ELECTROCARDIOGRAM

BY: KEVERNE JHAY P. COLAS, RN,

Electrocardiogram (ECG)
• a diagnostic tool that measures and records
the electrical activity of the heart in exquisite
detail. Interpretation of these details allows
diagnosis of a wide range of heart conditions.
These conditions can vary from minor to life
threatening.
• The term electrocardiogram was introduced
by Willem Einthoven in 1893 at a meeting of
the Dutch Medical Society. In 1924,
Einthoven received the Nobel Prize for his
life's work in developing the ECG.
• The 12- lead ECG that is used throughout the
world was introduced in 1942.
 Reasons to Have an ECG
Heart problems can produce a wide array of symptoms.
• Without the benefit of an ECG, it may be impossible to tell
whether these symptoms are being caused by a heart problem
or just mimics of one.

Common symptoms that frequently require an ECG include the

following:
• Chest pain or discomfort
• Shortness of breath
• Nausea
• Weakness
• Palpitations (rapid or pounding heartbeats or increased
awareness of heart beating)
• Anxiety
• Abdominal pain
• Fainting (syncope)
 The Heart
• The heart itself is made up of 4 chambers, 2 atria
and 2 ventricles. De-oxygenated blood returns to
the right side of the heart via the venous
circulation. It is pumped into the right ventricle
and then to the lungs where carbon dioxide is
released and oxygen is absorbed. The
oxygenated blood then travels back to the left
side of the heart into the left atria, then into the
left ventricle from where it is pumped into the
aorta and arterial circulation.
 The Heart
• Systolic blood pressure:
Is the pressure created in the arteries when the
ventricles contract

• Diastolic blood pressure:

When the ventricles starts to refill, the pressure
from the arteries falls simultaneously the atriums
contract creating pressure known as the diastolic
pressure.
 The Heart
• Image: The passage of blood through the heart
 The Heart
• Image: The cardiac conduction system
 The Heart
• Image: The cardiac conduction system
 Properties of the Cardiac Muscle
• Rhythmicity – ability of the heart to contract
at regular timing
Each contraction is accompanied by an
electrical charge
An inherent property independent of any
stimulation from nerves
The heart beats with definite rhythm on 4
phases: stimulation, transmission,
contraction and relaxation
 Properties of the Cardiac Muscle
• Contractility – ability to contract in response to
a stimuli
Ability of the heart to shorten its length or
contract in response to stimuli after
depolarization
Intrinsic ability of the heart to change its force
of contraction
Ability of cardiac cells to contract in an
organized manner rests in the unique
structure of myocardial cells
 Properties of the Cardiac Muscle
• Automaticity – ability of the heart to pace or
to spontaneously initiate or propagate an
action potential (characteristic of
pacemaker cell)
Ability to beat spontaneously and
repetitively even without external
neurohormonal control
No stimulus required to propagate an
action potential
 Properties of the Cardiac Muscle

• Excitability/Irritability - ability of the heart

to respond to a stimulus with the strongest
possible contraction or none at all (All or
None Law)
Influenced by: hormonal or nutritional
balance, adequacy of oxygen supply, drug
therapy and products of infection
 Properties of the Cardiac Muscle

• Refractoriness – ability of the myocardium

to prevent from responding to a new
stimulus while the heart is still in a state of
contraction in order to preserve cardiac
rhythm
Stages: Absolute, Relative
 Properties of the Cardiac Muscle

• Extensibility – ability of the heart to stretch

during diastole as the heart fills with blood
 Starling’s Law of the heart:
“The longer the fiber length (up to a certain
limit), the stronger the contraction.”
 Properties of the Cardiac Muscle

• Conductivity – ability of the heart muscle

fibers to conduct or transmit an electrical
impulse to the next cell (dromotropic
characteristic).
For contraction to take place, the heart
must conduct impulses via a specialized
route.
 DEFINITION OF TERMS
• Inotropic Effect
Refers to a change in myocardial
contractility
A positive inotropic effect results in an
increase in myocardial contractility
A negative inotropic effect results in a
decrease in myocardial contractility
 DEFINITION OF TERMS
• Chronotropic Effect
Refers to a change in heart rate
A positive chronotropic effect refers
to an increase in heart rate
A negative chronotropic effect
refers to a decrease in heart rate
 DEFINITION OF TERMS
• Dromotropic Effect
Refers to a change in the speed of
conduction through the AV junction
A positive dromotropic effect results in
an increase in AV conduction velocity
A negative dromotropic effect results
in a decrease in AV conduction velocity
12 LEAD ECG
• Limb Leads
• RA: Red Right arm
• LA: Yellow Left arm
• LL: Green Left leg
• RL: Black Right leg
• Bipolar Standard Limb
• Leads
• • Leads I, II, III
• • Augmented Unipolar
• Leads
• • Leads aVR, aVL, aVF
 Unipolar Precordial Leads

• Chest Leads
• V1 Red 4th ICS RPSB
• V2 Yellow 4th ICS LPSB
• V3 Green Midway between V2 and V4
• V4 Brown 5th ICS LMCL
• V5 Black LAAL Lateral & horizontal to V4
• V6 Violet LMAL Lateral & horizontal to V4
• V1: 4th intercostal space right
sternal border
• V2: 4th intercostal space left sternal
border
• V3: halfway between V2 and V4
• V4: left 5th intercostal space,mid-
clavicular line
• V5: horizontal to V4, anterior
axillary line
 Role of the ECG Machine
• The ECG machine is designed to recognise and record any
electrical activity within the heart. It prints out this
information on ECG paper made up of small squares 1mm
squared.
Role of the ECG Machine
 Role of the ECG Machine
• Each electrical stimulus takes the form of a wave and so
patterns emerge made up of a number of connected waves.
In this way it is possible to calculate the duration of
individual waves.
• 10 small squares vertically is equal to 1 millivolt. So it is
possible to calculate the amount of voltage being released
within the heart. If the line is flat at any time in the duration
of a series of waves, it indicates no electrical activity at that
particular moment.
• The direction in which the waves point indicates whether
electricity is moving towards or away from a particular lead.
Role of the ECG Machine
 Sinus Rhythm

• Sinus rhythm is the name given to the normal rhythm of

the heart where electrical stimuli are initiated in the SA
node, and are then conducted through the AV node and
bundle of His, bundle branches and Purkinje fibres.
• Depolarisation and repolarisation of the atria and
ventricles show up as 3 distinct waves on ECG. A
unique labelling system is used to identify each wave.
• Less muscle means less cells which means less
voltage.
Sinus Rhythm
 The Waveforms
• Waveform: movement away from the baseline
in either a positive or negative direction.
• Segment: a line in between waveforms.
• Interval: a waveform with a segment.
• Complex: composed of several waveforms.
 The P Wave
• The first wave (p wave) represents atrial
depolarisation
 The QRS Complex
• After the first wave there follows a short period where the
line is flat. This is the point at which the stimulus is delayed
in the bundle of His to allow the atria enough time to pump
all the blood into the ventricles.
• As the ventricles fill, the growing pressure causes the valves
between the atria and ventricles to close. At this point the
electrical stimulus passes from the bundle of His into the
bundle branches and Purkinje fibres. The amount of electrical
energy generated is recorded as a complex of 3 waves known
collectively as the QRS complex. Measuring the waves
vertically shows voltage. More voltage is required to cause
ventricular contraction and therefore the wave is much
bigger.
 The Q Wave
• Q wave and represents depolarisation in the
septum.
 The R Wave
• R wave represents the ventricular
depolarisation
 The S Wave
• S wave represents depolarisation of the
Purkinje fibres.
 The T Wave
• T wave represents ventricular repolarisation.
 The ST Segment
• There is a brief period between the end of the QRS complex
and the beginning of the T wave where there is no conduction
and the line is flat. This is known as the ST segment and it is a
key indicator for both myocardial ischemia and necrosis if it
goes up or down.
 The PR Segment
• There is a brief period between the end of the P wave and the
beginning of the Q wave where the line is flat. This is called
the PR segment which represents the AV node conduction.
Prolonged PR segment are indicative of AV blocks.

The PR Interval
• Begins with the onset of the P wave and ends with the onset of
the QRS complex. This is a physiologic delay in the AV node.
Role of the ECG Machine
 ECG Interpretation (7 step approach)
• Initial Survey
• Rhythm Check
• Atrial Rate (P-P)
• Ventricular Rate (R-R)
• Axis Determination
• Intervals:
– PR interval: 0.12-0.20 msec
– QRS: 0.08-0.12 msec
– Qt: 0.44 msec (M= 0.32-0.44; F= 0.32- 0.46)
• Final Interpretation
 ECG interprétation
• Measurements:

Wave Duration Amplitude Axis

• P wave • 0.1 sec • <2.5 mv • 0° to +75°
• QRS • 0.06 to 0.10 • Depends on • +90° to - 30°
complex secs the size and
• QT interval • Bazett’s proximity of
formula the chamber
• Poor man’s
guide

• PR interval • 0.12 to 0.20

secs
 Initial Survey
• Check the presence of waves, position,
regularities or irregularities
 Rhythm Check
• If P wave is present and succeeded by a QRS
complex then the rhythm is sinus.
• If the P wave is absent or the conduction is
initiated by the AV node then the rhythm is
junctional.
 Rate (atrial or ventricular)
• Regular Rhythm
– 300 method:
• Count the number of big boxes between P-P for atrial and
R-R for ventricular rate then divide the number to 300
– 1500 method:
• Count the number of small boxes between P-P for atrial and
R-R for ventricular rate then divide the number to 1500
• Irregular Rhythm
– Count the number of QRS complexes in a 6 second
strip and multiply it by 10.
 The QRS axis
• Thumb method
• Plot method
• Reciprocal lead method
 The QRS axis
• Thumb method
– Left thumb= lead 1
– Right thumb= lead AVF

I
LEAD
+ -
+ N RAD
AVF
- LAD ERAD
 The QRS axis
• Plot method
– Graph leads I and AVF according to their
deflection (positive or negative) on an inverted X
and Y axis graph.
 The QRS axis
• Reciprocal lead method
– Check the unipolar and bipolar limb leads (I,II,III,
AVR, AVL, AVF) for equiphasic QRS complex and
check its 90 degree angle lead/ reciprocal lead.
 Intervals
• PR interval
– 1st degree AV block: if the PR interval is equally
prolonged
– 2nd degree AV block/ Mobitz type I (wenckebach): if
there are dropped QRS complexes on an increasing
PR prolongation
– 2nd degree AV block/ Mobitz type II: if there are
dropped QRS complexes with equally prolonged PR
interval
– 3rd degree AV block (complete heart block): regular
R-R intervals, chaotic PR interval, wide or narrow
QRS complex
 Interpret the ECG
• Specify the ff:
– Rhythm
– Rate: AR and VR
– The site where the dysrhythmia originated
– The mechanism of dysrhythmia
• If you have normal findings in any of the steps
then specify what is normal
Right Bundle Branch Block

Left Bundle Branch Block

1st Degree AV Block
2nd Degree AV Block type 1
2nd Degree AV Block type 2
3rd Degree AV Block
Accelerated idioventricular
The dying heart
asystole
Atrial bigeminy
Atrial fibrillation
Atrial flutter
Gulo-gulong heart
Normal sinus rhythm (nsr)
Nsr with premature atrial complex
Ventricular fibrillation
Ventricular tachycardia
Torsades de pointes
~END~
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