ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY
● It is an important diagnostic tool that in some settings is obtained
by the Respiratory Therapist.
● This can place the RT in a prime position to recognize and respond
to life-threatening arrhythmias.
● It can be done using either:
● 12-lead system: provides more diagnostic value than the
alternative approach, 12-lead ECG provides a more complete
assessment of the electrical activity of the heart by viewing it from
12 different angles.
● 3-lead system: It is commonly used for telemetry.

ECG
● It is inexpensive, non-invasive, and easy to obtain
● It is used primarily to help evaluate a patient with signs and/or
symptoms of myocardial disease.
● A physician would order an ECG for most adult patients
complaining of the classic clinical symptoms associated with heart
disease. 12 LEAD ECG
○ Certain types of chest pain ● The equipment is gathered includes:
■ Ask patient to be specific ○ Portable ECG unit
■ Pleuritic: lateral ○ Lead Wires – permit the connection between the ECG
■ Heart attack: can be anywhere unit and the electrodes, which have adhesive permitting
○ Shortness of breath temporary attachment to the skin.
○ Dyspnea with palpitations ○ Electrodes
○ Weakness ● Generally, the lead wires should be attached to the electrodes
○ Lethargy before being placed on the skin to avoid unnecessary pressure to
○ Syncope the skin’s surface. The lead wires are often marked to help ensure
proper placement on the patient’s body.
It is routinely used to detect abnormalities that are occurring or have already
occurred, such as a myocardial infarction (MI), the general health status of 12 LEAD ECG 2 SUBDIVISIONS
middle-aged or older patients or for preoperative screening. ● 6 CHEST (PRECORDIAL) LEADS
○ It consists of your V1-V6
*Levine Sign - universal sign for ischemic chest pain/ heart attack ○ It is considered as unipolar because it permits
measurement of electrical activity in one direction
BASIC PRINCIPLES OF ELECTROPHYSIOLOGY
● The muscle cells of the heart normally are stimulated and paced by ● 6 EXTREMITY (LIMB) LEADS
the electrical activity of the cardiac impulse-conducting system. ○ It is considered as bipolar because it would allow
● The impulse-conducting system cells have the ability to stimulate measurement of electrical activity in two different angles
the heart without the influence of the nervous system. Autonomic or directions.
nervous system normally plays a major role in controlling heart ○ Einthoven’s Triangle - It is an imaginary formation of
function. three limb leads in a triangle used in
● Cardiac muscle cells normally generate an electrical imbalance electrocardiography, formed by the two shoulders and
across the cell membrane, with a positive charge on the outside the pubis. The shape forms an inverted equilateral
and a negative charge on the inside. triangle with the heart at the center. It is named after
● The impulse-conducting system has three (3) types of cardiac cell Willem Einthoven, who theorized its existence.
capable of electrical excitation:
● Pacemaker cells: (eg, sinoatrial (SA) node — 60-100 bpm, V1
atrioventricular (AV) node — 40- 60 bpm) ● 4th ICS R sternal border
● Specialized rapidly conducting tissue (eg, Purkinje Fibers) V2
● Atrial and Ventricular muscle cells. ● 4th ICS L sternal border
● The ability of these cells to depolarize without stimulation is known V4
as automaticity. ● 5th ICS L midclavicular line
● Each of these cardiac cell groups varies in degree of automaticity. V3
● Between V2 & V4
IMPULSE-CONDUCTING SYSTEM V5
● It is responsible for initiating the heartbeat and controlling the heart ● 5th ICS anterior axillary line
rate V6
● It also coordinates the contraction of the heart chambers, which is ● 5th ICS L midaxillary line
essential to move blood effectively
● A defect in the impulse-conducting system may lead to inadequate ❖ RED, BLACK, YELLOW, ADN GREEN
cardiac output and decreased tissue perfusion
● SA node – which is located in the upper portion of the right atrium, CELL AND FUNCTION
has the greatest degree of automaticity and paces the heart.
PACEMAKER CELLS
● Specialized cells that have a high degree of automaticity and
provide electrical power for the heart.

CONDUCTING CELLS
● Cells that conduct the electrical impulse throughout the heart.
MYOCARDIAL CELLS complexes and divide this number into 300 to obtain the
● Myo – Muscle of your heart HR.
● Cells that contract in response to electrical stimuli and pump blood. ● 1 large box is = 0.20 sec x 5

ELECTROGRAPHIC PAPER & MEASUREMENTS 2. S2: MEASURE THE PR INTERVAL

● Electrocardiographic paper is made up of grid-like boxes that ● Determine the number of small boxes between the start
define time on the horizontal axis and voltage on the vertical axis. of the P wave and the start of the QRS complex
● Dark lines – circumscribe larger boxes that are 5x5 mm ● Normally, this interval is <0.20 second (five small boxes)
● Lighter lines – define smaller boxes that are 1x1 mm and is consistently the same for each complex.
● Speed – 25 mm/sec ● PR intervals that are >0.20 second or vary from one
● The standard ECG is calibrated so that 1 mV causes an upward complex to the next indicate an abnormality in the
deflection of 10 small boxes or 2 large impulse-conducting system.
● boxes on the vertical axis; this allows measurement of the exact
voltage occurring during depolarization of the cardiac muscle 3. S3: EVALUATE THE QRS COMPLEX
fibers.
4. S4: EVALUATE THE T WAVE
● Normally, the T wave is upright and rounded.
View Facing Lead
● Inverted T wave suggest ischemia of the heart muscle,
and abnormal configuration of the T wave occurs with
Lateral I, aVL, V5, V6
electrolyte abnormalities such as hyperkalemia.
Inferior II, III, aVF
5. S5: EVALUATE THE ST SEGMENT
Septal V1, V2 ● The ST segment should be flat or at least no more than
1 mm above or below baseline.
Anterior V3, V4 ● As stated earlier, significant elevation or depression of
the ST segment indicates serious problems with
oxygenation of the myocardium and must be recognized
BASIC ELECTROGRAPHIC WAVES as soon as possible.

P WAVE 6. S6: IDENTIFY THE R-R INTERVAL

● It represents atrial depolarization (contraction) ● The R-R interval is identified to assess regularity of the
● Normal P wave: .12 – .20 sec (3mm) or 3 small boxes rhythm.
● Deflection: Upward or Positive ● The distance, in mm or time, is measured between the R
waves of several successive QRS complexes.
QRS COMPLEX ● Normally, there is little variance in the R-R interval
● It represents ventricular depolarization (contraction) between QRS complexes, but if the variance between
● Normal QRS: 0.8 – .10 sec the different R-R intervals exceeds 0.12 second, an
● Q Deflection: Downward or Negative abnormal rhythm exists.
● R Deflection: Upward or Positive
● S Deflection: Downward or Negative 7. S7: IDENTIFY THE MEAN QRS AXIS
● The limb lead exhibiting the largest amount of voltage is
T WAVE identified
● It represents ventricular repolarization (relaxation) ● If the lead shows a positive QRS complex, the axis is
● Normal T wave: Precordial = <5mm; Limb = <10mm very close to the position on the hexaxial reference circle
● Deflection: Upward or Positive where that limb lead is labeled.
● Flattened T wave – ischemia (slight blockage), electrolyte ● If the QRS complex with the most voltage is negative,
abnormality (hypokalemia) the mean axis is moving in the opposite direction from
● Peaked T wave: Hyperkalemia where that lead is labeled on the hexaxial reference
● T wave inversion – may indicate MI (tissue necrosis or tissue circle.
death)
IDENTIFYING ARRHYTHMIAS
PR INTERVAL
● It represents the start of atrial contraction to the start of ventricular I. NORMAL SINUS RHYTHM
contraction ● Begins with an upright P wave that is identical from one
● Normal PR Interval: .12 - .20 sec (3-5 small boxes) complex to the next
● Deflection: Upward or Positive ● PR interval is consistent throughout the rhythm strip and
is 0.12 to 0.20 sec
ST SEGMENT ● The QRS complexes are identical and no longer than
● It represents from the end of ventricular depolarization to the start 0.12
of ventricular repolarization ● The ST segment is flat
● Normal ST Segment: 0.08 sec (2 small boxes) ● The R-R interval is regular and does not vary more than
● Deflection: Flat or Isoelectric 0.12 sec between QRS complexes
● If there is ST depression: Myocardial Ischemia ● The HR is between 60-100 bpm
● If there is ST elevation: Myocardial Infarction

ECG INTERPRETATION
1. S1: IDENTIFY THE ATRIAL & VENTRICULAR RATES
● Identify the HR by counting the number of QRS
complexes (for the ventricular rate) or the number of P
waves (for the atrial rate) in 6 seconds (30 large boxes)
and multiply this number by 10.
● If the rate is regular, the clinicians also can count the
number of large boxes between two successive
II. SINUS TACHYCARDIA
● HR rate is 100-150 bpm
● Rhythm: regular
● P wave is appropriately present before each QRS
complex, normal configuration
● PR Interval > or = to 0.20 sec
● QRS complex: <0.12 sec
● This abnormality is common and can be caused by
numerous problems: anxiety, pain, fever, hypovolemia,
hypoxemia
● It also may be a side effect of certain medications such
as adrenergic bronchodilators. Treatment typically
involves eliminating the underlying cause.
III. SINUS BRADYCARDIA
● HR: <60 bpm that is otherwise normal
● P wave is appropriately present before each QRS
complex, normal configuration
● PR interval: > or = to 0.20 sec
● QRS complex: <0.12 sec
● It represents a significant clinical problem if it causes the
patient’s bp to decrease significantly or impairs tissue
perfusion, causing symptoms such as fatigue,
lightheadedness, or syncope
● It is most often caused by hypothermia, abnormalities in
the SA node or intense athletic conditioning
● ATROPINE – to stimulate the heart rate when clinical
bradycardia symptoms occur
IV. SINUS ARRHYTHMIA
● Sinus arrhythmia is a common arrhythmia and is
recognized by the irregular spacing between QRS
complexes
● The spacing is measured by identifying the intervals
between the R waves of successive QRS complexes,
which are normally consistent
● When the R-R interval varies >.012 second throughout
the rhythm strip, sinus arrhythmia is present
● This arrhythmia may occur with the effects of breathing
on the heart or as a side effect of medications such as
digoxin. Most cases of sinus arrhythmia are benign and
do not need treatment.
V. FIRST-DEGREE HEART BLOCK
● PR interval: >0.20 sec
● Rhythm: Regular, there is one P wave before each QRS
● This tracing indicates that the impulse from the SA node
is getting through to the ventricles but is abnormally
delayed in passing through the AV node or bundle of His.
● QRS complex: normal config
● R-R interval: regular
● First-degree heart block is common after an MI that
damages the AV node, or it may be a complication of
certain medications, such as digoxin and beta blockers
● Treatment usually is not needed for first-degree heart
block if the patient is able to maintain an adequate bp
VI. SECOND-DEGREE HEART BLOCK
● Two types:
● Type I (Wenckebach or Mobitz Type I)
● Type II (Mobitz Type II)
VI. A. TYPE I (WENCKEBACH OR MOBITZ TYPE I)
● It occurs when an abnormality in the AV junction delays or blocks
conduction of some of the impulses through the AV node
● It can be recognized by progressive prolongation of the PR interval
until one impulse does not pass on the ventricles at all
● Seen as a P wave not followed by a QRS complex
● Treatment is not needed because it usually does not impair cardiac
output or cause symptoms.
VI. B. TYPE II (MOBITZ TYPE II)
● It is less common and is more often the result of serious problems
such as MI or ischemia
● Seen as a series of non-conducted P waves followed by a P wave
that is conducted to the ventricles
● Sometimes the ratio of non-conducted to conducted P waves is
fixed at 3:1 or 4:1
● The PR interval for the conducted impulses is consistent
● Treatment:
● It requires treatment in most cases because the resulting reduction
in ventricular rate causes a decrease in bp
● Medications such as atropine provide a better cardiac output until a
pacemaker can be inserted
● Because Type II block may progress to third-degree heart block
without warning, a pacemaker is indicated even if the patient is
asymptomatic
VII. THIRD-DEGREE HEART BLOCK
● It is the most serious of the different types of heart block
● It indicates that the conduction system between the atria and
ventricles is completely blocked and impulses generated in the SA
node are not conducted to the ventricles
● The atria and ventricle are paced by independent sources
● Most commonly, the atria are paced by the SA node, and the
ventricle are paced by the AV node
● This arrhythmia can be recognized when it is established that there
is no relationship between the P waves and the QRS complexes
● The P-P intervals are regular and the R-R intervals are regular, but
they have no correlation with one another
● The QRS complexes are normal in config if the ventricles are
paced by the AV node
 ● If the ventricles are paced by an ectopic site in the myocardium,
the QRS complexes may be abnormally wide. Typically, the
ventricular rate is slower than the atrial rate.
● It is a serious arrhythmia because it often is caused by MI or drug
toxicity (especially digitalis)
● It may render the heart unable to meet the normal metabolic
demands of the body
● The treatment is usual medication to speed up the ventricles and a
temporary external pacemaker until a permanent one can be
placed.
VIII. ATRIAL FLUTTER
● It is the rapid depolarization of the atria resulting from an ectopic
focus that depolarizes at a rate of 250 to 350 times per minute
● Typically, only one ectopic focus is causing the arrhythmia, which
results in each P wave appearing similar
● Characteristic: saw-toothed baseline pattern
● Numerous P waves are present for every QRS complexes
● QRS complexes are normal in config
● R-R interval may be regular or it may vary, depending on the ability
of the atrial impulse to pass through AV node
● Various conditions can produce atrial flutter. Rheumatic heart
disease, coronary heart disease, stress, renal failure, and
hypoxemia
● This arrhythmia is not considered life-threatening, but it may lead
to atrial fibrillation if untreated.
● Treatment:
● Medication such as digoxin, beta blockers, or calcium channel
blockers
● Once the rate is significantly slowed, cardioversion is attempted to
return the heart rhythm back to a normal sinus rhythm.
IX. ATRIAL FIBRILLATION
● It is present when the atrial muscle quivers in an irregular pattern
that does not result in a coordinated contraction
● The baseline electrical activity appears erratic, and no true P
waves are seen in atrial fibrillation
● The AV node determines the ventricular response to the atrial
activity by controlling which impulses pass through and which do
not
● The ventricular rate is often very irregular and results in an
abnormal R-R interval
● The causes of atrial fibrillation are similar to the causes of atrial
flutter
● Atrial fibrillation is a more serious arrhythmia because it can lead to
a significant reduction in cardiac output resulting from the loss of
the atrial kick that helps fill the ventricles before systole
● The resulting stagnation of blood in the atria can lead to formation
of blood clots, which can lead to pulmonary emboli or an embolic
stroke
● Treatment:
● Similar to the treatment of atrial flutter
● However, patients with sustained atrial fibrillation are often treated
with anticoagulants or antithrombotic medications to treat potential
blood clot formation, medications to slow the heart rate and
cardioversion.
X. PREMATURE VENTRICULAR CONTRACTION
● Premature beats can occur when a potion of the
impulse-conducting system or myocardium other than the SA node
becomes diseased and triggers depolarization of the surroundings
cardiac cells
● Sources for the impulse outside the SA node are called ectopic foci
● Ectopic foci occur when hypoxia, acid-base, imbalances, or
electrolyte abnormalities are present and cause the cardiac cells I
the ventricles to become abnormally excited
● PVCs are easy to recognize because they cause a unique and
bizarre QRS complex that is much wider than normal
● The QRS complex of a PVC is wider than normal because the
ectopic foci is using channels outside the normal conduction
system to move the impulse throughout the myocardium
● PVCs have no P wave preceding them and may occur as a
singular event or more commonly as a temporary run of PVCs
● They also may occur at every other beat (bigeminy) or ever third
beat (trigeminy)
● Treatment:
● Treatment is based on the frequency and cause of the PVCs and is
needed when the PVCs are frequent (more than 6 per min), paired
together, or multifocal (appear differently because they come from
more than 1 ectopic focus) or when they land directly on the T
wave (R on T phenomenon)
● In such cases, treatment must be prompt because the problem
may progress rapidly to ventricular tachycardia and ventricular
fibrillation
● Antiarrhythmic medications (eg, lidocaine) may offer a temporary
solution until the underlying cause can be addressed.
XI. VENTRICULAR TACHYCARDIA
VT is a run of three or more PVCs
It usually is easy to recognize as a series of wide, bizarre QRS complexes
that have no preceding P wave
The ventricular rate is usually 100 to 250 bpm
It is considered sustained V-Tach if it lasts longer than 30 sec
Treatment:
Must be prompt and specific and usually consists of cardioversion followed
by long-term antiarrhythmic drugs (eg, Amioderone) for long-term
suppression
Patients at high-risk recurrent VT may have an internal
cardioverter-defibrillator (ICD) placed so that if VT occurs it can be treated
automatically and promptly
XII. PULSELESS ELECTRICAL ACTIVITY (PEA)
● It is a serious condition characterized by a disassociation between
the electrical and mechanical activity of the heart
● In essence, the ECG pattern on the monitor does not generate a
pulse
● PEA is relatively rare and generally does not occur without a
precipitating event, such as a tension pneumothorax, MI, drug
overdose, or severe electrolyte or acid-base disturbances
● Treatment:
● Involves emergency life support and the immediate reversal of the
cause
● PEA also illustrates why RTs and other clinicians should never
“treat the monitor” and underscores the importance of using ECGs
as just one of the several clinical indicators in assessing patients.
● Agonal Gasps (Last Breath) – involuntary and insufficient
respirations that are caused by low oxygen in the blood.