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.













Figure 1. The normal electrocardiogram.


he 12-lead electrocardiogram (ECG) remains one of the most useful clinical tools in the evaluation of the cardiac patient. Its use is widespread and can be of use as part of the assessment process in many presentations such as: w Chest pain w Shortness of breath w Blackouts w Palpitations w Syncope w And many others… Mark Whitbread is the Clinical Practice Manager for the London Ambulance Service
Key words w ECG w Patient history w 10 rules w Isoelectric line
Accepted for publication 19 January 2006

However, the 12-lead ECG must be looked at carefully and in a systematic way and this often takes many years to master. The ECG should always be used along with the patient’s history. Each month an ECG will be presented with a short patient history for the reader to analyze. In this first edition, a systematic approach to analysing ECGs is presented along with a normal 12-lead ECG (Figure 1) so that the reader can practice applying the framework to the ECG. The framework uses ten rules that can be applied to any ECG.

The ten rules

A starting framework for the systematic approach to the 12-lead ECG. For positioning of the leads see Figure  2 and for the view of the limb leads see Figure 3. w All waves are negative in aVR. This has to be so: aVR represents electrical

activity as seen from the right shoulder. The sinus node is placed top right in the heart nearest the right shoulder and the electrical activity is moving downwards and leftwards towards the left ventricle. w The ST segment starts on the isoelectric line, except in V1 and V2 where it may be elevated (not >1 mm). The normal ST then curves gently in the direction of the T wave and should not remain exactly horizontal w The PR interval should be 0.12–0.2 seconds. A longer PR implies AV block, a shorter PR may indicate a vulnerability to supraventricular arrhythmias w The QRS complex should not exceed 0.11–0.12 seconds. A wider QRS is sometimes seen in healthy people but may represent an abnormality of intraventricular conduction w The QRS and T waves tend to have the


British Journal of Cardiac Nursing

February 2007

Vol 2 No 2

II and V2 to V6. The end of the T wave should not dip below the baseline. Osborne S (2003) Critical Care Nursing:  Science and Practice. w The T wave is upright in I II and V2 to V6. if the QRS in aVL is dominantly positive than the T wave in that lead should also be positive. Oxford Limb leads Figure 3. This is sometimes seen in unstable angina.Practical Procedures Table 1. For example. Standard chest lead placement B. Adam SK. View of the limb leads Subscribe today: Call freephone: 0800 137201 59 British Journal of Cardiac Nursing February 2007 Vol 2 No 2 . Otherwise there is axis deviation w The P wave is upright in I II and V2 to V6. Slight disparities are likely to be normal w The R wave in the precordial (chest) leads grows from V1 to at least V4 where it may or may not decline again. A narrow q is expected in V6 and represents the early septal activation. Right sided chest lead placement Figure 2. By implication they may be flat or negative in other leads w There is no Q wave or only a small q (< 0. 2003. 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 V5 V4 4th intercostal space V6R V5R V4R V1R aVF augmented view foot/left leg 6 Chest leads: V1 V2 V3 V4 V5 V6 From: Adam and Osborne.04second in width) in I. V2 V3 V3R V2R A. Oxford University Press. Positioning of chest leads RA I LA II III LL same general direction in the standard (limb) leads. 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.

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