Basics of 12 Lead ECG's

Vector
There are three basic "laws" of
Electrocardiography.
These "laws" have to do with the direction of flow of
electrical conduction in the heart or what we term
as vector.

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 Basics of 12 Lead ECG's
Vector
1. Movement of the electrical impulse
towards the positive electrode will result in a
positive deflection on the ECG.

- + =

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 Basics of 12 Lead ECG's
Vector
2. Movement of the electrical impulse toward the
negative electrode will result in a negative
deflection on the ECG.

- + =

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 Basics of 12 Lead ECG's
Vector
3. Movement of an electrical impulse perpendicular to a
line between the positive and negative electrodes
results in a bi-phasic (part upright and part
downward) deflection on the ECG.

- + =

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 Basics of 12 Lead ECG's
Vector
By understanding this concept of vector and knowing the
"normal" vector of each of the 12 leads of the 12 lead ECG
it becomes quite easy to identify problems in the direction
of depolarization. It is also from this knowledge that one
identifies the Mean QRS Axis. Using the six limb leads we
identify the axis in relation to what is known as the frontal
plane. Two major factors help to determine this mean QRS
Axis, they are:

1. The anatomical position of the heart

2. The direction of ventricular depolarization.

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 Basics of 12 Lead ECG's
Determining AXIS
Technique #1: Two Lead Method or Quadrant Method

This method uses just two leads of the six limb leads and works
well in critical situations to get a general idea of the Mean
Axis of the QRS. We will look at Lead 1 and at Lead AVF for
this technique.

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Basics of 12 Lead ECG's
Determining AXIS
1. Leads 1 and AVF divide
the thorax into quadrants,
(Left, Normal, Right, No Man's)

2. If leads 1 and AVF are both

upright then the Axis is
normal.

3. If lead 1 is upright and lead

AVF is downward the Axis is
Left.

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Basics of 12 Lead ECG's
Determining AXIS

4. If lead AVF is upright and lead 1

is downward then the Axis is Right

5. If both leads are downward then

the Axis is extreme Right Shoulder
and most often is Vent. Tachy

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 Basics of 12 Lead ECG's
Determining AXIS
Method 2 : Three Lead technique

This method uses the three limb leads I, II, III

to determine the axis of the QRS.

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 LEAD 1 LEAD 2 LEAD 3

Normal UPRIGHT UPRIGHT UPRIGHT

Physiological UPRIGHT /
UPRIGHT NEGATIVE
Left Axis BIPHASIC
Pathological
UPRIGHT NEGATIVE NEGATIVE
Left Axis
UPRIGHT
Right Axis NEGATIVE BIPHASIC UPRIGHT
NEGATIVE

Extreme Right
NEGATIVE NEGATIVE NEGATIVE
Axis

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 Basics of 12 Lead ECG's
Determining AXIS

Method # 3: Using the Hexaxial Diagram to find

the degree of Axis Deviation

This technique is a little hard to learn

but it is also the most accurate( + or 100 to 150)

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 Basics of 12 Lead ECG's
Determining AXIS
Marked RAD -90
-60
-120

aVR
LAD
To determine the
-30
-150 aVL
axis a scale must
be used such as
180 0
the one at the
I
left.
150
30

120 II
III 60
Normal Axis
90 aVF
RAD
-30-30
toto+120
+100
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 Basics of 12 Lead ECG's
Determining AXIS
Marked RAD -90 First you must find the
-120
-60
most equiphasic QRS
LAD complex in the six limb
aVR -30 leads. This is done by
-150 aVL adding and subtracting
180 0 the number of squares
I each QRS complex has
above the baseline and
150 below the baseline in
each lead.
30

120 II
III 60
Normal Axis
90 aVF
RAD -30-30
toto+120
+100
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 Basics of 12 Lead ECG's
Determining AXIS
The axis will be
perpendicular (right
Marked RAD -90
-60
-120
LAD angle) to this lead.
aVR -30 If the perpendicular
-150 aVL lead has a positive QRS,
180 0 orient the axis to the
I
positive pole of this lead.
150 If it is negative then
orient it to the negative
30
II
120
III 60
Normal Axis pole.
90 aVF
RAD -30 -30
to to+120
+100
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 Basics of 12 Lead ECG's
Causes of Abnormal Axis
Left Axis Deviation = An axis between -30 and -90

May be normal in the elderly and very obese

Due to high diaphragm during pregnancy, ascites, or ABD
tumors
Left Anterior Hemiblock
Left Bundle Branch Block
WPW Syndrome
Congenital Lesions
Right Vent. Pacer or ectopic rhythms
Emphysema

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 Basics of 12 Lead ECG's
Causes of Abnormal Axis
Right Axis Deviation = An axis between +120 and
+180

Can be normal variant

Right Vent. Hypertrophy
Right Bundle Branch Block
Left Posterior Hemiblock
Left Ventricular ectopic rhythms
Some right Vent. Ectopic rhythms
WPW Syndrome

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 Basics of 12 Lead ECG's
Causes of Abnormal Axis
Extreme Right Axis Deviation = An axis
between -90 and +180

Ventricular ectopic rhythms

Right Vent. Paced rhythms
Less commonly seen in patients with
cardiomyopathies and in those with multiple MI's

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