the axis presentation
DESCRIPTION
Learn how & why to determine the QRS axisTRANSCRIPT
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The ECG AxisAdam Thompson, EMT-P
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WARNING
Axis determination is not as difficult to understand as people think. It is the foundation of ECG interpretation. Don’t try to understand everything, choose the method that suits you best!
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Cardiology Stuff
Please ask questions!!
Don’t worry, I’ll explain this stuff
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The 6-Step Method
• 1. Rate & Rhythm• 2. Axis Determination• 3. Intervals• 4. Morphology• 5. STE-Mimics• 6. Ischemia, Injury, & Infarct
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45 y/o Male with Chest Pain
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Pathologies
Frontal Plane Axis Precordial Axis
ERAD-90 to 180
Right Axis Deviation90 to 180
Pathological Left Axis Deviation
-30 to -90
Early TransitionCounterclockwise
Rotation
Late TransitionClockwise Rotation
• Ventricular Rhythm• Paced Rhythm• Dextrocardia• Electrolyte derangement
• May be normal• LPFB• Pulmonary disease• RVH• RBBB• WPW• Dextrocardia•Venrticular Rhythm
• Pregnancy• LAFB• WPW• Pulmonary disease• LBBB• Hyperkalemia• Q-waves, MI
• Posterior wall infarction• RVH• RBBB• WPW
• Sometimes Normal, especially in women• Anterior MI• LVH• LAFB• LBBB• Lung Disease
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Ventricular Axis
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Ventricular Depolarization
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What’s Normal?
• The normal QRS Axis is about 60°• This can vary, and the normal range is between 0° to 90°
I+0°
I-
II+
III-
III+
II-
aVR-
aVR+
aVF+
aVF-
aVL+
aVL-
30°
-30°
60°90°
120°
150°
+/-180°
-150°
-120°
-90°-60°
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Willem Einthoven
Won the Nobel Prize in Physiology or Medicine in 1924 for inventing the string galvanometer which was the first EKG.
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Einthoven’s Triangle
• Electrically, leads I, II, & III form an equilateral triangle.
• Einthoven’s Law
I + (-II) + III = 0
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Einthoven’s Law
• How it works• Lead I
– The R wave is about 7 1/2 mm tall.– The S wave is about 2 1/2 mm deep.– Subtract the S wave from the R wave
• you come up with 5 mm.
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Einthoven’s Law
• Lead I = 5mm• Lead II
– It’s essentially a monophasic QS complex. – About -10 mm.
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Einthoven’s Law
• Lead I = 5mm• Lead II = -10mm• Lead III
– R wave that is about 1 mm high.– The S wave is about 16 mm deep. – Subtract the S wave from the R
wave.– -15 mm.
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Einthoven’s Law
• Lead I = 5mm• Lead II = -10mm• Lead III = -15mm
– Plug the numbers in.
I + (-II) + III = 0
5 + 10 -15 = 0
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Einthoven’s Law
The equilateral triangle
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Electrical Axis
Ventricular depolarization
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Mean Vector
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Mean Vector
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The Hexaxial Reference System
I
IIIII
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Hexaxial Diagram
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Hexaxial Diagram
I
IIIII aVF
aVLaVR
I+0°
I-
II+
III-
III+
II-
aVR-
aVR+
aVF+
aVF-
aVL+
aVL-30°
-30°
60°90°120°
150°
+/-180°
-150°
-120°-90° -60°
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The Hexaxial Reference System
I+0°
I-
II+
III-
III+
II-
aVR-
aVR+
aVF+
aVF-
aVL+
aVL-30°
-30°
60°
90°120°
150°
+/-180°
-150°
-120°
-90°-60°
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The Hexaxial Method
We only need to concentrate on the first six leads
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The Hexaxial Method
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The Hexaxial Method
Step 1: Find the equiphasic lead
I+0°I-
II+
III-
III+
II-
aVR-
aVR+
aVF+
aVF-
aVL+
aVL-
30°
-30°
60°90°120°
150°
+/-180°
-150°
-120°
-90° -60°
Step 4: Is the perpendicular lead positive or negative?
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QRS Axis
ERAD LAD
RAD Normal
180 0
-90
90
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The Hexaxial Method
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The Hexaxial Method
Let’s try another one
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The Quadrant Method
ERAD LAD
RAD Normal
180 0
-90
90
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Quadrant Method
- I I +
aVF -
Negative QRS Complex in aVF
Positive QRS Complex in aVF
aVF +
- I I +
aVF +
aVF -
Positive QRS in Lead I
Negative QRS in Lead I
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Quadrant method
Is Lead I up or down?
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Quadrant Method
- I I +
aVF +
aVF -
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Quadrant method
Is aVF up or down?
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Quadrant Method
- I I +
aVF +
aVF -
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Quadrant Method
- I I +
aVF +
aVF -
ERAD LAD
RAD Normal
180 0
-90
90
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Quadrant Method
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Frontal Plane Axis Pathologies
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Print Master
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Fascicular Block
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If all else fails…
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Precordial Axis
Limb Leads Precordial Leads
Lead I aVR V1 V4
Lead II aVL V2 V5
Lead III aVF V3 V6
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Pathologies
Frontal Plane Axis Precordial Axis
ERAD-90 to 180
Right Axis Deviation90 to 180
Pathological Left Axis Deviation
-30 to -90
Early TransitionCounterclockwise
Rotation
Late TransitionClockwise Rotation
• Ventricular Rhythm• Paced Rhythm• Dextrocardia• Electrolyte derangement
• May be normal• LPFB• Pulmonary disease• RVH• RBBB• WPW• Dextrocardia•Venrticular Rhythm
• Pregnancy• LAFB• WPW• Pulmonary disease• LBBB• Hyperkalemia• Q-waves, MI
• Posterior wall infarction• RVH• RBBB• WPW
• Sometimes Normal, especially in women• Anterior MI• LVH• LAFB• LBBB• Lung Disease
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The Precordial Axis
V1
V2
V3
V4
V5V6
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Precordial Axis
Normal R-wave progression
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Precordial Axis
Early R-wave progression
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Precordial Axis
Late R-wave progression
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Bundle Branch Blocks
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Bundle Branch Blocks
1
2
3
Left Bundle Branch Block
V1
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Bundle Branch Blocks
1
2
3
Right Bundle Branch Block
V1
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Bundle Branch Blocks
V1
V1
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Bundle Branch Blocks
= RBBB
= LBBB
V1
V1 GT
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BBBs
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BBBs
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RBBB Morphologies
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LBBB Morphologies
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Pathologies
Frontal Plane Axis Precordial Axis
ERAD-90 to 180
Right Axis Deviation90 to 180
Pathological Left Axis Deviation
-30 to -90
Early TransitionCounterclockwise
Rotation
Late TransitionClockwise Rotation
• Ventricular Rhythm• Paced Rhythm• Dextrocardia• Electrolyte derangement
• May be normal• LPFB• Pulmonary disease• RVH• RBBB• WPW• Dextrocardia•Venrticular Rhythm
• Pregnancy• LAFB• WPW• Pulmonary disease• LBBB• Hyperkalemia• Q-waves, MI
• Posterior wall infarction• RVH• RBBB• WPW
• Sometimes Normal, especially in women• Anterior MI• LVH• LAFB• LBBB• Lung Disease
![Page 62: The axis presentation](https://reader035.vdocument.in/reader035/viewer/2022062705/55654d0dd8b42a77078b46e2/html5/thumbnails/62.jpg)
Bundle Branch Blocks
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Bundle Branch Blocks
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Practice
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Practice
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Practice
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Pathologies
Frontal Plane Axis Precordial Axis
ERAD-90 to 180
Right Axis Deviation90 to 180
Pathological Left Axis Deviation
-30 to -90
Early TransitionCounterclockwise
Rotation
Late TransitionClockwise Rotation
• Ventricular Rhythm• Paced Rhythm• Dextrocardia• Electrolyte derangement
• May be normal• LPFB• Pulmonary disease• RVH• RBBB• WPW• Dextrocardia•Venrticular Rhythm
• Pregnancy• LAFB• WPW• Pulmonary disease• LBBB• Hyperkalemia• Q-waves, MI
• Posterior wall infarction• RVH• RBBB• WPW
• Sometimes Normal, especially in women• Anterior MI• LVH• LAFB• LBBB• Lung Disease
![Page 73: The axis presentation](https://reader035.vdocument.in/reader035/viewer/2022062705/55654d0dd8b42a77078b46e2/html5/thumbnails/73.jpg)
45 y/o Male with Chest Pain
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The End
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Questions?
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