RESPONDING TO THE CALL bell,you find George Smythe, 67, sittingup in bed and complaining of chestdiscomfort. Mr. Smythe had a laparo-scopic cholecystectomy earlier today.You take his vital signs and perform achest pain assessment, which in-cludes the onset, location, quality,intensity, duration, and any radiationof the discomfort. You ask aboutassociated signs and symptoms andfactors that aggravate or relieve thepain. Following your facility’s proto-col, you administer supplementaloxygen at 2 to 4 liters/minute vianasal cannula and page the physi-cian on call, who orders stat serumcardiac biomarkers, a 12-lead elec-trocardiogram (ECG), and sublin-gual nitroglycerin.

Do you know what to look for todetermine if Mr. Smythe’s 12-leadECG is abnormal? Could you rec-ognize signs that he’s having amyocardial infarction (MI)? If youcan independently interpret a 12-lead ECG, you can anticipate andprepare for the emergency careyour patient may need.

In this article, I’ll cover thebasics of 12-lead ECG interpreta-tion, focusing on a normal ECG.Next month, I’ll discuss ECGabnormalities.

What’s happening in the heartThe heart’s internal conduction cir-cuit initiates each heartbeat andcoordinates all parts of the heart tocontract at the proper time. A nor-mal heartbeat is initiated in thesinoatrial (SA) node, a specializedgroup of cells in the right atrium.The SA node depolarizes at a rateof 60 to 100 times/minute, causingthe atria to contract and propelblood into the ventricles.

Atrial depolarization producesthe first element on the ECGwaveform: the P wave. The P waveis the first part of the cardiac cycleand appears as a small, semicircu-lar bump (see Tracing a normalECG waveform).

The wave of depolarization con-tinues through the atria until itencounters the next importantstructure, the atrioventricular

(AV) node. The AV node receivesthe atrial impulse and (after abrief pause to let the ventricles fill)transmits it to the ventricles via thebundle of His. A collection of car-diac conduction fibers, the bundleof His splits into the right and leftbundle branches.

The bundle branches are high-speed conducting fibers that rundown the intraventricular septumand transmit the cardiac impulse tothe Purkinje fibers. These fibersform a complex network that min-gles with ventricular myocardialcells. The function of the Purkinjefibers is to rapidly stimulate ven-tricular muscle fibers, resulting inthe next major event in the cardiaccycle: ventricular depolarization.

Ventricular depolarization gen-erates the QRS complex, the electri-cal equivalent of ventricular sys-tole. (Remember that electricalactivity precedes mechanical activi-ty, and the ECG shows only electri-cal activity.) If you palpate a carotidor radial pulse while looking at acardiac monitor, you should feel apulse with each QRS complex onthe monitor.

The QRS complex normally hasa duration of 0.06 to 0.1 second. Aduration greater than 0.12 second

36 Nursing2006, Volume 36, Number 11 www.nursing2006.com

Find how the ECG translates

the heart’s electrical activity into a waveform and

what it tells you about your

patient’s condition.

BY GUY GOLDICH, RN, CCRN, MSN

12-leadECG

Understanding the

part I

usually indicates prolonged ven-tricular conduction caused by abundle-branch block. The QRScomplex is variable in appearanceand may have a different shape (ormorphology) in different patientsor even look different in variousECG leads in the same patient. TheQRS complex may have one, two,or three wave components,depending on the lead and yourpatient’s condition.

The last major wave componentof the ECG is the T wave, which islarger than the P wave and round-ed or slightly peaked. Immediatelyfollowing the QRS complex, it rep-resents ventricular repolarizationor a metabolic rest period betweenheartbeats. During repolarization,

electrolytes such as potassium,sodium, and calcium cross the cellmembrane (back to their originallocation) to prepare the cardiac cellfor the next depolarization.

Besides the three waveforms, thenormal ECG cardiac cycle tracinghas two important segments, or flat(isoelectric) parts of the tracingbetween the waveforms: the PRinterval and the ST segment.

The PR interval is the periodfrom the beginning of the P wave tothe beginning of the QRS complex.It consists of the P wave plus theshort isoelectric segment that termi-nates at the start of the QRS com-plex. The normal PR interval lasts0.12 to 0.2 second; this representsthe time from SA node depolariza-

tion to ventricular depolarization. Ifthe PR interval is less than 0.12 sec-ond, then the cardiac impulse didn’tfollow the normal conduction path-way. If the PR interval is longer than0.2 second, then a disease processmay be affecting the cardiac con-duction pathway, keeping it fromfunctioning properly.

The ST segment consists of theisoelectric line between the end ofthe QRS complex and the begin-ning of the T wave. The ST seg-ment reveals information aboutthe heart’s oxygenation status. Forexample, myocardial ischemia (atemporary, reversible decrease inoxygenation) often results in anST segment below the baseline ofthe ECG tracing. When myocar-dial cells are injured (reversiblephysical damage from lack of oxy-gen), the ST segment often is ele-vated above the baseline. So ST-segment elevations are a key indi-cator of MI. I’ll discuss this indetail in the next part of thisseries. For tips on how to use theECG to calculate heart rates andmore, see Paper training.

Catching the waveIf you examine a 12-lead ECG,you’ll notice that some QRS com-

www.nursing2006.com Nursing2006, November 37

PR interval

ST segmentQRS complex

QT interval

P

R

T

Q S

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Tracing a normal ECG waveform

plexes have upward deflectionsand others have downward deflec-tions. Here’s why.

Each ECG lead has a positive (orsensing) electrode and a negativeelectrode, which acts as an anchor.The positive electrode lookstoward its negative electrode andsenses whether electrical energy isbeing directed toward or awayfrom the positive electrode.

When electrical energy is directedtoward the positive monitoring elec-trode, the QRS complex has anupward deflection. When the electri-cal energy is directed away from thepositive monitoring electrode, theQRS complex has a downwarddeflection. The more directly alignedthe direction of the electrical energywith the positive electrode, the moreupright the complex. If the electricalenergy approaches the positive mon-itoring electrode at a glancing angle,the complex will still be upright, butless upright than if the energy weredirectly aligned with the positiveelectrode.

Energy arriving at a perpendicu-lar angle to the positive electroderesults in either a waveform withlittle deflection (isoelectric) orequal amounts of positive and neg-ative deflection.

As the energy is directed awayfrom the positive electrode, theQRS complex becomes progres-sively more negative. When ener-gy flow is directed totally awayfrom the positive electrode, theQRS complex is deflected directlydownward.

Going with the flow: A look at vectorsAll cardiac cells are electrochemi-cal, meaning they generate electri-cal energy during depolarization.This electrical energy, called a vec-tor, has strength (measured in mil-livolts) and direction (measured indegrees from an arbitrary zero pointcalled the electrical axis). Each car-diac cell generates its ownmicrovector. The mathematical

average of these microvectors is themean QRS vector or mean vector,which follows the conduction path-way of the heart—downward andto the left. The mean vector flowsslightly to the left of the ventricularseptum because the left ventriclehas more and larger cardiac cells.

Generally, each person has aunique mean vector direction,which remains constant unless hiscardiac status changes. For exam-ple, left ventricular hypertrophysecondary to heart failure pulls themean vector even more sharply tothe left side.1 A person who has amean vector in an abnormal direc-tion is said to have an axis devia-tion. (For details, see Axis deviation:As easy as pie (charts).)

Putting it all togetherThe mean vector is a representa-tion of the overall electrical proper-

ties of the heart. A 12-lead ECG isthe electrical record of the meanvector from 12 different monitor-ing sites (leads) on the surface ofthe body. As when you look at anyobject, you need to see all theangles to get a complete picture.

Looking at limb leadsThe first six leads of the 12-leadECG come from four electrodesplaced on the patient’s arms andlegs; the right lower leg electrode isthe ground electrode. The limbleads record the mean vector in theup-down and left-right directionalong the body’s frontal plane.Because they use separate positiveand negative electrodes, they’recalled bipolar or standard leads.• Lead I has the positive electrodeon the left arm and looks towardthe negative electrode on the rightarm for electrical energy. Because

38 Nursing2006, Volume 36, Number 11 www.nursing2006.com

Paper trainingYou can use the markings on ECG paper to calculate events within the cardiaccycle. 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 mil-limeter (small block) being 0.1 millivolt of electrical energy. However, in prac-tice, deflections are typically described as being in millimeters, not millivolts.

By counting the number of small squares and multiplying by 0.04, you cancalculate the duration of any event in the ECG tracing. A QRS complex that’s 2.5small squares wide is 0.1 second. You also can use the ECG paper to calculateheart rates, using one of two methods. In the 6-second method, you start bylooking for the markings (usually short vertical lines) at the top of the rhythmstrip or ECG paper. These markings divide the ECG paper into 3-second inter-vals. Count the number of QRS complexes contained in two intervals (6 sec-onds) and multiply by 10. This method works for both regular and irregularheart rhythms.

In the division method, count the number of small squares between any twoheartbeats. Make sure you use the same part in both QRS complexes—usuallythe peak of the complex works the best. Divide 1,500 by the number of smallsquares and you’ll have the heart rate in beats per minute. This method isaccurate only with regular heart rates because irregular heart rhythms have avarying number of small squares between any two QRS complexes.

Amplitudeor voltage

1 mV

0.04 second

3 seconds

0.5 mV (5 mm)

0.1 mV (1 mm)

0.20 second

the mean vector travels from upperright to lower left, energy flowstoward the positive electrode oflead I, resulting in an upward de-flection of the QRS. And becausethe mean vector doesn’t flow di-rectly toward lead I, but approach-es it at a somewhat broad angle,the upward deflection of the QRScomplex is moderate.• In lead II, the positive electrodeis on the left foot and the negativeelectrode is on the right arm. Be-cause the mean vector flowsdirectly at the positive lead IIelectrode, this lead usually hasthe most upright QRS complexesand the most prominent P wavesof the entire 12-lead ECG. That’swhy lead II is a favorite monitor-ing lead in many intensive careand telemetry units.• Lead III puts the positive elec-trode on the left foot and the nega-tive one on the left arm. The meanvector flow approaches lead IIIdownward from the right, againproducing an upward QRS deflec-tion. Because the angle is narrowerthan the angle between the meanvector and lead I, the lead III QRScomplex is more upright than thelead I QRS complex.

The second set of limb leads arecalled the augmented or unipolarleads and use a single positive mon-itoring electrode. The negative elec-trode is an electrically calculated

location at the center of the heart.2

• Lead aVR is the only limb leadon the right side of the body. Itspositive monitoring electrode islocated on the right arm and looksdownward and to the left. Themean vector also flows downwardand to the left, directly away fromlead aVR, resulting in a negativedeflection for all waveforms. In anormal ECG, lead aVR is the onlylimb lead with a downwardlydeflected QRS.• Lead aVL positions a positiveelectrode on the left arm and looksto the right and downward toward tothe center of the heart (in contrastto lead I, which looks strictly to theright). The mean vector approachesaVL at a very broad angle, produc-ing the least upright QRS complexamong the limb leads.

• Lead aVF has its positive moni-toring lead on the left leg andlooks straight up to the center ofthe chest. The mean vectorapproaches aVF at a fairly directangle, although not as directly aslead II, so lead aVF has veryupright QRS complexes withprominent P waves. Because leadsII, III, and aVF all look upward atthe oncoming mean vector, theirwaveforms share many qualities,such as highly positive QRS com-plexes and prominent P waves.Because these leads look upwardat the bottom or inferior ventricu-lar wall of the heart, they’reknown as the inferior leads.

Six chest leads weigh inThe six chest or precordial leads lieacross the anterior chest and mea-sure the mean vector in the hori-zontal plane.• Lead V1 is located at the rightsternal border, fourth intercostalspace, and lies above the right ven-tricle and septum.• Lead V2 is at the left side of thesternum, fourth intercostal space.• Lead V3 is midway between leadsV2 and V4.• Lead V4 is at the midclavicularline in the fifth intercostal space.• Lead V5 is at the anterior axillaryline in the fifth intercostal space.• Lead V6 is at the midaxillaryline, fifth intercostal space, and ispositioned above the lateral wall of

www.nursing2006.com Nursing2006, November 39

V1

V2

V3

V4

V5

V6

Lead I

Lead II

Lead III

Lead aVR

Lead aVL

Lead aVF

40 Nursing2006, Volume 36, Number 11 www.nursing2006.com

Axis deviation: As easy as pie (charts)Combining your assessment skills with an understanding of axis deviation can give you a more detailed picture of your patient’s condition. Thehexaxial reference system and the quadrant method can help you visualize problems with cardiac conduction.

Hexaxial reference systemThe 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 an abnormal axis can give you cluesabout what’s going wrong in the heart’s electrical system.

To measure the electrical axis, imagine all six limb leads displayed simultaneouslyaround a central point in a circle, which 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 vector’s directioncan 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 of75 degrees. (Although you can calculate your patient’s electrical axis, all modern 12-lead ECG machines provide this information automatically.)

The normal electrical axis of the heart falls between -30 and +90 degrees.Although this is a wide range, it’s a numeric equivalent of the concept that the elec-trical 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-30 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 rangeof -90 to -180 degrees is called an indeterminate axis or extreme right axisdeviation.

Quadrant methodTo approximate axis deviation using the quadrant method, divide the circle (which represents the patient’s heart) into four quadrants (see theillustration below). You need only two ECG leads to make this assessment. Examine leads I and aVF. If lead I is upright, then the vector is flow-

ing right to left. If lead aVF is upright, the vector is directed top to bottom. If they’reboth upright, the electrical axis must fall into the lower left or normal quadrant. Thisquadrant roughly matches the criteria for normal electrical axis, indicating a normaldirection of electrical conduction.

Left axis deviation occurs when lead I is upright and lead aVF is down or negative.The electrical axis is located in the upper right quadrant. The mean vector is abnor-mally directed to the left side of the heart. A left axis deviation can be caused bymany different pathologic conditions. Some left bundle-branch blocks will produce aleft axis deviation because the cardiac vector flows abnormally from the right side ofthe heart to the left. Because the mean vector is not conducted by infarcted tissueand flows away from it, an inferior-wall myocardial infarction will produce a left axisdeviation (due to a negative QRS in lead aVF). Many patients with pacemakers havea left axis deviation because the pacemaker leads are on the right side of the heart.

Finally, some structural body changes will produce a left axis deviation. Inadvanced pregnancy, the enlarged uterus may occupy so much space in theabdomen that the elevated diaphragm pushes the heart to a more horizontal or leftward-lying position, producing a left axis deviation. Similarly, short and squat ormorbidly obese patients may have a left axis deviation because of the heart’s position in the chest.

You can recognize a right axis deviation when lead I is negative and lead aVF is upright. The mean vector is abnormally directed to theright side of the heart. Causes of right axis deviation include chronic obstructive pulmonary disease and right ventricular hypertrophy. In bothinstances, enlargement of the right cardiac chambers pulls the mean vector to the right side. A right bundle-branch block causes the meanvector to flow from left to right, resulting in right axis deviation. Children and tall, thin adults may have a normal right axis deviation if theheart 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 vectoris directed upward and to the right. If you find an indeterminate axis deviation on your patient’s ECG, check the leads; incorrect ECG leadplacement is a common cause of this finding. Other causes are some types of pacemakers, abnormal cardiac rhythms such as ventriculartachycardia, congenital heart disease, or dextrocardia (heart positioned on the right side of the chest).

– 90°

aVL

I

IIaVF

aVR

III

– 60°

– 30°

+ 30°

+ 60°+ 90°

+ 120°

+ 150°

– 150°

– 120°

± 180° O°

Normal range

Extreme rightaxis deviation

Left axisdeviation

Right axisdeviation

Normal

I I

aVF

I

aVF

I

aVF

aVF

– 90°

0°

+ 90°

± 180°

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Earn CE credit online: Go to http://www.nursingcenter.com/CE/nursing and receive a certificate within minutes.

INSTRUCTIONS

Understanding the 12-lead ECG, part ITEST INSTRUCTIONS• To take the test online, go to our secure Web site at http://www.nursingcenter.com/ce/nursing.• On the print form, record your answers in the test answer sectionof the CE enrollment form on page 42. Each question has only onecorrect answer. You may make copies of these forms.• Complete the registration information and course evaluation.Mail the completed form and registration fee of $22.95 to:Lippincott Williams & Wilkins, CE Group, 2710 YorktowneBlvd., Brick, NJ 08723. We will mail your certificate in 4 to 6weeks. For faster service, include a fax number and we will faxyour certificate within 2 business days of receiving your enroll-ment form. • You will receive your CE certificate of earned contact hours and ananswer key to review your results. There is no minimum passing grade.• Registration deadline is November 30, 2008.

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PROVIDER ACCREDITATIONLippincott Williams & Wilkins, the publisher of Nursing2006, willaward 2.5 contact hours for this continuing nursing education activ-ity. Lippincott Williams & Wilkins is accredited as a provider of con-tinuing nursing education by the American Nurses CredentialingCenter’s Commission on Accreditation. This activity is also providerapproved by the California Board of Registered Nursing, ProviderNumber CEP 11749 for 2.5 contact hours. Lippincott Williams &Wilkins is also an approved provider by the American Associationof Critical-Care Nurses (AACN 00012278, CERP Category A),Alabama #ABNP0114, Florida #FBN2454, and Iowa #75.Lippincott Williams & Wilkins home study activities are classifiedfor Texas nursing continuing education requirements as Type 1.Your certificate is valid in all states.

the left ventricle.The mean vector in the hori-

zontal plane is influenced by theoverwhelming power of the leftventricle and can be thought ofas flowing toward the left side.Because the mean vector flowsaway from lead V1, this lead hasa downward QRS deflection; theQRS is almost totally upright inleads V5 and V6 because themean vector flows directly atthese leads. The QRS complexbecomes progressively moreupright across the chest wallfrom V1 to V6, a change knownas R-wave progression (see R-waveups and downs).3 This is anothercharacteristic of a normal ECG.

Putting it all togetherPrepared with our new knowl-edge of 12-lead ECGs, let’s exam-ine Mr. Smythe’s 12-lead ECG.His heart rate is normal, and yousee clear P waves, QRS complex-es, and T waves. The PR intervalis 0.14 second, which falls withinthe normal range. The QRS com-plex should be less than 0.12 sec-ond; Mr. Smythe’s QRS complexesare 0.08 second wide. The Twaves are upright and normallooking. Finally, the ST segmentis level with the baseline.

Mr. Smythe’s limb leads are allupright with the normal exceptionof aVR. Lead II is the most uprightand aVL is the least upright. Thechest leads demonstrate down-ward lead V1 and upright leads V5and V6 with normal R-wave pro-gression across the chest wall.

You conclude that Mr. Smythehas a normal 12-lead ECG, indi-cating no electrical abnormalitiesin heart function. However, he’snot out of the woods yet. Sometypes of ischemic chest pain aren’tapparent on routine ECG, so thephysician may consider following

up with a stress test.4

Mr. Smythe’s normal ECG, neg-ative cardiac enzymes, and benignpatient history led the medicalteam to rule out a cardiac sourcefor his discomfort. He was dis-charged home the next day with aprescription for pantoprazole andtold to follow up with his healthcare provider if his chest discom-fort recurs.

In this article, you’ve learned torecognize the features of the nor-mal ECG. Next month, I’ll exam-ine some abnormalities of the 12-lead ECG and discuss how toassess for MIs and arrhythmias.‹›REFERENCES1. Dubin D. Rapid Interpretation of EKGs, 6thedition. Tampa, Fla., Cover Publishing, 2000.

2. Conover MB. Understanding Electrocardiography,8th edition. St. Louis, Mo., Mosby, Inc., 2002.

3. Huszar RJ. Basic Dysrhythmias: Interpretation& Management, 3rd edition. St. Louis, Mo.,Mosby, Inc., 2002.

4. Urden LD, et al. Thelan’s Critical Care Nursing: Diagnosis and Management, 5th edition.St. Louis, Mo., Mosby, Inc., 2005.

Guy Goldich is assistant nurse-manager of the car-diac intensive care unit at Abington (Pa.) MemorialHospital and an adjunct faculty member at the hos-pital’s Dixon School of Nursing.

The author has disclosed that he has no significant relationship with or financial interest in any commer-cial companies that pertain to this educational activity.

V1 V2 V3 V4 V5 V6

S wave

R wave

R-wave ups and downs

1. The normal heartbeat is initiated in the a. SA node. c. bundle of His.b. AV node. d. Purkinje fibers.

2. The structure that briefly delays animpulse (to let the ventricles fill) is thea. SA node. c. bundle of His.b. AV node. d. Purkinje fibers.

3. The QRS represents a. atrial repolarization.b. atrial depolarization.c. ventricular depolarization.d. ventricular repolarization.

4. Which QRS duration indicates a bundle-branch block?a. 0.04 second c. 0.10 second b. 0.08 second d. 0.14 second

5. The T wave representsa. atrial depolarization.b. atrial repolarization.c. ventricular depolarization.d. ventricular repolarization.

6. Which reveals information about theheart’s oxygenation status? a. PR interval c. ST segmentb. QT interval d. QRS complex

7. Electrical energy generated duringdepolarization is calleda. an axis. c. axis deviation.b. a vector. d. the cardiac cycle.

8. Which of the following represents normal axis?a. QRS complex positive in leads I and aVFb. QRS complex negative in leads I and aVFc. QRS complex positive in lead I and negative in

lead aVFd. QRS complex negative in lead I and positive in

lead aVF

9. Which represents left axis deviation?a. QRS complex positive in leads I and aVFb. QRS complex negative in leads I and aVFc. QRS complex positive in lead I and negative in

lead aVFd. QRS complex negative in lead I and positive in

lead aVF

10. Left axis deviation can be caused bya. pulmonary embolism.b. right ventricular hypertrophy.c. chronic obstructive pulmonary disease.d. an inferior-wall MI.

11. Which of the following leads view thehorizontal plane of the heart?a. V1 through V6b. I, II, IIIc. aVR, aVL, aVFd. I, II, III, aVR, aVL, aVF

12. Which chest lead is placed at the rightsternal border, fourth intercostal space?a. lead V1 c. lead V3b. lead V2 d. lead V4

13. R-wave progression refers to the QRScomplex becoming progressively morea. positive from lead I to lead III.b. positive from lead aVR to lead aVF.c. positive from lead V1 to V6.d. negative from lead V1 to V6.

14. Myocardial injury generally is repre-sented by an ST segment that isa. above the baseline.b. level with the baseline.c. below the baseline.d. isoelectric.

15. On the horizontal axis, a small box onECG paper is equal toa. 0.04 second. c. 0.1 millivolt.b. 0.1 second. d. 1 mm.

Understanding the 12-lead ECG, part IGENERAL PURPOSE To familiarize nurses with the basics of 12-lead ECG interpretation. LEARNING OBJECTIVES After reading the precedingarticle and taking this test, you should be able to: 1. Discuss the cardiac conduction system. 2. Describe vectors and axis deviation. 3. Explain the 12 leads of the standard ECG.

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