ELECTROCARDIOGRAM

How Procedure is performed

The individual lies on a bed or couch while electrodes are placed on the skin at the
wrists, ankles, and several locations across the chest. The electrodes are connected by
wires to a control unit that selects different combinations of heart signals to record. The
resulting electrical signals are amplified and recorded on paper or displayed on a
monitor. The test takes only a few minutes and is painless.

Definition:

Is the graphical recording of the electrical activities of the heart. It indicates alteration
of myocardial oxygenation.

Purpose:

To diagnose electrical aberrations in the electrical activity of the heart, such as:

a. MI, Angina Pectoris

b. Cardiac dysrythmias

c. Cardiomegaly

d. Inflammatory disease of the heart

Principles:

1. Place leads properly to get accurate results/ reading

2. Explain the procedure to the patient.

3. Provide privacy

Electrocardiogram taking

1. Explain the procedure to the patient

2. Assemble the equipments:

 - ECG machine

- Electrode paste

- Conductive paste or alcohol swab

3. Close room/door/ bedside curtain

4. Place the client in a supine position or semi-fowlers position

5. Remove clothing on the chest part

6. Instruct client to lie still without talking

7. Standardize ECG machine

8. Cleanse and prepare the skin, wipe the site with alcohol

9. Attach leads:

Limb leads:

Right arm: RED

Left arm: yellow

Right leg: black

Left leg: green

PRECORDIAL LEADS:

V1- Right 4th intercostals space sternal border RED

V2- Left 4th intercostals space sternal border YELLOW

V3- midway, between V2 and V4 left GREEN

V4- 5th intercostal space, mid clavicular left BROWN

V5- 5th intercostals space anterior axillary left BLACK

V6- 5th intercostals space, midaxillary left VIOLET

For 15 lead ECG in addition to 12 leads

V3- Right intercostals space at level of V3

V4- Right intercostals space mid clavicular

V7-5th Intercostals space postertior left

10. Start to run the ECG machine, 12 lead and long lead 11

Bipolar limb leads: L1, L2, and L3

Unipolar limb leads: AVR, AVL, and AVF

Chest leads: V1, V2, V3, V4, V5, and V6

11. Disconnect electrodes and leads and wipe electrode paste if present.

12. On the ECG strip, check the tracing and write the name of the patient, age, date and time
taken

13. Mount the ECG strips on the ECG sheet

14. Refer the ECG results to the doctor

15. Return ECG machine properly

The 12-lead ECG

Over the years, we have evolved several systems that go to make up the 12-lead ECG. These are:

• Bipolar leads: the reference point is on one limb, the `sensing' electrode (if you wish) is
on another limb. The leads are termed I, II, and III.

• Unipolar leads: The reference point is several leads joined together, and the sensing lead
is on one limb. These leads are conventionally augmented, in that the reference lead on
the limb being sensed is disconnected from the other two.
 • The V leads, which extend across the precordium, V1 in the fourth right interspace, V2
4th left, V4 at the apex (5th interspace, midclavicular line), V3 halfway in between V2
and V4, and V5 & V6 in the 5th interspace at the anterior and mid axillary lines
respectively.

We can visualise the directions of the various leads --- I points left, and aVF points directly down
(in a 'Southward' direction). The other leads are arranged around the points of the compass ---
aVL about 30o more north of I, II down towards the left foot, about 60o south of I, and III off to
the right of aVF. aVR `looks' at the heart from up and right, so effectively it's seeing the
chambers of the heart, and most deflections in that lead are negative.

(a net positive vector in AVR is unusual, and suggests that lead placement was incorrect. If the
leads were correctly sited, then think dextrocardia, or some other strange congenital
abnormality).

It's usual to group the leads according to which part of the left ventricle (LV) they look at. AVL
and I, as well as V5 and V6 are lateral, while II, III and AVF are inferior. V1 through V4 tend to
look at the anterior aspect of the LV (some refer to V1 and V2 `septal', but a better name is
perhaps the `right orientated leads'). Changes in depolarisation in the posterior aspect of the heart
are not directly seen in any of the conventional leads, although "mirror image" changes will tend
to be picked up in V1 and V2.
ECG READING

An ECG Paper

Waves and Intervals

Feature Description Duration

RR The interval between an R wave and the next R wave is the inverse of the heart
0.6 to 1.2s
interval rate. Normal resting heart rate is between 50 and 100 bpm

During normal atrial depolarization, the main electrical vector is directed from
P wave the SA node towards the AV node, and spreads from the right atrium to the 80ms
left atrium. This turns into the P wave on the ECG.

The PR interval is measured from the beginning of the P wave to the beginning
PR of the QRS complex. The PR interval reflects the time the electrical impulse
120 to 200ms
interval takes to travel from the sinus node through the AV node and entering the
ventricles. The PR interval is therefore a good estimate of AV node function.

The PR segment connects the P wave and the QRS complex. This coincides
with the electrical conduction from the AV node to the bundle of His to the
PR bundle branches and then to the Purkinje Fibers. This electrical activity does
50 to 120ms
segment not produce a contraction directly and is merely traveling down towards the
ventricles and this shows up flat on the ECG. The PR interval is more clinically
relevant.

The QRS complex reflects the rapid depolarization of the right and left
QRS
ventricles. They have a large muscle mass compared to the atria and so the 80 to 120ms
complex
QRS complex usually has a much larger amplitude than the P-wave.

The point at which the QRS complex finishes and the ST segment begins. Used
J-point N/A
to measure the degree of ST elevation or depression present.

ST The ST segment connects the QRS complex and the T wave. The ST segment
80 to 120ms
segment represents the period when the ventricles are depolarized. It is isoelectric.

The T wave represents the repolarization (or recovery) of the ventricles. The
interval from the beginning of the QRS complex to the apex of the T wave is
T wave 160ms
referred to as the absolute refractory period. The last half of the T wave is
referred to as therelative refractory period (or vulnerable period).

ST The ST interval is measured from the J point to the end of the T wave. 320ms
interval

The QT interval is measured from the beginning of the QRS complex to the end
300 to
QT of the T wave. A prolonged QT interval is a risk factor for ventricular
430ms[citation
interval tachyarrhythmias and sudden death. It varies with heart rate and for clinical needed]
relevance requires a correction for this, giving the QTc.

The U wave is not always seen. It is typically low amplitude, and, by definition,
U wave
follows the T wave.

The J wave, elevated J-Point or Osborn Wave appears as a late delta wave
J wave following the QRS or as a small secondary R wave . It is considered
pathognomic of hypothermia or hypocalcemia.[24]

Interpreting an ECG
Interpreting an electrocardiogram (ECG) is a skill you can master only with practice. The
three basic elements of an ECG waveform are the P wave, the QRS complex, and the T
wave. Use these elements to develop a consistent approach for reading waveforms,
following this eight-step approach.

1. Evaluate the P wave.

Observe its size, shape, and location in the waveform. If the P wave consistently
proceeds the QRS complex, the electrical impulse is being initiated bv the sinoatrial
node.

2. Evaluate the atrial rhythm.

The P wave should occur at regular intervals, with only small variations associated with
respiration. Using calipers, you can easily measure and compare the interval between P
waves (the P-P interval).

3. Determine the atrial rate.

A quick method is to count the number of P waves in two 3-second segments and
multiply by 10. For a more accurate approach, count the small squares between the
apex of two P waves. Each small square equals 0.04 second; 1,500 squares equal 1
minute. Divide 1,500 by the number of squares you counted to get the atrial rate.

4. Calculate the duration of the PR interval.

Count the small squares between the beginning of the P wave and the beginning of the
QRS complex. Multiply that number by 0.04 second.The normal interval is between 0.12
and 0.20 second, or between three and five small squares wide. If the interval is wider,
the conduction of the impulse to the ventricle is delayed.

5. Evaluate the ventricular rhythm.

Use calipers to measure the R-R intervals. Place the calipers on the same point of each
QRS complex. If the R-R intervals are consistent, the ventricular rhythm is regular.

6. Determine the ventricular rate.

Use the formula for calculating the atrial rate (Step 3), except count the small squares
between two R waves. Also check that the QRS complex is shaped appropriately for the
lead you're monitoring.

7. Calculate the duration of the QRS complex.

Count the squares between the beginning and the end of the QRS complex and multiply
by 0.04 second. A normal QRS complex is less than 0.72 second.

8. Calculate the duration of the QT interval.

Count the number of squares from the beginning of the QRS complex to the end of the
T wave. Multiply this number by 0.04 second. The normal range is 0.36 to 0.44 second,
or 9 to 11 small squares.