Pre Hospital Recognition and Management

of Acute Illness and Long Term Conditions

In the prehospital environment, performing an
ECG is essential assessment tool commonly
used by ambulance staff.

Therefore there is a requirement to:

◦ Understand basic Cardiac Function
◦ Understand the Conductivity through the heart
◦ Understand lead location and why
◦ Interpret ECG rhythms
Do not worry there is no heart
diagram to label, just a quick
recap…

So, who can remember the flow of

•Deoxygenated blood ?
•Oxygenated blood ?
•The Circulatory System ?
•What happens through gaseous
exchange ?
Any movement away from the baseline of the ECG,
represents some cardiac event. For example the P-wave
represents ‘atrial depolarisation’.
Any movement away from the baseline of the ECG,
represents some cardiac event. For example the P-
wave represents ‘atrial depolarisation’.
PR Interval - initiation of impulse at SA node
– ventricular depolarisation
- duration of 0.12 – 0.20 seconds
QRS Complex - represents ventricular depolarisation, and the impulse
travelling down the Bundle of His an into the Purkinje
Fibres
- duration of 0.035 -0.045 seconds
ST Segment – represents the time between depolarisation and
repolarisation.
myocardium maintains contraction
T wave – represents ventricular
repolarisation
 Electrolytes – are means of which the cell
develops ‘electricity’.
 Its important to know about electrolytes as you
can understand how ‘electrical activity’ within
the heart occurs and also how electrolyte
imbalances can be ‘life threatening’.
 It is beneficial to understand how myocardial
cells become polarised and depolarised, and
how this allows the cells to contract.
 C1 – 4th intercostal space to right of
sternum.
C2 – 4th intercostal space to left of
sternum.
C4 – 5th intercostal space, mid-clavicular,
ECG Placing of limb and to left of sternum.
precordial leads C6 – straight line from C4, mid-axilla, to
left of sternum.
C3 – mid-point between C2 & C 4
C5 – mid-point between C4 & C6.
The ECG machine reads Right Left
the -ve and +ve poles
of the limb electrodes - I +
to produce leads I, II, III.
- -

In physics, ‘two vectors

are equal as long as
they are parallel and of
III
the same intensity’. II

This allows us to see

the vectors through the +
+
centre of the heart.
 AVF
II III
Right Left

Vectors as seen
through and AVR -
perceived by the Augmented
ECG monitor. Vector Right

Notice the AVL –

I Augmented
symmetry!!!!
Vector Left
This creates the
first 6 leads of AVF –
the 12 lead ECG Augmented
Vector Foot
AVL AVR
 AVF
II III
Compare the
representation of the
vectors as waves, and
what can you interpret I

from this??
AVR
AVL
The precordial or chest leads look
right through the ‘transverse plane’
of the heart.

These provide a further detailed

analysis of the heart.

Notice this omits a small portion of

the heart!!!
Heart Rate
Machine does it for you…

If not a rough guide of how to calculate the

heart rate is to:

No. of cycles in six second x 10

(cycles in 6 seconds) x 10.

Here are some examples, work out the HR…

Common causes of an abnormal 12-lead ECG
 Arrhythmia
 Conduction disturbance – pre-excitation,
bundle branch block
 Ventricular abnormalities – ventricular
hypertrophy
 Coronary heart disease- ischaemia / injury /
infarction
 Hypothermia
 Pulmonary Embolism
 Electrolyte Disturbance
 Congenital abnormality
 ‘Sinus Rhythms’

 Effectively means ‘regular’

 An ECG where the ‘conductivity’ follows a

normal pattern through the heart from SA
node through the AV node and to the Perkinje
Fibres will be term ‘Sinus’.
Normal Sinus Rhythm

Rate: 60 -100 bpm With Normal Sinus Rhythm, there is

Regularity – Regular no irregularity throughout all
P-wave – Present complexes. The SA node originates
PR interval – Normal the impulse, and the flow of the
QRS width - Normal complex unfolds with out glitch.
Sinus Bradycardia
Rate – < 50 - 60bpm
(dependent on sources)
Regularity – Regular
P-wave – Present
PR interval – Normal - slightly
prolonged
QRS width – Normal – slightly
prolonged
The beats are slower. The SA node
may not be the originator of the
impulse (atrial pacemaker). As the
rate is slow the complex and the
interval tend to be slightly
prolonged.
Sinus Tachycardia
Rate – > 100bpm The beats are faster. The SA
Regularity – Regular node may not be the
P-wave – Present originator of the impulse
PR interval – Normal - slightly (atrial pacemaker). As the
shortened rate is quicker the complex
QRS width – Normal – slightly and the interval are slightly
shortened shorter.
Sinoatrial Block Sinoatrial Block carries the same
Rate – Varies concept as Sinus Pause/Arrest,
Regularity – Irregular with the exception that the
P-wave – Present except in times of period where the beat is
dropped beat dropped, the time followed for
PR interval – Normal the next is rhythmic. The
QRS width – Normal pathology involved is a non-
Dropped Beats - Yes conducted beat from the normal
pacemeaker.
Sinus Pause/Arrest
Sinus Pause/Arrest is a common pre-
Rate – Varies hospital presentation, generally in
Regularity – Irregular older people. The length of a pause is
P-wave – Present except in variable, however is preceded and
times of pause/arrest followed by a normal sinus rhythm.
PR interval – Normal There is no criterion between the
QRS width – Normal length of when the missed complex
Dropped Beats - Yes becomes a ‘sinus arrest’ as opposed
to a ‘sinus pause’
System for Determining Heart Rate
 Is there any electrical activity?
 What is the ventricular rate?
 Is the QRS rhythm regular or irregular?
 Is the QRS complex width normal or
prolonged? (< 3 small squares)
 Is atrial activity present?
 Is the P-R interval normal? (3-5 small squares)
 How is atrial activity related to ventricular
activity?
What is a cardiac arrhythmia (or dysrhythmia)

List the most common cardiac arrhythmias

What symptoms might a patient experience

during a fast arrhythmia and during a slow
arrhythmia?
P – Wave and P-R Interval abnormalities.
P wave – simulates atrial depolarisation, starting
at the SA node.
P-R interval – simulates atrial depolarisation and

the delay at the AV junction.

P waves should be present, singular and

symmetrical
P-R interval (normal) should last between 0.12 –

0.20 seconds.
Atrial Flutter So the SA node fires many
Rate – Atrial Rate – 250-300 bpm impulses towards the AV node,
Ventricular Rate – 125-160 bpm which in turn accepts the same
Regularity – Usually regular but impulse on every occasion
may vary. (disregarding the others) allowing
P-wave – Saw tooth appearance, the rhythm to appear regular. Less
multiples known as ‘F-waves’. occasional circumstances, the
PR interval – varies variable rate of acceptance from
QRS width – Normal the AV node can differ at ratio’s
2:1 to 3:1, but nevertheless still
appear rhythmic.
Atrial Fibrillation
Rate – Variable, the ventricular
response can be fast/slow.
Regularity – Irregularly irregular
P-wave – None – chaotic atrial
activity
PR interval – None
QRS width – None
AF occurs through the hectic
firing of pacemaker cells that do
not necessarily originate form the
SA node. The ventricular response
from these haphazard atrial
contractions is to seldom accept
and stimulate the ventricles into
contracting thereafter. Hence
there is no regularity to the ECG
rhythm.
Atrial fibrillation is the result of multiple wavelets of
depolarisation (shown by arrows) moving around the
atria chaotically.
First Degree Block First Degree Block occurs from a
prolonged physiologic block in the AV
Rate – Dependent on underlying
node. This can occur because of
condition
medication, vagal stimulation, disease
Regularity – Regular
and other forms. The residing factor
P-wave – Present
of First Degree Block is simply a
PR interval – Prolonged >0.2
prolonged P-R interval which is
seconds
longer than 0.20 seconds.
QRS width – Normal
Wide Complex Tachycardia Also known as SVT and is where the
initiation of the Ventricular
Rate – Usually between 140- depolarisation occurs within the atria
180bpm, but can be significantly above the AV node. Therefore prior to
higher the AV node receiving the electrical
Regularity – Regular impulse, an excitation occurs within
the atria which stimulates ventricles
P-wave – Generally buried in the
into contracting earlier. Due to the
initiation of the QRS complex conduction pathway of the ventricles
PR interval – Absent being quicker than the atria, the
QRS width – Wider complexes, due impulse generated at the AV node
to pre-excitation. soon catches the impulse generated
by the atria and overrides it
completing the QRS complex.
Wolff-Parkinson-White Syndrome Wolff-Parkinson-White (WPW) Syndrome
is a genetic defect from birth. The
Rate – Associated to tachycardic
pathophysiology behind patients with
rhythms, but can present
WPW is they have an extra conducting
normal
bundle (Kent Bundle) which is usually on
Regularity – Regular
the left side of the heart. Within this
P-wave – Regularly present
bundle there is no AV node to delay
PR interval – Shortened – <0.12
Ventricular contraction, so depolarisation
seconds
commences earlier on the effected side.
QRS width – Wider complexes,
However, the impulse delivered from the
due to pre-excitation.
AV node is stronger and faster, so when
initiated soon catches up with the initial
pre-excitation and supersedes it.
Junctional (Bradycardia) Rhythm
Rate – Usually 40-60bpm
Regularity – Regular
P-wave – Generally Absent, can be
inverted or after QRS complex.
PR interval – Generally absent, if
present does not stimulate
ventricular depolarisation
QRS width – Normal
A Junctional rhythm arises as an
‘escape rhythm’. A Junctional
Rhythm occurs when the normal
pace making function of the atria
and SA node is generally absent.
Stimulation of the AV node can
arise from other aspects of the
atria, but not with the same
intensity or frequency. Stimulation
may not occur at all in the atria
(Idioventricular Rhythm) and the
ventricular response thereafter
becomes less regular (close
association to third degree heart
What is going on here then??

What can you identify from this ECG strip??

QRS Complex Abnormalities
QRS complex simulates the depolarisation of
the ventricles, starting oat the AV node.
Within a sinus rhythm the normal duration of

a QRS complex should be between 0.06-0.11

seconds.
Abnormalities of the QRS complex tend to be
a ‘widening’ of the QRS complex, or complete
dropped complexes altogether
Premature Ventricular Contraction (PVC)
Rate – Depends on the underlying
rhythm
Regularity – Irregular
P-wave – Not present on the PVC
PR interval – No P-wave present
QRS width – excessively wide, bizarre in
appearance.
PVC’s are caused by the premature
firing of the AV node. The AV node
generates the impulse prior to the
SA node initiating the impulse.
Therefore the ventricles not yet
being repolarised are not expecting
to receive the impulse. This
therefore shows the earlier
ventricular response with the slower
pathway due to the unexpected
nature of receiving the impulse.
Mobitz I Second Degree Heart Block
Rate – Depends on underlying
rhythm
Regularity – Regularly Irregular
P-wave – Present and normal
PR interval – Variable, dependent on
which part of the process you are
monitoring.
P:QRS ratio - Varied dependent on
severity of case
QRS width – Normal
Dropped beat - Yes
Also known as the ‘Wenckebach
phenomenon’. Refers to the
prolonging of the PR interval as
each complex continues until
eventually an entire beat is dropped.
Resultant form this is the
continuation of the process. The
Wenckebach phenomenon occurs
through the diseased AV node
which has a long refractory period.
Mobitz II Second Degree Heart Block
Rate – Depends on the underlying rhythm complex is missed. The key aspect here
Regularity – Regularly Irregular
P-wave – Present and normal
PR interval – Normal
P:QRS ratio – Varied dependent on the
severity of the case
QRS width – Normal
Dropped Beats: Yes
In Mobitz II, there are grouped beats
until the point, where an entire QRS
is that PR interval remains within the
norm throughout each completed beat.
The ratio can vary, for example the case
above has three P waves to one
completed beat (3:1). This can vary and
doesn’t necessarily need to be
symmetrical. This rhythm is caused by a
diseased AV node, and is an indicator of
bad things to come (3rd degree Heart
Block)
Third Degree Heart Block
Rate – separate rates for the
underlying sinus rhythm and
escape rhythms. No association
Regularity – Dependent on severity
P-wave – Present
PR interval – variable no associated
pattern
QRS width – normal, can be wide
Referred to as complete heart
block. There is no association
between the SA node and the AV
node. Therefore the atria and
ventricles are firing at will,
showing no synchronicity on the
ECG strip. Can present at any
rate dependent on the case.
12 Lead ECG interpretation
Follow a systematic approach –
 Calculate Heart Rate
 Assess Cardiac Rhythm
 Look at P waves and the P-R interval
 Measure QRS Duration
 Look at ST segments
 Look at T waves and U Waves
 Look at Q-T interval
Right Bundle Branch Block (RBBB)
Rate – Depends on the underlying
condition
Regularity – Generally regular
P-wave – Normally present
PR interval – Can be absent in
affected leads
QRS width – wider in affected leads
The pathophysiology of a RBBB is
the simplicity of a ‘block’ in the
Right Bundle Branch, causing a
delay in depolarisation of the
right ventricle. Causing an extra
‘kink’ in the affected leads
(known as the R-S-R
phenomenon)
Leads effected by the RBBB

II AVR V1 V4

II AVL V2 V5

III AVF V3 V6
Left Bundle Branch Block (LBBB) The pathophysiology of a LBBB is
the simplicity of a ‘block’ in the Left
Rate – Depends on the underlying Bundle Branch, causing a delay in
depolarisation of the right ventricle.
condition
Causing an extra ‘kink’ in the
Regularity – Generally regular
affected leads (known as the R-S-R
P-wave – Normally present phenomenon)
PR interval – Can be absent in
affected leads
QRS width – wider in affected
leads
Leads Effected by the LBBB

I AVR V4

II AVL V2 V5

III AVF V3
Ischaemia: Temporary shortage of 02 at cellular
level
 Typically = ST Depression
 May be transient (e.g. with pain)
 Good sign if resolves with px (GTN)
 ST Elevation
 T Wave Changes – may become tall, flattened,
inverted or biphasic
 Normal to have inverted T in III, AVR & V1
 Deep arrowhead inversion = suggestive of
myocardial ischaemia
 If history of MI with inverted T waves – may
become upright with Ischaemia
ST Segment Abnormalities
ST segment is the process of which the
ventricles have depolarised and are preparing
and start to repolarise.
T wave itself is the repolarisation of the

ventricles.

Themost significant ST segment abnormality

is……….
 ST ELEVATION

….. Acute Myocardial Infarction

Characteristics are BASELINE

 ST segment elevation in the leads looking directly at the
infarct
There must be at least TWO adjacent leads displaying

adequate elevation.
Limb leads (I, II, III, AVR, AVL, AVF) must show a minimum of

1mm elevation
Chest Leads (V – V ) must show a minimum of 2mm of
1 6

elevation
.

There must be ‘reciprocal changes’ (ST depression) in opposite

areas of the heart to where the infarct has occurred.

Regions of where ST elevation would be prevalent in the
corresponding AMI’s.
I AVR V1 V4

LATERAL SEPTAL ANTERIOR

II AVL V2 V5
HIGH
INFERIOR LATERAL
SEPTAL LATERAL

III AVF V3 V6

INFERIOR INFERIOR ANTERIOR LATERAL

What type of AMI are we looking at here??
What type of AMI are we looking at here??
What type of AMI are we looking at here??
What type of AMI are we looking at here??
Are we looking at an AMI here?
Findings with healthy people:
 Tall R waves
 Prominent U waves
 ST segment elevation (high ­take-off, benign early
repolarisation)
 Exaggerated sinus arrhythmia
 Sinus bradycardia
 Wandering atrial pacemaker
 Wenckebach phenomenon
 Junctional rhythm
 1st degree heart block