ECG

The tissues in the human body are electrical conductors and when the
electrical current flows in the heart we can measure it on the surface of the
body, using an electrocardiograph (ECG). One of the major elements in the
cardiac conduction system, the system that controls the heart rate is the SA
node, (SA stands for sinoatrial) this system generates electrical impulses and
conducts them throughout the muscle of the heart, stimulating the heart to
contract and pump blood. The SA node is the heart's natural pacemaker. The
SA node consists of a cluster of cells that are situated in the upper part of the
wall of the right atrium (the right upper chamber of the heart). The SA node is
also called the sinus node. The electrical signal generated by the SA node
moves from cell to cell down through the heart until it reaches the
atrioventricular node (AV node), a cluster of cells situated in the centre of the
heart between the atria and ventricles. The AV node serves as a gate that
slows the electrical current before the signal is permitted to pass down
through to the ventricles. This delay ensures that the atria have a chance to
fully contract before the ventricles are stimulated. After passing the AV node,
the electrical current travels to the ventricles along the bundles of His special
fibers embedded in the walls of the lower part of the heart. The autonomic
nervous system, the same part of the nervous system as controls the blood
pressure, controls the firing of the SA node to trigger the start of the cardiac
cycle. The autonomic nervous system can transmit a message quickly to the
SA node so it in turn can increase the heart rate to twice normal within only 3
to 5 seconds. This quick response is important during exercise when the heart
has to increase its beating speed to keep up with the body's increased
demand for oxygen.

Electrocardiograph
This is the recording of the electrical activity of the heart as detected by the
difference in voltage between electrodes placed at certain locations on the
body surface. The sequential electrical activation of the heart is displayed as
an analogue waveform on a monitor screen with P,Q,R,S T components.
Typical wave amplitudes :R wave 1-7mV ,P wave as low as 50uV
ECG amplifier frequency response :
For patient monitoring typically of between 0.5Hz - 40Hz For full diagnostic
monitoring 0.5Hz - 150Hz
The standard ECG waveform has two main components: depolarization and
repolarization. The P wave and QRS complex denote atrial and ventriclar
depolarization, respectively). The ST segment, T wave and the U wave
account for ventricular repolarization. (Atrial repolarization is not seen on the
surface ECG, as it is "buried" in the QRS complex.)

The ECG provides information on

1. Cardiac arrhythmias
2. Myocardial Ischaemia
3. Myocardial infarction
By observing the ECG waveform morphology in the different ECG leads it
is possible to deduce the electrical activation sequence and whether the wave
shape ,amplitudes and durations are within normal limits or abnormal
Cardiac arrhythmias
Arrhythmias are disturbances in the regularity in cardiac rhythm.
These can cause a reduction in cardiac output (E.G. ventricular tachycardia)

ventricular tachycardia

or can be life threatening (E.g. ventricular fibrillation.)

ventricular fibrillation

Myocardial ischaemia and myocardial infarction

If the blood flow to the heart is reduced due to coronary artery disease and
the oxygen supply is not sufficient then ischaemia results in the myocardium.
This is seen on the ECG as a displacement up or down of the ST segment. If
the ischaemia is monitored constantly then early intervention can take place.
The ST depression or elevation can be detected and measured and displayed
automatically

Resting ECG ST “flat” Exercise ECG ST depressed

If the blood flow to part of the heart muscle (myocardium) is stopped then the
area of myocardium served by that blood vessel infarcts or dies. This is
shown in the ECG waveform with changes which depend on the infarct area
and ECG lead viewed

Anterior myocardial infarction – note the elevated ST segment

ECG electrode application

The ECG will normally be derived from between 3 and 10 surface electrodes.
3 for basic patient monitoring and 10 for a diagnostic 12 lead ECG.
ECG electrodes should be placed as far as possible in locations which are
less prone to movement. ECG electrodes are usually either dry gel adhesive
or wet gel adhesive with a silver /silver chloride electrode and a press stud or
tab connector.

Amplitudes

12 lead

placement

why 12 and only 10 leads