Chapter 3

THE ELECTROCARDIOGRAPH

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 Learning Outcomes
3.1 Explain the three types of leads and how each is
recorded.
3.2 Identify the functions of common ECG machines.
3.3 Explain how each ECG machine control is used.
3.4 Recognize common electrodes.
3.5 Describe the ECG graph paper.
3.6 Calculate heart rates using an ECG tracing.

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 Learning Outcome 3.1
Producing the ECG Waveform
Key Terms
Augmented lead Leads
Bipolar lead Limb lead
Einthoven’s triangle Precordial lead
Electrodes Unipolar lead

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 Producing the ECG Waveform
• The 12-lead ECG produces a complete picture of the heart’s
electrical activity.
• The ECG waveform indicates how the heart is functioning
electrically.
• Each lead in a 12-lead ECG produces a single view from a
slightly different angle.

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 12-Lead ECG
10 lead wires
• Six chest leads
• Four limb leads
• Coded by color and letter

Each lead is attached to an electrode

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 Identifying Lead Wires

Jump to Identifying Lead Wires A

ppendix
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 Einthoven’s Triangle

Jump to Einthoven’s Triangle Appen

dix
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 Waveform Types
• Isoelectric – flat, no current flowing

• Positive – upright, current flows to positive electrode

• Negative – downward, current flows away from positive

electrode

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 Types of Leads
10 lead wires
• Three standard leads
• Three augmented leads
• Six chest leads

Produce 12 different views

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 Standard Limb Leads
• Lead I – records tracing from right arm (-) to left arm (+)

• Lead II – records tracing from right arm (-) to left leg (+)

• Lead III – records electrical activity from left arm (-) to

left leg (+)

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 Standard Limb Lead Tracings

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 Augmented Leads
aVR
• Records activity from heart to right arm
• Usually produces a negative deflection

aVL
• Records activity from heart to left arm

aVF
• Records activity from heart to left leg

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 Augmented Lead Tracings

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 Chest Lead Placement and Tracings

Jump to Chest Lead Placement a

nd Tracings Appendix
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 Learning Outcome 3.1
Apply Your Knowledge #1

What are the names of the standard limb leads?

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 Learning Outcome 3.1
Apply Your Knowledge #1
Answer
What are the names of the standard limb leads?

Leads I, II, and III

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 Learning Outcome 3.1
Apply Your Knowledge #2

How many chest leads are there on a standard 12-lead ECG?

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 Learning Outcome 3.1
Apply Your Knowledge #2
Answer
How many chest leads are there on a standard 12-lead ECG?

Six

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 Learning Outcome 3.2
ECG Machines
Key Terms
Input

Multichannel recorder

Output display

Serial ECG comparison

Signal processing

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 ECG Machines
• Weigh less than 10 pounds

• Most have the same basic parts

• Read instructions before using

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 Multichannel ECG Machine
• Monitors three to six leads at a time

• Recording time of approximately 10 seconds.

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 Multichannel ECG Recording

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 Primary ECG Machine Functions
• Input

• Signal processing

• Output display

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 Other ECG Machine Functions
• Computerized measurement and analysis

• Storage

• Communication

• Interpretation

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 Advancing Technologies
• Single-channel to 3-lead to 12-lead machines

• Digital wireless technology

• Digital storage systems

©McGraw-Hill Education. Courtesy of GE Healthcare Systems

 Learning Outcome 3.2
Apply Your Knowledge

What are the three primary functions of an ECG machine?

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 Learning Outcome 3.2
Apply Your Knowledge
Answer
What are the three primary functions of an ECG machine?

Input, signal processing, and output display

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 Learning Outcome 3.3
ECG Controls
Key Terms
Artifact Millimeter (mm)

Bradycardia Millivolt (mV)

Gain Speed control

Hertz (Hz) Tachycardia

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 Speed Control
• Regulates speed of paper

• Normally 25 mm/sec

• Changes must be noted on ECG report

• Very fast heart rates may require 50 mm/sec paper speed

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 Gain Control
• Controls height of waveform

• Normal setting is 10 mm/mV

• 20 mm/mV doubles tracing size

• 5 mm/mV reduces size by half

• Changes must be noted on ECG report

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 Artifact Filter
• Normal setting between 40 and 150 Hz

• Used to reduce artifact or abnormal marks on tracing

• Corrects only the printed output

• Computer interpretation not filtered

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 LCD Display
• Area where patient info can be viewed

• Newer machines may indicate incorrect lead placement in the

display

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 Other ECG Machine Controls
Heart rate limits
• Activate an audio alarm and marking on the tracing
• Bradycardia
• Tachycardia

Lead Selector
• Runs each lead individually

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 Learning Outcome 3.3
Apply Your Knowledge #1

True or False: Very fast heart rates may require a faster paper
speed.

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 Learning Outcome 3.3
Apply Your Knowledge #1
Answer
True or False: Very fast heart rates may require a faster paper
speed.

True

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 Learning Outcome 3.3
Apply Your Knowledge #2

Which of the ECG controls can be used to make the tracing

appear larger?

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 Learning Outcome 3.3
Apply Your Knowledge #2
Answer
Which of the ECG controls can be used to make the tracing
appear larger?

Gain

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 Learning Outcome 3.4
Electrodes
• Sensors that pick up electrical activity, conducting to the ECG
machine
• Ten electrodes are used for the 12-lead ECG
• Most electrodes are disposable

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 Caution!!!
Disposable electrodes are used for only one ECG.
• Exception: When second ECG is performed immediately after
the first and electrodes have not been moved

Expiration date must be checked prior to use

Never mix electrode types!

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 Learning Outcome 3.4
Apply Your Knowledge

What are some advantages of using disposable electrodes?

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 Learning Outcome 3.4
Apply Your Knowledge
Answer
What are some advantages of using disposable electrodes?

They reduce the possibility of cross-contamination; can be

discarded for easier cleanup; gel is already applied.

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 Learning Outcome 3.5
ECG Graph Paper
Dot Matrix Standard Grid
• Requires less ink • Less expensive

• Easier to read
• Makes sharper photocopies

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 Handling ECG Graph Paper
• Graph paper may be heat/pressure-sensitive and easily
erased.

• Some graph paper requires no special handling/storage and is

guaranteed for 50 years.

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 ECG Graph Paper Essentials
Paper supply
• Keep extra paper on ECG
cart

Read directions
• Know how to change the
paper

Law and ethics

• Tracings must be kept at
least 7 years

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 Graph Paper Measurements
Small box
• 1 mm by 1 mm
• Represents 0.04 second horizontally at 25 mm/sec
• Represents 0.1 mV vertically

Large box
• 5 mm by 5 mm
• Represents 0.20 second horizontally at 25 mm/sec
• Calibrated so that 1 cm = 1 mV vertically

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 Example of Graph Paper Measurements

Jump to Example of Graph Paper

Measurements Appendix
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 Learning Outcome 3.5
Apply Your Knowledge

What substances can damage the ECG report?

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 Learning Outcome 3.5
Apply Your Knowledge
Answer
What substances can damage the ECG report?

Alcohol, plastic, sunlight, and x-ray film can erase the ECG
tracing.

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 Learning Outcome 3.6
Calculating Heart Rate

• R-R interval/300 method

• 1500 method

• 6-second method

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 Calculating Heart Rate Using
the 300 Method
Least accurate method
• Incomplete boxes not counted

Calculation
• Determine number of large boxes between two consecutive R
waves
• Divide number into 300

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 300 Method Example

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 Calculating Heart Rate Using
the 1500 Method
• Count the number of small squares between two
R waves
• Divide into 1,500

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 Calculating Heart Rate Using
the 6-Second Method
• Identify a 6-second section of tracing
• Count the number of complete complexes in the 6-second
section
• Multiply the number of complexes by 10
• Do not count incomplete complexes

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 6-Second Example

6-second section

Last complex not complete,

not included

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 Learning Outcome 3.6
Apply Your Knowledge #1

Each large box is equal to how many seconds?

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 Learning Outcome 3.6
Apply Your Knowledge #1
Answer
Each large box is equal to how many seconds?

0.2 second

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 Learning Outcome 3.6
Apply Your Knowledge #2
Using the 6-second method, what is the approximate heart rate
shown in this 6-second strip?

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 Learning Outcome 3.6
Apply Your Knowledge #2
Answer
Using the 6-second method, what is the approximate heart rate
shown in this 6-second strip?

60 bpm; multiply 6 times 10. The last complex is not complete,

so it is not counted.
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 Chapter Summary 1
• A 12-lead ECG uses 10 lead wires to produce 12 views of the
electrical activity of the heart.

• Standard, augmented, and chest leads are used to produce

the ECG.

• Standard leads are bipolar, and augmented and chest leads

are unipolar.

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 Chapter Summary 2
• Input, signal processing, and output display are the basic
functions of the ECG.

• Many advances have been made in ECG technology over the

last 30 years.

• ECG controls include a speed control, gain control, and artifact

filter.

• Various types of ECG electrodes are used for ECG machines,

but most are disposable.

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 Chapter Summary 3
• 2types of ECG graph paper are
The two most commonly used
standard grid and dot matrix.

• ECG machines are calibrated so that each box represents a

specific time and voltage.

• Heart rate can be calculated using three different methods: R-

R interval, 1500 method, and 6-second method.

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 Appendix Slides

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 Identifying Lead Wires Appendix
An example of color coding for chest lead wires: V1: red; V2:
yellow; V3: green; V4: blue; V5: orange; V6: purple. Arrows point
to the position of each lead on the chest.

Jump to Identifying Lead Wires

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 Einthoven’s Triangle Appendix
Left: Human silhouette showing the right and left arm leads at
the right and left shoulders and the right and left leg leads on the
right and left legs. Second human silhouette labeled Einthoven’s
triangle, showing the triangle formed by the left leg, left arm,
and right arm leads.

Right: Separate view of Einthoven’s triangle with the heart in the

middle of the triangle and arrows to show the direction of
recording. Using the points of the compass as a measure, lead I
goes west; lead II goes south-southeast; lead III goes south-
southwest; lead aVR goes west-northwest; lead aVL goes east-
northeast; and lead aVF goes south.

Jump to Einthoven’s Triangle

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 Chest Lead Placement and Tracings Appendix
Top left: Human rib cage with the placement of V1 through V6
Top middle: transverse section through the heart showing the
placement and direction of current for V1 through V6
Top right: Legend identifying placement of all six chest leads:
• V1—Fourth intercostal space, right sternal border
• V2—Fourth intercostal space, left sternal border
• V3—Halfway between V2 and V4
• V4—Fifth intercostal space at the midclavicular line
• V5—On the same horizontal level with V4, at the anterior
axillary line
• V6—On the same horizontal level with V4 and V5, at the
midaxillary line Jump to Chest Lead Placement a
nd Tracings
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 Example of Graph Paper Measurements
Appendix
ECG waveform on graph paper with time and voltage marked.
The vertical axis represents voltage and the horizontal axis
represents time in seconds. One small box horizontally equals 1
mm or 0.1 mV. One small box vertically equals 1 mm or 0.04
second.
• Five vertical heavy lines or boxes equal 1 second
• One vertical heavy line or box equals 0.2 second
• Smallest vertical line or box equals 0.04 second
• Two large horizontal heavy lines or boxes equal 1 mV

Jump to Example of Graph Paper

Measurements
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