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Ecg made easy
1. MAKING ECG’S EASYMAKING ECG’S EASY
APPLICATION FOR THEAPPLICATION FOR THE
ECGECG
EVALUATING THE ECGEVALUATING THE ECG
2. 2
Upon completion one willUpon completion one will
be able to:be able to:
• Describe what an ECG is.Describe what an ECG is.
• Describe the proper hook-upDescribe the proper hook-up
procedure for a 12-Lead ECGprocedure for a 12-Lead ECG
• Identify basic normal ECGIdentify basic normal ECG
waveform morphology.waveform morphology.
• Distinguish between basic ECGDistinguish between basic ECG
arrhythmia and artifact.arrhythmia and artifact.
7. 7
12 LEAD ECG12 LEAD ECG
Learning objectives:Learning objectives:
Describe the correctDescribe the correct
placement of all electrodesplacement of all electrodes
Proper Skin preparationProper Skin preparation
Care of the ECG machine, wiresCare of the ECG machine, wires
and electrodesand electrodes
8. 8
Principles ofPrinciples of
ElectrocardiographElectrocardiograph
• Electrocardiograph – is theElectrocardiograph – is the
instrument that records theinstrument that records the
electrical activity of the heartelectrical activity of the heart
• Electrocardiogram (ECG) is theElectrocardiogram (ECG) is the
record of that activityrecord of that activity
9. 9
HOOKING UP THEHOOKING UP THE
12-LEAD ECG12-LEAD ECG
• Proper skin prepProper skin prep
• Placement of the limbPlacement of the limb
electrodeselectrodes
• Placement of the chestPlacement of the chest
electrodeselectrodes
14. 14
LETS REVIEWLETS REVIEW
• What is an ECGWhat is an ECG
• What are the limb leads?What are the limb leads?
• What are the chest leads?What are the chest leads?
• Why do skin prep?Why do skin prep?
16. 16
INFORMATION ON THEINFORMATION ON THE
ECGECG
• Patients demographicsPatients demographics
• Heart rate and measurementsHeart rate and measurements
• Speed ECG is recorded atSpeed ECG is recorded at
• Voltage ECG is recorded atVoltage ECG is recorded at
• What the filter is set onWhat the filter is set on
18. 18
WHAT YOU NEED TOWHAT YOU NEED TO
LOOK FORLOOK FOR
• Are the limb leads hooked upAre the limb leads hooked up
correctly?correctly?
• Are the chest leads hooked upAre the chest leads hooked up
correctly?correctly?
• Is the ECG free of artifact.Is the ECG free of artifact.
• Is this ECG a Critical ValueIs this ECG a Critical Value
19. 19
IS the ECG HOOKED UPIS the ECG HOOKED UP
CORRECTLY?CORRECTLY?
LIMB LEADSLIMB LEADS
Normal 12-leadNormal 12-lead
• AVR – alwaysAVR – always
negativenegative
• Lead I – alwaysLead I – always
positivepositive
• Lead II, III –Lead II, III –
positive orpositive or
biphasicbiphasic
CHEST LEADSCHEST LEADS
COLUMN IIICOLUMN III
• R wave progressionR wave progression
• Small to TallSmall to Tall
COLUMN IVCOLUMN IV
• R wave progressionR wave progression
• Tall to SmallTall to Small
20. 20
RULING OUT LIMB LEADRULING OUT LIMB LEAD
REVERSALREVERSAL
• Avr is always negativeAvr is always negative
• Lead I is always positiveLead I is always positive
• Lead II and III positive for the PLead II and III positive for the P
wave and usually the QRSwave and usually the QRS
complexcomplex
21. 21
CHEST LEADSCHEST LEADS
CHEST LEADSCHEST LEADS
COLUMN IIICOLUMN III
• R wave progressionR wave progression
• Small to TallSmall to Tall
COLUMN IVCOLUMN IV
• R wave progressionR wave progression
• Tall to SmallTall to Small
35. 35
BASIC CRITICALBASIC CRITICAL
VALUESVALUES
• Bradycardia – HRBradycardia – HR << 40bpm40bpm
• Tachycardia HRTachycardia HR >> 120bpm120bpm
• PVC’s - 4 or more in a rowPVC’s - 4 or more in a row
• ST ElevationST Elevation
36. 36
LOOKING AT THELOOKING AT THE
RHYTHMRHYTHM
• Evaluate theEvaluate the
rhythm strip atrhythm strip at
the bottom ofthe bottom of
the 12-lead forthe 12-lead for
the followingthe following
• Is the rhythmIs the rhythm
regular orregular or
irregular?irregular?
• Is there a PIs there a P
wave beforewave before
every QRSevery QRS
complexcomplex
• Are they anyAre they any
abnormal beats.abnormal beats.
45. 45
LETS SUMMARIZELETS SUMMARIZE
How do we produce an excellentHow do we produce an excellent
12-lead ECG?12-lead ECG?
Proper skin prepProper skin prep
Correct electrode placementCorrect electrode placement
Recognize and know how toRecognize and know how to
correct problemscorrect problems
Recognize basic critical valuesRecognize basic critical values
Editor's Notes
In an adult with a healthy heart, the heart rate is usually about 72 beats per minute.
The excitatory and electrical conduction system of the heart is responsible for the contraction and relaxation of the heart muscle.
The heart is divided into four chambers, but it functions as a two sided pump.
Top is the right and left atria
Bottom is the right and left ventricles
The right side of the heart receives and pumps venous blood to the lungs.
The left side of the heart receives (from the lungs) and pumps arterial blood to the body.
The sinoatrial node (SA node) is the pacemaker where the electrical impulse is generated. This node is located along the posterior wall of the right atrium right beneath the opening of the superior vena cava. It is crescent shaped and about 3 mm wide and 1 cm long.
The impulse travels from the SA node through the internodal pathways to the atrioventricular node (AV node).
The AV node is responsible for conduction of the impulse from the atria to the ventricles. The impulse is delayed slightly at this point to allow complete emptying of the atria before the ventricles contract. The impulse continues through the AV bundle and down the left and right bundle branches of the Purkinje fibers.
The Purkinje fibers conduct the impulse to all parts of the ventricles, causing contraction (Guyton, 1982).
Lets look at how the conduction system related to what we record on the ECG.
P wave: the sequential activation (depolarization) of the right and left atria
QRS complex: right and left ventricular depolarization (normally the ventricles are activated simultaneously)
ST-T wave ventricular repolarization
U wave: origin for this wave is not clear - but probably represents &quot;afterdepolarizations&quot; in the ventricles PR interval: time interval from onset of atrial depolarization (P wave) to onset of ventricular depolarization (QRS complex)QRS duration: duration of ventricular muscle depolarizationQT interval: duration of ventricular depolarization and repolarizationRR interval: duration of ventricular cardiac cycle (an indicator of ventricular rate)PP interval: duration of atrial cycle (an indicator of atrial rate)
Recorded on graph paper.
Time is measured across
Voltage is measured up and down.
Small squares 1mm high 0.04 secs wide
5 small squares = 1 large square
1 large square is 5mm high and 0.20 sec wide
Both re-usable and disposable electrodes rely on the electrolyte in the electrodes to
make an effective connection between the machines electrode and the patient’s
electro-physiological signals.
These signals are not picked up just off the surface of the skin,
where dead or dry skin, oils and hair all prevent the signals from being detected.
The signals are under this surface, and thus we have to prepare the patient so that
the electrolyte can reach the signals beneath.
This is achieved by:
Removing oil, greasy and dirt from the skins sites with alcohol
ELECTRODE PLACEMENT
The standard 12-Lead ECG is a collect of tracings of electrical activity occurring in the heart. Each lead provides a tracing, which is characteristic of a different view of the same electrical activity. Other words we take 12 different angles (pictures) of the same activity.
In a standard 12-lead ECG there are 6 limb leads with a three-electrode connection made to the Right arm, Left arm and Left leg. The right leg is also hooked up to the machine but this is your ground lead and does not generate a signal on the ECG.
The chest electrodes are labelled “V” and are numbered from 1 to 6.
The placement of these electrodes needs to be exact to give the optimum information as possible. If the electrodes are placed incorrectly on the chest, the tracing will reveal duplication of some information, while other areas will not be represented properly.
Incorrect placement of the electrodes can lead to serious errors of interpretation.
There are six chest leads: V1, V2,V3,V4, V5 and V6.
V1 at the fourth intercostal space, at the right margin of the sternum
V2at the fourth intercostal space, at the left margin of the sternum
V3midway between the position of leads V2 and V4 (in a straight line)
V4at the fifth intercostals space at the junction of the left midclavicular line
V5 midway between the position of leads V4 and V6 (straight down from the axillary
Line on the same horizontal position as V4 and V6
V6at the horizontal position of V4, at the left of the midaxillary line.
Lets look at this ECG for the limb leads?
Is lead I positive? Is AVR negative
We have reversed our limb electrodes we have the right arm on the left arm and reverse.
We need to have R wave progression
In column III the R wave(first positive wave of the QRS) goes from short to tall V1 shortest R wave
V2 R wave taller than in V1 and V3 has the tallest R wave.
In column IV the R wave is always the shortest in V6.
Is this ECG hooked up correctly for the limb leads?
Is it for the chest leads?
Lets evaluate this ECG to see if the Limb leads and Chest Leads are hooked up correctly?
Is this ECG HOOKED UP CORRECTLY FOR LIMB AND CHEST?
Lead I = right arm and left arm
Lead II = right arm and left Leg
Lead III = left arm and Left Leg.
Look at the number of large boxes before two R waves and then using this method find the HR .
I just remember that 2 ½ large boxes or less is critical value for tachycardia
7 or more large boxes is critical for bradycardia
Look at the rhythm strip is it regular or irregular.
How many large boxes are between two R waves = 5 = 60bpm
