Electrocardiogram Monitoring

Introduction
Graphic depiction of the electrical forces generated by the heart Noninvasive, inexpensive, and highly versatile

test

1.Nomenclature of ECG Deflection, Intervals and Segments. In: Luthra A, editor.ECG made it easy. Jaypee:2007.p.1-13. 2.Goldberger AL. Electrocardiography. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrisons principles of internal medicine(16th ed). McGraw-Hill;2005.p.1311-1319.

Advantages of ECG
Detects arrhythmias Detects conduction disturbances Detects myocardial ischemia Reveals findings related to metabolic disturbances Reveals increased susceptibility to sudden cardiac death

Goldberger AL. Electrocardiography. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrisons principles of internal medicine(16th ed). McGraw-Hill;2005.p.1311-1319.

Basic Concepts of ECG

ECG waveforms are labeled alphabetically
P wave QRS complex : Represents atrial depolarization : Represents ventricular depolarization

ST-T-U complex : Represents ventricular repolarization

Goldberger AL. Electrocardiography. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrisons principles of internal medicine(16th ed). McGraw-Hill;2005.p.1311-1319.

ECG Waveform Components

P Wave
First ECG deflection of each cardiac cycle
Represents the depolarization of both atria

Basic concept and the normal electrocardiogram. In: Weinberg RW, Miller KC, Somers J, editors. Rapid analysis Of Electrocardiogram: a self study programme. Lippincott Williams And Wilkins; 1999.p.3-17.

Contd..
First half is produced largely by depolarization of the right atrium Second half is produced largely by depolarization

of the left atrium

The wave of depolarization spreads through the ventricles predominantly from the endocardial area to the epicardium
Hurst JW. Naming of the waves in the ECG, with a brief account of their genesis. Circulation. 1999 Dec 21;100(25):e148.

Contd..
Location Amplitude Duration : Precedes the QRS complex : 2 to 3 mm high : 0.06 to 0.12 second upright

Configuration : Usually rounded and

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

Abnormal P Wave
Peaked, notched or enlarged P wave may indicate
Atrial hypertrophy Chronic obstructive pulmonary disease Pulmonary emboli Heart failure

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

P-R Interval
Includes the P wave and P-R segment

Represents the time of transmission of the electrical

impulse from the atria to ventricles

Basic concept and the normal electrocardiogram. In: Weinberg RW, Miller KC, Somers J, editors. Rapid analysis Of Electrocardiogram: a self study programme. Lippincott Williams And Wilkins; 1999.p.3-17.

Contd..
Location : From the beginning of the P wave to the beginning of the QRS complex Duration : 0.12 to 0.20 second

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

Abnormal P-R Interval

Short interval (shorter than 0.12 sec) may

indicate

Junctional arrhythmias

Pre-excitation syndromes

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

Prolonged PR interval (greater than 0.20 second) may represent

Conduction delay through the atria at AV junction caused by digoxin toxicity

Heart block

Slowing related to ischemia or conduction tissue disease

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

QRS Complex
Represents depolarization of both ventricles

Basic concept and the normal electrocardiogram. In: Weinberg RW, Miller KC, Somers J, editors. Rapid analysis Of Electrocardiogram: a self study programme. Lippincott Williams And Wilkins; 1999.p.3-17.

 Q wave - First initial deflection in a given lead that is negative R wave - First positive deflection

S wave - A negative deflection after an R wave

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

Contd..

Location- Follows the PR interval

Amplitude-5 to 30 mm high Duration- 0.06 to 0.10 second or half of the PR interval Configuration- The QRS complex is subdivided into specific deflection or waves (Q,R, and S wave)

Abnormal QRS Complex

Deep wide Q wave may indicate that myocardial infraction Notched R wave may signify a bundle branch

block
Missing QRS complex may indicate AV block or ventricular standstill

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

ST Segment
Represents the earlier phase of repolarization of both the ventricles

Basic concept and the normal electrocardiogram. In: Weinberg RW, Miller KC, Somers J, editors. Rapid analysis Of Electrocardiogram: a self study programme. Lippincott Williams And Wilkins; 1999.p.3-17.

Contd..
Extends from the end of QRS complex to the beginning of T wave

Usually isoelectric or on the baseline

Neither

elevated

(positive)

nor

depressed

(negative) The point at which the ST segment joints the QRS complex is known as the J (junction) point
Basic concept and the normal electrocardiogram. In: Weinberg RW, Miller KC, Somers J, editors. Rapid analysis Of Electrocardiogram: a self study programme. Lippincott Williams And Wilkins; 1999.p.3-17.

Contd..
A change in the ST segment may indicate myocardial injury or ischemia
Location- Extend from the S wave

to the beginning of the T wave

Deflection-Usually isoelectric or on the baseline (neither positive nor negative)

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

T Wave
Represents electrical recovery, repolarization of ventricle Wave of repolarization moves predominantly from

epicardium to endocardium
Tall, peaked or tented T wave may signify myocardial injury or hyperkalemia Inverted T wave may signify myocardial ischemia
1.Step by step method for accurate electrocardiogram interpretation. In: Khan MG, editor. Rapid ECG Interpretation. Human Press;2007.p.25-40. 2.Hurst JW. Naming of the waves in the ECG, with a brief account of their genesis. Circulation. 1999 Dec 21;100(25):e148.

QT Interval
Include the QRS complex, S-T segment, and the T wave

Measured from the beginning of the QRS complex to the

end of T wave

Basic concept and the normal electrocardiogram. In: Weinberg RW, Miller KC, Somers J, editors. Rapid analysis Of Electrocardiogram: a self study programme. Lippincott Williams And Wilkins; 1999.p.3-17.

Contd..
Prolonged QT interval indicates prolonged

ventricular repolarization or congenital prolonged QT syndrome Short QT interval (less than 0.36 second) may result from digoxin toxicity or hypercalcemia

Electrocardiogram analysis. In: Levine J, Munden J, Schaeffer L, Thompson G,editors. Portable ECGinterpretation. Lippincott Williams & Wilkins; 2007. P.257-364.

ECG Leads
12 conventional ECG leads record the potential difference between electrodes placed on the surface of the body1 Leads are divided into two groups2
Six extremity (limb) leads Six chest (precordial) leads

Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38

Limb Leads
Record electrical activity in the hearts frontal plane from the anterior to the posterior axes

Electrocardiogram analysis. In: Levine J, Munden J, Schaeffer L, Thompson G, editors. Portable ECG interpretation. Lippincott Williams & Wilkins; 2007. P.257364.

Placement of Limb Leads

Limb Leads Lead I Lead II Lead III aVR aVL aVF Placement Connects the right arm with the left arm Connects the right arm with the left leg Connects the left arm with the left leg Right arm Left arm Left leg

Electrocardiogram analysis. In: Levine J, Munden J, Schaeffer L, Thompson G,editors. Portable ECGinterpretation. Lippincott Williams & Wilkins; 2007. P.257-364.

Precordial Leads
Records electrical activity in the hearts horizontal plane from either a superior or an inferior approach

Placement of Precordial Leads

Precordial Leads Placement

V1
V2

Fourth intercostals space, just to the right of the sternum

Opposite V1, over the fourth intercostals space at the left sterna border

V3
V4 V5 V6

Midway between V2 and V4

Over the fifth intercostals space at the left midclavicular line Over the fifth intercostals space at the left anterior axillary line Over the fifth intercostals space at the left anterior axillary line

Goldberger AL. Electrocardiography. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrisons principles of internal medicine(16th ed). McGraw-Hill;2005.p.1311-1319. Electrocardiogram analysis. In: Levine J, Munden J, Schaeffer L, Thompson G,editors. Portable ECGinterpretation. Lippincott Williams & Wilkins; 2007. P.257-364.

Steps of ECG Interpretation

Assess rhythm, then the heart rate Determine the duration of the P-R or P-Q interval, the duration of the QRS complexes, and the QT interval

Diagram the diagnostic cardiac vectors

Establish an electrical anatomic cardiac differential diagnosis

Step by step method for accurate electrocardiogram interpretation. In: Khan MG, editor. Rapid ECG Interpretation. Human Press;2007.p.2540. The Clinical Use of Electrocardiography. In: Hurst JW, editor. Interpreting electrocardiogram: using basic principles and vector concepts.Informa Healthcare; 2001.p. 95-100.

Contd..
Establish a differential diagnosis of cardiac diseases
Correlate the information identified in the electrocardiogram with other clinical data

The Clinical Use of Electrocardiography. In: Hurst JW, editor. Interpreting electrocardiogram: using basic principles and vector concepts.Informa Healthcare; 2001.p. 95-100.

Contd..
ECG interpretation should end with one of the following statements:

Normal ECG ECG within normal limits Borderline ECG Abnormal ECG

Step by step method for accurate electrocardiogram interpretation. In: Khan MG, editor. Rapid ECG Interpretation. Human Press;2007.p.25-40.

ECG Monitoring

Arrhythmia Monitoring

Thrombolytic therapy for AMI increases arrhythmias

Improves prognosis in the post AMI period

Reasons for Arrhythmia Monitoring

Arrhythmias in AMI Patients within 48 hrs

Detection of ventricular tachycardia in AMI patients

Sinus Arrhythmia
Rhythm : Cyclic, irregular; varies with respiratory

cycle
Rate P wave PR interval QRS complex T wave QT interval : 70 beats/min : Normal : 0.16 second : 0.06 second : Normal : 0.36 second

Baseline data a protocolfor reading ECG. In: Taylor GJ, editor. 150 practice ECG ; Interpretation and review. Malden, Mass. : Blackwell Science;2002.p.3-21.

Sinus Arrhythmia

Sinus Tachycardia
Rhythm : Regular

Rate
P wave PR interval

: 120 beats/min
: Normal precedes each QRS complex : 0.14 second

QRS complex : 0.06 second T wave QT interval : Normal : 0.34 second

Sinus node Arrhythmia.In: Williams L, Wilkins editors. LPN expert guides: Ecg interpretation. Lippincott Williams & Wilkins; 2007.p.68-78.

Sinus Tachycardia

Sinus Bradycardia
Heart rate : Less than 60 beats/min

Rhythm
arrhythmia

: Regular unless associated with sinus

P wave

: Normal, only slight changes in morphological features

PR and QRS interval QT interval PR interval

: Normal

: Lengthens : More than 0.12 seconds

Arrhythmias originating in sinus node. In: Conover MB, editor. Understanding electrocardiography. Mosby; 2002.p.45-60.

Sinus Bradycardia

Paroxysmal Supraventricular Tachycardia

Heart Rate :130-270 beats/min

Rhythm

:Usually Regular unless the impulse originates

from multiple atrial foci

P:QRS

:1:1 relationship, although the P wave may often be hidden in the QRS complex or T wave

QRS complex :Generally normal, but ST-T changes

Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.

Paroxysmal Supraventricular Tachycardia

Atrial Flutter
Heart Rate
Atrial heart rate is 250 to 350 beats/min Ventricular rate of about 150 beats/min

Rhythm
The atrial rhythm is regular The ventricular rhythm may be regular if a fixed

atrioventricular block is present or irregular if a

variable block exists

Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.

 P:QRS: Usually 2:1 block but it may vary between 2:1 and 8:1
Atrial rate of 300 beats/min and a Ventricular rate of 150 beats/min, but it may vary between 2:1 and 8:1

QRS complex: Normal

Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.

Atrial Fibrillation
Heart rate:
The atrial rate is 350 to 500 beats/min Ventricular rate is 60 to 170 beats/min.

Rhythm: Irregularly irregular P:QRS: The P wave is absent QRS complex: Normal

Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.

Ventricular Premature Beats

Heart Rate: Depends on the underlying sinus rate and frequency Rhythm: Irregular

P:QRS: No P wave
QRS complex: Wide and bizarre, with a width of more than 0.12 second

Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.

Ventricular Tachycardia
Heart Rate: 100 to 200 beats/min Rhythm: Usually regular P:QRS: No fixed relationship

QRS complex: Wide, more than 0.12 second in

width

Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.

Ventricular Fibrillation
Heart rate: Rapid and grossly disorganized Rhythm: Totally irregular P:QRS: None seen

QRS complex: Not present

Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.

Ischemic Heart Disease

 Ischemia causes typical changes in the ECG

Repolarization abnormalities: Evidenced by inversion of T wave Severe repolarization abnormalities: Evidenced by displacement of STsegments
o o Transient ST Segment: Reflects subendocardial ischemia Elevated ST Segment: Reflects severe transmural ischemia

Thys DM, Nanang J. Electrocardiographic monitoring. In: Estafanous FG, Barash PG, Reves JG. Cardiac anesthesia principles and clinical practice. Lippincott Williams & Wilkins;2001.p.175-94.

ST segment abnormality in ischemia

ECG Monitoring Device

Types of ECG machines

Singlechannel recorders One lead at a time is recorded

Multichannel recorders Simultaneous recording of all the leads at once

12-lead ECG machines 10 lead wires connected to the machine

Advanced electrocardiography. In ECG interpretation.a two-in-one references for nurses; Williams L. Editors. 2005. Page no.205-207.

Steps to record Multichannel ECG

The cord of the ECG machine is plugged into a grounded outlet Patients identification data is entered as prompted by the machine Electrodes are properly placed on the patients chest, arms and legs ECG paper speed selector is set to 25mm/sec AUTO button is pressed and ECG is recorded
Advanced electrocardiography. In ECG interpretation.a two-in-one references for nurses; Williams L. Editors. 2005. Page no.205-207.

Machine is turned off and the recording is finished Electrode is removed and the patients skin is clean

Advanced electrocardiography. In ECG interpretation.a two-in-one references for nurses; Williams L. Editors. 2005. Page no.205-207.

ECG machine is composed of the following parts:

Galvanometer Heated stylus Lead wires Electrodes ECG paper

Performing an ECG. In: Phlebotomy technician specialist: a practical guide to phlebotomy Kalanick KA, editors. 2004. Page no.-292-293. .

Galvanometer
Measures electrical current by electromagnetic action Detects the electrical activity of the heart through

electrodes placed on patients skin

Performing an ECG. In: Phlebotomy technician specialist: a practical guide to phlebotomy Kalanick KA, editors. 2004. Page no.-292-293. .

Placement of Electrodes and Leads

Shaving of body hair from the electrode site Application of alcohol swab to remove oil and dead tissues from the electrode site Attachment of electrodes to ECG cables Switching on the monitor and printing of samplre rhythm strip. Interference in the strip verifies firm placement of the electrodes

Cardiovascular emergencies. In : Nancy Caroline's Emergency Care in the Streets: Trauma Medical Caroline NL. Aaos, editors. (6th edition). Jones and barlett . publishers; 2006. Page no. 41-43.

Types of Electrodes
Types of electrodes Adhesive Ag/AgCl electrodes Dry electrodes Signal quality Very good Electrode artifacts Very low Motion artifacts Caused by varying skin potential Varying electrode potential causes motion artifacts Occur due to skin potential changes

Low

High

Capacitively coupled Good electrodes

Do not occur at all

Ottenbacher J, Jatoba.L, Groffmann U, Stork W, et al. ECG electrodes for a context-aware cardiac permanent monitoring system. In : World Congress on medical physics and biomedical engineering. Kim SI, Suh TS, editors. IFMBE proceedings; 2006. Page no. 672-673.

12-Lead ECG
Lead provides electrical picture of the heart from a specified vantage point 12 different pictures of the electrical activity of

the heart recorded in standard ECG

Limb leads- Lead I, Lead II, Lead III, aVR, aVL, aVF Precordial leads- V1 to V6
Cardiovascular emergencies. In : Nancy Caroline's Emergency Care in the Streets: Trauma Medical Caroline NL. Aaos, editors. (6th edition). Jones and barlett publishers; . 2006. Page no. 41-43.

ECG Paper
Heat-sensitive paper on which electrical activity in the heart is recorded Composed of small square blocks and large

square blocks
Small blocks are 1mm by 1mm(1 mm2 ) Large blocks are 5 mm by 5 mm (5 mm2)

ECG basics. Editors. In Guide to ECG analysis. Catalano JT, editors. (2nd edition). Lippincott publishing house; 2002. Page nos.26-27.

Contd..
Time is measured on horizontal plane Amplitude is measured on vertical plane Each small square represents 0.04 sec

Larger square represents 0.2 sec

Paper speed is 25 mm/sec

Measurement of heart rate and intervals. In: Understanding electrocardigraphy. Brown SC, Anderson C, editors. (8th edition); 1996. Page no. 41-42.

Time and voltage measurements on ECG paper

Measurement of heart rate and intervals. In: Understanding electrocardigraphy. Brown SC, Anderson C, editors. (8th edition); 1996. Page no. 41-42.

Criteria for normal P waves

Duration not more than 0.12 sec.

Amplitude not more than 0.25 mV Smooth and rounded in contour May be upright or biphasic in leads V1 and V2

Waves and intervals. In: Understanding ECG. Mehta PJ, editors. (6th edition). Mesh publishing house ltd; 2002. Page no.-10-15.

Criteria for normal T waves

For limb leads
Upright T wave if QRS complex is positive and inverted T waves if

QRS complex is negative.

Always upright in leads 1 and 11 Always inverted in a VR

Waves and intervals. In: Understanding ECG. Mehta PJ, editors. (6th edition). Mesh publishing house ltd; 2002. Page no.-10-15.

 For precordial leads

In lead V1- normally upright In leadV2- normally upright Must be upright in leads V3 to V6 Height should not be > 2/3 and not<1/8 of height of proceeding R wave in leads V3 to V6 Angle between mean frontal plane QRS axis

and mean frontal plane T axis must be less

than 45 degrees
Waves and intervals. In: Understanding ECG. Mehta PJ, editors. (6th edition). Mesh publishing house ltd; 2002. Page no.-10-15.

Criteria for normal U waves

Small rounded wave (<1mm) Same polarity as the T wave and

hence upright in most leads

Waves and intervals. In: Understanding ECG. Mehta PJ, editors. (6th edition). Mesh publishing house ltd; 2002. Page no.-10-15.

Components of ECG wave complexes

Boon NA, Bono DP de. In: Diseases of the cardiovascular system. In : Principles and practice of medicine. Edwards CRW, Bouchier I.A.D, editors. (16th edition); 1991. Page no. 260.

Impulse Conduction
Waves, intervals, segments, complexes on ECG tracing correspond to depolarization and repolarization of cardiac cycle Electrodes deflect minute electrical impulses Identification of the wave, interval, segment or complexes corresponding to specific electrical activity determine the conditions of patients heart
Performing an ECG. In: Phlebotomy technician specialist: a practical guide to phlebotomy Kalanick KA, editors. 2004. Page no.-292-293. .

Conclusion
Graphic representation of the electrical activity in the heart ECG paper is a type of graph paper that has

preset measurements for time and voltage

ECG leads are electrical views of the heart from different positions 12 lead ECGs provide 12 different pictures of the electrical activity of the heart