12-Lead Electrocardiography              a comprehensive course                   Adam Thompson, EMT-P, A.S.
Frontal Axis
Precordial Axis• Sometimes called Z axis• Clockwise or Counterclockwise rotation
Precordial Axis                 Frontal Plane Axis                          Precordial Axis   ERAD               Right Axi...
Precordial Axis Precordial Leads = V LeadsSometimes called Chest Leads
Precordial Axis                  4       1  3                    3   • The main impulse travels       2              2    ...
Precordial Axis                  4       1  3                    3       2              2                 V1   V2         ...
Precordial Axis• The normal transition zone is between  V3 and V4.• V1 should be predominately negative.• V6 should be mos...
Precordial AxisLets take a look at a 12-lead
Precordial AxisIs V1 mostly negative?
Precordial AxisIs V6 mostly positive?
Precordial AxisWhere is the transition?
Precordial AxisThe Precordial Axis is Normal
Precordial Axis                         V1                               V2                                    V3         ...
Precordial Axis                         V1                               V2                                    V3         ...
Precordial Axis                          V1                                 V2                                      V3    ...
Precordial Axis                           V1                                 V2                                       V3  ...
Precordial Axis
Precordial AxisEarly Transition - Counterclockwise Rotation
Precordial AxisEarly Transition - Counterclockwise Rotation
Precordial Axis Another Example
Precordial AxisLate Transition - Clockwise Rotation
Precordial Axis                 Frontal Plane Axis                          Precordial Axis   ERAD               Right Axi...
Precordial AxisAxis Determination                        Normal R-wave progression                                        ...
Precordial AxisAxis Determination                                                                        Thompson 100     ...
Precordial AxisAxis Determination                        Late R-wave progression                                          ...
Bundle Branch BlocksLeft Bundle Branch Block                  V1       1                                   2              ...
Bundle Branch BlocksRight Bundle Branch Block                  V1    1                            2                       ...
Bundle Branch Blocks   V1   V1
Bundle Branch BlocksV1     = RBBBV1                            GT     = LBBB
RBBB Morphologies
LBBB Morphologies
Bundle Branch Blocks               Frontal Plane Axis                          Precordial Axis   ERAD             Right Ax...
Bundle Branch Blocks
Bundle Branch Blocks
The End       “Its finally over”       …Well almost.More to come in lesson three.
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5 precordial axis

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  • Counterclockwise rotation, indeterminate axis
  • A LBBB doesn’t always cause late r-wave progression, but it is common.
  • A RBBB will always cause early r-wave progression
  • 5 precordial axis

    1. 1. 12-Lead Electrocardiography a comprehensive course Adam Thompson, EMT-P, A.S.
    2. 2. Frontal Axis
    3. 3. Precordial Axis• Sometimes called Z axis• Clockwise or Counterclockwise rotation
    4. 4. Precordial Axis Frontal Plane Axis Precordial Axis ERAD Right Axis Pathological Early Transition Late Transition Deviation Left Axis Counterclockwise Clockwise -90 to 180 90 to 180 Deviation Rotation Rotation -30 to -90• Ventricular • May be normal • Pregnancy • Posterior wall • SometimesRhythm • LPFB • LAFB infarction Normal,• Paced • Pulmonary • WPW • RVH especially inRhythm disease • RBBB women • Pulmonary• Dextrocardia • RVH disease • WPW • Anterior MI• Electrolyte • RBBB • LBBB • LVHderangement • WPW • Hyperkalemia • LAFB • Dextrocardia • Q-waves, MI • LBBB •Venrticular • Lung Disease Rhythm
    5. 5. Precordial Axis Precordial Leads = V LeadsSometimes called Chest Leads
    6. 6. Precordial Axis 4 1 3 3 • The main impulse travels 2 2 down then to the left.Mean vectorCardiac vector
    7. 7. Precordial Axis 4 1 3 3 2 2 V1 V2 V3 V6Mean vector V4 V5Cardiac vector
    8. 8. Precordial Axis• The normal transition zone is between V3 and V4.• V1 should be predominately negative.• V6 should be mostly positive.
    9. 9. Precordial AxisLets take a look at a 12-lead
    10. 10. Precordial AxisIs V1 mostly negative?
    11. 11. Precordial AxisIs V6 mostly positive?
    12. 12. Precordial AxisWhere is the transition?
    13. 13. Precordial AxisThe Precordial Axis is Normal
    14. 14. Precordial Axis V1 V2 V3 V4 V5 V6Now picture the precordial leads in this pattern.
    15. 15. Precordial Axis V1 V2 V3 V4 V5 V6Normal transition
    16. 16. Precordial Axis V1 V2 V3 V4 V5 V6Early transition = Counterclockwise Rotation
    17. 17. Precordial Axis V1 V2 V3 V4 V5 V6Late transition = Clockwise Rotation
    18. 18. Precordial Axis
    19. 19. Precordial AxisEarly Transition - Counterclockwise Rotation
    20. 20. Precordial AxisEarly Transition - Counterclockwise Rotation
    21. 21. Precordial Axis Another Example
    22. 22. Precordial AxisLate Transition - Clockwise Rotation
    23. 23. Precordial Axis Frontal Plane Axis Precordial Axis ERAD Right Axis Pathological Early Transition Late Transition Deviation Left Axis Counterclockwise Clockwise -90 to 180 90 to 180 Deviation Rotation Rotation -30 to -90• Ventricular • May be normal • Pregnancy • Posterior wall • SometimesRhythm • LPFB • LAFB infarction Normal,• Paced • Pulmonary • WPW • RVH especially inRhythm disease • RBBB women • Pulmonary• Dextrocardia • RVH disease • WPW • Anterior MI• Electrolyte • RBBB • LBBB • LVHderangement • WPW • Hyperkalemia • LAFB • Dextrocardia • Q-waves, MI • LBBB •Venrticular • Lung Disease Rhythm
    24. 24. Precordial AxisAxis Determination Normal R-wave progression Thompson 93ECG - 20ECG – 20This is a rare example of an isolated Lateral Wall Infarct. This injury pattern is nearly always due to an occlusion to the LeftCircumflex (LCx). 5 Easy Steps
    25. 25. Precordial AxisAxis Determination Thompson 100 Early R-wave progressionECG – 26ECG – 26This ECG is an example of Right Bundle Branch Block (RBBB). RBBB is presentwhen a wide supraventricular rhythm presents with a positive terminal deflection in V1.Other findings include appropriate T-wave discordance, and a slurred S-wave in Lead I
    26. 26. Precordial AxisAxis Determination Late R-wave progression Thompson 90ECG – 17ECG – 17This is an example of an Antero-Septal MI, with some lateral wall extension. This is likely due to a proximal occlusion of the LeftAnterior Descending coronary artery (LAD). The LAD, termed ―Widow Maker‖, supplies predominately the left ventricle.
    27. 27. Bundle Branch BlocksLeft Bundle Branch Block V1 1 2 3
    28. 28. Bundle Branch BlocksRight Bundle Branch Block V1 1 2 3
    29. 29. Bundle Branch Blocks V1 V1
    30. 30. Bundle Branch BlocksV1 = RBBBV1 GT = LBBB
    31. 31. RBBB Morphologies
    32. 32. LBBB Morphologies
    33. 33. Bundle Branch Blocks Frontal Plane Axis Precordial Axis ERAD Right Axis Pathological Early Transition Late Transition Deviation Left Axis Counterclockwise Clockwise -90 to 180 90 to 180 Deviation Rotation Rotation -30 to -90• Ventricular • May be normal • Pregnancy • Posterior wall • SometimesRhythm • LPFB • LAFB infarction Normal,• Paced Rhythm • Pulmonary • WPW • RVH especially in• Dextrocardia disease • RBBB women • Pulmonary• Electrolyte • RVH disease • WPW • Anterior MIderangement • RBBB • LBBB • LVH • WPW • Hyperkalemia • LAFB • Dextrocardia • Q-waves, MI • LBBB •Venrticular • Lung Disease Rhythm
    34. 34. Bundle Branch Blocks
    35. 35. Bundle Branch Blocks
    36. 36. The End “Its finally over” …Well almost.More to come in lesson three.

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