Electrocardiography

A recording of the electrical activity of the heart over time

Gold standard for diagnosis of cardiac arrhythmias
Helps detect electrolyte disturbances (hyper- & hypokalemia)
Allows for detection of conduction abnormalities
Screening tool for ischemic heart disease during stress tests
Helpful with non-cardiac diseases (e.g. pulmonary embolism or
hypothermia
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Electrocardiogram (ECG/EKG)
Is a recording of electrical activity of heart conducted thru ions in
body to surface
Fig 13.22a
13-60
ECG Graph Paper
Runs at a paper speed of 25 mm/sec
Each small block of ECG paper is 1 mm
2

At a paper speed of 25 mm/s, one small block equals 0.04 s
Five small blocks make up 1 large block which translates into 0.20 s (200 msec)
Hence, there are 5 large blocks per second
Voltage: 1 mm = 0.1 mV between each individual block vertically








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Normal conduction pathway:


SA node -> atrial muscle -> AV node -> bundle of His -> Left and Right Bundle
Branches -> Ventricular muscle







Recording of the ECG:
Leads used:
Limb leads are I, II, II. So called because at one time subjects had to literally
place arms and legs in buckets of salt water.
Each of the leads are bipolar; i.e., it requires two sensors on the skin to make a
lead.
If one connects a line between two sensors, one has a vector.
There will be a positive end at one electrode and negative at the other.
The positioning for leads I, II, and III were first given by Einthoven. Form the
basis of Einthovens triangle.
Fig. 13.22b
3 distinct waves are
produced during
cardiac cycle
P wave caused by
atrial depolarization
QRS complex caused
by ventricular
depolarization
T wave results from
ventricular
repolarization
ECG
Fig 13.24
13-63
Elements of the ECG:
P wave: Depolarization of both atria;
Relationship between P and QRS helps distinguish various cardiac
arrhythmias
Shape and duration of P may indicate atrial enlargement
PR interval: from onset of P wave to onset of QRS
Normal duration = 0.12-2.0 sec (120-200 ms) (3-4 horizontal boxes)
Represents atria to ventricular conduction time (through His bundle)
Prolonged PR interval may indicate a 1st degree heart block
QRS complex: Ventricular depolarization
Larger than P wave because of greater muscle mass of ventricles
Normal duration = 0.08-0.12 seconds
Its duration, amplitude, and morphology are useful in diagnosing cardiac
arrhythmias, ventricular hypertrophy, MI, electrolyte derangement, etc.
Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec
are abnormal and may represent MI


ST segment:
Connects the QRS complex and T wave
Duration of 0.08-0.12 sec (80-120 msec

T wave:
Represents repolarization or recovery of ventricles
Interval from beginning of QRS to apex of T is referred to as the absolute
refractory period

QT Interval
Measured from beginning of QRS to the end of the T wave
Normal QT is usually about 0.40 sec
QT interval varies based on heart rate
Fig. 13.24b
Fig. 13.24c
Fig. 13.24d
Elements of the ECG:
P wave
Depolarization of both atria;
Relationship between P and QRS helps distinguish various cardiac
arrhythmias
Shape and duration of P may indicate atrial enlargement
QRS complex:
Represents ventricular depolarization
Larger than P wave because of greater muscle mass of ventricles
Normal duration = 0.08-0.12 seconds
Its duration, amplitude, and morphology are useful in diagnosing
cardiac arrhythmias, ventricular hypertrophy, MI, electrolyte
derangement, etc.
Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec
are abnormal and may represent MI
PR interval:
From onset of P wave to onset of QRS
Normal duration = 0.12-2.0 sec (120-200 ms) (3-4
horizontal boxes)
Represents atria to ventricular conduction time (through
His bundle)
Prolonged PR interval may indicate a 1st degree heart
block
Fig. 13.24g
T wave:
Represents repolarization or recovery of ventricles
Interval from beginning of QRS to apex of T is referred to as the absolute
refractory period
ST segment:
Connects the QRS complex and T wave
Duration of 0.08-0.12 sec (80-120 msec

QT Interval
Measured from beginning of QRS to the end of the T wave
Normal QT is usually about 0.40 sec
QT interval varies based on heart rate

Ischemic Heart Disease
Is most commonly due to atherosclerosis in coronary arteries
Ischemia occurs when blood supply to tissue is deficient
Causes increased lactic acid from anaerobic metabolism
Often accompanied by angina pectoris (chest pain)
13-78
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Myocardial Infarction
RealMedia Movie
Ischemic Heart Disease
Detectable by changes in S-T segment of ECG
Myocardial infarction (MI) is a heart attack
Diagnosed by high levels of creatine phosphate (CPK) & lactate
dehydrogenase (LDH)
Fig 13.34
13-79
Arrhythmias Detected on ECG
Arrhythmias are abnormal heart rhythms
Heart rate <60/min is bradycardia; >100/min is tachycardia
Fig 13.35
13-80
Arrhythmias Detected on ECG continued
In flutter contraction rates can be 200-300/min
In fibrillation contraction of myocardial cells is
uncoordinated & pumping ineffective
Ventricular fibrillation is life-threatening
Electrical defibrillation resynchronizes heart by depolarizing all cells at
same time
Fig 13.35
13-81
AV node block occur when node is damaged
Firstdegree AV node block is when conduction through AV node
> 0.2 sec
Causes long P-R interval
Second-degree AV node block is when only 1 out of 2-4 atrial APs
can pass to ventricles
Causes P waves with no QRS
In third-degree or complete AV node block no atrial activity
passes to ventricles
Ventricles driven slowly by bundle of His or Purkinjes

Arrhythmias Detected on ECG continued
13-82
AV node block occurs when node is damaged
Firstdegree AV node block is when conduction thru AV
node > 0.2 sec
Causes long P-R interval
Arrhythmias Detected on ECG continued
Fig 13.36
13-83
Second-degree AV node block is when only 1 out of 2-4 atrial
APs can pass to ventricles
Causes P waves with no QRS
Arrhythmias Detected on ECG continued
Fig 13.36
13-84
In third-degree or complete AV node block, no atrial
activity passes to ventricles
Ventricles are driven slowly by bundle of His or Purkinjes

Arrhythmias Detected on ECG continued
Fig 13.36
13-85
Representation in culture

In TV medical dramas, an isoelectric ECG (no cardiac electrical activity, aka, flatline,
is used as a symbol of death or extreme medical peril.

Technically, this is known as asystole, a form of cardiac arrest, with a partcularly bad
prognosis.

Defibrillation, which can be used to correct arrythmias such as ventricular
fibrillation and pulseless ventricular tachycardia, cannot correct asystole.
EEG(electrencephalogram)
The electroencephalogram (EEG) is a recording of the
electrical activity of the brain from the scalp.
The first recordings were made by Hans Berger in 1929
Origin of EEG waves
Electroencephalogram
EEG is the record of electrical activity of brain(
superficial layer i.e. the dendrites of pyramidal cells)
by placing the electrodes on the scalp.
Generation of large EEG signals by synchronous activity
Objectives of EEG practical
Familiarize with the principles of techniques
involved
Count frequencies and measure the amplitudes of
the record obtained.
Categories the records into appropriate rhythms ,
, ,and .

Cont
Objectives of EEG practical
Identify and describe changes produced by
provocation tests.
e.g. eye opening & closing, intermittent photic
stimulation (IPS) clapping sound, induce thinking &
hyperventilation.
Appreciate clinical uses of EEG
EEG Waves
Alpha wave -- 8 13 Hz.
Beta wave -- >13 Hz. (14 30 Hz.)
Theta wave -- 4 7.5 Hz.
Delta waves 1 3.5 Hz.
D T A B
Different types of brain waves in normal EEG
EEG Recording From Normal Adult Male
Alpha wave
rhythmic, 8-13 Hz
mostly on occipital lobe
20-200 V
normal,
relaxed awake rhythm with eyes closed
Beta wave
irregular, 14-30 Hz
mostly on temporal and frontal lobe
mental activity
excitement
Theta wave
rhythmic, 4-7 Hz
Drowsy, sleep
Delta wave
slow, < 3.5 Hz
in adults
normal sleep rhythm
Different types of brain waves in normal EEG
Rhythm Frequency
(Hz)
Amplitude
(uV)
Recording
& Location
Alpha()
8 13 50 100 Adults, rest, eyes closed.
Occipital region
Beta()
14 - 30 20 Adult, mental activity
Frontal region
Theta()
5 7 Above 50 Children, drowsy adult,
emotional distress
Occipital
Delta()
2 4 Above 50 Children in sleep
D T A B
Requirements
EEG machine (8/16 channels).
Silver cup electrodes/metallic bridge electrodes.
Electrode jelly.
Rubber cap.
Quiet dark comfortable room.
Skin pencil & measuring tape.
Computerized EEG Machine
Electrode Positioning system
EEG Electrodes
Sliver Electrodes
Electrodes Cap
Procedure of EEG recording
A standard EEG makes use of 21 electrodes linked in
various ways (Montage).
Ask the subject to lie down in bed.
Apply electrode according to 10/20% system.
Check the impedance of the electrodes.
10 /20 % system of EEG electrode placement
Procedure of EEG recording
Ask the subject to close his/her eyes.
Select a montage.
Press run switches on to run the paper.
Procedure of EEG recording
Press the calibration knob to check voltages & time
constant.
Always observe subject for any abnormal muscle
activity.
Ask the subject to open eyes for 10 sec.and ask him/her
to close eyes. (do this procedure for several times in
each montage)
EEG Electrodes
Each electrode site is labeled with a letter and a
number.
The letter refers to the area of brain underlying the
electrode
e.g. F - Frontal lobe and T - Temporal lobe.
Even numbers denote the right side of the head and
Odd numbers the left side of the head.
Two types of recording
Bipolar both the electrodes are at active site
Bipolar montage are parasagital montage.
Unipolar one electrode is active and the other is
indifferent kept at ear lobe.
Always watch for any abnormal muscle activity.
Ask the subject to open eyes for 10 sec. then ask them to close
the eyes.
Montage
Different sets of electrode arrangement on the scalp by
10 20 system is known as montage.
21 electrodes are attached to give 8 or 16 channels
recording.
Analysis
Electrical activity from the brain consist of primarily of
rhythms.
They are named according to their frequencies (Hz)
and amplitude in micro volt (v).
Different rhythms at different ages and different
conditions (level of consciousness)
Usually one dominant frequency (background
rhythm)
Factor influencing EEG
Age
Infancy theta, delta wave
Child alpha formation.
Adult all four waves.
Level of consciousness (sleep)
Hypocapnia(hyperventilation) slow & high
amplitude waves.
Hypoglycemia
Hypothermia
Low glucocorticoids
Slow waves
Desynchronization or Alpha block




Cause:
Eyes opening (after closure)
Thinking by the subject (mathematical calculation)
Sound (clapping)
Eye opening
Alpha rhythm changes to beta on eye opening
(desynchronization / - block)
Thinking
Beta waves are observed
Provocation test
Intermittent photic stimulation
Increase rate & decrease amplitude

Hyperventilation
Decrease rate & increase in amplitude


Use of EEG
Epilepsy
Generalized (grandmal) seizures.
Absence (petitmal) seizures.
Localize brain tumors.
Sleep disorders (Polysomnography)
Narcolepsy
Sleep apnea syndrome
Insomnia and parasomnia
Helpful in knowing the cortical activity, toxicity, hypoxia
and encephalopathy &
Determination of brain death.
Flat EEG(absence of electrical activity) on two records run 24 hrs
apart.
Sleep studies
The EEG is frequently used in the investigation of
sleep disorders especially sleep apnoea.
Polysomnography : EEG activity together with
heart rate,
airflow,
respiration,
oxygen saturation and
limb movement
Sleep patterns of EEG
There are two different kinds of sleep:
Rapid eye movement sleep (REM-Sleep)
Non-REM sleep (NREM sleep)/ slow wave sleep
NREM sleep is again divided into 4 stages (I to
IV). The EEG pattern in sleep is given in the
following table:
Stages of sleep EEG pattern Somatic or
Behavioral changes
Alert Alpha activity on
eye closed
Desynchronization
on eye opening
Respond to verbal
commands
I (Drowsiness) Alpha dropout &
appearance of
vertex waves &
theta.
Reduced HR & RR
II (Light sleep) Sleep spindles,
vertex sharp
waves & K-
complexes
Reduced HR & RR

III ( Deep Sleep) Much slow
background K-
complexes

Reduced HR & RR

IV (very deep
sleep)
Synchronous delta
waves, some K-
complexes
Reduced HR & RR
REM sleep
(paradoxical
sleep)
Desynchronization
with faster
frequencies
HR, BP & RR irregular
Marked hypotonia
Rapid eye movement
50 60 /min.
Dreaming threshold
of arousal
Changes in brain waves during different stages of
sleep & wakefulness
Changes in brain waves during different
stages of sleep & wakefulness
Sleep Spindle
K - complex
Video monitoring
Simultaneous video monitoring of the patient during
the EEG recording is becoming more popular. It allows
the physician to closely correlate EEG waveforms with
the patients activity and may help produce a more
accurate diagnosis.
EEG Artifacts
Biological artifacts
Eye artifacts (including eyeball, ocular muscles and eyelid)
ECG artifacts
EMG artifacts
Glossokinetic artifacts (minor tongue movements)
External artifacts
Movement by the patient
settling of the electrodes
Poor grounding of the EEG electrodes
the presence of an IV drip
ECG Artifacts
What is EEG and what is montage?
The electroencephalogram (EEG) is a recording of the
electrical activity of the brain from the scalp.

Arrangements of electrodes by 10/20% system is
known as montage.
What is the advantage of provocation test
while recording EEG?
Provocation test e.g. hyperventilation, intermittent
photic stimulation are done to trigger the epileptic
focus.
Compare & contrast Alpha & Beta waves of
EEG
Alpha
In awake resting with eyes
closed
Frequency 8 13 Hz.

Voltage 50uV.

Beta
In awake thinking
subjects.
Frequency - >13Hz.
(14 30 Hz.)
Voltage 20uV.
What stage of sleep is indicated by slow waves
of EEG(4 7Hz.) ?

4 7 Hz. (Theta) waves are seen during stage 2 & 3
(light and deep ) sleep
In the following tracing of EEG what changes do you observe after
point A.
What may be its possible cause?




Rhythm has changed from to(at point A) ,it is called
alpha block or desynchronization.
Causes:
Eyes opening
Thinking e.g. mathematical calculations.
Sound (clapping)
What changes are seen in EEG of an epileptic child suffering
from absence seizure (petit mal)?
In petit mal spike and wave (dome shaped) 3 cps.
Pattern is seen.

INTRODUCTION
Electromyogram (EMG) is a technique for evaluating and
recording the activation signal of muscles.
EMG is performed by an electromyograph, which records
an electromyogram.
Electromyograph detects the electrical potential generated
by muscle cells when these cells contract and relax.
INTRODUCTION Contd.
EMG Apparatus Muscle Structure/EMG
ELECTRICAL CHARACTERITICS
The electrical source is the muscle membrane potential of
about -70mV.
Measured EMG potentials range between
< 50 V up to 20 to 30 mV, depending on the muscle under
observation.
Typical repetition rate of muscle unit firing is about 7-20 Hz.
Damage to motor units can be expected at ranges between
450 and 780 mV
ELECTRODE TYPES

Intramuscular -
Needle Electrodes




Extramuscular - Surface
Electrodes
EMG PROCEDURE
Clean the site of application of
electrode;
Insert needle/place surface
electrodes at muscle belly;
Record muscle activity at rest;
Record muscle activity upon
voluntary contraction of the
muscle.
EMG Contd.
Muscle Signals are
Analog in nature.

EMG signals are also
collected over a specific
period of time.
Analog Signal
EMG Contd.
EMG processing:

Amplificatio
n
& Filtering
Signal pick up
Conversion of Analog
signals to Digital signals
Computer
APPLICATION OF EMG
EMG can be used for diagnosis of Neurogenic or
Myogenic Diseases.

You tube link of EMG
SAMPLE EMG DATA