chapter

Determining Axis and Hemiblock

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Chapter 3 Objectives
Describe the intraventricular conduction
system Define axis and axis deviation Using a simple chart, determine axis and the presence of hemiblock Describe the clinical significance of axis deviation and hemiblock

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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Hexaxial System
Traditional method 6 limb leads at
various angles Somewhat tedious and difficult to master

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

What Is Axis?
Overall direction of
travel of electrical impulses as they move through the heart Normal axis is downward and toward the left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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Normal Axis
Upright complexes
in Leads I, II, III Forces going toward all three leads Impulses going toward a positive, make a positive deflection

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Left Axis

Normal variant in
adults Common in obesity and athletes Lead II can show upward or halfway deflection Lead III is down

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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Pathological Left Axis

Disease process Suggests anterior
hemiblock Patients are 4 times more likely to arrest with a hemiblock and chest pain

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Right Axis Deviation

Rare occurrence in
adults Almost always pathological Associated with posterior hemiblock Lead I down and Lead III up

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Extreme Right Axis Deviation

Indeterminate axis Usually ventricular in
origin Down in all three leads, I, II, III

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Fascicular Block (Hemiblock)

A block of one of the
two fascicles of the left bundle ECG diagnosis Based on axis deviation

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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Anterior Hemiblock
Pathological left axis 4x higher mortality
rate when with an AMI Proximal occlusion until proven otherwise

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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Posterior Hemiblock
Right axis deviation Very high mortality
with an AMI Serious problem involving two coronary arteries

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To Determine Axis
Run Leads I, II, and III Leads must be on the limbs! Look at the net QRS deflection in each
lead (does it go up or down, or halfway) Compare to the rapid axis and hemiblock chart

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Calculated Axis Angle

Machine calculates
this for you Use it with your chart Look at the QRS axis or the R axis on some units Follow the chart

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Rapid Axis and Hemiblock Chart

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Practice 12-Leads

Use the Rapid Axis and Hemiblock Chart!

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Normal Axis

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Normal Axis

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Right Axis Deviation

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anterior Hemiblock

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Normal Axis

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Normal Axis

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physiological Left

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anterior Hemiblock

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anterior Hemiblock

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anterior Hemiblock

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anterior Hemiblock

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Posterior Hemiblock

Page, 12-Lead ECG for Acute and Critical Care Providers 2006 by Pearson Education, Inc. Upper Saddle River, NJ