Introduction

n Instrument: electrocardiograph
n Recording: electrocardiogram
n First ECG-recording: 1887 by A Waller
n ECG measures: electrical changes during
a cardiac cycle

ECG
n Electrodes
n Conducting system

ECG practical

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Conducting system ECG essential to:

n Diagnose & manage abnormal rhythms
S-A node
Spontaneously n Diagnose cause of chest pain
initiate
impulses n Early intervention in myocardial infarction
A-V node
n Assist in diagnosis of:
n dizziness
Bundle of His
n syncope
n breathlessness
Bundle branches

Purkinje fibres

ECG practical ECG practical

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ECG – general
n Clinical diagnosis depends on history n Sum of all cells
n Use electrodes placed on surface of body

Evidence to
support Rhythm
diagnosis

ECG = Tool ECG practical ECG practical

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 Heart rhythm Heart rhythm

Sinus rhythm Arrhythmia

https://www.getbodysmart.com/circulatory-system/heart-conduction-system
https://www.getbodysmart.com/circulatory-system/heart-conduction-system

ECG practical ECG practical

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Checklist
n Prepare skin

Obtaining a n Use quality electrodes

n Correct placement of electrodes

recording – n Insure good electrode-to-patient contact

Practical points

D Crafford 2010 ECG practical ECG practical

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Prepare skin Electrodes

n Shave hair from electrode sites n Use only electrodes specified by the
n Remove skin manufacturer of the device
n skin prep pad or paper towel n Note “Use by date”
n Clean sites n Tightly re-seal (prevent electrodes from drying out)
n soap and water n Use shortly after packaging opened
n Dry skin
Explain
procedure to
patient

ECG practical ECG practical

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 Placement of electrodes Leads vs electrodes
Place 10 electrodes on specific sites to
obtain a 12 lead ECG recording
Lead = electrical
picture of heart

Detected through
electrodes
ECG practical ECG practical

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12 Leads
n 3 Standard / Bipolar limb leads
Right Left
n 3 Augmented / Unipolar limb leads
n 6 Precordial / Chest leads

aVRA
R aVLA
L

Used as
earth

NN aVLL
F

ECG practical D Crafford 2010 ECG practical

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Leads Leads
n Standard / Bipolar limb leads (3) n Augmented / Unipolar limb leads (3)
n Measures potential difference between 2 points n In practice, these are the same electrodes used for leads I, II
Match and III (ECG machine does the switching and rearranging of
markers to the electrodes)
sights!!

aV R aV L

N aV F

ECG practical ECG practical

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 Leads Placing of electrodes
n Precordial / Unipolar chest leads (6) Right
Mid clavicle
Left

V1 V2
V3 4th ICS
V4 V5 V6
5th ICS

ECG practical ECG practical

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12 Lead ECG

The 12 lead
ECG

ECG practical ECG practical

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12 Lead ECG Artefacts

Rhythm strip
Lead – P wave most clearly (usually Lead II)

Artefacts caused by:

• Cell phone
• Electrical interference
• Muscle tremor
• Patient movement
ECG practical ECG practical

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 Electrical interference Muscle movement
Limbs Chest

Thickened baseline
ECG practical ECG practical

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Placing of electrodes
Exercise ECG

R L Different parts
N F
of ECG

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Standard ECG paper Standard ECG paper

Voltage (mV)

5mm

Time (sec) Speed:

25mm/sec 5mm
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 Standard ECG paper Standard ECG paper

How many
large squares?
*1 sec
*1 min
1mm

1mm 1mm = 0.04 sec

ECG practical
5mm = 0.2 sec ECG practical

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Standard ECG paper

How many
large
squares?

1mm = 0.1 mV
1mV?
Calibration
5mm = 0.5 mV

ECG practical ECG practical

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Calibration Calibration - example

Calibration
signal
1mV = 1cm

ECG practical ECG practical

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 Electrocardiogram – Waves
Check calibration R

(1mV = 1cm) J-point

Voltage (mV)
P T
U

Check speed Q S
Iso-electric/
25mm/sec QRS complex Baseline

Time (sec)
ECG practical ECG practical

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Electrocardiogram - Activity Electrocardiogram – Activity

R R
Atrial
depolarisation
(contract)
(0.08-0.1sec)

Hypertrophy
Voltage (mV)

Voltage (mV)

P T P T
U U

Q S Q S
Muscle mass
atria vs ventricles Ventricular depolarisation &
Arterial repolarisation
(0.12 sec / 3 small blocks)

>>> Conduction problems

ECG practical ECG practical

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Electrocardiogram - Activity Electrocardiogram - Activity

R R

Ventricular
repolarisation
(relax)
(0.2 sec) Repolarisation
Voltage (mV)

Voltage (mV)

of papillary
Infarction muscles
P T P T
U U

Q S Q S

ECG practical ECG practical

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 Electrocardiogram - Segments Electrocardiogram - Segments
R R
Voltage (mV)

Voltage (mV)
PR segment ST segment
P T P T

Q S Q S

Time (sec) Time (sec)

ECG practical ECG practical

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Electrocardiogram - Segments Electrocardiogram - Segments

R R

ST Elevation
Myocardial
infarction
(STEMI)
Voltage (mV)

Voltage (mV)

ST segment ST segment
P T P T

Q S Q S
Depressed =
Myocardial
ischemia

Time (sec) Time (sec)

ECG practical ECG practical

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Electrocardiogram - Intervals Electrocardiogram - Intervals

R R
Voltage (mV)

Voltage (mV)

P T P T

Q S Q S

PR interval QT interval

Time SA node à ventricular muscle Time ventricles to depolarize and

(0.12-0.2 sec /3-5 small blocks) repolarize (not > 0.45 s)
Most time taken up by delay in AV node ECG practical
>>> Abnormal electrolytes/ drugs ECG practical

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 Electrocardiogram Electrocardiogram

R R

ECG practical ECG practical

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12 Leads Match markers to sights

n 3 Standard / Bipolar limb leads
n 3 Augmented / Unipolar limb leads Check calibration
n 6 Precordial / Chest leads (1mV = 1cm)

Check speed
25mm/sec

Good electrical
ECG practical
contact ECG practical

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Heart rate

Heart rate n Normocardia

* 60-100 beats/min

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 Heart rate Heart rate
n Sinus tachycardia n Sinus bradycardia
n >100 beats/min (at rest) n <60 beats/min (at rest)
n Sympathetic stimulation (vagus inhibited) n Parasympathetic stimulation (vagus stimulated)
n Anxiety/stress n Hypothyroidism
n Fever, hyperthyroidism n Very fit athletes
n Acute blood loss/fall in blood pressure

ECG practical ECG practical

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Heart rate Calculation of heart rate

R R
n Your heart rate ???

Count the large blocks between two R peaks = n

Heart rate = 300
n
= 300
4
= 75 beats/min

ECG practical ECG practical

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Calculation of heart rate Calculation of heart rate

R R

Count the large blocks between two R peaks = n Count the small blocks between two R peaks = n
Count the small blocks between two R peaks = n
Heart rate = 300 Heart rate = 1500
Heart rate = 1500
n n
n = 1500
= 300
= 1500
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20
= 100 beats/min = 107 beats/min
= 75 beats/min

ECG practical ECG practical

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 Heart rate - short cut Heart rate – practice
R-R interval Heart rate R-R interval Heart rate
(large squares) (beats/min) (large squares) (beats/min)
1 300 1 300
2 150 2 150
3 100 3 100
4 75 4 75
5 60 5 60
6 50 6 50
R R

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Take care!

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