One Minute Moment

ECG MONITORING
Physics principles:

The electrocardiograph is essentially an electronic device that

amplifies the very small potentials present at the surface of the body,
so that they can be displayed on a video screen or recorded
permanently on paper. The signal is picked up by electrodes placed at
certain well-defined anatomical positions on the body surface.

The heart of the ECG is an electronic amplifier with two input

terminals, where G is the gain of the amplifier. It measures the difference between two voltages

Electrical voltage or potential, unlike length or mass, is not an absolute quantity, but rather a relative
quantity, in that potential itself cannot be measured, only differences in potential. Thus V+ and V- are
each measured with respect to some third reference point that is arbitrarily taken to be at zero potential.
In electrocardiography, this point is the right leg.

Electrodes are the actual conductive pads attached to the body surface. Any pair of electrodes can
measure the electrical potential difference between the two corresponding locations of attachment. Such
a pair forms a lead. However, "leads" can also be formed between a physical electrode and a virtual
electrode, known as the Wilson's central terminal, whose potential is defined as the average potential
measured by three limb electrodes that are attached to the right arm, the left arm, and the left foot,
respectively.

Commonly, 10 electrodes attached to the body are used to form 12 ECG leads, with each lead measuring a
specific electrical potential difference.

The resulting graphic representation of the voltages will give information on the magnitude of the
differential and the direction.

Use in PICU:

- Continuous monitoring of heart rate

- Signs of myocardial infarction
- Monitoring of arrhythmias
- Medication monitoring (e.g., drug-induced QT prolongation, Digoxin toxicity) and management of
overdose (e.g., tricyclic overdose)
- Electrolyte abnormalities, such as hyperkalemia

Troubleshooting

1. Check electrode site selection. Site selection is key in patients with heavy or labored

breathing. If possible, move electrodes to sites that will minimize electrode movement.

2. Is the patient moving excessively? Is patient's breathing labored? Encourage the patient to

relax and breathe using the diaphragm rather than chest expansion.

3. Is the monitor in diagnostic mode rather than monitoring mode? Changing to the

monitoring mode can reduce respiratory artifact.

4. Check the electrodes to see if they have dried out. If so, replace.

5. Patient Cable movement? If the patient cable is moving excessively, wandering baseline

can occur. If possible, secure the cable with a garment clip or safety pin.

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One Minute Moment
6. Lead wire movement? If possible, lead wires should be secured to eliminate movement.

Lead wires should be checked for wear. If the lead wire has been used for an extended period

of time, connections can become "stretched" causing excessive lead wire movement.

7. Has proper skin prep been performed? With most skin types, no skin prep is required.

However, patients with excessively oily skin may require prepping with an alcohol or acetone

wipe. Loss of contact may result if the solution is not allowed to dry completely and is trapped

under the electrode. Placement sites should be shaved in excessively hairy patients.

8. Skin impedance varies greatly from patient to patient. Even with proper skin preparation,

a patient with high skin impedance may cause a delay in receiving a stable trace.

Tips & Tricks

❖ Point 1

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