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W EDNES DA Y , MA RC H 2, 2011
ECG
Definition
Transthoracic interpretation of the electrical activity of the heart over time captured and externally recorded by skin electrodes
How it works?
The ECG works mostly by detecting and amplifying the tiny electrical changes on the skin that are caused when the heart muscle "depolarizes" during each heart beat.
How to do ECG?
Place the patient in a supine or semi-Fowler's position. If the patient cannot tolerate being flat, you can do the ECG in a more upright position.
Instruct the patient to place their arms down by their side and to relax their shoulders.
Make sure the patient's legs are uncrossed.
Remove any electrical devices, such as cell phones, away from the patient as they may interfere with the machine.
If you're getting artifact in the limb leads, try having the patient sit on top of their hands.
Causes of artifact: patient movement, loose/defective electrodes/apparatus, improper grounding#
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Placement of electrodes
Electrodes- usually consist of a conducting gel, embedded in the middle of a self-adhesive pad onto which cables clip. Ten electrodes are used for a 12-lead ECG.
Leads
Leads- the tracing of the voltage difference between two of the electrodes and is what is actually produced by the ECG recorder.
Limb leads
Augmented aVR, aVL, aVF (also derived from RA, LA, LL, they measure the electric potential at one
limb leads point with respect to a null point)
Precordial V1, V2, V3, V4, V5 and V6 (Because of their close proximity to the heart, they do not
leads require augmentation)
These leads help to determine heart’s electrical axis. The limb leads and the augmented limb leads form the frontal plane. The precordial leads form the horizontal
plane.
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ECG Interpretation
We go systematically: rate, rhythm, cardiac axis, QRS complexes, hypertrophies, bundle branch block, ST segment, QT interval and T wave
Rate Rate= 300/(the number of large square between R-R interval), or
Rate= 1500/(number of small square between R-R interval), example below
If the rhythm is not regular, count the number of electrical beats in a six-second strip and
multiply that number by 10.(Note the ECG strip has 3 second marks) Example below:
Or count the number of beats on any one row over the ten-second strip (the whole lenght)
and multiply by 6. Example:
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Findings:
Normal 60-99 -
Rhythm Look at p waves and their relationship to QRS complexes. Lead II is commonly used
Regular or irregular?
If in doubt, use a paper strip to map out consecutive beats and see whether the rate is the
same further along the ECG.
Measure ventricular rhythm by measuring the R-R interval and atrial rhythm by measuring
P-P interval.
* rhythms can come from SA node (sinus), AV or internodal node (atrial) or ventricular
Rhythm findings:
Interpretation Findings
Normal sinus ECG rhythm characterized by a usual rate of anywhere between 60-
rhythm (NSR) 99 bpm, every P wave must be followed by a QRS and the P wave is
upright in leads I and II
Sinus pause or In disease (e.g. sick sinus syndrome) the SA node can fail in its
arrest pacing function. If failure is brief and recovery is prompt, the result is
only a missed beat (sinus pause). If recovery is delayed and no other
focus assumes pacing function, cardiac arrest follows.
Escape rhythm An escape beat is a heart beat arising from an ectopic focus in failed
sinus node or heart block.
The ectopic impulse appears only after the next anticipated sinus
beat fails to materialize- usually a single escape beat. If prolong
failure/block: rhythm of escape beats is produced to assume full
pacing function. (cardiac protection mechanism). Examples:
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Premature A premature beat also arises from an ectopic pacemaker: The non-
beats sinus impulse is early, initiating a heart beat before the next
anticipated sinus beat, competing with the sinus node. Examples
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Atrial Flutter Rate=~300bpm, similar to A-fib, but have flutter waves, ECG baseline
adapts ‘saw-toothed’ appearance’. Occurs with atrioventricular block
(fixed degree), eg: 3 flutters to 1 QRS complex:
Types:
Sinoatrial node reentrant tachycardia (SANRT)
Ectopic (unifocal) atrial tachycardia (EAT)
Multifocal atrial tachycardia (MAT)
A-fib or A flutter with rapid ventricular response. Without rapid
ventricular response both usually not classified as SVT
AV nodal reentrant tachycardia (AVNRT)
Permanent (or persistent) junctional reciprocating tachycardia (PJRT)
AV reentrant tachycardia (AVRT)
Ventricular fast heart rhythm, that originates in one of the ventricles- potentially
tachycardia (V- life-threatening arrhythmia because it may lead to ventricular
tach or VT) fibrillation, asystole, and sudden death.
Rate=100-250bpm,
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2. Mobitz Type 2
P-R interval is constant, duration is normal/prolonged. Periodacally, no
conduction between atria and ventricles- producing a p wave with no
associated QRS complex. (blocked p wave).
Cardiac/ Electrical impulse that travels towards the electrode produces an upright (positive)
QRS axis deflection (of the QRS complex) relative to the isoelectric baseline. One that travels away
produces negative deflection. And one that travels at a right angle to the lead, produces a
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biphasic wave.
Remember, positive(upgoing) QRS complex means the impulse travels towards the lead.
Negative means moving away.
Right axis normal finding in children and tall thin adults, chronic lung
deviation disease(COPD), left posterior hemiblock, Wolff-Parkinson-White
syndrome, anterolateral MI.
QRS Non-pathological Q waves are often present in leads I, III, aVL, V5 and V6
complexes R(V6) < R(V5)
The depth of the S wave usually < 30mm
Pathological Q wave > 2mm deep and >1mm wide or 25% amplitude of subsequent R
wave
P pulmonale
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Tall peaked P wave. Generally due to enlarged right atrium-
commonly associated with congenital heart disease, tricuspid
valve disease, pulmonary hypertension and diffuse lung
disease.
Biphasic P wave
Its terminal negative deflection more than 40 ms wide and
more than 1 mm deep is an ECG sign of left atrial
enlargment.
P mitrale
Wide P wave, often bifid, may be due to mitral stenosis or left
atrial enlargement.
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ST segment
Normal ST
segment
flat (isoelectric) ± Same level with subsequent PR
segment ‡Elevation or depression of ST segment
by 1 mm or more, measured at J point is abnormal.
J point is the point between QRS and ST segmen
Diagnosing Criteria:
MI
ST elevation in > 2 chest leads > 2mm elevation
ST elevation in > 2 limb leads > 1mm elevation
Q wave > 0.04s (1 small square)
Be careful of LBBB
The diagnosis of acute myocardial infarction should be made
circumspectively in the presence of pre-existing LBBB. On the other
hand, the appearance of new LBBB should be regarded as sign of acute
MI until proven otherwise.
Localizing MI
Look at ST changes, Q wave in all leads. Grouping the leads into
anatomical location, we have this:
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Location of MI Lead with ST changes Affected coronary
artery
Anterior V1, V2, V3, V4 LAD
*To help identify MI, right sided and posterior leads can be applied
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Pericarditis
Digoxin
Q-T interval
Normal QT
‡As a general guide the QT interval should be 0.35- 0.45 s,(<2 large
square) and should not be more than half of the interval between
adjacent R waves (R-R interval)
To calculate the heartrate-corrected QT interval QTc. Bazett's formula is
used:
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Hypokalemia
Hypercalcemia/
hypocalcemia
Pulmonary SIQIIITIII = deep S wave in lead I, pathological Q wave in lead III, and inverted T wave
embolism in lead III:
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