Electrocardiogram (ECG)

Ken M.Fonghe M.D.

Any Department

Raw Materials

Electrodes

Connecting wires

Amplifier

torage and !ransmission de"ice

Electrodes

!wo types

#ipolar leads

$nipolar leads

#ipolar %eads

record the "oltage differential &etween the

wrists and the legs

placed on the left leg' the right wrist' and

the left wrist' forming a triang(lar
mo"ement of the electrical imp(lse in the
heart that can then &e recorded.

$nipolar %eads

record the "oltage difference &etween a

reference electrode and the &ody s(rface
to which they are attached

attached to the right and left arms and the

right and left legs

placed at specific areas on the chest and

are (sed to "iew the changing pattern of
the heart)s electrical acti"ity

Models of Electrodes

plate' s(ction' fl(id col(mn' and fle*i&le'

among others

+late electrodes are metal dis,s which are

constr(cted o(t of stainless steel' German
sil"er' or nic,el

held onto the s,in with adhesi"e tape

(ction electrodes (se a "ac((m system

to remain in place

designed o(t of nic,el or sil"er and sil"er

chloride and are attached to a compressor
that creates the "ac((m

Fl(id col(mn electrode' is less sensiti"e to

patient mo"ement &eca(se it is designed to
a"oid direct contact with the s,in

Fle*i&le electrode is most (sef(l for ta,ing

EKG readings in infants. -t is a mesh
wo"en from fine stainless steel or sil"er
wire with a fle*i&le lead wire attached. !he
electrode attaches to the s,in li,e a small
&andage.

Amplifier

con"ert the wea, electrical signal from the

&ody into a more reada&le signal for the
o(tp(t de"ice

!he sections of the amplifier which recei"e

direct signals from the patient are
separated from the main power circ(itry of
the rest of the EKG machine &y optical
isolators' pre"enting the possi&ility of
accidental electric shoc,.

!he primary amplifier is fo(nd in the main

power circ(itry. -n this powered amplifier'
the signal is con"erted to a c(rrent s(ita&le
for o(tp(t to the appropriate de"ice.

!he most common form of o(tp(t for EKG

machines is a paper.strip recorder. !his
de"ice pro"ide a hard copy of the EKG
signal o"er time.

Many other types of de"ices are also (sed'

incl(ding comp(ters' oscilloscopes' and
magnetic tape (nits.

ince the data collected is in analog form'

it m(st &e con"erted to digital form for (se
&y most electronic o(tp(t de"ices.

For this reason the primary circ(itry of the

EKG typically has a &(ilt.in analog to digital
con"erter section.

ince the signal is wea,ly transmitted

thro(gh the s,in to the electrodes' an
electrolyte paste is (s(ally (sed.

!his paste is applied directly to the s,in.

-t is composed primarily of chloride ions

which help form a cond(cti"e &ridge
&etween the s,in and the electrode'
allowing &etter signal transmission.

/ther components incl(de mo(nting clips'

"ario(s sensors' and thermal papers.

Normal pregnancy induces no

characteristic electrocardiographic
changes other than slight left-axis
deviation as a result of the altered
heart position.

Reading and -nterpretation

+ wa"e0 atrial depolari1ation

2R comple*0 "entric(lar depolari1ation

! wa"e0 "entric(lar repolari1ation

+2 or +R inter"al0 &etween the &eginning

of the + wa"e and the &eginning of the
2R comple*

Reading and -nterpretation

+ wa"e0 atrial depolari1ation

2R comple*0 "entric(lar depolari1ation

! wa"e0 "entric(lar repolari1ation

+2 or +R inter"al0 &etween the &eginning

of the + wa"e and the &eginning of the
2R comple*

2! inter"al0 from the &eginning of the 2R

comple* to the end of the ! wa"e

3 point0 4(nction &etween the end of the

2R and the &eginning of ! segment












Row 1 Row 2 Row 3 Row 4
0
2
4
6
8
10
12
Column 1
Column 2
Column 3

ST depression and T-wave inversion in the right to

midprecordial leads are also often present. This pattern,
formerly called right ventricular "strain," is attributed
to repolarization abnormalities in acutely or chronically
overloaded muscle.

Electrocardiogram in a normal neonate <24 hr of age. Note the dominant R wave and upright T waves in
leads V
3
R and V
1
V
3
R paper speed ! "# mm$sec%.

uring the !st days of life, right axis deviation, large

" waves, and upright T waves in the right precordial
leads #$%" or $&" and $!' are the norm.

(s pulmonary vascular resistance decreases in the !st few

days after birth, the right precordial T waves become
negative.

)n the great ma*ority of instances, this change occurs

within the !st &+ hr of life.

,pright T waves that persist in leads $%", $&", or $!

beyond ! w- of life are an abnormal finding indicating
right ventricular hypertrophy or strain, even in the
absence of ."S voltage criteria.

The T wave in $! should never be positive before / yr of

age and may remain negative into adolescence.

Electrocardiogram of a normal infant. Note the tall R and small & waves in V
4
R and V
1
and the
inverted T wave in these leads. ' dominant R wave is also present in V
(
.

)n a newborn, the mean QRS frontal-plane axis normally lies in the range of 0!!1 to
0!+1 degrees.

The right-sided chest leads reveal a larger positive #"' than negative #S' wave and
may do so for months or years because the right ventricle remains relatively thic-
throughout infancy.

2eft-sided leads #$
3
and $
/
' also reflect right-sided dominance in the early neonatal
period, when the " 4 S ratio in these leads may be 5!.

( dominant " wave reflecting left ventricular forces 6uic-ly becomes evident within
the !st few days of life.

7ver the years, the ."S axis gradually shifts leftward, and the right ventricular
forces slowly regress.

2eads $
!
, $
%
", and $
&
" display a prominent " wave until / mo to + yr of age.

8ost children have an " 4 S ratio 9! in lead $

&
" until they are & yr of age.

The T waves are inverted in leads $

&
", $
!
, $
:
, and $
%
during infancy and may remain so
into the middle of the :nd decade of life and beyond.

The processes of right ventricular thinning and left ventricular growth are best
reflected in the ."S-T pattern over the right precordial leads.

The diagnosis of right or left ventricular hypertrophy in a pediatric patient can be

made only with an understanding of the normal developmental physiology of these
chambers at various ages until adulthood is reached.

(s the left ventricle becomes dominant, the ;<= evolves to the characteristic pattern
of older children and adults.

Electrocardiogram of a normal child. Note the relativel) tall R waves and inversion of the T
waves in V
4
R and V
1
.

Normal adult electrocardiogram. Note the dominant & wave in lead V
1
. This pattern in an
infant would indicate the presence of left ventricular h)pertroph).

!he ECG sho(ld always &e e"al(ated systematically to a"oid the possi&ility of
o"erloo,ing a minor' &(t important a&normality.

/ne approach is to &egin with an assessment of rate and rhythm' followed &y
a calc(lation of the mean frontal.plane 2R a*is' meas(rements of segment
inter"als' assessment of "oltages' and' finally' assessment of ! and !.wa"e
a&normalities.

"ate and rhythm

> waves4 present, upright in leads ), a$?@ inverted in

a$", up to :.3mm, uniform

."S complex

>" intervals

.T intervals

ST segment4 ( slight elevation of the ST segment may

occur in normal teenagers and is attributed to early
repolarization of the heart.

T wave

.-T interval #.-Tc' can be calculated by dividing the

measured .-T interval by the s6uare root of the preceding
"-" interval. ( normal .-Tc should be 51.&3.

/#0 slight left a*is de"iation

!han, 5o(