How does an ECG work?

Lukubi Lwiindi (Dr),

Human Physiologist.
 THE ELECTROCARDIOGRAM
• The ECG may be recorded by using an active
or exploring electrode connected to an
indifferent electrode at zero potential
(unipolar recording), or by using two active
electrodes (bipolar recording).
• In a volume conductor, the sum of the
potentials at the points of an equilateral
triangle with a current source in the center is
zero at all times.
•
• A triangle with the heart at its center
(Einthoven's triangle) can be approximated
by placing electrodes on both arms and on
the left leg.
• These are the three standard limb leads
used in electrocardiography.
• If these electrodes are connected to a
common terminal, an indifferent electrode
that stays near zero potential is obtained.
 INDICATIONS FOR ECG

 To check for problems with the flow of

electricity through the heart .
 To diagnose changes in the heart
rhythm
 To monitor or evaluate the individual
with heart conditions.
• Each electrical stimulus takes the form of
a wave and so patterns emerge made up
of a number of connected waves. A
standard ECG is printed at 25mm per
second or 25 small squares per second. In
this way it is possible to calculate the
duration of individual waves.
• 10 small squares vertically is equal to 1
millivolt. at that particular moment
 WHAT IS AN ECG?

 a graphic recording of the electrical potential

produced in association with the heart beat. Graphic
representation of the electrical impulses generated
by the heart during the cardiac cycle of contraction
and relaxations (Perry & Potter, 2006)
The electrical impulses are conducted to the body
surface where they are detected by electrodes placed
on the chest and limbs. The electrodes carry the
impulses to a continuously running graph that plots
the ECG pattern
 RECORDING

 The machine records the electrical activity

within the heart.
 It is used to produce tracing of the heart
known as electrocardiogram ECG.
 The standard ECG machine has lead wires
that are attached to a patient chest to
produce the electrical tracing
 TYPES OF ECG
They are two common types:

 Rhythm strip ECG monitor.

 12-lead ECG machine

THE 12 LEAD MACHINE
 OVERVIEW OF PROCEDURE
• GRIP
• Greet, rapport, introduce,
identify, privacy,
• explain procedure,
permission
• Lay patient down
• Expose chest, wrists,
ankles
• Clean electrode sites
• May need to shave
• Apply electrodes
• Attach wires correctly
 Turn on machine
Calibrate to 10mm/ mV
Rate at 25mm/ s Record
and print
 Label the tracing
 Name, DoB
• DoB, , hospital
• number, date and time,
• reason for recording
• Disconnect if adequate
and remove electrodes
 ELECTRODE PLACEMENT

• 10 electrodes in total are placed on the

patient
• Firstly self-adhesive ‘dots’ are attached to
the patient.
• These have single electrical contacts on
them
• The 10 leads on the ECG machine are then
clipped onto the contacts of the ‘dots dots’
 The 12 Lead Standard
• Usually performed when person is resting in
supine position.
• Composed of three bipolar limb leads: I, II,
and III; three augmented voltage leads: aVR,
aVL, aVF; and six chest or precordial leads:
V1 – V6.
• All limb leads lie in frontal plane.
• Chest leads circle heart in transverse plane
 Electrode placement in 12 lead ECG

• Six are chest electrodes-

called V1-6 or C1-6
• 4 are limb electrodes
• Right arm -Ride
• Left arm- Your
• Left leg -Green
• Right leg-Bike
• Remember –the right leg
electrode is a neutral or
“dummy
 FOR THE CHEST ELECTRODES
• V1 -4 intercostal space right sternal edge
th

• V2- 4 intercostal space left sternal edge

th

( To find the 4 intercoastal space, palpate

th

the manubriosternal angle of Louis).

Directly adjacent is the 2nd rib, with the, 2
n d

intercostal space directly below. Palpate

inferiorly to find the 3 and then 4 space
rd th

• V4 over the apex (5 ICS, mid-clavicular

th

line)

• V3 halfway between V2 and V4

• V5 at the same level as V4 but on the

anterior axillary line

• V6 at the same level as V4 an

• Limb Leads
• Limb leads are made up
of 4 leads placed on the
extremities: left and
right wrist; left and right
ankle.
• The lead connected to
the right ankle is a
neutral lead, like you
would find in an electric
plug. It is there to
complete an electrical
circuit and plays no role
in the ECG itself
 RECORDING THE TRACE
• Different ECG machines have different
buttons that you have to press.
• Ask one of the staff on the ward if it is a
machine that you are unfamiliar with.
• Ask the patient to relax completely. Any
skeletal muscle activity will be picked up as
interference.
• If the trace obtained is no good, check that
all the dots are stuck down properly
• they have a tendency to fall off.
 ELECTRO PHYSIOLOGY
• Pacemaker sinoatrial node
• Impulse travels across atria
• Reaches AV node
• Transmitted along interventricular septum
in Bundle of His
• Bundle splits in two (right and left
branches)
• Purkinje fibres
 How does ECG work?
• Electrical impulse (wave of depolarisation)
picked up by placing electrodes on patient
• The voltage change is sensed by measuring
the current change across 2 electrodes
• a positive electrode and a negative electrode
• If the electrical impulse travels towards the
positive electrode this results in a positive
deflection.
• If the impulse travels away from the positive
electrode this results in a negative deflection.
Action Potentials = Change in membrane
potential occurring in nerve, muscle, heart
and other cells

The ECG is not an action potential but

reflects their cumulative effect at the
level of the skin where the recording
electrodes
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are located. 22
 The Chest or Precordial Leads

V6

Over the
Left Ventricle
V5

V1 V2 V3 V4

Over right Over Interventricular

ventricle Septum

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 Intervals and Segments of the Normal
EKG

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 INTERVALS AND SEGMENTS !
• PR Interval- Onset of P wave to onset
of QRS. (.12-.20sec or 3-5 small
squares)
• QRS Complex-Beginning and end of
QRS wave.(0.08 -12sec duration or 3
small squares)
• QT interval- Beginning of QRS to end of
T wave.( Calculated as corrected QT = .
42 sec 0r 10 - 12 ss)
• ST segment ( no elevation or
depression)

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Waves of the ECG.
 ECG
• P Wave-Atrial Depolarization
• PR Segment-Indicative of the delay in the AV node conduction
• PR Interval-Refers to all electrical activity in the heart before the
impulse reaches the ventricles
• Q Wave-First negative deflection after the P wave but before the R
wave
• R Wave-First positive deflection following the P wave
• S Wave-First negative deflection after the R wave
• QRS Complex-Signifies ventricular depolarization ...leads to
ventricular systole.
• ST segment: isoelectric line, ventricles in complete depolarisation.
• Note: Atrial repolarization wave is buried in the QRS complex.
• T Wave-Indicates ventricular repolarization...leads to ventricular
diastole.

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ECG intervals.
 Feature Description Duration

The interval between an R wave and the next R

RR interval wave: Normal resting heart rate is between 60 and 0.6 to 1.2s
100 bpm.

During normal atrial depolarization, the main

electrical vector is directed from the SA node
80ms
P wave towards the AV node, and spreads from the right
(0.08s)
atrium to the 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 of the QRS complex.
120 to
The PR interval reflects the time the electrical
PR interval 200ms
impulse takes to travel from the SA node to the AV
(0.12- 0.20s)
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. The impulse vector is from the AV node to
the bundle of His to the bundle branches and then to 50 to
PR
the Purkinje fibers. This electrical activity does not 120ms
segment
produce a contraction directly and is merely traveling (0.05 -0.12s)
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

QRS right and left ventricles. They have a large muscle mass 80 to 120ms
complex compared to the atria, so the QRS complex usually has a (0.08 -0.12s)
much larger amplitude than the P-wave.

The ST segment connects the QRS complex and the T wave.

ST 80 to 120ms
The ST segment represents the period when the ventricles
segment (0.08 -0.12s)
are depolarized.
 The beginning of T wave represents the repolarization (or
recovery) of the ventricles. The interval from the of the QRS
complex to the apex of the T wave is referred to as the 160ms
T wave
absolute refractory period. The last half of the T wave is (0.16s)
referred to as the relative refractory period (or vulnerable
period).
The ST interval is measured from the J point to the end of 320ms
ST interval
the T wave . (0.32s)

The QT interval is measured from the beginning of the

QRS complex to the end of the T wave. A prolonged QT Up to 420ms in
QT interval interval is a risk factor for ventricular tachyarrhythmias heart rate of 60
and sudden death. It varies with heart rate and for bpm
clinical relevance requires a correction for this.

The U wave is hypothesized to be caused by the

repolarization of the interventricular septum. They normally
U wave have a low amplitude, and even more often completely
absent. They always follow the T wave and also follow the
same direction in amplitude.
 Myocardial Infarction
• Evolution of typical changes in the ECG
following myocardial Infarction.

ECG Findings
• Within the few hours of the onset of
symptoms, the ECG shows ST segment
elevation and in the following days
there is a series of ECG changes.