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 Physiological Left Axis

Pathological Left Axis Right Axis

UPRIGHT
UPRIGHT UPRIGHT

UPRIGHT UPRIGHT / BIPHASIC

NEGATIVE
UPRIGHT BIPHASIC NEGATIVE

UPRIGHT
NEGATIVE NEGATIVE

NEGATIVE

UPRIGHT

Extreme Right Axis

NEGATIVE

NEGATIVE

NEGATIVE

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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 -120 aVR -150

-60
LAD

-30 aVL 0 I

180

To determine the axis a scale must be used such as the one at the left.

150 30 120 III 60 90 aVF II

Normal Axis -30 +100 -30 toto+120

RAD

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Basics of 12 Lead ECG's

Determining AXIS
Marked RAD

-90 -120 aVR -150

-60
LAD

-30 aVL 0 I

180

150 30 120 III 60 90 aVF II

Normal Axis -30 +100 -30 toto+120

First you must find the most equiphasic QRS complex in the six limb leads. This is done by adding and subtracting the number of squares each QRS complex has above the baseline and below the baseline in each lead.
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RAD

Basics of 12 Lead ECG's

Determining AXIS
Marked RAD

-90 -120 aVR -150

-60
LAD

-30 aVL 0 I

180

150 30 120 III 60 90 aVF II

Normal Axis

The axis will be perpendicular (right angle) to this lead. If the perpendicular lead has a positive QRS, orient the axis to the positive pole of this lead. If it is negative then orient it to the negative pole.
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RAD

-30 -30 to +100 to +120

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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