B18 - Lecture Note On ECG PDF

Biomedical
Instrumentation
A. Intro & ECG
B18/BME2
Dr Gari Clifford
(Based on slides from
Prof. Lionel Tarassenko)
Biomedical Instrumentation B18/BME2
Who am I?
UL in Biomed Eng
Dir CDT in Healthcare Innovation @ IBME
Signal Processing & Machine Learning for
Clinical Diagnostics
mHealth for Developing Countries
Low Cost Electronics
EWH / OxCAHT
Vital signs monitoring

Clinical need
Every day, people die unnecessarily in hospitals

20,000 unscheduled admissions to Intensive Care p.a.
23,000 avoidable in-hospital cardiac arrests per annum
Between 5% and 24% of patients with an unexpected
cardiac arrest survive to discharge
Vital sign abnormalities observed up to 8 hours
beforehand in >50% of cases
Identifying at-risk patients
Acutely ill patients in hospital (e.g. in the Emergency Dept)

have their vital signs (heart rate, breathing rate, oxygen
levels, temperature, blood pressure) continuously monitored
but
Patient monitors generate very high numbers of false alerts

(e.g. 86-95% of alarms - MIT studies in 97 & 06)
Nursing staff mostly ignore alarms from monitors (alarm

noise), apart from the apnoea alarm, and tend to focus
instead on checking the vital signs at the time of the 4-hourly
observations
Continuous bedside monitoring in

Emergency Department
Course Overview
1. The Electrocardiogram (ECG)
2. The Electroencephalogram (EEG)
3. Respiration measurement using Electrical Impedance
Plethysmography/Pneumography
4. Oxygen Saturation using Pulse Oximetry
5. Non-invasive Blood Pressure

Course text books
Biomedical Engineering Handbook, Volume I,

2nd Edition, by Joseph D. Bronzino (Editor),
December 1999, ISBN: 0-849-30461-X
Medical Instrumentation: Application and

Design, 3rd Edition, by John G. Webster
(Editor), December 1997, ISBN: 0-471-15368-0
Relevant lecture notes
OP-AMP CIRCUITS Year 1, pages 1 to 42
FILTER CIRCUITS Year 1, pages 1 to 15
INSTRUMENTATION Year 2, pages 1 to 4, 17-18, 22

to 28 and 38 to 52.
Please e-mail val.mitchell@eng.ox.ac.uk if you would

like copies of the above.
Course website:
http://www.robots.ox.ac.uk/~gari/teaching/b18/
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B18 (Undergrad)
Question sheet 1: three sessions, 9 a.m. - noon on Friday of
Week 7, in LR4
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Week 8, in LR4
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Biomedical
Instrumentation
1. The Electrocardiogram
(ECG)
The Electrocardiogram
If two surface electrodes are attached to

the upper body (thorax), the following
electrical signal will be observed:
This is the electrocardiogram or ECG

The origin of the ECG
Atrial and ventricular contractions are the result

of carefully timed depolarisations of the cardiac
muscle cells
The timing of the heart cycle depends on:
Stimulus from the pacemaker cells

Propagation between muscle cells
Non-excitable cells
Specialised conducting cells (Atrio-Ventricular Node)
Important specific structures
Sino-atrial node = pacemaker (usually)

Atria
After electrical excitation: contraction
Atrioventricular node (a tactical pause)
Ventricular conducting fibers (freeways)
Ventricular myocardium (surface roads)
After electrical excitation: contraction
Excitation of the Heart
Excitation of the Heart
Cardiac Electrical Activity
Putting it al together:
Approximate model of ECG
To a first approximation, the

heart can be considered to
be an electrical generator.
This generator drives (ionic)
currents into the upper body
(the thorax) which can be
considered to be a passive,
resistive medium
Different potentials will be
measured at different points
on the surface of the body
Recording the ECG

P1
RT1
RA
P2
P1
RP
LA
RT2
P2
RL
LL
Points P1 and P2 are arbitrary observation points on the torso;

RP is the resistance between them, and RT1 , RT2 are lumped
thoracic medium resistances.
.
Typical ECG signal
Components of the ECG waveform

P-wave: a small low-voltage deflection caused by the
depolarisation of the atria prior to atrial contraction.
QRS complex: the largest-amplitude portion of the ECG,
caused by currents generated when the ventricles depolarise
prior to their contraction.
Components of the ECG waveform

T-wave: ventricular repolarisation.
P-Q interval: the time interval between the beginning of the P
wave and the beginning of the QRS complex.
Q-T interval: characterises ventricular repolarisation.
Recording the ECG
To record the ECG we need a transducer capable of

converting the ionic potentials generated within the
body into electronic potentials
Such a transducer is a pair of electrodes and are:
Polarisable (which behave as capacitors)

Non-polarisable (which behave as resistors)
Both; common electrodes lie between these two extremes
The electrode most commonly used for ECG signals,

the silver-silver chloride electrode, is closer to a nonpolarisable electrode.
Silver-silver chloride electrode
Electrodes are usually metal discs and a salt of that

metal.
A paste is applied between the electrode and the skin.
This results in a local solution of the metal in the paste at
the electrode-skin interface. Some of the silver dissolves
into solution producing Ag+ ions:
Ag Ag+ + eIonic equilibrium takes place when the electrical field is
balanced by the concentration gradient and a layer of
Ag+ ions is adjacent to a layer of Cl- ions.
Electrode-electrolyte interface
Electrode
e-
eeAg
Ag
Ag
Ag
Current I
Ag+
Cl-
Ag+
Ag+
Cl-
Cl-
Cl-
Ag+
Gel
Illustrative diagram of electrode-electrolyte interface in case of Ag-AgCl electrode

Electrodes are usually metal discs and a salt of that metal.

A paste is applied between the electrode and the skin.
This results in a local solution of the metal in the paste at
the electrode-skin interface.
Ionic equilibrium takes place when the electrical field is
balanced by the concentration gradient and a layer of Ag+
ions is adjacent to a layer of Cl- ions.
This gives a potential drop E called the half-cell potential
(normally 0.8 V for an Ag-AgCl electrode)
Electrode
Ag+
Ag+
Ag+
Ag+
Ag+
Ag+
Ag+
Cl-
Cl-
Cl-
Cl-
Cl-
Cl-
Cl-
Gel
Skin
Ag Ag+ + e-
The double layer of charges also has

a capacitive effect.
Since the Ag-AgCl electrode is
primarily non-polarisable, there is a
large resistive effect.
This gives a simple model for the
electrode.
However, the impedance is not infinite
at d.c. and so a resistor must be
added in parallel with the capacitor.
The double layer of charges also has

a capacitive effect.
Since the Ag-AgCl electrode is
primarily non-polarisable, there is a
large resistive effect.
This gives a simple model for the
electrode.
However, the impedance is not infinite
at d.c. and so a resistor must be
added in parallel with the capacitor.
The Overall Model
The resistors and capacitors may not be exactly equal.

Half cell potentials E and E' should be very similar.
Hence V should represent the actual difference of ionic
potential between the two points on the body where the
electrodes have been placed.
Electrode placement
VI = (potential at LA) (potential at RA)
VII = (potential at LL) (potential at RA)
VIII = (potential at LL) (potential at LA)
The right leg is usually grounded (but see later)
ECG Amplification
Problems in ECG amplification
The signal is small (typical ECG peak

value ~1mV) so amplification is needed
Interference is usually larger amplitude

than the signal itself
1st Problem: Electric Field Interference
Capacitance between power lines and

system couples current into the patient
This capacitance varies but it is of the order

of 50pF (this corresponds to 64M at 50Hz
... recall Xc=1/C )
If the right leg is connected to the common

ground of the amplifier with a contact
impedance of 5k, the mains potential will
appear as a ~20mV noise input.
Electrical power system
50 pF
RA
LA
RL
the 50 Hz interference is common to

both measuring electrodes !
(common mode signals)
LL
5k
The solution
The ECG is measured as a differential signal.

The 50Hz noise, however, is common to all the
electrodes.
It appears equally at the Right Arm and Left Arm

terminals.
Rejection therefore depends on the use of a

differential amplifier in the input stage of the
ECG machine.
The amount of rejection depends on the ability
of the amplifier to reject common-mode voltages.
Common Mode Rejection Ratio

(CMRR)
vin= vcm+ vd
Ad & Acm
vout= Acmvcm + Advd
CMRR = Ad / Acm
(ratio of differential gain to
common mode gain)
Three Op-Amp Differential Amplifier

Ad1 =
v1' v1 v1 v 2 v 2 v 2'
i
R2
R1
R2
v1' (1
R2
R
)v1 2 v 2
R1
R1
R2
R2
v (1 )v 2
v1
R1
R1
'
2
2 R2
v v (v 2 v1 )(1
)
R1
'
2
'
1
2 R2
Ad1 = 1
R1

Ad1 =
v1' v1 v1 v 2 v 2 v 2'
i
R2
R1
R2
v1' (1
R2
R
)v1 2 v 2
R1
R1
R2
R2
v (1 )v 2
v1
R1
R1
'
2
2 R2
v v (v 2 v1 )(1
)
R1
'
2
'
1
When v1 = v2 = vcm, Acm = 1


Ad1 =
v1' v1 v1 v 2 v 2 v 2'
i
R2
R1
R2
v1' (1
R2
R
)v1 2 v 2
R1
R1
R2
R2
v (1 )v 2
v1
R1
R1
'
2
2 R2
v v (v 2 v1 )(1
)
R1
'
2
CMRR is product of CMRR

for each input amplifier
'
1
CMRR =
Ad 1 . Ad 2
Acm1 . Acm 2
2nd problem: Magnetic Induction
Current in magnetic fields

induces voltage in the loop
formed by patient leads
RA
The solution is to minimise

the coil area (e.g. by twisting
the lead wires together)
LA
RL
LL
3rd problem:
Source impedance unbalance
If the contact impedances are not balanced (i.e. the

same), then the bodys common-mode voltage will be
higher at one input to the amplifier than the other.
3rd problem:
Source impedance unbalance
If the contact impedances are not balanced (i.e. the

same), then the bodys common-mode voltage will be
higher at one input to the amplifier than the other.
Hence, a fraction of the common-mode voltage will be

seen as a differential signal.
see problem on example sheet
Summary
Output from the differential amplifier consists of

three components:
The desired output (ECG)

Unwanted common-mode signal because the
common-mode rejection is not infinite
Unwanted component of common-mode signal
(appearing as pseudo-differential signal at the input)
due to contact impedance imbalance
Driven right-leg circuitry
The common-mode voltage can be

controlled using a Driven right-leg circuit.
A small current (<1A) is injected into the

patient to equal the displacement currents
flowing in the body.

LA
+
A1
R2
RA
Ra
LA
A4
R1
+
Ra
R2
RA
RL
LL
A2
+
RL
R0
The common-mode voltage can be controlled using

a Driven right-leg circuit.
A small current (<1A) is injected into the patient to

equal the displacement currents flowing in the body.
The body acts as a summing junction in a feedback

loop and the common-mode voltage is driven to a
low value.
This also improves patient safety (R0 is v. large

see notes).
Other patient protection
(Defib Protection)
Isolation
Filtering
Amplification
Anti-alias filtering
Digitization
Static defibrillation protection
For use in medical situations, the ECG

must be able to recover from a 5kV, 100A
impulse (defibrillation)
Use large inductors and diodes
Patient Isolation
Opto-isolators
DC-DC
Converters
RF Shielding & Emissions
Electromagnetic compatibility (EMC)
Electromagnetic disturbance (EMD)
degradation of the performance of a piece of equipment, transmission channel, or system

(such as medical devices) caused by an electromagnetic disturbance
Electrostatic discharge (ESD)
any EM phenomenon that may degrade the performance of equipment, such as medical
devices or any electronic equipment. Examples include power line voltage dips and
interruptions, electrical fast transients (EFTs), electromagnetic fields (radiated emissions),
electrostatic discharges, and conducted emissions
Electromagnetic interference (EMI)
the ability of a device to function (a) properly in its intended electromagnetic environment,
and (b) without introducing excessive EM energy that may interfere with other devices
the rapid transfer of electrostatic charge between bodies of different electrostatic potential,
either in proximity in air (air discharge) or through direct contact (contact discharge)
Emissions
electromagnetic energy emanating from a device generally falling into two categories:
conducted and radiated. Both categories of emission may occur simultaneously, depending
on the configuration of the device
Testing
Electrical safety
(from Lecture B)
Physiological effects of electricity:
Electrolysis
Neural stimulation
Tissue heating
Electrolysis
Electrolysis takes place when direct current

passes through tissue.
Ulcers can be developed, for example if a

d.c. current of 0.1 mA is applied to the skin
for a few minutes.
IEC601 limits the direct current (< 0.1 Hz)

that is allowed to flow between a pair of
electrodes to 10 A.
Neural stimulation
An action potential occurs if the normal

potential difference across a nerve
membrane is reversed for a certain
period of time.
This results in a sensation of pain (if

sensory nerve has been stimulated) or
muscle contraction (if motor nerve has
been simulated).
Hazards of neural stimulation

The effects of neural stimulation depend on the amplitude
and frequency of the current, as well as the location of the
current injection.
If the current is injected through the skin, 75 mA 400 mA

at 50 Hz can cause ventricular fibrillation.
Beware: under normal (dry) conditions, the impedance of the skin
at 50 Hz is usually between 10 k and 100 k; if the skin is wet,
the impedance can be 1 k or less.
If the current is directly applied to the heart wall (e.g. failure

of circuitry in a cardiac catheter), 100A can cause
ventricular fibrillation.
Tissue heating
The major effect of high-frequency

(> 10 kHz) electrical currents is heating.
The local effect depends on the current

amplitude and frequency as well as the
length of exposure.
Think about your mobile phone usage

Electricity can also be good for you
Electrical shock is also applied to patients in

clinical practice for therapeutic purposes.
These applications make use of the neural

stimulation effect:
Pacemakers (to stimulate the heart)

Defibrillators (to stop ventricular fibrillation)
Implantable Stimulators for Neuromuscular Control
(to help paralysed patients regain some neuromuscular
control).
Electricity can also be good for you

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Biomedical

Biomedical Instrumentation B18/BME2

Vital signs monitoring

Every day, people die unnecessarily in hospitals

Biomedical Instrumentation B18/BME2

Identifying at-risk patients

Acutely ill patients in hospital (e.g. in the Emergency Dept)

Patient monitors generate very high numbers of false alerts

Nursing staff mostly ignore alarms from monitors (alarm

Continuous bedside monitoring in

Biomedical Instrumentation B18/BME2

5. Non-invasive Blood Pressure

Course text books

Biomedical Engineering Handbook, Volume I,

Medical Instrumentation: Application and

Biomedical Instrumentation B18/BME2

Relevant lecture notes

OP-AMP CIRCUITS Year 1, pages 1 to 42

FILTER CIRCUITS Year 1, pages 1 to 15

INSTRUMENTATION Year 2, pages 1 to 4, 17-18, 22

Please e-mail val.mitchell@eng.ox.ac.uk if you would

Do you want all these lectures printed out

(You can use

Biomedical Instrumentation B18/BME2

ToDo (for you)

Sign up on weblearn for revision sessions

Hand in sheets before hand!

Biomedical Instrumentation B18/BME2

If two surface electrodes are attached to

This is the electrocardiogram or ECG

The origin of the ECG

Atrial and ventricular contractions are the result

The timing of the heart cycle depends on:

Stimulus from the pacemaker cells

Biomedical Instrumentation B18/BME2

Important specific structures

Sino-atrial node = pacemaker (usually)

Biomedical Instrumentation B18/BME2

Excitation of the Heart

Biomedical Instrumentation B18/BME2

Excitation of the Heart

Biomedical Instrumentation B18/BME2

Cardiac Electrical Activity

Biomedical Instrumentation B18/BME2

Approximate model of ECG

To a first approximation, the

Recording the ECG

Points P1 and P2 are arbitrary observation points on the torso;

Biomedical Instrumentation B18/BME2

Typical ECG signal

Biomedical Instrumentation B18/BME2

Components of the ECG waveform

Biomedical Instrumentation B18/BME2

Components of the ECG waveform

Q-T interval: characterises ventricular repolarisation.

Biomedical Instrumentation B18/BME2

Recording the ECG

To record the ECG we need a transducer capable of