12 Lead ECG Color Codes 1 - 04

12 Lead ECG
Interpretation: Color
Coding for MIs
Anna E. Story, RN, MS
Director, Continuing Professional Education

Critical Care Nurse
Online Instructional Designer
2004
Anna Story
Objectives
review the ECG waveform and intervals

Define myocardial ischemia, injury and
infarction
Identify the 5 major infarct areas on the 12
lead
Name occluded arteries common to the area
Differentiate ECG changes reflecting
ischemia, injury and infarction
Identify cardiac enzymes associated with ACS
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MI Definition
A result of occlusion of arterial flow

to the myocardium.
Ischemia, injury and necrosis is
result
Occlusion occurs via spasm, blood
clot or stenosis
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The 12-Lead view
Each limb lead I, II, III, AVR, AVL, AVF

records from a different angle
All six limb leads intersect and visualize
a frontal plane
The six chest leads (precordial) V1, V2,
V3, V4, V5, V6 view the body in the
horizontal plane to the AV node
The 12 lead ECG forms a camera view
from 12 angles
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Views from Augmented

and Limb Leads- Frontal
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Precordial lead snapshots
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Think of each
precordial lead as
a horizontal view
of the heart at the
AV node
With the limb leads
and the precordial
leads you have a
snapshot of heart
portions
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Unipolar and Bipolar
Limb leads I, II, III are bipolar and have a

negative and positive pole
AVR, AVL and AVF are unipolar
Electrical potential differences are measured

between the poles
No negative lead
The heart is the negative pole
Electrical potential difference is measured
betweeen the lead and the heart
Chest leads are unipolar
The heart also is the negative pole

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Lead Placement is
Important
Each positive electrode

acts as a camera
looking at the heart
Ten leads attached for
twelve lead diagnostics.
The monitor combines 2
leads.
Mnemonic for limb leads
White on right
Smoke(black) over
fire(red)
Clouds (white) over
grass(green)
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Precordial Leads
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I and
AVL
V3 &
v4
V1 & v2
II, III and AVF
V5 &
v6
Where the positive

electrode is positioned,
2004 Anna Storydetermines what part of the
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The ECG Tracing: Waves
P- wave
Marks the beginning of the cardiac cycle and measures

the electrical impulse that causes atrial depolarization
and mechanical contraction
QRS- Complex
Measures the impulse that causes ventricular

depolarization
Q-wave- may or may not be evident on the ECG

R-wave- first upward deflection following P wave
S-wave- the first downward deflection following the R-wave
T- wave
Marks ventricular repolarization that ends the cardiac

cycle
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Intervals and Segments
P-R interval
QRS Interval
Time interval for impulse to go from AV node to stimulate

Purkinjie fibers
Less than 0.12 secs
QT Interval
Time interval for impulse to go from the SA to the AV node

normal 0.12-0.20 secs
Time interval from beginning of depolarization to the end of

repolarization
Should not exceed the length of the R-R
ST segment
end of the S to the beginning of the T

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The ECG Tracing
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ECG Changes : Ischemia
T-wave inversion ( flipped T)

ST segment depression
T wave flattening
Biphasic T-waves
Baseline
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ECG Changes: Injury
ST segment elevation of greater than 1mm in

at least 2 contiguous leads
Heightened or peaked T waves
Directly related to portions of myocardium
rendered electrically inactive
Baseline
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ECG Changes: Infarct
Significant Q-wave where none previously existed

Why?
Impulse traveling away from the positive lead
Necrotic tissue is electrically dead

No Q-wave in Subendocardial infarcts
Why?
Not full thickness dead tissue
But will see a ST depression
Often a precursor to full thickness MI
Criteria
Depth of Q wave should be 25% the height of the R wave
Width of Q wave is 0.04 secs
Diminished height of the R wave
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Evolving MI and Hallmarks

of AMI
Q wave
ST Elevation
1 year
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T wave
inversion
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Dissecting the 12 Lead

ECG
Horizontal marks time

Vertical marks amplitude
6 limb leads
6 precordial leads
Positioning measures 12 perspectives or
views of the heart
The 12 perspectives are arranged in vertical
columns
Limb leads are I, II, III, AVR, AVL, AVF
Precordial leads are V1, V2, V3, V4, V5, V6
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A Normal 12 Lead ECG
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A Normal 12 Lead ECG
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Color Coding ECGs

Anterior
Yellow indicates V1,

V2, V3, V4
Anterior infarct with ST

elevation
Left Anterior Descending
Artery (LAD)
V1 and V2 may also indicate
septal involvement which
extends from front to the
back of the heart along the
septum
Left bundle branch block
Right bundle branch block
2nd Degree Type2
Complete Heart Block
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Anterior MI
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Color Coding ECGInferior
Blue indicates leads

II, III, AVF
Inferior Infarct with

ST elevations
Right Coronary
Artery (RCA)
1st degree Heart
Block
2nd degree Type 1, 2
3rd degree Block
N/V common, Brady
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Inferior MI
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As an aside.
Right sided EKG

Ever heard of it?
Ever done one?
Think about it..
For your cases that are clearly inferior MIs

Obtain a dextrocardiogram whenever ST
segment elevation is noted in Inferior
leads
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Right Sided EKG????
RVI occurs around 40% in

inferior MIs
Significance
The single most

accurate tool used in
measuring RVI.
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Larger area of infarct

Both ventricles
Different treatment
Right leads look directly

at Right Ventricle and can
show ST elevations in
leads II. III. AVF, V4R , V5R
and V6R
Occlusion in RCA and
proximal enough to
involve the RV
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Clinical Triad of RVI
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Hypotension
Jugular vein
distention
Dry lung sounds
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Color Coding ECG- Lateral
Red indicates leads

I, AVL, V5, V6
Lateral Infarct
with ST
elevations
Left Circumflex
Artery
Rarely by itself
Usually in combo
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Lateral MI
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Color Coding ECGPosterior
Green indicates leads V1,

V2
Posterior Infarct with ST
Depressions and/ tall R wave
RCA and/or LCX Artery
Understand Reciprocal changes
The posterior aspect of the
heart is viewed as a mirror
image and therefore
depressions versus
elevations indicate MI
Rarely by itself usually in
combo
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Posterior MI
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Color Coding ECGSubEndo
No color for
SubEndocardial
infarcts since they
are not transmural
Look for diffuse or
localized changes
and non Q wave
abnormalities
T-wave inversions
ST segment
depression
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SubEndo MI
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More than one color shows

abnormality
A combination of infarcts such as:
Anterolateral yellow and red

Inferoposterior blue and green
Anteroseptal yellow and green
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Putting it ALL together
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Practice 1
Anterior MI with lateral

involvement
Click
for
answer
ST elevations V2, V3, V4
ST elevations II, AVL, V5
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Practice 2
Click
for
answer
Anteroseptal MI
ST elevations V1, V2, V3,

V4
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Practice 3
Click
for
answer
Inferior MI
ST elevation 2,3 AVF
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Practice 4
Click
for
answer
Inferior lateral MI
ST elevations 2, 3, AVF
ST elevations V5
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Practice 5
Click
for
answer
Acute inferior
MI
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Lateral
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Additional Practice Strips
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Cardiac Enzymes
Indicating Infarct
Normals
CPK- 10-155u/liter
CPK-MB < than 5% IU/liter

LDH 85-200 IU/liter
begin rise 3-6 hours and peaks 12-24 with return

to norm 3-5 days
Begin rise 12 hours, peaks 36-72 and normal

around 10 days
LDH 1- 18.1% - 29% of total

LDH 2- 27.4% to 37.5% of total
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Cardiac Enzymes
Indicating Infarct
Troponins- Now the

Gold Standard!
Rises after 3-6 hours

Negative Troponin
within 6 hours of
onset of S&S rules
out the MI
Peaks at about 20
hours
May be raised for 14
days
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Cardiac Enzymes
Indicating Infarct
Troponin T
84% sensitivity for MI 8 hours after onset of

symptoms
22% for unstable angina
Advantages
Highly sensitive for detecting myocardial ischemia

Levels may help to stratify risks
Disadvantages
Less specific than Troponin I

Increased in angina
Increased in chronic renal failure
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Cardiac Enzymes
Indicating Infarct
Troponin I
90% sensitivity for MI 8 hours after onset of

S&S and 95% specificity
Level greater than 1.2 suggest MI
Negative rules out MI
Obtain two negative troponin values 4 hours
apart
Normally exceedingly low
Even a small elevation indicates

myocardial damage
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References
Twelve Lead Electrocardiography for ACLS Providers, D.

Bruce Foster, D.O.
W.B. Saunders Company
Rapid Interpretation of EKGs , Dale Dubin, M.D., Cover
Publishing Co. 1998
ECGs Made Easy, Barbara Aehlert, RN, Mosby, 1995
The 12 Lead ECG in Acute Myocardial Infarction, Tim Phalen,
Mosby, 1996
Color Coding EKGs , Tim Carrick, RN, H &H Publishing, 1994
www.ecglibrary.com/ecghome.html
www.urbanhealth.udmercy.edu/ekg/read.html
www.ecglibrary.com/ecghome.html
www.nyerrn.com/h/ekg.htm
Drawings by Jill Gregory, Medical Illustrator, CGEY
2004
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12 Lead ECG Color Codes 1 - 04

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12 Lead ECG Color Codes 1 - 04

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12 Lead ECG

Anna E. Story, RN, MS

Director, Continuing Professional Education

review the ECG waveform and intervals

A result of occlusion of arterial flow

The 12-Lead view

Each limb lead I, II, III, AVR, AVL, AVF

Views from Augmented

Precordial lead snapshots

Unipolar and Bipolar

Limb leads I, II, III are bipolar and have a

AVR, AVL and AVF are unipolar

Electrical potential differences are measured

Chest leads are unipolar

The heart also is the negative pole

Each positive electrode

Where the positive

The ECG Tracing: Waves

Marks the beginning of the cardiac cycle and measures

Measures the impulse that causes ventricular

Q-wave- may or may not be evident on the ECG

Marks ventricular repolarization that ends the cardiac

Intervals and Segments

Time interval for impulse to go from AV node to stimulate

Time interval for impulse to go from the SA to the AV node

Time interval from beginning of depolarization to the end of

end of the S to the beginning of the T

The ECG Tracing

ECG Changes : Ischemia

T-wave inversion ( flipped T)

ECG Changes: Injury

ST segment elevation of greater than 1mm in

ECG Changes: Infarct

Significant Q-wave where none previously existed

Necrotic tissue is electrically dead

Evolving MI and Hallmarks

Dissecting the 12 Lead

Horizontal marks time

A Normal 12 Lead ECG

A Normal 12 Lead ECG

Color Coding ECGs

Yellow indicates V1,

Anterior infarct with ST

Color Coding ECGInferior

Blue indicates leads

Inferior Infarct with

Right sided EKG

For your cases that are clearly inferior MIs

Right Sided EKG????

RVI occurs around 40% in

The single most

Larger area of infarct

Right leads look directly

Clinical Triad of RVI

Color Coding ECG- Lateral

Red indicates leads

Color Coding ECGPosterior

Green indicates leads V1,

Color Coding ECGSubEndo

More than one color shows

A combination of infarcts such as:

Anterolateral yellow and red

Putting it ALL together