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Practical Procedures

Reading a normal ECG


This month we revisit Mark Whitbread’s tool for reading a 12-lead ECG,
followed by this month’s ECG.

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Figure 1. The normal electrocardiogram.

T
he 12-lead electrocardiogram However, the 12-lead ECG must be activity as seen from the right shoul-
(ECG) remains one of the most looked at carefully and in a systematic der. The sinus node is placed top right
useful clinical tools in the evaluation way and this often takes many years to in the heart nearest the right shoulder
of the cardiac patient. Its use is widespread master. The ECG should always be used and the electrical activity is moving
and can be of use as part of the assessment along with the patient’s history. downwards and leftwards towards the
process in many presentations such as: Each month an ECG will be presented left ventricle.
w Chest pain with a short patient history for the reader w The ST segment starts on the isoelec-
w Shortness of breath to analyze. In this first edition, a system- tric line, except in V1 and V2 where it
w Blackouts atic approach to analysing ECGs is pre- may be elevated (not >1 mm). The
w Palpitations sented along with a normal 12-lead ECG normal ST then curves gently in the
w Syncope (Figure 1) so that the reader can practice direction of the T wave and should not
w And many others… applying the framework to the ECG. The remain exactly horizontal
framework uses ten rules that can be w The PR interval should be 0.12–0.2
applied to any ECG. seconds. A longer PR implies AV block,
Mark Whitbread is the Clinical a shorter PR may indicate a vulnerabil-
Practice Manager for the London The ten rules ity to supraventricular arrhythmias
Ambulance Service A starting framework for the systematic w The QRS complex should not exceed
Key words approach to the 12-lead ECG. For posi- 0.11–0.12 seconds. A wider QRS is
w ECG w Patient history w 10 rules tioning of the leads see Figure 2 and for sometimes seen in healthy people but
w Isoelectric line the view of the limb leads see Figure 3. may represent an abnormality of intra-
Accepted for publication 19 January 2006 w All waves are negative in aVR. This has ventricular conduction
to be so: aVR represents electrical w The QRS and T waves tend to have the

58 British Journal of Cardiac Nursing February 2007 Vol 2 No 2


Practical Procedures

Table 1.
Definition of
electrocardiogram leads

3 Limb leads:
I II III
3 Augmented (modified) limb leads:
aVL (augmented view left)

aVR (augmented view right)
V1
V6 V6R V1R
aVF augmented view foot/left leg
V5 V5R 6 Chest leads:
V1
V4 V4R
V2
V3
4th intercostal
V4
space V2 V3 V3R V2R V5
V6
A. Standard chest lead B. Right sided chest lead From: Adam and Osborne, 2003.
placement placement

same general direction in the standard


Figure 2. Positioning of chest leads (limb) leads. For example, if the QRS
in aVL is dominantly positive than the
T wave in that lead should also be
positive. Slight disparities are likely to
be normal
w The R wave in the precordial (chest)
RA LA leads grows from V1 to at least V4
I
where it may or may not decline again.
A spurious abnormality frequently
occurs in R wave size or growth because
of faulty placement of precordial leads
w The QRS is mainly upright in I and II.
Otherwise there is axis deviation
II III w The P wave is upright in I II and V2 to
V6. By implication they may be flat or
negative in other leads
w There is no Q wave or only a small q (<
0.04second in width) in I, II and V2 to
V6. A narrow q is expected in V6 and
represents the early septal activation.
w The T wave is upright in I II and V2 to
V6. The end of the T wave should not
LL dip below the baseline. This is some-
times seen in unstable angina.
Limb leads
Adam SK, Osborne S (2003) Critical Care Nursing:
Science and Practice. Oxford University Press,
Figure 3. View of the limb leads Oxford

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British Journal of Cardiac Nursing February 2007 Vol 2 No 2 59

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