ECG Monitoring I

Jessica Cheuk
Learning outcomes
After completion of this chapter, students will be able to :
1. List and briefly describe the four properties of cardiac cells.
2. Explain the normal cardiac conduction system, beginning with the
sinus node and ending with the Pukinje fibers.
3. Draw a normal cardiac cycle as seen in normal sinus rhythm and
identify the waveforms, intervals, and complexes
4. Interpret the basic components of the electrocardiogram.
5. To outline the steps of interpreting an ECG
Electrophysiology of the heart

What is ECG?
Monitoring Lead System
 The 3 Lead Cardiac Monitoring System

Lead Views Rationale for use

Lead I Lateral ▪ Useful in patients with respiratory distress
▪ Left arm and right arm electrodes involved and placements
less affected by chest motion compared with other leads
Lead II Inferior ▪ Produces large, upright visible P waves and QRS complexes
for determining underlying rhythm

Lead III Inferior ▪ Helpful in detecting ischemia, injury, and infarction in the
inferior wall
▪ Ischemia related to the right coronary artery is best seen in
lead III
The 5 lead Cardiac Monitoring System
• It monitors any of the 12 leads of the ECG. The
chest electrode must be moved to the
appropriate chest location
• the four limb electrodes are positioned on the
body according to their designations. The fifth
chest electrode is placed on the chest in the
designated precordial position.
• If monitor V1, the chest electrode is placed in the
fourth intercostal space, right sternal border
• Switch to a different chest lead for monitoring,
the electrode must be repositioned on the https://i.pinimg.com/736x/a5/35/f4/a535f4a
patient’s chest precordial leads. ca3eab3bdaa8338e56e20c450--sistema-
cardiovascular-cardiac-nursing.jpg
 Holter monitoring
• Recording of ECG rhythm for 24-48 hr
and then correlating rhythm changes
with symptoms and activities
recorded in diary.
• Normal patient activity is encouraged
to simulate conditions that produce
symptoms. Electrodes are placed on
chest, and a recorder is used to store
information until it is recalled,
printed, and analyzed for any rhythm
disturbance.
• It can be performed on an inpatient
or outpatient basis.
https://api.kramesstaywell.com/Content/ebd5aa86-5c85-4a95-
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illustrations/Images/acardio20140402v0005.jpg
What is ECG?
• Electrical activities of the heart can be recorded in the form of
electrocardiogram (ECG)or elektrokardiogramm (EKG).

• An ECG is a composite recording of all the action potentials

produced by the nodes and the cells of myocardium.

• ECG monitoring
➢HR
➢Detect arrhythmia / dysrhythmia
➢Myocardial ischemia, injury or infraction
➢Effects of medication & electrolyte imbalances
Basic electrophysiology

1. Properties of myocardial cells

2. The cardiac conduction system

3. Cardiac action potential

4. Refractory periods
Properties of myocardial cells
Pacemaker cells • Automaticity
➔The ability to initiate an impulse
• Excitability
➔The ability to respond to an impulse
• Regularity
➔The ability to generate an impulse at regular intervals
• Conductivity
➔The ability to transit an impulse

Myocardial cells • Contractility

➔The ability to respond with contraction
The electrical conduction system

The intrinsic pacemaker cells

SA node 60- 100 BPM
AV node 45-50 BPM
Bundle of His 40-45 BPM
Purkinje cells 35-40 BPM
Cardiac Action Potential
• Cardiac action potential refers to the change in the electrical charge
inside the cardiac cell when it is stimulated.
• This electrical change is caused by the flow of specific ions, or electrically
charged particles, into and out of the cardiac cell.
• Phases 0 to phases 4
• This electrical change creates
➢ polarization
➢ depolarization
➢ repolarization
Cardiac Action Potential

Adapted from Critical care nursing : Diagnosis and management (8th ed.). P. 177
Polarization
• It is the electrical state that exists at the cardiac cell
membrane when the cell is at rest.
• In this state, no electrical activity is occurring, and the
ECG displays a flat, isoelectric line.
• When the cardiac cell is polarized, the inside the cell is
more negative than the outside of the cell.
Depolarization
• The inside of the cell becomes more
positive due to the rapid influx of Na+
into the cell.
• P wave represents atrial depolarization
• QRS complex represents ventricular
depolarization.
• Depolarization is the electrical event that
results in a contraction of the cardiac
muscle, a mechanical event.
Repolarization
• The restoration of the polarized state at the
cell membrane.
• Repolarization can be thought of as the
recovery of the cell on its original polarized
state.
• After the cell depolarizes, the diffusion of
sodium ions into it stops & K+ ions diffuse
out, leaving mostly negatively charged ions
inside the cell.
• On the ECG, the ST segment & the T wave
represent ventricular repolarization.
Refractory Periods
Ventricular depolarization

Ventricular repolarization

Atrial depolarization

Relative Supernormal
Absolute refractory period refractory period
period
Refractory Periods
• Refractory is a term that refers to the resistance of the cell membrane
to respond to a stimulus. The refractory period extends beyond the
length of the cardiac contraction and protects the cardiac muscle
from spasm or tetany.
• There are 3 refractory periods: the absolute refractory period, the
relative refractory periods, and the supernormal period.
Absolute refractory period
• It is the brief period during
depolarization when the cells
will not respond to further
stimulation, no matter how
strong the stimulus.
• This period corresponds with the
onset of the QRS complex to the
peak of the T wave.
Relative refractory period
• vulnerable period
• During this period some cardiac cells
have repolarized, and if they receive a
stronger than normal stimulus they may
respond.
• This response is known “R-on-T
phenomenon”, because it occurs when a
stimulus, causing Q”R”S depolarization,
lands on the vulnerable downslope of the
“T” wave.
• This phenomenon may cause a life-
threatening dysrhythmia known as
ventricular fibrillation
https://ecgwaves.com/wp-content/uploads/2016/08/r-on-t.jpg
R-on-T phenomenon

https://ecgwaves.com/wp-content/uploads/2016/08/r-on-t.jpg
Supernormal period
• During this period a weaker than
normal stimulus can cause
depolarization of cardiac cells.
• On the ECG, this period
corresponds to the end of the T
wave.
• Dysrhythmias may occurs.
ECG components
Electrocardiogram (ECG/EKG)
ECG Wave - P wave
• Atrial depolarization
• The P wave reflects the contraction of the atrial
after the sinoatrial node transmits an electrical
pulse.
• Upright
• The duration of the P wave is 0.06-0.12 sec or
60 to 120ms.
• P wave should precede each QRS complex
ECG Wave - P wave
P wave inverted
1. Electrode misplacement
2. Dextrocardia
3. Retrograde atrial depolarization
ECG – P wave
P pulmonale
• tall & peak, >2.5mm in
amplitude
• due to right atrial enlargement
➔ Stronger electrical currents
P mitrale
• Broadened & notched
• Duration equal or >0.12Sec
• Due to Lt atrial enlargement
• ➔ delayed depolarization of
the Lt atrium
ECG Wave – PR interval
• It reflects depolarization of the Rt & Lt atria and the
delay through the AV junction.
• It measure from the beginning of the P wave to the
beginning of the QRS complex.
• Normal duration: 0.12 to 0.2 or 120-200ms
• PR segment as isoelectric line
ECG Wave – PR interval
Abnormal
Prolonged PR interval
• >0.2 sec, e.g. first degree AV block
• Shortened PR interval can be
found in preexcitation rhythms,
e.g. enhanced AV nodal
conduction
ECG Wave – QRS complex
• QRS complex reflects the contraction of
the ventricle after Purkinje fibers
transmit an electrical impulse.
• It is measured from beginning of the Q
to the end of the S.
• Normal duration: <0.12 sec
• It represents ventricular depolarization
and atrial repolarization
ECG Wave – QRS complex
Abnormal
• Widened QRS complex
(>0.12 sec), premature
ventricular contraction
(PVC), idioventricular
rhythm, ventricular
tachycardia
• Missing QRS complex,
e.g. AV block, heart block
• Pathological Q wave
ECG Wave – Pathologic Q wave
• An abnormally deep Q wave (more than 1/3 of the entire
height of the QRS complex).
• It indicate cardiac cell necrosis from the previous myocardial
infraction.
ECG Wave – ST segment
• It reflects the period of time from the end of
ventricular depolarization to the beginning of
ventricular repolarization.
• Measured at the J point (the end of the QRS
complex) to beginning of the T wave.
• Normally, it is isoelectric.
• ST segment depression of 1 to 2 mm may
indicate myocardial ischemia
 Classification of ST elevation
ACLS guideline 2016
ST elevation myocardial infarction (STEMI)

• ST- segment elevation in 2 or more contiguous leads or new left

bundle branch (LBBB)
• ST elevation in lead V2 & V3 > 2mm
➢1.5mm for all women
➢2mm for men younger than 40 years old
• ST elevation in other leads > 1mm
**Contiguous lead refer limb lead that “look” at the same area or are
numberically consecutive chest leads (i.e. V1-V6)**
Baseline of ECG

PR segment & TR
segment used as
R-R interval
reference points to
the isoelectric line

T P
ST segment measurement

• ST-segment elevation/depression is
measured 0.06 to 0.08 sec after the J
point.
• J point (the end of the QRS complex)
to beginning of the T wave.

Adapted from Critical care nursing : Diagnosis and

management (8th ed.). P. 369
ST elevation

Adapted from Critical care nursing : A holistic approach (10th ed.). P. 427
ECG Wave – T wave
• Ventricular repolarization.
• Usually rounded and deflected in the same
direction as the preceding QRS complex.
• Inverted T is suggested of myocardial ischemia.
• Tall & peak T waves may be suggestive of
hyperkalemia
• http://4.bp.blogspot.com/-
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ECG Wave – U wave
• It is a small, flat wave sometimes seen after T
wave.
• Possible causes: by ventricular repolarization of
the Purkinje fibers or delayed mechanical
relaxation of ventricular myocardium.

Abnormal
• Prominent U wave may seen in hypokalemia,
hypothermia, ischemia, ventricular
repolarization and long QT syndrome.
ECG Wave – QT interval
• It measures from the beginning of QRS
complex to the end of T wave.
• Duration: 0.38 to 0.42 sec
• It represents the total duration of
ventricular depolarization &
repolarization. Calculation of QTc
• A prolonged QT interval may be a result
of antidysrhythmic drugs, hypokalemia,
hypocalcemia, hypomagnesia.
Summary of ECG wave pattern
Associated pattern Electrical activity Graphic Depiction
P Wave Atrial depolarization

PR segment Delay at AV node

QRS complex Ventricular depolarization

T wave Ventricular repolarization

Isoelectric line No electrical activity

Interpreting the ECG
 Rhythm Analysis

Step 1 : Determine regularity

Step 2: Calculate rate
Step 3: Assess the P waves
Step 4: Determine PR interval
Step 5: Determine QRS duration
Step 6: Examine the ST segment
Step 7: Identify the rhythm & determine its clinical significance
Step 1: Determine regularity
P

• Identify the P-P intervals

• Look at the R-R distances
• Regular/ Occasionally irregular/ Regularly irregular?/ Irregularly
irregular

Regular rhythm
Step 2a: Calculate rate
R-R is 20 small squares

The 1500 method e.g. HR= 1500/20

▪ A more accurate method = 75/mins
▪ For rhythm which is regular
▪ Count the number of small squares
between 2 consecutive P or R waves (must
be regular)
▪ Then divide 1500 by the number of small
squares
Step 2b: Calculate rate
R-R is 4 large squares

The 300 method e.g. HR= 300/4

▪ For rhythm which is regular
▪ Count the number of large squares between 2 = 75/mins
consecutive R (R-R interval) or P waves
▪ Then divide 300 by the number of large squares
▪ (300 large squares = 1 min)
Step 2c: Calculate rate
8 QRS in 30 large square

30 large squares

The 6-sec method e.g. HR= 8 x 10= 80/mins

◼ Not very accurate
◼ Use in irregular and regular rhythm
◼ Count the number of QRS complexes in
a 6 second strip (30 large squares), and
multiply by 10 (1 min)
Step 3: Assess the P waves

• Are there P waves?

• Is the duration normal (0.06-0.12 sec)?
• Normal & similar size & shape?
• Are any P waves inverted?
• Do every P wave followed by a QRS complex?

• Finding: Normal P wave with every QRS

Step 4: Assess the PR interval

• Count the small squares between the start of P wave

and the start of QRS complex
• normal: 0.12 – 0.20 sec

• Finding : 4 x 0.04 = 0.16 sec

Step 5 :QRS duration

• It is measured from beginning of the Q to the end of the S.

• Normal QRS duration: 0.04 -0.12 sec (1-3 boxes)
• Finding : 1 x 0.04 = 0.04 sec
Step 6: Examine the ST segment

• Is it isoelectric, elevated, or depressed?

Step 7: Identify the rhythm

Regularity Regular
Rate 75-80/min
P waves normal
PR interval 0.12s
QRS duration 0.12s

Interpretation Normal Sinus rhythm

Step 8: Determine its clinical significance

• Is the patient symptomatic? (Check

skin, neurological status, renal
function, coronary circulation, and
hemodynamic status or blood C.O. = HR x SV
pressure.)
• Is the dysrhythmia life-threatening?
• Is the dysrhythmia new or chronic?
ECG interpretation
Normal Sinus rhythm
R R

P T P T

Q S Q S

Regularity Regular
Rate 60-100/min
P waves normal
PR interval 0.12-0.2 sec
QRS duration <0.12 sec
 Sinus Bradycardia
R R
P T P T

Q S Q S

Regularity Regular Electrical impulse generates in SA node and conducts normally at a slow rate 40-60
BPM
Rate <60 min
P waves One P per each QRS Causes:
Uniform & upright • Can be normal especially in athletes & during sleeping.
• Excessive vagal stimulation by vomiting, carotid sinus massage, suctioning.
PR interval 0.12-0.2 sec & constant • non- cardiac disorders, i.e. hyperkalemia, increase ICP (intracranial pressure).
QRS 0.12 sec physiological nervous system response to increase ICP of result Cushing reflex
duration of increased BP, irregular breathing and bradycardia.
• Drug effects: beta-adrenergic blockers, digoxin, calcium channel blocker and
amiodarone.

➔Common symptoms include fatigue, dizziness and breathless.

57
Sinus Tachycardia
R R
P T P T

Q S QS

Regularity Regular
Electrical impulse generates in SA
Rate >100 /mins node at a rapid rate.
P waves One P per each QRS,
uniform and upright
PR interval 0.12-0.2 sec & constant
QRS 0.12 sec
duration
Sinus Tachycardia

Causes
• The result of a normal physiologic response to physical exercise,
fever, anxiety, pain, hypoxia, congestive heart failure (CHF), acute MI,
infection, sympathetic stimulation, anemia, or other stressors that
may increase the body’s requirement for increased oxygen.

• Medications such as epinephrine, atropine, and dopamine

• Caffeine/ alcohol
Sinus Arrhythmia/ Sinus Dysrhythmia
R R

P T P T

Q S Q S

Note The rate increases slightly with inspiration and decreases slightly with expiration.

Regularity irregular
Rate 60-100bpm • Electric impulse originates in the SA node
• Impulses discharged at an irregular
P waves One P per each QRS
interval
PR 0.12-0.2 sec & • Irregularity corresponds with respiratory
interval constant pattern
QRS 0.12 sec
duration
 Sinus Arrest
R R

P T P T

Q S Q S

Regularity Regular
Rate underlying may be normal
P waves One P per each QRS, uniform and upright
Absent during pause
PR interval 0.12-0.2 sec & constant
QRS duration 0.12 sec
Absent during pause
Sinus Arrest

• SA node fails to fire & no pulses is conducted.

• Pt with sinus arrest is at risk for syncope.

• Causes
1. Enhance vagal tone
2. Coronary artery disease
3. Sick sinus syndrome (SSS)
4. Myocarditis
5. Medication (e.g. beta-blocker, calcium channel blocker)
Thank you!
References
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