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ECGs The Basics (Part 1) Lecture

The document provides an overview of electrocardiography (ECG/EKG) including: 1) It describes the cardiac conduction system and how electrical impulses are generated and transmitted through the heart, triggering mechanical contractions. 2) Key aspects of the normal ECG waveform are defined including the P wave, PR interval, QRS complex, and QT interval. 3) Proper placement of the 10 electrodes for a 12-lead ECG is outlined to provide different views of the electrical activity in the heart. 4) Reasons for obtaining a 12-lead ECG in a clinical setting are given, focusing on detecting abnormalities that could indicate reduced blood flow to the heart muscle from

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36 views

ECGs The Basics (Part 1) Lecture

The document provides an overview of electrocardiography (ECG/EKG) including: 1) It describes the cardiac conduction system and how electrical impulses are generated and transmitted through the heart, triggering mechanical contractions. 2) Key aspects of the normal ECG waveform are defined including the P wave, PR interval, QRS complex, and QT interval. 3) Proper placement of the 10 electrodes for a 12-lead ECG is outlined to provide different views of the electrical activity in the heart. 4) Reasons for obtaining a 12-lead ECG in a clinical setting are given, focusing on detecting abnormalities that could indicate reduced blood flow to the heart muscle from

Uploaded by

liudmyla zakordonets
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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ECG

The Basics And Beyond (Part 1)


MAKSYM ZAHORODNYI, PHD, ASSOCIATE PROFESSOR
Pearls

• Treat the patient not the paper.


• Electrical activity triggers mechanical activity. No electrical
activity = no mechanical activity
• But electrical activity does not guarantee mechanical activity.
• The more cells involved the larger the deflection on the ECG.
• If the wave of electrical activity is moving toward the
electrode, the wave will be positive (above the baseline); if the
wave is moving away from the electrode the wave will be
negative (below the baseline).
CARDIAC
CONDUCTION
SYSTEM
1
3

5
Purkinje
fibers
CARDIAC CONDUCTION SYSTEM

• Electrical cells arranged in a systematic pathway

• Predominant pacemaker starting the electrical flow comes


from the SA node

• Electrical cells are part of the conduction system

• Muscle cells are the mechanical cells


Cardiac Conduction System
NORMAL ECG

One small box = .04 seconds


One large box = .20 seconds

Conduction picture courtesy of New Mexico Heart Institute


Anatomy and the ECG
• The P wave = atrial activation (SA node
to AV node).

• The PR interval = onset of atrial


activation to onset of ventricular
activation.

• The QRS complex = electrical


ventricular activation.

• The ST-T segment = ventricular


repolarization.

• The QT interval = the duration of


ventricular activation and recovery.
Definition of Normal Sinus Rhythm

• Heart rate
• 60-100 Adult
• 80-160 Infant
• 80-130 Toddler
• 75-115 6 year old
• Regular rhythm
• P waves round, same shape and before each QRS
• Normal PR interval (0.12-0.20 sec or 3-5 small boxes)
• Normal QRS interval (< 0.12 sec or < 3 small boxes)
• QRS positive in leads I, II, aVF, V3-V6
Cardiac Conduction System
NORMAL ECG

Conduction picture courtesy of New Mexico Heart Institute


SINUS RHYTHM
• The P wave is upright in leads I and II
• Each P wave is usually followed by a Q
• The heart rate is 60­-100 beats/min
EKG WAVEFORMS
• P wave represents atrial stimulation
• P wave is rounded and upright
• PR interval
• Includes the P wave and the isoelectric PR segment
• PR interval is the time it takes for an impulse to travel from the SA node
through the internodal pathways toward the ventricles
• Includes delay time in the AV node
• Normal PR interval is 0.12 – 0.20 seconds
PR
Interval

Normal
0.12 –
0.20
seconds
PR INTERVAL ABNORMALITIES

• PR interval <0.12 seconds


• Impulse did not begin in the normal pacemaker site of the SA node but
somewhere in the atria
• PR interval >0.20 seconds
• There was a longer than normal delay transmitting the impulse through
the AV node
• A change in the PR interval measurement generally
will not make the patient symptomatic
EKG WAVE FORMS CONT’D

• QRS complex
• Consists of the Q, R, and S waves collectively
• Represents ventricular depolarization or discharge of
electrical energy throughout ventricular muscle
• Larger than the P wave because ventricular depolarization
involves a larger muscle mass than atrial depolarization
• Palpation of a pulse is generated by ventricular
depolarization (seen as the QRS complex)
• Normal timing usually considered between 0.06 and
0.11 seconds
• Normal is less than 0.12 seconds
QRS COMPLEX

QR
S
QRS COMPLEX MEASUREMENT

• From beginning of Q wave – usually fairly straight forward


• Stop measurement at end of S wave; not necessarily where QRS
intersects baseline
• On S wave, watch for small notch or other indicator that electrical flow
is changing
• Not always so easy to determine stop point
• Do not include ST segment or T wave
• Abnormally wide QRS indicates delay in conduction time through the
ventricles
EKG WAVE FORMS CONT’D

• T wave
• Represents ventricular repolarization
• Repolarization is the phase of electrical activity where electrical charges
(influenced primarily by sodium (Na+) and potassium (K+)) return to
their original state and prepare to respond to the next electrical charge
received

• Atria repolarize during ventricular depolarization so


the small atrial T wave is hidden during the larger QRS
complex
WHEN TO OBTAIN A 12-LEAD EKG
• Any patient presenting with signs and/or symptoms
of an acute coronary syndrome
• Consider atypical AMI presentations
• Elderly
• Women
• Patient with long standing history of diabetes
• Any patient presenting with a Second degree Type II
(classical) or 3rd degree heart block
• Consider the origin of heart block from an AMI until proven otherwise
WHAT ARE WE LOOKING FOR?

• Abnormalities that indicate interruption in the blood


flow to the myocardium
• Plaque formation diminishes blood flow through the coronary arteries
• Patients may be asymptomatic while damage
silently develops
• Plaque rupture begins a cascade of events that further compromises
blood flow through the injured vessel(s)
• This cascade of events could lead to an acute
coronary syndrome (ie: acute MI)
CORONARY CIRCULATION
• Coronary arteries and veins
• Myocardium extracts the largest amount of oxygen as blood
moves into general circulation
• Oxygen uptake by the myocardium can only improve by
increasing blood flow through the coronary arteries
• If the coronary arteries are blocked, they must be reopened if
circulation is going to be restored to that area of tissue
supplied
12-LEAD ELECTRODES

• A lead is a tracing of the electrical activity between 2


electrodes
• Leads view the heart from the front of the body
• Top, bottom, right, and left side of heart
• Leads view the heart as if it were sliced in half
horizontally
• Front, back, right, and left sides of heart
• Each lead has a positive and a negative electrode
STANDARD 12-LEAD EKG

• Six limb leads


• Leads I, II, III, aVR, aVL, aVF
• Six chest leads (precordial leads)
• V1, V2, V3, V4, V5, V6
• Information from 12 leads obtained from
the attachment of only 10 electrodes
VIEW THE LEADS PROVIDE

• II, III, aVF – view inferior wall of heart


• V1 and V2 – view septal wall of heart
• V3 and V4 – view anterior wall of heart
• I, aVL, V5, V6 – view lateral wall of
heart
PREPARATION FOR 12 LEAD EKG

• Skin preparation
• Hair removal
✔clip hair if necessary so electrodes adhere
• Clean and dry skin surface
✔gently rub skin area with gauze pad
⬥ need to remove skin oils & dead skin
✔ if diaphoretic patient wipe with towel/gauze
or use antiperspirant spray
• Patient positioning
• Preferably flat
✔Heart rotates position as the patient
position changes
• If patient is elevated, note that information
on the EKG
PRECORDIAL CHEST LEADS

For every person, each precordial lead placed in the same relative
position
✔ V1 - 4th intercostal space, R of sternum
✔ V2 - 4th intercostal space, L of sternum
✔ V4 - 5th intercostal space, midclavicular
✔ V3 - between V2 and V4, on 5th rib
✔ V5 - 5th intercostal space, anterior axillary line
✔ V6 - 5th intercostal space, mid-axillary line
1st ICS

2nd ICS

3rd ICS

• Precordial
leads
12-LEAD ELECTRODE PLACEMENT
I a V V
V 4
1
R

a V V
II V 2 5
L

I V V
a
I 3 6
V
I F
BIBLIOGRAPHY

• Aehlert, B. EKG’s Made Easy third Edition. Elsevier Mosby.


2006.
• Beasley, B. Understanding EKG’s A Practical Approach.
Brady. 2003.
• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles
and Practices. Third Edition. Brady. 2009.
• Ellis, K. EKG Plain and Simple. Prentice Hall. 2002.
• Page, B. 12 Lead EKG for Acute and Critical Care Providers.
Brady. 2005.
THANK YOU
QUESTIONS?

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