Resuscitation 83 (2012) e115–e116
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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
ECGs: Colour-coding for initial training
Sir,
We describe the use of the four primary
to define the four distinct electrical
windows of the 12-Lead ECG: inferior, lateral, anterior, right to
facilitate initial training for reading ECGs.
The rhythm strip (usually lead II) is most commonly viewed
first after confirmation of the patient details.1 Additionally, when
recording an ECG, the left leg lead (which is the positive electrode
for leads aVF, II and III) is always coloured Green by convention
(Europe, not USA). Therefore Green is the colour for all three infe-
rior leads (II, III, aVF). The left arm ECG lead (which is the positive
electrode for aVL and lead I) is always Yellow. Hence the four lat-
eral leads (I, aVL, V5, V6) are Yellow. Similarly the right arm ECG
lead (positive electrode for aVR) is always Red, so the right-ward
leads (aVR, V1) are Red. The remaining fourth primary colour, Blue,
is used for the anterior Leads V2-4; especially important as this
is prognostically the most significant territory for an MI. Conse-
quently, Blue is viewed before Red: . ECG
paper could even be printed colour-coded for clarity and under-
standing (Fig. 1).
Colour-coding the chest leads themselves would promote cor-
rect placement: to the right of the sternum (4th inter-costal
space), running from the left of the sternum, with
being more lateral (Fig. 1).
The groupings correlate broadly to the blood supply of the heart
walls, hence the logic of understanding the basic anatomy of the
coronary arterial supply (Fig. 1). This correlation is explained on
page 26, Chapter 4, of the ALS Manual.1 Which myocardial territory
is involved typically determines which groupings of leads/colours
are affected:
0300-9572/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2012.01.034
• .
• .
• ± septum: , extending to .
colours:
• .
It is easier to detect differences by comparing and contrast-
ing four coloured groupings – as opposed to 12 individual ECG
leads, especially for ST segment changes associated with acute
coronary syndrome – typically raised in infarction and depressed
in ischaemia, the opposite being the case for posterior changes.
Ischaemia is a frequent cause of cardiac arrest and arrhythmia
requiring timely recognition. ‘Reciprocal Changes’ can develop in
other leads from those demonstrating infarction, which is of help
in substantiating infarction. The possible need for additional chest
leads to the right of for detection of Right Ventricular
Infarction, and to the left of for detection of Posterior
Infarction must be remembered.2
It is useful for such logical understanding to keep basic coronary
anatomy in mind. The right coronary artery (RCA) and circumflex
artery (horizontal division of the left coronary artery), both run
in the atrio-ventricular groove, the former anteriorly, the latter
posteriorly. The left anterior descending artery (LAD) (the vertical
division of the left coronary artery) and the posterior descending
artery (PDA) both run in the inter-ventricular groove, the former
anteriorly and the latter posteriorly (Fig. 1).
As with history taking and clinical examination, pattern recog-
nition – here of the 12-Lead ECG – is paramount. By systematically
and sequentially comparing and contrasting four distinct ECG
groupings – as opposed to 12 individual
leads – colour by colour, we suggest detection of abnormalities
is simpler. Colour-coding of the chest leads , ,
would also help secure correct placement.
 e116 Letter to the Editor / Resuscitation 83 (2012) e115–e116

Fig. 1. Coronary arteries; positioning of ECG leads ; corresponding 12 Lead ECG.

Conflict of interest statement R.J. Jabbour

J. Baksi
No conflicts of interest to declare. N.S. Peters
Cardiology Department, Imperial College Healthcare
Acknowledgement Trust, St Mary’s Hospital, Praed Street, London W2
1NY, United Kingdom
We thank Anne Wodmore and Chris Priest, Medical Illustration
Unit, Imperial College Healthcare Trust, for Figure. Robin Touquet ∗
Accident and Emergency, Kingston Hospital, Surrey
References KT2 7QB, United Kingdom

[1].Nolan J, Soar J, Lockey A, et al. Advanced life support (ALS). 6th ed. London WC1H ∗ Corresponding author. Tel.: +44 0208 788 6993.
9HR: Resuscitation Council UK, Tavistock House North, Tavistock Square; 2011.
[2].Khan JN, Chauhan A, Mozdiak E, Khan JM, Varma C. Posterior myocardial infarc- E-mail address: robintouquet@uk2.net (R. Touquet)
tion: are we failing to diagnose this? Emerg Med J 2012;29:15–8.
25 January 2012
E. Blakeway
Guys and St Thomas’ NHS Trust, Westminster Bridge 28 January 2012
Road, London SE1 7EH, United Kingdom