Medical nursing practice PR: 1

Electrocardiogram (ECG)
Dr.halgord Ali
Khalat H.karim
Definition:
an electrocardiogram is the test that recording electrical activity of heart and
information of heart rhythm to determine cardiac condition.

Define as graphic recording of the electrical change that occur within the heart during
cardiac cycle.
 Indication of ECG
Heart rate & rhythm.
Cardiac arrhythmias.
Myocardial infraction & Ischemic heart disease.
Surgical procedure.
Cardiac history.
Trauma.
Respiratory illnesses.
Chest pain.
Electrolyte imbalance.
When look an ECG you should look at:
• Rhythm: Regular or Irregular
• Heart Rate: 70-100 bpm
• P: present or absent & normal range<=0.12
second
• QRS: present or absent & normal range (0.08
-0.10)second
• ST : should be flat like➡
• T : should be like this ➡
An electrical stimulus is generated by the sinus node (also called the
sinoatrial node, or SA node). This is a small mass of specialized tissue
located in the right upper chamber (atria) of the heart. The sinus node
generates an electrical stimulus regularly, 60 to 100 times per minute
under normal conditions.
The electrical impulse travels from the sinus node to the
atrioventricular node (also called AV node).
There,
impulses are slowed down
for a very short period,
then continue down the conduction
pathway via the bundle of His
into the ventricles.
The bundle of His divides into
right and left pathways,
called bundle branches,
to stimulate the right and left ventricles.
 ECG leads
ECG have 12 lead, contain:
 Chest lead:
 V1:4th intercostals space to the right of the sternum.
 V2:4th intercostals space to the left of the sternum.
 V3:midway between V2 and V4.
 V4:5th intercostals space at the midclavicular line.
 V5:anterior axillary line at the same level as V4.
 V6:midaxillary line at the same level as V4 and V5.
 ECG leads
Limp lead:
Red lead : right arm.
Yellow lead: left arm.
Green lead: left foot.
Black lead: right foot.
-Lead I,records the difference in
voltage between the left arm (LA) and right arm
(RA) electrodes: Lead I = LA −RA

-Lead II records the difference between the left

leg (LL) and right arm (RA) electrodes: Lead II = LL −RA

-Lead III records the difference between the left

leg (LL) and left arm (LA) electrodes: Lead III = LL − LA

-Lead aVR Augmented Vector Right, positive electrode right

shoulder.
-Lead aVL Augmented Vector Left, positive electrode left
shoulder.
-Lead aVF Augmented Vector Foot, positive electrode on
Foot.
 ECG paper
The ECG paper is a strip of graph paper with large and
small grids. On the horizontal axis, each 1 mm
square (the smallest square) represents 0.04
seconds, and each large square (5 mm) represents
0.2 seconds.
 ECG waves
 P wave: atrial depolarization.
 QRS wave: ventricular depolarization.
 T wave: ventricular repolarization.
• Depolarization—electrical stimulation of the heart muscle causing
the heartcells to contract
• Repolarization—resting or relaxation phase of the heart muscle
Normal ECG
 P wave
atrial depolarization.
<0.12 second in duration.
<2.5mm in amplitude.
⃝ Abnormality (P wave)
֍ Absent P wave:
1- Atrial fibrillation.
2- Senoatrial block.
3- Hyperkalaemia.
⃝Abnormality (P wave)
֍ Present P wave:
1- Right Atrial Enlargement: >2.5mm amplitude
2- Left Atrial Enlargement: > 0.12 duration
 QRS wave
*ventricular depolarization.
*<0.12 second in duration.
*5mm-15mm in amplitude
⃝Abnormality (QRS wave)
֍ Q wave:
normal (duration 0.04 s) (Amplitude 2mm)
if the duration and amplitude are more than normal
range lead to (had inferior MI)
 T wave
*ventricular repolarization
*0.20 second duration
*3.5mm-4mm amplitude
 ECG wave
• PR Interval
The interval is measured from where the P wave
begins until the beginning of the QRS complex.
Normal duration (0.12 – 0.20 s)
- If the PR interval duration more than 0.20 s lead to
(first degree atrio ventricular block) (AV block)
 ECG wave
• QRS Complex
The QRS interval is measured from the begins of
Q wave to the end of the S wave.
 ECG wave
• QT Interval
Measure the QT interval from the beginning of
the QRS complex to the end of the T wave.
 ECG wave
• ST Interval
The ST segment is the flat line begins at the end
of the QRS complex and continues to
beginning of the T wave.
 ECG wave
• R-R interval
the interval from the onset of one R wave to the 
onset of the next one.
 Heart Rate
• Heart rate can be calculated using the following
method (if regular):
 Count the number of large squares present
within one R-R interval
 Divide 300 by this number to calculate the heart
rate
• If irregular:
 Count the R wave within 30 large squares and
multiple 10.
 Atrial Fibrillation (AF)
 Rhythm: irregular. HR:100 bpm.
 P wave: absent.
 QRS wave: present but narrow (0.04second).
 ST: abnormal. T wave: abnormal.
 Atrial Fibrillation (AF)
Prevention:
• Eating a heart-healthy diet
• Increasing regular physical activity
• Avoiding smoking
• Maintaining a healthy weight
• Limiting or avoiding caffeine and alcohol
• Reducing stress, as intense stress and anger.
• Medication.
 Supra Ventricular Tachycardia
SVT
Rhythm: regular. HR:>200 bpm
P wave: hidden in T wave.
QRS wave: present but narrow 0.04 second.
ST: abnormal. T wave: abnormal.
  Supra Ventricular Tachycardia
SVT
 Adenosine: 6 mg intravenous push over 1-3 seconds
followed by rapid flush with 20 ml normal saline.
 Isoptin:2.5mg/mL. 2.5-5 mg IV over 2 minutes.
 Vagal Maneuvers.
 Cough.
 Cardioversion.
 Gag reflex.
 Ventricular fibrillation (VF)
Rhythm: irregular. HR:150-240bmp.
P wave: absent.
QRS wave: absent.
ST: no ST segment. T wave: absent.
 Ventricular Tachycardia (VT)
Rhythm: regular. HR:>200bpm.
P wave: absent.
QRS wave: present but wide (0.24 second).
ST: no ST segment. T wave: absent.
 VF &VT
Defibrillation or DC shock
CPR
Medication
For VF box on the heart
  ST Elevation
STEMI
• elevated ST wave.
• full blockage of the coronary artery.
  ST Depression
NSTEMI
• depressed ST wave or T-wave inversion.
• partial blockage of the coronary artery.
 MI
 Troponin test
 Catheter
 Ballon and stent. angioplasty
 Medication (asprin.plavex)
A systole
Atropine 0.5–1.0 mg given intravenously at
intervals of 3 to 5 minutes.
Adrenaline (Epinephrine)
CPR.