ECG GUIDELINES

Donna J. Castillo, MD
 Electrocardiogram

ECG or EKG
graphic recording of electric potentials generated by
the heart
signals are detected by metal electrodes attached to
the extremities & chest wall
these are amplified & recorded by the
electrocardiograph
non-invasive & inexpensive
 Purpose

detects :
 Arrhythmias, conduction disturbances, & myocardial ischemia
reveals:
 findings related to life-threatening metabolic disturbances (e.g.
hyperkalemia) or
 increased susceptibility to sudden cardiac death (e.g.
prolonged QT syndrome)
detects pacemaker malfunction
 CONTRAINDICATION

NONE
 ECG leads

Limb leads
 R arm = RA (red)
 L arm = LA (yellow)
 R foot = RF (black)
 L fot = LF (green)
 ECG leads

V1 = red
V2= yellow
V3= green
V4= brown
V5 = black
V5= violet
 ECG leads

V1 = 4th ICS at R sternal

V2= 4th ICS at L sternal
V3 = halfway bet V2 & V4
V4 = 5th ICS L midclavicular
V5 = 5th ICS L ant axillary
V6 = 5th ICS at L mid=axillary
V3R = halfway bet V1 & V4R
V4R = 5th ICS at R midclavicular
 Preparing the patient

Make sure the patient is comfortable

Expose contact areas adequately
Rub contact areas with alcohol
Apply ECG cream or lotion to each area

No need to do the ff:

 Remove coins
 Remove belt with buckle
 Remove jewelries (unless directly in contact with electrode)
 Procedure

Turn on the machine

 Check the stylus
 Speed usually at 25mm/sec
Introduce a 1 mV standardization pulse
 A square wave should consist of 10 small squares
Set limb leads then the chest leads
Each lead should contain at least 5 complexes
 Procedure

All ECG complexes should be within the printed

lines. Double small complexes and half large
complexes. Indicate by 2x or ½

Label all tracings:

 Patients name
 Date and time ECG was taken
Standardization
 Technical Aspects in ECG Taking

Errors – arise from commission or omission on the

part of the operator
 Mixing up of limb leads and chest lead wires
 Placing electrodes 1 intercostal space higher or lower
 Incorrect standardization; improper labeling
 Incorrect paper speed.

Artifacts – produced accidentally or incidentally by

the machine, operator, patient, or environmental
factors
Parts of ECG
Relationship of ECG to Anatomy
 How to Interpret

Components of ECG interpretation

 Rate
 Rhythm
 Axis
 Hypertrophy
 Ischemia & Infarction
 Miscellaneous findings (including normal variants)
Normal ECG tracing
 Components of a Normal ECG

Should be normal sinus rhythm

Normal QRS axis
Normal heart rate
Normal P wave morphology
Normal PR interval
Normal QRS complex
1P : 1 QRS
Normal QT interval
Normal ST segment
Normal T wave Parts of ECG
 Heart Rate

Rate interpretation has 3 possibilities

 Bradycardia (<60 bpm)
 Normal rate (60-100)
 Tachycardia (100 bpm)

HR = 1500_____
# of small boxes
13. What is the heart rate?

55bpm
 Rhythm

Common rhythm interpretations

Sinus rhythm
Common supraventricular arrhythmias
 Atrial fibrillation
 Atrial flutter
 Supraventricular tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia (SVT)
 Rhythm

Heart Blocks
 First degree AV block
 Second degree AV block Mobitz type I (Wenckebach)
 Second degree AV block Mobitz type II
 Third degree AV block
 Left or Right Bundle branch block
PR interval
 0.12 – 0.20 secs
 Shortened PR interval : Wolf-Parkinson-White syndrome
Lown Ganong Levine syndrome
 Long PR interval : AV blocks

Parts of ECG
 1◦ AV block

PR interval 0.32 secs

2◦ AV block
 3◦ AV block

•Atria & ventricles depolarize independently.

•QRS complexes less frequent; regular at 40 to 55 bpm but normal shape
Normal QRS <0.12 in duration
 >0.12 : bundle branch blocks

Rhythm
Right Bundle Branch Block

•Broad QRS complex ≥0.12

sec
•rR’ pattern or a wide slurred
R wwave in V1 and/or V2
•Broad S in leads V5, V6 and
or I
Left Bundle Branch Block

•Broad QRS complex of ≥0.12sec

•Wide slurred R wave in V5, V6 and/or lead I
•Broad S wave in V1 and/or V2
 Rhythm

Ventricular arrhythmias
 Premature ventricular contractions (PVCs)
 Ventricular tachycardia
 Ventricular fibrillation
PVCs
Ventricular tachycardia
Ventricular tachycardia
Ventricular fibrillation
R on T phenomenon
 Rhythm analysis

Identify the P wave

Check the relation of P wave to QRS
 P wave is before QRS (normal)
 P wave buried or after QRS (SVT, complete heart block)
Check PR interval ( N 0.12 – 0.20 sec)
 Short PR (WPW syndrome)
 Prolonged PR (1st or 2nd deg AV block)
Check QRS duration (N <0.10 sec)
 Wide QRS (bundle branch blocks)
Check the relation of RR and PP interval
AXIS

How to Interpret
 AXIS

lead Ilead aVF

Normal Axis++
Left Axis Deviation+-
Right Axis Deviation-+
Indeterminate axis--
 Normal axis

AXIS
 Left Axis Deviation

AXIS
AXIS
 Hypertrophy

Interpretation has six possibilities

 No hypertrophy
 Left Ventricular hypertrophy (LVH)
 Right Ventricular hypertrophy (RVH)
 Left Atrial Enlargement (LAE)
 Right Atrial Enlargement (RAE)
 Combination

How to Interpret
•S wave in V1 + R wave in
V5 & V6 >35mm
• RAD +
• Lead V1 : R wave >s
wave
• Deep S wave in
leads V5 & V6
• ST dep & T wave
inversion in V1 – V3
P wave
 Height <2.5 mm in lead II
 Width <0.11 s in lead II
Atrial enlargement
 Myocardial Ischemia

Criteria
 At least 1 mm ST segment depression
 Symmetrically or deeply inverted T wave
 Myocardial Infarction

Criteria
 St elevation ≥2mm in 2 or more chest leads or ≥ 1 mm in 2 or
more limb leads
 Q waves ≥ 0.04 sec (1 small square)
AXIS
Anterior wall MI
Anterolateral wall MI
Inferior wall MI
Inferolateral wall MI
 Other conditions

Hypokalemia
Hyperkalemia
Hypocalcemia
Hypercalcemia
Digitalis effect/ digitalis toxicity
hypomagnesemia
hyperkalemia
hypokalemia
•Prolonged PR interval
•Scooping of the ST segment
•Short QT interval

Toxicity : all types of arrhythmias, usually PVCs or

paroxysmal atrial tachycardia
Torsades de Pointes
 Nursing Responsibilities

Before the procedure

 Explain the procedure to the patient
 Tell the patient that no food or fluid restriction is necessary
 Assure the patient that no electric current flow will occur. He
or she will feel nothing during the procedure
 Expose only patient’s chest and arms. Keep the abdomen and
thighs adequately covered
 Nursing Responsibilities

During the Procedure:

 The skin areas designated for electrode placement are
prepared by using alcohol swabs to remove skin oil or debris.
Sometimes the skin is shaved if the patient has a large amount
of hair
 Pads with special gel are applied to ensure electrical
conduction between the skin & the electrodes.
 Electrodes are applied to four extremities. It is recommended
to apply it on upper arm because there are fewer muscle
tremors
During the procedure:
 List medications the patient is taking on the ECG request form
 Tell the patient that this procedure carries no discomfort and
takes only few minutes. He must maintain a relaxed supine
position during the procedure.
After the procedure:
 Remove the electrodes from the patient’s skin and wipe off the
electrogel
 Indicate on the ECG strip or request slip if the patient was
experiencing chest pain during the study. This symptom may
be correlated to arrhythmia found on ECG.

review of tracings.pptx