ELECTROCARDIOGRAPHY

DEFINITION

Electrocardiography(ECG or EKG) is the process of recording the electrical activity of

the heart, over a period of time using electrodes placed over the skin.
It is very commonly performed to detect any cardiac problems. In a conventional 12-lead
ECG, ten electrodes are placed on the patient's limbs and on the surface of the chest. The
overall magnitude of the heart's electrical potential is then measured from twelve different
angles ("leads") and is recorded over a period of time (usually ten seconds). In this way, the
overall magnitude and direction of the heart's electrical depolarization is captured at each
moment throughout the cardiac cycle. The graph of voltage versus time produced by
this noninvasive medical procedure is an electrocardiogram.

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INDICATION
The overall goal of performing an ECG is to obtain information about the structure and
function of the heart. Medical uses for this information are varied and generally need
knowledge of the structure and/or function of the heart to be interpreted. Some indications for
performing an ECG include:

 Suspected myocardial infarction (heart attack) or chest pain

ST elevated myocardial infarction (STEMI)

non-ST elevated myocardial infarction (NSTEMI)

 Suspected pulmonary embolism or shortness of breath

 A third heart sound, fourth heart sound, a cardiac murmur or other findings suggestive of
a structural heart disease. Perceived arrhythmia either by pulse or palpitations

 Monitoring of known cardiac arrhythmias

 Fainting or collapse

 Monitoring the effects of a medication on the heart (e.g. drug-induced QT prolongation)

 Assessing severity of electrolyte abnormalities, such as hyperkalaemia

 Hypertrophic cardiomyopathy screening in adolescents as part of a sports physical out of

concern for sudden cardiac death (varies by country)

 Perioperative monitoring in which any form of anaesthesia is involved (e.g. monitored

anesthesia care, general anesthesia); typically both intraoperative and postoperative

 As a part of a preoperative assessment some time before a surgical procedure (especially

for those with known cardiovascular disease or who are undergoing invasive, cardiac,
vascular or pulmonary procedures, or who will receive general anesthesia)

 Cardiac stress testing

 Computed tomography angiography (CTA) and magnetic resonance angiography (MRA)

of the heart (ECG is used to "gate" the scanning so that the anatomical position of the
heart is steady)

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ELECTRICAL COMPONENTS
DEFLECTION DESCRIPTION
P wave First wave seen wave indication atrial depolarization
PR interval Beginning of the P wave to the beginning of the QRS complex.
QRS Represent Ventricular depolarization
ST segment Measurers time between ventricular depolarization and
beginning of depolarization
T Wave Represent ventricular repolarization
QT interval Represent ventricle depolarization and repolrization it extend
from the beginning of the QRS complex to the end of the T wave
U Wave Represent Repolarization of purkinje fiber

Normal rhythm produces four entities – a P wave, a QRS complex, a T wave, and a U wave –
that each have a fairly unique pattern. However, the U wave is not typically seen and its
absence is generally ignored. Changes in the structure of the heart and its surroundings
(including blood composition) change the patterns of these four entities

STEPS

STEPS 1 – Calculate the heart rate the simplest method for obtaining the rate is to count the
number of R wave in a 6 inch strip of the ECG tracing which equal 6 second ) multiply this
sum by 10 to get the rate per minute beat/min) because the ECG paper is marked in to 3
inch interval (at the top margin ) the approximate heart rate can be rapidly calculated .

Another method is to count the number of large squares between R waves find an R wave
crossing a large square count the number rate is as follows

 1 large square = 300 beats/min.

 2 large squares = 150 beats/min.
 3 large square = 100 beats /min
 4 large squares = 75 beats /min.
 5 large square = 60 beats /min
 6 large square = 50 beats /min
 7 large squares = 43 beats /min
 8 large square = 37 beats /min
 9 large square = 33 beats /min
 10 squares = 30 beats /min

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STEPS 2 – Measure the regularity (rhythm) of the R waves this can be done by gross
observation or actual measurement of the intervals. If the R waves occur at regular interval
( variance ,0.12 second between beats ) the ventricular rhythm is normal when there are
difference in r-r interval (.0.12 second ) the ventricular rhythm is said to be irregular the
division of ventricular rhythm in to regular and irregular categories assists in identifying the
mechanism of many dysrhythmias.

STEP 3 - Examination the p wave if P waves are present and precede each QRS complex
the heartbeat originate in the sinus node and a sinus rhythm exist the absence of p waves
or an abnormality in their position with respect to the QRS complex indicate that the
impulse started outside the sinoatrial node and that an ectopic pacemaker is in command

STEP 4 – Measure the p-r interval normally this interval should be between 0.12 and 0,
20second prolongation or reduction of this interval beyond these limit indicate a defect in the
conduction system between the atria and the ventricles.

STEPS 5 – Measure the duration of the QRS complex if the width between the onset of the
Q wave and the completion of the S wave is greater than 0.12 second (three fine lines on the
paper an intra-ventricular conduction defect exists.

STEPS 6 – Examination the ST segment normally this segment is electric meaning it is

neither elevated nor depressed because the positive and negative force are equally
balanced during this period elevation or depression of the ST segment indicate an
abnormally in the onset of recovery of the ventricular muscle usually because of injury
(MI)

STEPS 7- Examination the T wave. Normally the T wave is upright and one third the height
of the height of the QRS complex any condition that interferes with normal repolarization
(MI) may cause the T waves to invert AN abnormally high serum potassium level cause the T
wave to become very tall sometimes the height of the QRS complex.

LEADS OF ECG PLACEMENT

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Standard limb leads (Bipolar lead of electrograph)

Lead Positive electrode Negative electrode View of heart

I LA RA Lateral
II LL RA Inferior
III LL LA Inferior
Augmented limb lead

Lead Positive electrode View of heart

aVR RA None
aVL LA Lateral
aVF LL Inferior

Standard chest lead electrode placement

Lead Positive electrode placement View of heart

V1 4th intercostals space to right of sternum Septum

V2 4th intercostals space to left of sternum Septum

V3 Directly between V2 and V4 Anterior

V4 5th intercostals space at left midclavicular line Anterior

V5 Level with V4 at left anterior axillary line Lateral

V6 Level with V5 at left midaxillary line Lateral

Colour coding of limb electrode

Electrode Colour

Left arm Yellow

Right arm Red
Left leg Green

Right leg Black

ARRHYTHMIAS

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An abnormal heart rhythm. In an arrhythmia the heart beats may be too rapid, too irregular or
too early. Rapid arrhythmias ( greater than 100 beats per minute) are called tachycardia. Slow
arrhythmias (slower than 60 beats per minute) are called bradycardia.

NORMAL SINUS RHYTHM

The term normal sinus rhythm (NSR) is sometimes used to denote a specific type of sinus
rhythm where all other measurements on the ECG also fall within designated normal limits,
giving rise to the characteristic appearance of the ECG when the electrical conduction system
of the heart is functioning normally.

Upright P waves all look similar.

PR intervals and QRS complexes are of normal duration.

Rhythm Regular

Rate Normal (60-100 bpm)

P Wave Normal (positive & precedes each QRS)

PR Interval Normal (0.12-0.20 sec)

QRS Normal (0.06-0.10 sec)

SINOATRIAL BLOCK
A sinoatrial block is a disorder in the normal rhythm of the heart, known as a heart
block, that is initiated in the sinoatrial node. The initial action impulse in a heart is
usually formed in the sinoatrial node (SA node) and carried through the atria, down
the internodal atrial pathways to the atrioventricular node (AV) node.

The block occurs in some multiple of the P-P interval.

After the dropped beat, cycles continue on time.

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 Rhythm Irregular when SA block occurs
Rate Normal or slow
P Wave Normal
PR Interval Normal (0.12-0.20 sec)
QRS Normal (0.06-0.10 sec)
Pause time is an integer multiple of the P-P interval Try to
Notes
identify specific type of atrial tachycardia

SINUS ARREST
Sinoatrial arrest (also known as sinus arrest or sinus pause) is a medical condition
wherein the sinoatrial node of the heart transiently ceases to generate the electrical
impulses that normally stimulate the myocardial tissues to contract and thus the
heart to beat.
 The SA node fails to discharge and then resumes.
 Electrical activity resumes either when the SA node resets itself or when a lower latent
 pacemaker begins to discharge.

 The pause (arrest) time interval is not a multiple of the normal P-P interval.

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 Rhythm Irregular due to pause

Rate Normal to slow

P Wave Normal

PR Interval Normal (0.12-0.20 sec)

QRS Normal (0.06-0.10 sec)

Notes Pause time is not an integer multiple of the P-P interval

SINUS ARRHYTHMIA
A sinus arrhythmia is an irregular heartbeat that's either too fast or too slow. One type
of sinus arrhythmia, called respiratory sinus arrhythmia, is when the heartbeat changes
pace when you inhale and exhale
 The SA node discharges irregularly.

 The R-R interval is irregular.

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Rhythm Irregular, varying with respiration

Rate Normal (60-100 bpm) and rate may increase during inspiration

P Wave Normal

PR Interval Normal (0.12-0.20 sec)

QRS Normal (0.06-0.10 sec)

Heart rate frequently increases with inspiration, decreasing with

Notes
expiration

SINUS BRADYCARDIA
Sinus bradycardia can be the result of many things including good physical fitness,
medications, and some forms of heart block. "Sinus" refers to the sinus node, the heart's
natural pacemaker which creates the normal regular heartbeat. Results from slowing of
the SA node.

Rhythm Regular

Rate Slow (< 60 bpm)

P Wave Normal

PR Interval Normal (0.12-0.20 sec)

QRS Normal (0.06-0.10 sec)

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SINUS TACHYCARDIA
Sinus tachycardia (also colloquially known as sinustach or sinus tachy) is
a sinus rhythm with an elevated rate of impulses, defined as a rate greater than 100
beats/min (bpm) in an average adult. The normal resting heart rate in the average male
adult ranges from 60–100 bpm and women 60-90bpm
 Results from increased SA node discharge.

Rhythm Regular

Rate Fast (> 100 bpm)

P Wave Normal, may merge with T wave at very fast rates

PR Interval Normal (0.12-0.20 sec)

QRS Normal (0.06-0.10 sec)

Notes QT interval shortens with increasing heart rate

ATRIAL RHYTHM
Atrial rhythms originate in the atria rather than in the SA node. The P wave will be positive, but
its shape can be different than a normal sinus rhythm
 P Waves differ in appearance from sinus P waves.
 QRS Complexes are of normal duration.

ATRIAL TACHYCARDIA
 A rapid atrial rate overrides the SA node and becomes the dominant pacemaker.

 Some ST wave and T wave abnormalities may be present.

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 Rhythm Regular

Rate 150–250 bpm

Normal, upright and uniform) but differ in shape from sinus P

P Wave
waves

PR Interval May be short (_0.12 sec) in rapid rates

QRS Normal (0.06-0.10 sec)

ATRIAL FIBRILLATION
Atrial fibrillation (AF or A-fib) is an abnormal heart rhythm characterized by rapid and
irregular beating of the atria. Often it starts as brief periods of abnormal beating which
become longer and possibly constant over time
 Rapid, erratic electrical discharge comes from multiple atrial ectopic foci.

 No organized atrial contractions are detectable.

Rhythm Irregular

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 Very fast (> 350 bpm) for Atrial, but ventricular rate may be
Rate
slow, normal or fast

P Wave Absent - erratic waves are present

PR Interval Absent

QRS Normal but may be widened if there are conduction delays

ATRIAL FLUTTER
Atrial flutter (AFL) is a common abnormal heart rhythm that starts in the atrial
chambers of the heart. When it first occurs, it is usually associated with a fast heart
rate and is classified as a type of supraventricular tachycardia
 AV node conducts impulses to the ventricles at a 2:1, 3:1, 4:1, or greater ratio (rarely
1:1).
 Degree of AV block may be consistent or variable.

Rhythm Regular or irregular

Rate Fast (250-350 bpm) for Atrial, but ventricular rate is often slower

P Wave Not observable, but saw-toothed flutter waves are present

PR Interval Not measurable
QRS Normal (0.06-0.10 sec)

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MULTIFOCAL ATRIAL TACHYCARDIA

Multifocal atrial tachycardia (MAT) is a cardiac arrhythmia caused by multiple sites of

competing atrial activity. It is characterized by an irregular atrial rate greater than 100
beats per minute (bpm).
 This form of WAP is associated with a ventricular response of _100 bpm.
 MAT may be confused with atrial fibrillation (A-fib); however, MAT has a visible P
wave.

Rhythm Irregular
Rate Fast (> 100 bpm)
Often changing shape and size from beat to beat (at least three
P Wave
differing forms)
PR Interval Variable
QRS Normal (0.06-0.10 sec)
T wave is often distorted Also review wandering atrial pacemaker
Notes
lesson

PREMATURE ATRIAL CONTRACTIONS

Premature atrial contractions (PACs), also known as atrial premature complexes (APC)
or atrial premature beats (APB), are a common cardiac dysrhythmia characterized by
premature heartbeats originating in the atria. While the sinoatrial node typically
regulates the heartbeat during normal sinus rhythm, PACs occur when another region
of the atria depolarizes before the sinoatrial node and thus triggers a premature
heartbeat.
 A single complex occurs earlier than the next expected sinus complex.

 After the PAC, sinus rhythm usually resumes.

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 Rhythm Irregular
Rate Depends on rate of underlying rhythm
P Wave Premature, positive and shape is abnormal
PR Interval Normal or longer
QRS 0.10 sec or less

VENTRICULAR RHYTHM
When the ventricles handle the pacemaking role, they can be observed on EKG tracings.

SUPRAVENTRICULAR TACHYCARDIA
Supraventricular tachycardia (SVT) is an abnormally fast heart rhythm arising from
improper electrical activity in the upper part of the heart.
 This arrhythmia has such a fast rate that the P waves may not be seen.

Rhythm Regular
Rate Fast (150-250 bpm)
P Wave Merged with T wave
PR Interval Normal (0.12 sec)
QRS Normal (.10 sec)
Notes PR interval can be difficult to measure

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VENTRICULAR TACHYCARDIA
Ventricular tachycardia (V-tach or VT) is a type of regular, fast heart rate that arises from
improper electrical activity in the ventricles of the heart.
 QRS complexes in monomorphic VT have the same shape and amplitude.

Rhythm Regular
Rate Fast (100-250 bpm)
P Wave Absent
PR Interval Not measurable
QRS Wide (>0.10 sec), bizarre appearance

VENTRICULAR FIBRILLATION
Ventricular fibrillation (V-fib or VF) is when the heart quivers instead of pumping due
to disorganized electrical activity in the ventricles
 Chaotic electrical activity occurs with no ventricular depolarization or contraction.
 The amplitude and frequency of the fibrillatory activity can be used to define the type of
fibrillation as coarse, medium, or fine.

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Rhythm Highly irregular
Rate Un measurable
P Wave Absent
PR Interval Not measurable
QRS None
Notes EKG tracings is a wavy line

ASYSTOLE
Asystole is a cardiac arrest rhythm with no discernible electrical activity on the EKG
monitor. It is a flat line EKG, P Waves and QRS complexes are not present The heart is
not functioning.
 Electrical activity in the ventricles is completely absent.

Rhythm Not present

Rate Absent

P Wave Absent

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 PR Interval Absent

QRS Absent

Notes Confirm with multiple lead

IDIOVENTRICULAR RHYTHM
This is called Idio ventricular Rhythm. Ventricular signals are transmitted cell-to-cell
between cardiomyocytes and not by the conduction system, creating wide sometimes
bizarre QRS complexes(> 0.12 sec). The rate is usually 20-40 bpm. If the rate is >40
bpm, it is called accelerated idio ventricular rhythm.
 QRS complex is _0.10 sec. P Waves are absent or, if visible, have no consistent
relationship to the QRS complex.

Rhythm Regular

Rate Slow (20-40 bpm)

P Wave Absent

PR Interval Not measurable

QRS Wide (>0.10 sec), bizarre appearance

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HEART BLOCK
Heart block is an abnormal heart rhythm where the heart beats too slowly (bradycardia ). In
this condition, the electrical signals that tell the heart to contract are partially or totally blocked
between the upper chambers (atria) and the lower chambers (ventricles).

BUNDLE BRANCH BLOCK

When a bundle branch or fascicle becomes injured (by underlying heart disease, myocardial
infarction, or cardiac surgery), it may cease to conduct electrical impulses appropriately. This
results in altered pathways for ventricular depolarization.
 Either the left or the right ventricle may depolarize late, creating a “notched” QRS
complex.

Rhythm Regular

Rate The underlying rate

P Wave Normal

PR Interval Normal (0.12-0.20 sec)

QRS Wide (>0.12 sec)

FIRST DEGREE HEART BLOCK

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First-degree atrioventricular block (AV block), or PR prolongation, is a disease of the electrical
conduction system of the heart in which the PR interval is lengthened beyond 0.20 seconds

Rhythm Regular
Rate The underlying rate
P Wave Normal
PR Interval Prolonged (>0.20 sec)
QRS Normal (0.06-0.10 sec)
A first degree AV block occurs when electrical impulses moving through
Notes the Atrioventricular (AV) node are delayed (but not blocked). First degree
indicates slowed conduction without missed beats.
SECOND DEGREE HEART BLOCK TYPE I
A second-degree type I AV block occurs when conduction within the AV node itself is
delayed in this progressive manner. It does not necessarily indicate intrinsic conduction
disease, and rarely requires a pacemaker to be implanted.
 P-R intervals become progressively longer until one P wave is totally blocked and
produces no QRS. After a pause, during which the AV node recovers, this cycle is
repeated.

Rhythm Irregular but with progressively longer PR interval lengthening

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 Rate The underlying rate

P Wave Normal

Progressively longer until a QRS complex is missed, then cycle

PR Interval
repeats

QRS Normal (0.06-0.10 sec)

SECOND DEGREE HEART BLOCK TYPE II

In second-degree type II AV nodal block (a.k.a. Mobitz Type II AV block), the AV node becomes
completely refractory to conduction on an intermittent basis. For example, three consecutive P
waves may be followed by a QRS complex, giving the ECG a normal appearance, then the fourth
P wave may suddenly not be followed by a QRS complex since it does not conduct through the
AV node to the ventricles.
 Conduction ratio (P waves to QRS complexes) is commonly 2:1, 3:1, or 4:1.
 QRS complexes are usually wide because this block usually involves both bundle

branches.

Rhythm Regular (atrial) and irregular (ventricular)

Characterized by Atrial rate usually faster than ventricular rate (usually

Rate
slow)

P Wave Normal form, but more P waves than QRS complexes

PR Interval Normal or prolonged

QRS Normal or wide

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THIRD DEGREE HEART BLOCK
Third-degree atrioventricular block (AV block), also known as complete heart block, is a
medical condition in which the nerve impulse generated in the sinoatrial node (SA
node) in the atrium of the heartdoes not propagate to the ventricles.
 Conduction between atria and ventricles is absent because of electrical block at or
below the AV node.
 “Complete heart block” is another name for this rhythm.

Rhythm Regular, but atrial and ventricular rhythms are independent

Characterized by Atrial rate usually normal and faster than ventricular

Rate
rate

P Wave Normal shape and size, may appear within QRS complexes

PR Interval Absent: the atria and ventricles beat independently.

QRS Normal, but wide if junctional escape focus

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MYOCARDIAL INFARCTION
Myocardial infarction (MI), commonly known as a heart attack, occurs when blood
flow decreases or stops to a part of the heart, causing damage to the heart muscle. The
most common symptom is chest pain or discomfort which may travel into the shoulder,
arm, back, neck, or jaw.
Location of MI by ECG leads

Progression of an acute myocardial infarction

 An acute MI is a continuum that extends from the normal state to a full infarction
 Ischemia – Lack of oxygen to the cardiac tissue, represented by ST segment depression,
T wave inversion or both
 Injury – An arterial occlusion with ischemia, represented by ST segment elevation
 Infarction - Death of tissue, represented by a pathological Q wave
ECG leads Region of left ventricle

V1 V2 Septal

V3 V4 Anterior

V5 V6 Lateral

V1 to V4 Anteroseptal

V3 to V6 Anterolateral

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I, aVL High lateral

II, III, aVF Inferior

ANTERIOLATERAL WALL MI
Acute anterolateral MI is recongnized by ST segment elevation in leads I, aVL and the
precordial leads overlying the anterior and lateral surfaces of the heart (V3 - V6).
Generally speaking, the more significant the ST elevation , the more severe the
infarction. There is also a loss of general R wave progression across the precordial leads
and there may be symmetric T wave inversion as well. Anterolateral myocardial
infarctions frequently are caused by occlusion of the proximal left anterior descending
coronary artery, or combined occlusions of the LAD together with the right coronary
artery or left circumflex artery.

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POSTERIOR WALL MYOCARDIAL INFARCTION
The ECG findings of a posterior wall myocardial infarction are different than the typical
ST segment elevation seen in other myocardial infarctions. A posterior wall MI occurs
when posterior myocardial tissue (now termed inferobasilar), usually supplied by the
posterior descending artery — a branch of the right coronary artery in 80% of
individuals — acutely loses blood supply due to intracoronary thrombosis in that vessel.
This frequently coincides with an inferior wall MI due to the shared blood supply.

INFERIOR WALL MYOCARDIAL INFARCTION

An inferior wall myocardial infarction — also known as IWMI, or inferior MI, or inferior
ST segment elevation MI, or inferior STEMI — occurs when inferior myocardial tissue
supplied by the right coronary artery, or RCA, is injured due to thrombosis of that
vessel. When an inferior MI extends to posterior regions as well, an associated posterior
wall MI may occur

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SEPTAL WALL MYOCARDIAL INFARCTION
Septal infarct is a patch of dead, dying, or decaying tissue on the septum. The septum is
the wall of tissue that separates the right ventricle of your heart from the left ventricle.
Septal infarct is also called septal infarction.
Acute septal MI is associated with ST elevation, Q wave formation and T wave inversion
in the leads overlying the septal region of the heart (V2 and V3).

ELECTROLYTE IMBALANCE ECG

An electrocardiogram(EKG) is often times obtained on patients shortly after they arrive
in the emergency department. This EKG can be used to evaluate for ischemic changes,
but also can give the provider some early insight into the patient’s electrolyte levels. A
combination of clinical history paired with EKG findings consistent with elevated
potassium levels, should prompt emergent treatment to stabilize the cardiac membrane.

HYPERKALEMIA
EKG changes progress from peaked T-waves to widened QRS and eventually to ventricular
tachycardia, fibrillation or pulseless electrical activity arrest. These progressive changes can
correlate with rising potassium levels. For example, peaked T waves might correspond with a
potassium level of approximately 6, whereas cardiac arrest generally occurs at higher levels.

 Peaked T waves

 Prolongation of PR interval

 Widening QRS Complex

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 Loss of P wave

 “Sine Wave”

 Asystol

HYPOKALEMIA
EKG changes can include increased amplitude and width of P wave, T wave flattening and
inversion, prominent U waves and apparent long QT intervals due to merging of the T and U
wave. The U-wave is a deflection following the T wave. Hypokalemia causes enlarged and
prominent T waves on the EKG. Potassium levels that are critically low (<1.7)

 ST depression.

 T wave inversion.

 Prominent U waves.

 Long QU interval.

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HYPERCALCEMIA
Elevated calcium level is defined as a level greater than 2.7 mmol/ L, with severe
hypercalcemia being greater than 3.4 mmol/L. The most common EKG finding associated
with hypercalcemia is shortening of the QT interval. In severe cases Osborn or J waves might
be seen or ventricular fibrillation might ensue. Recognition of these EKG findings can
prompt urgent treatment. The main ECG abnormality seen with hypercalcaemia is shortening
of the QT interval.

 In severe hypercalcaemia, Osborn waves (J waves) may be seen

 Ventricular irritability and VF arrest has been reported with extreme hypercalcaemia

HYPOCALCEMIA
The most common finding on EKG in patients with hypocalcaemia is a prolonged QT
interval without any further changes. Hypocalcaemia will rarely cause more serious cardiac
arrhythmias, although atrial fibrillation might be found. Causes of a low calcium level
include hypo parathyroid, low Vitamin D levels, acute pancreatitis and furosemide use.

 Hypocalcaemia causes QT prolongation primarily by prolonging the ST segment.

 The T wave is typically left unchanged.

 Dysrhythmias are uncommon, although atrial fibrillation has been reported.

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ARTEFACT
In electrocardiography, an ECG artefact is used to indicate something that is not "heart-
made." These include (but are not limited to) electrical interference by outside sources,
electrical noise from elsewhere in the body, poor contact, anchine malfunction.

SUMMARY
Electrocardiography(ECG or EKG) is the process of recording the electrical activity of
the heart, over a period of time using electrodes placed over the skin. It is very commonly
performed to detect any cardiac problems. In a conventional 12-lead ECG, ten electrodes are
placed on the patient's limbs and on the surface of the chest. The overall magnitude of the
heart's electrical potential is then measured from twelve different angles ("leads") and is
recorded over a period of time (usually ten seconds). In this way, the overall magnitude and
direction of the heart's electrical depolarization is captured at each moment throughout
the cardiac cycle. The graph of voltage versus time produced by this noninvasive medical
procedure is an electrocardiogram. The overall goal of performing an ECG is to obtain
information about the structure and function of the heart. Medical uses for this information
are varied and generally need knowledge of the structure and/or function of the heart to be
interpreted. Normal rhythm produces four entities – a P wave, a QRS complex, a T wave, and
a U wave – that each have a fairly unique pattern. However, the U wave is not typically seen
and its absence is generally ignored. Changes in the structure of the heart and its surroundings
(including blood composition) change the patterns of these four entities. Myocardial
infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or
stops to a part of the heart, causing damage to the heart muscle. The most common symptom
is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. An

28
electrocardiogram(EKG) is often times obtained on patients shortly after they arrive in the
emergency department. This EKG can be used to evaluate for ischemic changes, but also can
give the provider some early insight into the patient’s electrolyte levels. A combination of
clinical history paired with EKG findings consistent with elevated potassium levels, should
prompt emergent treatment to stabilize the cardiac membrane. In electrocardiography,
an ECG artefact is used to indicate something that is not "heart-made." These include (but are
not limited to) electrical interference by outside sources, electrical noise from elsewhere in
the body, poor contact, anchine malfunction.

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