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LAST MONTH, I described thecomponents of the 12-lead electro-cardiogram (ECG) and how to rec-ognize a normal ECG. In this arti-cle, I’ll explain some advancedtechniques that you can use tointerpret common ECG abnormali-ties: bundle-branch blocks,myocardial infarction (MI), andcommon dysrhythmias.

Bundle-branch blocks:Obstruction in the conduction

Probably the most common ECGabnormality you’ll encounter is abundle-branch block, whichappears on the ECG as a wider-than-normal QRS complex (morethan 0.12 second in duration). Asyou know, the cardiac impulse,originating in the sinoatrial (SA)node,normally travels through thebundle of His into the right andleft bundle branches in the sep-tum. The two bundle branches ter-minate in the Purkinje fibers. When the impulse reaches them,ventricular depolarization begins.Normally the impulse is deliv-ered to myocardial cells on bothsides of the heartsimultaneously,so depolarization begins at thesame time on both sides of theheart. The result is a veryfast, syn-chronous contraction of the ventri-cles. On ECG, the normal QRScomplex duration from two intactbundle branches is 0.12 second orless (three or fewer small squaresof the ECG paper).Abundle-branch block occurswhen one of the two bundlebranches can’t conduct the cardiacimpulse to the myocardial cells.The most common cause of chron-ic bundle-branch block is ischemicheartdisease. When anartery sup-plying the bundle branch narrows,the flow of oxygenated blood isreduced and the bundle branchcan’t conduct impulses normally.Acommon cause of acutebundle-branch block is acute MI.If the MI involves the ventricularseptum, one of the bundle branch-es may become infarcted, leadingto a loss of conduction. Althoughuncommon, physical injury of abundle branch during an invasiveproceduresuch as cardiac cathe-terization or heart surgery also mayproduce a bundle-branch block.

•

In a

right bundle-branch block(RBBB),

impulse conduction tothe right ventricle is blocked. Thecardiac impulse is conducted onlyto the left side of the heartwhereleft ventricular depolarization

Nursing2006,

Volume 36, Number 12www.nursing2006.com

Learn to recognize bundle-branch blocks, myocardial infarction, and common dysrhythmias.

BY GUY GOLDICH, RN, CCRN, MSN

12-leadECG

Understanding the

part II

Lead V

showing RBBB

begins. The right side of the heartdepolarizes only in response to thecell-to-cell wave of depolarizationthat travels from the left side of theheart. This cell-to-cell depolariza-tion is much slower than the nor-mal synchronous depolarization;that’s why the QRS complex is sig-nificantly wider than normal.Examine lead V

to identify anRBBB. In lead V

, the normal QRScomplex consists of a small Rwave, then a large S wave. As yourecall, lead V

looks at the rightside of the heart. A small vectororiginating in the septum towardV

creates a small upward R wave,then the predominant mean QRSvector creates the large S wave asthe mean QRS vector flows awayfrom lead V

.In RBBB, the path of the meanQRS vector is changed due to left-to-right slow conduction; lead V

now records a delayed R waveapproaching it, resulting in a posi-tive R wave. So the key identifier of RBBB in lead V

is a QRS complexwider than 0.12 second with adelayed (longer than 0.07 second)positive main R wave. Some RBBBsmay display a triphasic waveform(“rabbit ears”) consisting of a smallr wave, downward S wave, and asecond, larger R wave.

•

In a

left bundle-branch block(LBBB),

electrical impulses don’treach the left side of the heartnormally, so once again, synchro-nous depolarization of the ventri-cles doesn’t occur. Depolarizationbegins in the right side of theheart and travels in a right-to-leftdirection via slow cell-to-celldepolarization. Lead V

recordsthe mean QRS vector directedaway from its positive lead,resulting in a wide downwardcomplex. Because the mean vec-tor takes a relatively longer timeto cross to the left side of theheart, the QRS complex is widerthan 0.12 second. The key to rec-ognizing an LBBB is a wide,downward S wave or rS wave inleads V

and V

Recognizing an MI

One of the most critical functionsof the 12-lead ECG is to determinewhether a patient is experiencingan acute MI. A series of predictableECG changes that occur during anMI help you identify it quickly andinitiate appropriate treatment.Among one of the earliestchanges in the ECG tracing is anelevation of the ST segment, indi-

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Lead V

showing LBBB

cating reversible myocardial injury(see

Understanding ST-segment ele-vation

). In a normal ECG, the STsegment is level with the tracing’sbaseline. When myocardial cellssustain injury from MI, depolariza-tion is impaired, resulting in ST-segment elevation in the leadsmonitoring the affected areas of theheart. An ST-segment-elevation MI(STEMI), the most serious type of MI, is associated with more com-plications and a higher risk of death.

The leads with ST-segment ele-vations identify the area of myocar-dial injury, so you can determinethe region of the heart affected byknowing which area is monitoredby which ECG lead. Let’s look atsome examples.

•

Because leads II, III, and aVF allmonitor the inferior (or bottom)wall of the heart from slightly dif-ferent directions, they’re usuallydescribed as the inferior leads. Thisarea of the heart is perfused by theright coronary artery. A patientwith a STEMI involving the inferi-or wall of the heart will have ele-vated ST segments in leads II, III,and aVF (see

Inferior-wall STEMI

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Another common infarct leadpattern occurs when an MIinvolves the intraventricular sep-tum, which is perfused by the leftanterior descending (LAD) coro-nary artery. In a

septal MI

, theleads monitoring the septum’selectrical activity will display ele-vated ST segments. Precordial (orchest) leads V

and V

, which arelocated on the anterior chest walldirectly over the septum, mostaccurately monitor the septum’selectrical activity. (These leadsalso are known as the septalleads.) The patient experiencing aseptal MI will have ST-segmentelevations in leads V

and V

•

Directly to the left of the septalarea of the heart is the largefrontal or

wall of theheart, which is also perfused bythe LAD coronary artery. As themost muscular and powerfulpumping wall of the heart, theanterior wall is responsible for alarge proportion of cardiac output.Anatomically, leads V

and V

arelocated directly above the anteriorwall of the heart and monitor itselectrical activity. An anterior-wallSTEMI will cause the ST segmentsin these leads to be elevated (see

Anterior-wall STEMI

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The lateral wall of the heart, per-fused by the left circumflex artery,

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