. This method
works for both regular and irregular
heart rhythms.
In the division method, count the
number of small squares between any
two heartbeats. Use the same part
in both QRS complexesusually the
peak of the complex works best. Dividing 1,500 by the number of small
squares gives the heart rate in beats
per minute. This method is accurate
only with regular heart rates because
irregular heart rhythms have a varying
number of small squares between
any two QRS complexes.

amplitude
of 1 mV
amplitude of
0.5 mV

0.2 seconds

0.2 seconds
1 second
horizontal axis (seconds)

microvectors is the mean QRS vector

or mean vector, which follows the
normal conduction pathway of the
heartdownward and to the left.
The mean vector flows slightly to
the left of the ventricular septum because the left ventricle has more and
larger cardiac cells.
Generally, each person has a
unique mean vector direction, which
remains constant unless his cardiac
status changes. For example, left
ventricular hypertrophy secondary
to heart failure pulls the mean vector
even more sharply to the left side.1 A
patient who has a mean vector in an
abnormal direction is said to have an
axis deviation. (For details, see Axis
deviation: As easy as pie [charts].)
The mean vector is a representation of the hearts overall electrical
properties. A 12-lead ECG is the
electrical record of the mean vector
from 12 different monitoring sites

(leads) on the surface of the body.

As when you look at any object, you
need to see all the angles to get a
complete picture.
Looking at limb leads
The first six leads of the 12-lead
ECG come from four electrodes
placed on the patients arms and
legs; the right lower leg electrode is
the ground electrode. The limb leads
record the mean vector in the updown and left-right direction along
the bodys frontal plane. Because
they use separate positive and negative electrodes, theyre called bipolar
or standard leads.
Lead I puts the positive electrode
on the left arm and looks toward
Lead I

August l Nursing2014 l 31

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the negative electrode on the right

arm for electrical energy. Because
the mean vector travels from upper
right to lower left, energy flows toward the positive electrode of lead I,
resulting in an upward deflection
of the QRS. And because the mean
vector doesnt flow directly toward lead I but approaches it at a
somewhat broad angle, the upward
deflection of the QRS complex is
moderate.
In lead II, the positive electrode
is on the left foot and the negative
electrode is on the right arm. Because
the mean vector flows directly at the
positive lead II electrode, this lead
usually has the most upright QRS
Lead II

complexes and the most prominent

P waves of the entire 12-lead ECG.
Thats why lead II is a favorite
monitoring lead in many intensive
care and telemetry units.
Lead III puts the positive electrode
on the left foot and the negative one
on the left arm. The mean vector
flow approaches lead III downward
from the right, again producing an
upward QRS deflection. Because
the angle is narrower than the angle
between the mean vector and lead I,
the lead III QRS complex is more upright than the lead I QRS complex.
The second set of limb leads are
called the augmented or unipolar
leads and use a single positive
Lead III

monitoring electrode. The negative

electrode is an electrically calculated location at the center of the
heart.2
Lead aVR is the only limb lead
on the right side of the body. Its
positive monitoring electrode is
located on the right arm and looks
downward and to the left. The mean
Lead aVR

vector also flows downward and

to the left, directly away from lead
aVR, resulting in a negative deflection for all waveforms. In a normal
ECG, aVR is the only limb lead with
a downwardly deflected QRS.
Lead aVL positions a positive electrode on the left arm and looks to the

Axis deviation: As easy as pie (charts)

Combining assessment skills with an understanding of axis deviation can give nurses a more detailed picture of a patients
condition. The hexaxial reference system and the quadrant method can help you visualize problems with cardiac conduction.
Hexaxial reference system
The normal QRS complex (or vector) represents the average electrical signal that the heart generates during depolarization. Within
the heart, the mean vector generally flows from upper right to lower left. The exact direction of that flow (called the electrical axis)
can be used as an assessment tool in the 12-lead ECG because
90
an abnormal axis can give clues about whats going wrong in the
60
120
hearts electrical system.
To measure the electrical axis, imagine all six limb leads displayed simultaneously around a central point in a circle, which
30
150 aVR
aVL
represents the heart (see the illustration at left). In this hexaxial system, the leads divide the circle into equal 30-degree
segments.
Each lead can be assigned a number of degrees, and the mean
O
180
I
vectors direction can be given in degrees. If the mean vector is
aligned directly with lead I, its axis is 0 degrees. A mean vector
directed halfway between leads II and aVF has an axis of 75 degrees.
(Although a patients electrical axis can be manually calculated,
+ 30
+ 150
all modern 12-lead ECG machines provide this information autoII
matically.)
III
aVF
The normal electrical axis of the heart falls between 0 and +90
+
60
+ 120
degrees. Although this is a wide range, its a numeric equivalent
+ 90 Normal range
of the concept that the electrical conduction of the normal heart
is right to left and top to bottom.
A left axis deviation occurs when the electrical axis of the heart is between 0 and 90 degrees. A right axis deviation
occurs when the electrical axis is in the +90 to +180 degree range. A mean vector having an electrical axis within the range
of 90 to 180 degrees is called an indeterminate axis or extreme right axis deviation.

32 l Nursing2014 l August

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Lead aVL

right and downward toward the center of the heart (in contrast to lead
I, which looks strictly to the right).
The mean vector approaches aVL at a
very broad angle, producing the least
upright QRS complex among the
limb leads.
Lead aVF has its positive monitoring lead on the left leg and looks
straight up to the center of the
chest. The mean vector approaches
aVF at a fairly direct angle, although
not as directly as lead II, so lead
Lead aVF

aVF has very upright QRS complexes with prominent P waves. Leads
II, III, and aVF all look upward
at the oncoming mean vector, so
their waveforms share many qualities, such as highly positive QRS
complexes and prominent P waves.
Because these leads look upward at
the bottom or inferior ventricular
wall of the heart, theyre known as
the inferior leads.
Six chest leads weigh in
The six chest or precordial leads
lie across the anterior chest and
measure the mean vector in the
horizontal plane.
Lead V1 is located at the right sternal border, fourth intercostal space,
and lies above the right ventricle and
septum.
Lead V2 is at the left side of the
sternum, fourth intercostal space.

Lead V3 is midway between leads

V2 and V4.
Lead V4 is at the midclavicular line
in the fifth intercostal space.
Lead V 5 is at the anterior
axillary line in the fifth intercostal
space.
Lead V6 is at the midaxillary line,
fifth intercostal space, and is positioned above the lateral wall of the
left ventricle.
The mean vector in the horizontal
plane is influenced by the overwhelming power of the left ventricle
and can be thought of as flowing toward the left side. Because the mean
vector flows away from lead V1, this
lead has a downward QRS deflection;
the QRS is almost totally upright in
leads V5 and V6 because the mean
vector flows directly at these leads.
The QRS complex becomes progressively more upright across the chest

Quadrant method
To approximate axis deviation using the quadrant method, divide the circle (which represents the patients heart) into four quadrants (see the illustration below). Only two ECG leads are required to make this assessment. Examine leads I and aVF. If lead I is
upright, then the vector is flowing right to left. If lead aVF is upright, the vector is directed top to bottom. If theyre both upright, the
electrical axis must fall into the lower left or normal quadrant. This quadrant roughly matches the criteria for normal electrical axis,
indicating a normal direction of electrical conduction.
Left axis deviation occurs when lead I is upright and lead aVF is down or
90
negative. The electrical axis is located in the upper right quadrant. The mean
vector is abnormally directed to the left side of the heart. A left axis deviation
Left axis
Extreme right
can be caused by many different pathologic conditions. Some left bundledeviation
axis deviation
branch blocks will produce a left axis deviation because the cardiac vector
I
I
flows abnormally from the right side of the heart to the left. Because the
mean vector is not conducted by infarcted tissue and flows away from it, an
inferior-wall myocardial infarction will produce a left axis deviation (due to
aVF
aVF
a negative QRS in lead aVF). Many patients with pacemakers have a left axis
0
180
deviation because the pacemaker leads are on the right side of the heart.
Right axis
Normal
Finally, some structural body changes will produce a left axis deviation.
deviation
In advanced pregnancy, the enlarged uterus may occupy so much space
I
I
in the abdomen that the elevated diaphragm pushes the heart to a more
horizontal or leftward-lying position, producing a left axis deviation. Similarly,
morbidly obese patients or patients with ascites or an abdominal tumor may
aVF
aVF
have a left axis deviation because of the hearts position in the chest.
A right axis deviation is apparent when lead I is negative and lead aVF
+ 90
is upright. The mean vector is abnormally directed to the right side of the
heart. Causes of right axis deviation include chronic obstructive pulmonary
disease and right ventricular hypertrophy. In both instances, enlargement of the right cardiac chambers pulls the mean vector to
the right side. A right bundle-branch block causes the mean vector to flow from left to right, resulting in right axis deviation. Children and tall, thin adults may have a non-pathologic right axis deviation if the heart hangs down in a more vertical position.
If both leads I and aVF are negative, then the axis deviation is termed indeterminate axis or extreme right axis deviation. The
mean vector is directed upward and to the right. If you find an indeterminate axis deviation on your patients ECG, check the leads;
incorrect ECG lead placement is a common cause of this finding. Other causes are some types of pacemakers, abnormal cardiac
rhythms such as ventricular tachycardia, congenital heart disease, or dextrocardia (heart positioned on the right side of the chest).

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wall from V1 to V6, a change known

as R-wave progression (see R-wave
ups and downs).3 This is another characteristic of a normal ECG.

R-wave ups and

downs5

V1

V2

V3

>

V4

V5

V6

Putting it all together

With this knowledge of 12-lead
ECGs in mind, Mr. Ss nurse
examines his 12-lead ECG. His
heart rate is normal, with clear
P waves, QRS complexes, and
T waves. The PR interval is 0.14
second, which falls within the
normal range. The QRS complex
should be less than 0.12 second;
Mr. Ss QRS complexes are 0.08
second wide. The T waves are upright and normal looking. Finally,
the ST segment is level with the
baseline (isoelectric).
Mr. Ss limb leads are all upright
with the exception of aVR, which is
normal. Lead II is the most upright
and aVL is the least upright. The
chest leads demonstrate downward
lead V1 and upright leads V5 and V6
with normal R-wave progression.
The nurse concludes that Mr. S
has a normal 12-lead ECG, indicating no electrical abnormalities.
However, hes not out of the woods
yet. Some types of myocardial ischemia arent apparent on a standard
12-lead ECG, so the healthcare

provider may consider following

up with a cardiac stress test.4
Mr. Ss normal ECG, negative
serum cardiac biomarkers, and
benign patient history lead the
medical team to rule out a cardiac
source for his discomfort. Hes
discharged home the next day and
scheduled for outpatient cardiac
stress testing.
REFERENCES
1. Khan MG, ed. Rapid ECG Interpretation. 3rd ed.
Totowa, NJ: Humana Press; 2008.
2. Wellens H, Conover MB. The ECG in Emergency
Decision Making. 2nd ed. Philadelphia, PA: W.B.
Saunders, Inc.; 2008.
3. Surawicz B, Knilans T. Chous Electrocardiography
in Clinical Practice. 6th ed. Philadelphia, PA: W.B.
Saunders, Inc.; 2008.
4. Libby P, Bonow R, Mann D, Zipes D. Braunwalds
Heart Disease. Philadelphia, PA: W.B. Saunders,
Inc.; 2008.
5. Thaler MS. The Only EKG Book Youll Ever Need.
5th ed. Philadelphia, Pa.: Lippincott Williams &
Wilkins; 2007:53.
Guy Goldich is course coordinator and instructor at
Abington, Pa., Memorial Hospitals Dixon School of
Nursing.
This article, which has been revised and updated,
originally appeared in the November issue of
Nursing2006.
The author and planners have disclosed no potential
conflicts of interest, financial or otherwise.
DOI-10.1097/[Link].0000451523.48857.26

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