12-Lead

Electrocardiography
a comprehensive course

s so n
Le
1

Adam Thompson, EMT-P, A.S.

Resource
 Course Objectives

Learn the basic concept behind electrical vectors.

Learn the 6 step process to 12-lead ECG interpretation.
Learn how to identify chamber enlargement.
Learn how to differentiate between atrial & ventricular
rhythms.
Learn how to identify bundle branch blocks.
Learn how to differentiate a STEMI from STE-Mimic
Learn when to perform a right-sided or posterior 12-lead
ECG.
 Lesson One

Learn the appropriate placement of the 12-

lead ECG electrodes.
Learn how to eliminate artifact and obtain a
clean recording.
Learn about the 6 step interpretation process.
Learn and apply the ability to determine rate
& rhythm.
 12-Lead ECG

In lead II? Youve got NO clue.

- Bob Page
12-Lead Placement
V1 - 4th ICS, right of
sternum
V2 - 4th ICS, left of
sternum
V3 - Between V2 & V4
V4 - 5th ICS, left
midclavicular line
V5 - Lateral to V4, left
anterior axillary line
V6 - Lateral to V5, left
midaxillary line
 Eliminate Artifact

The patients chest should be bare.

All hair that inhibits adequate electrode
contact should be shaved.
Benzoin tincture may be used to
enhance adhesive.
 The Culprit Electrode

Precordial leads are easy. V1 has artifact?

Check V1 electrode.
If Leads I & III have artifact, check left
shoulder.
If Leads I & II have artifact, check right
shoulder.
Leads II & III? Check left leg electrode.
 Precordial Leads

Precordium - area of chest over heart

Precordial Leads
Right Precordial Leads
Precordial Leads
Left Precordial Leads
 Limb Leads
Obtained from Red, White, Black, &
Green electrodes
 12 Leads
Limb Leads Precordial Leads
Lead I aVR V1 V4

Lead II aVL V2 V5

Lead III aVF V3 V6

 Contiguous Leads

Lead I aVR V1 V4

Lead II aVL V2 V5

Lead III aVF V3 V6

 Contiguous Leads

Lead I aVR V1 V4
high lateral septal anterior

Lead II aVL V2 V5
inferior high lateral septal low lateral

Lead III aVF V3 V6

inferior inferior anterior low lateral
The 6-Step Method

1. Rate & Rhythm

2. Axis Determination
3. Intervals
4. Morphology
5. STE-Mimics
6. Ischemia, Injury, & Infarct
 The 6-Step Method
Rate & Rhythm

What is your initial rhythm interpretation?

Is the rhythm too fast or too slow?
Are we certain it is supraventricular?
If the QRS complexes are wide, it is
ventricular until proven otherwise.
 The 6-Step Method
Axis Determination

Is the axis normal?

Is it left axis deviation?
Is it right axis deviation?
Extreme right axis deviation?
Consider pathologies!
 The 6-Step Method
Intervals

Double check PR-interval and QRS

duration
Identify the QT or QTc interval
Consider pathologies for abnormal
intervals.
 The 6-Step Method
Morphology

If QRS is wide, what is morphology in V1?

Bundlebranch block?
Bifascicular block?
Identify chamber enlargement.
Consider T-wave morphology
Consider possible pathologies that correlate
with altered morphologies.
 The 6-Step Method
STE-Mimics

Determine if a paced rhythm, LBBB, LVH,

Early repol, pericarditis, WPW, or
hyperkalemia is present.
By this step, many possible pathologies have
already been ruled out or in.
 The 6-Step Method
Ischemia, Injury, & Infarct

Is it an obvious STEMI? ie. Tombstones?

Identify ST-elevation, & ST-depression.
Identify hyperacute T-waves or Q-waves.
Consider reciprocal changes.
Do you show changes in contiguous leads?
Consider culprit artery, and affected area of the heart.
 12-Lead Basics

Measurements are usually accurate

 12-Lead Basics

GE-Marquette 12SL Interpretive Algorhythm

Relatively reliable on clean ECG tracing.
 12-Lead Basics

The patient age and gender should always be entered into the
12-lead monitor.
12-Lead Basics

Typical 12-Lead ECG

12-Lead Basics

Typical 12-Lead ECG

12-Lead Basics

Typical 12-Lead ECG

12-Lead Basics

Typical 12-Lead ECG

12-Lead Basics

Typical 12-Lead ECG

12-Lead Basics
12-Lead Basics

Typical 12-Lead ECG

12-Lead Basics

QuickTime and a
mpeg4 decompressor
are needed to see this picture.
 Rate & Rhythm

Interpret the rhythm

Identify the rate
Is it regular or irregular?
Identify P-waves
Identify PR-interval
 Rate & Rhythm
Calculate the Rate

300 150 100 75 60

 Rate & Rhythm

Is the rate too fast or too slow?

Intrinsic Rates:
SA Node - 60 to 100
AV Junction - 40 to 60
Purkinje Fibers - 20 to 40
Rate & Rhythm
Regular or Irregular
Rate & Rhythm
Regular or Irregular
 Rate & Rhythm
P-Waves

Are P-waves present?

Is there a P-wave for every QRS?
Is there a QRS for every P-wave?
Do the P-waves appear after the QRS?
 Rate & Rhythm
PR-Interval

Is the PR-interval consistent?

Is the PR-interval > 0.20 sec (200ms)?
Does the PR-interval lengthen?
 Rate & Rhythm

The next step is to interpret the rhythm

that the patient is in.
The following is a brief ECG arrhythmia
review.
Sinus Rhythms
 Normal Sinus Rhythm
Rate: 60 - 100 bpm
Rhythm: Regularly Regular
P wave: Present
P:QRS ratio: 1 to 1
PR-interval: Normal
QRS Width: < 120 ms (0.12 sec)
Normal Sinus Rhythm
Normal Sinus Rhythm
Normal Sinus Rhythm
Normal Sinus Rhythm
Normal Sinus Rhythm
 Sinus Arrhythmia
Rate: 60 - 100 bpm
Rhythm: Varies with respiration
P wave: Present
P:QRS ratio: 1 to 1
PR-interval: Normal
QRS Width: < 120 ms (0.12 sec)
Sinus Arrhythmia
 Sinus Bradycardia
Rate: < 60 bpm
Rhythm: Regularly-Regular
P wave: Present
P:QRS ratio: 1 to 1
PR-interval: Normal
QRS Width: < 120 ms (0.12 sec)
Sinus Bradycardia
Sinus Bradycardia
Sinus Bradycardia
Sinus Bradycardia
 Sinus Tachycardia
Rate: > 100 bpm
Rhythm: Regularly-Regular
P wave: Present
P:QRS ratio: 1 to 1
PR-interval: Normal
QRS Width: < 120 ms (0.12 sec)
Sinus Tachycardia
Sinus Tachycardia
Sinus Tachycardia
Sinus Tachycardia
 Sinus Pause/Arrest
Rate: Varies
Rhythm: Irregular
P wave: Present except for pause
P:QRS ratio: 1 to 1
PR-interval: Normal
QRS Width: < 120 ms (0.12 sec)
 Premature Atrial Contraction
Rate: Determine underlined rate
Rhythm: Irregular
P wave: Present, may be different w/ PAC
P:QRS ratio: 1 to 1
PR-interval: Normal, may vary w/ PAC
QRS Width: < 120 ms (0.12 sec)
 Ectopic Atrial Tachycardia
Rate: 100 - 180 bpm
Rhythm: Regular
P wave: Present, may be different w/ ectopy
P:QRS ratio: 1 to 1
PR-interval: Normal, different w/ ectopy
QRS Width: < 120 ms (0.12 sec)
 Wandering Atrial Pacemaker
Rate: < 100 bpm
Rhythm: Irregularly-Irregular
P wave: At least 3 different morphologies
P:QRS ratio: 1 to 1
PR-interval: Variable
QRS Width: < 120 ms (0.12 sec)
 Multifocal Atrial Tachycardia
Rate: > 100 bpm
Rhythm: Irregularly-Irregular
P wave: At least 3 different morphologies
P:QRS ratio: 1 to 1
PR-interval: Variable
QRS Width: < 120 ms (0.12 sec)
Atrial Flutter
 Atrial Flutter
Rate: Atria (250-350), Ventricles (125-175)
Rhythm: Usually Regular
P wave: Saw toothed F waves
P:QRS ratio: Variable, 2:1 is common
PR-interval: Variable
QRS Width: < 120 ms (0.12 sec)
Atrial Flutter
3:1
Atrial Flutter
2:1
Atrial Fibrillation
Atrial Fibrillation
 Atrial Fibrillation
Rate: Variable, depending on ventricles
Rhythm: Irregularly-Irregular
P wave: None, chaotic atrial activity
P:QRS ratio: None
PR-interval: None
QRS Width: < 120 ms (0.12 sec)
Atrial Fibrillation
Atrial Fibrillation
Atrial Fibrillation
Atrial Fibrillation
 Premature Junctional
Contraction
Rate: Determine underlying rhythm
Rhythm: Irregular
P wave: none, antegrade, or retrograde
P:QRS ratio: 1:1 or retrograde
PR-interval: None, short, or retrograde
QRS Width: < 120 ms (0.12 sec)
 Junctional Escape Beat
Rate: Determine underlying rhythm
Rhythm: Irregular
P wave: none, antegrade, or retrograde
P:QRS ratio: 1:1 or retrograde
PR-interval: None, short, or retrograde
QRS Width: < 120 ms (0.12 sec)
 Junctional Rhythm
Rate: 40 - 60 bpm
Rhythm: Regular
P wave: none, antegrade, or retrograde
P:QRS ratio: 1:1 or retrograde
PR-interval: None, short, or retrograde
QRS Width: < 120 ms (0.12 sec)
Accelerated Junctional Rhythm
Rate: 60 - 100 bpm
Rhythm: Regular
P wave: none, antegrade, or retrograde
P:QRS ratio: 1:1 or retrograde
PR-interval: None, short, or retrograde
QRS Width: < 120 ms (0.12 sec)
Narrow Complex Tachycardia

Sinus Tach P

MAT P

Ectopic A-Tach P

Junctional P

AVNRT/AVRT P

A-Flutter F F F F

P
P-Wave F
Flutter Wave
 Premature Ventricular
Contraction
Rate: Determine underlying rhythm
Rhythm: Irregular
P wave: None with PVC
P:QRS ratio: None
PR-interval: None
QRS Width: > 120 ms (0.12 sec) WIDE
Premature Ventricular Contraction

Polymorphic
More than one one shape of QRS complex

Multifocal
More than one focus or site of initial
impulse.
Premature Ventricular Contraction

1 2
 Ventricular Escape Beat
Rate: Determine underlying rhythm
Rhythm: Irregular
P wave: None with PVC
P:QRS ratio: None
PR-interval: None
QRS Width: > 120 ms (0.12 sec) WIDE
Ventricular Rhythms
 Idioventricular Rhythm
Rate: 20 - 40 bpm
Rhythm: Regular
P wave: None
P:QRS ratio: None
PR-interval: None
QRS Width: > 120 ms (0.12 sec) WIDE
Idioventricular Rhythm
Accelerated Ventricular Rhythm
Rate: 40 - 100 bpm
Rhythm: Regular
P wave: None
P:QRS ratio: None
PR-interval: None
QRS Width: > 120 ms (0.12 sec) WIDE
 Ventricular Tachycardia
Rate: 100 - 200 bpm
Rhythm: Regular
P wave: None, complete AV disassociation
P:QRS ratio: None
PR-interval: None
QRS Width: > 120 ms (0.12 sec) WIDE
Ventricular Tachycardia
 Torsade de Pointes
Rate: 200 - 250 bpm
Rhythm: Irregular
P wave: None
P:QRS ratio: None
PR-interval: None
QRS Width: > 120 ms (0.12 sec) WIDE
 Ventricular Fibrillation
Rate: Indeterminate
Rhythm: Chaotic
P wave: None
P:QRS ratio: None
PR-interval: None
QRS Width: None
 1st Degree Heart Block
Rate: Identify underlying rate
Rhythm: Regular
P wave: Present
P:QRS ratio: 1 to 1
PR-interval: > 200 ms (0.20 sec)
QRS Width: < 120 ms (0.12 sec)
1st Degree Heart Block
 2nd Degree Heart Block - Type I
Rate: Identify underlying rate
Rhythm: Regularly-Irregular
P wave: Present
P:QRS ratio: Variable
PR-interval: Variable (going, going, gone)
QRS Width: < 120 ms (0.12 sec)
2nd Degree Heart Block - Type I
1st Degree AVB 2nd Degree AVB - Type I
 2nd Degree Heart Block - Type II
Rate: Identify underlying rate
Rhythm: Regularly-Irregular
P wave: Present
P:QRS ratio: x:x - 1
PR-interval: Normal *Dropped QRS
QRS Width: < 120 ms (0.12 sec)
 3rd Degree Heart Block
Rate: Atrial & Ventricular rates differ
Rhythm: Regular
P wave: Present
P:QRS ratio: Variable
PR-interval: No pattern
QRS Width: Normal or WIDE
3rd Degree Heart Block

QuickTime and a
decompressor
are needed to see this picture.
3rd Degree Heart Block
 AV Blocks
Is the PR-interval a constant length?

Yes No
Dropped QRS? P-wave for every QRS?

Yes No Yes No
2nd Degree Type II 1st Degree 2nd Degree Type I 3rd Degree
 Interpretation Pearl

When interpreting an ECG rhythm,

always consider the company it keeps.
Associated Signs & Symptoms
Past medical history
Medicationsetc
 ECG Rhythms

You must understand the basic ECG

arrhythmias prior to moving on.

Review the previous slides until you think

youve got it.

The next slide may assist you if youre still

having a hard time.
The ECG Dance

QuickTime and a
mpeg4 decompressor
are needed to see this picture.
 The Golden Rule

ECG Interpretation is largely based on THEORY.

Give five cardiologists the same ECG to interpret,

and you may receive five different interpretations.
 The End

End of Lesson 1
Lesson 2 will include axis determination