ECG Basics for Nurses

Prof. Dr. Aswinikumar Surendran. MD Professor, Department of Medicine Government medical College Hospital Thiruvananthapuram, South India. +9147124699824, +9194447799984 draswinikumars@gmail.com

What is ECG?
Graphical Depiction of Electrical Forces

Importance of ECG
Life Line of the Patient

ECG Reeading Not a

Nurses
Role in the ICU

Why Learn ECG?

Valuable Easily Attained Skill

Uses of ECG
Specific for Nurses
Heart Rate Normal / Tachycardia / Bradycardia Stress testing Early detection of Ischemia Holter monitoring Aarrhythmia testing Carditis Myocarditis / Pericarditis Drug Effect Digoxin / Quinidine / Adriamycin Electrolyte Imbalance Hypokalemia / Hyperkalemia Arrhythmias Ventricular / Supraventricular Heart Blocks AV Nodal / RBBB / LBBB Coronary Circulation Ischemia / Injury / Infarct Chamber Enlargement LAE / RAE / LVH / RVH Electrical Axis Normal / Right axis / Left axis ICU monitoring Early detection of arrhythmia

Conduction Pathway
From SA Node to Ventricular Muscle
SA Node Left Atrial muscle Right Atrial muscle His Bundle AV Node

Right Bundle Branch

Left Bundle Branch

Right Ventricular Muscle

Left Ventricular Muscle

Pacemakers of Hearrrrrt
If one fails, the other will take over

Inherent Rate 60-80 Inherent Rate 40-60

Inherent Rate 20-40

Inventor
Einthoven

ECG Machine
Modified Galvanometer

ECG Paper
Moves at a spped of 25mm/sec

Black paper

Erased by heated stylus

Heat sensitive substance coated

Cheap: Rs1/- per ECG

ECG
Recording

ECG
Leads

6 Limb Leads
Oriented to frontal plane

II III and aVF Inferior Wall

6 Chest Leads
Oriented to horizontal plane

1 aVL V5V6 Lateral Wall

V1V2V3V4 Anterior Wall

Standardization
1 mv of current produces 10mm deflection

Standardization
Half Standardization

10 sd 1 mV

5 sd

1 mV

ECG Paper
Measurements
How to measure the height of a wave?
How to measure the duration of a wave or interval of a wave?

5 small divisions = 0.2 seconds

Amplitude measured vertically Time measured in the horizontally

1 small divisions = 0.04 seconds

Rest
Only multiples

ECG Waves
PQRSTU named by Einthoven
R

P Q S

P: First positive wave of cardiac cycle Q: First negative deflection of the cycle R: First positive deflection of the cycle S: 2nd negative deflection of the cycle S: can also be a 1st -ve wave following R T: Positive wave following QRS complex U: Small +ve wave following the T wave

Waves Regrouped
For Convenience
QRS complex U wave

P wave

T wave

P wave-Atrial contraction; QRS complexVentricular contraction, T wave-Vent relaxation, U wave-Also Vent origin

Intervals
For Calculation of Heart rate
RR interval QRS duration

PR Interval

QT interval

PR: AV nodal delay

QRS: Vent Conduction

RR interval for heart rate calculation

QT: Total time, Cardiac Cycle

PQRST
Electrical correlation
Atrial depolarization

QRS Ventricular depolarization U wave

Ventricular repolarization P wave PR/QRS T wave Ventricular repolarization

Atrial repolarization?

P Wave
Atrial Stimulation

P wave is upward convex Prominent in leads II and V1

P negative in aVR and V1 -/absent in Junctional rhythm

P Wave
Shape - Widening

Normal P

P Mitrale

Wide and notched

Left Atrial Enlargement

P Wave
Shape peaked

Normal P

P Pulmonale

Signifies RAE

Tall and Peaked

Right Atrial Enlargement

PR Interval
Denotes AV nodal delay
PR interval A physiological necessity

PR Interval

Normal 3-5 SD

PR Interval
Abnormalities

Prolonged PR: 0.21s Rheumatic Fever I0 Heart Block

Short PR: <0.12 sec

WPW syndrome
Junctional rhythm

QRS Duration
Time for Ventricular contraction

Normal 0.06 to 0.10 sec

Abnormal > 0.11 sec

Prolonged QRS Ventricular contraction Delay

Right Bundle Branch Block

Conduction Delay in Right Ventricle

R r T S RBBB V1 q

Deep slurred S
V6

RBBB
ECG

Left Bundle Branch Block

Conduction Delay in Left Ventricle

T LBBB

LBBB
V6

V1

LBBB
ECG

Q Wave
Comes After PR Interval

No Q

QRS

Normally No Q

1st negative deflection

Q Wave
Abnormal Dimensions

>0.04sec

Width >0.04sec

Depth > 1/4th of height

Importance of Q Wave
Indicates Heart Attack

ST Segment
From End of S to Beginning of T

ST PR
Normal ST segment

ST

PR

ST segment elevation

ST Segment Elevation
Straight and Coving

Coving ST

ST PR
Straight ST segment elevation

PR
Coving ST segment elevation

J Point Elevation
Innocent Early Repolarisation

J Point

J point elevation

ST Segment Elevation
Actual Measurement

ST PR
0.08 sec to the right of J point

STEMI and NSTEMI

Changes in ST segment

ST Segment Elevation
Importance

ST Segment Depression
Suggestive of Angina

Normal ST segment

ST segment Depression

T Wave
Normal And Abnormal

Normal T

Peaked T

Symm T

Biphasic T

Tall peaked T Wave

Acute myocardial Infarction

Hyperacute MI Tall peaked T wave

Tall peaked T Wave

Acute myocardial Infarction ECG

Tall Peaked T Wave

Hyperkalemia (High potassium)

Hyperkalemia

Tall peaked T Wave

Hyperkalemia ECG

T Inversion
Suggestive of Ischemia

Biphasic T wave

Symmetrical T Inversion

T Inversion
In Anterior and Inferior Leads

ECG in a Normal Person

No or small Q, isoelectric ST, Normal T

ECG in Heart Attack

Q appears, ST is elevated & T inverted

Acute Myocardial Infarction

Progressive Changes

15 min

2 hours

VAT
30 min

ST
3 hours

1 week

ST downs

Peak T
1 hour

T Biphasic
4 hours

ST Normal

1 month

ST

Q appears

T upright

1 year

Early changes of AMI

Acute Myocardial infraction

Healing and old infarction

Myocardial Infarction
Anterior Wall

Thrombus

Seen in V2 to V4 If in V1 - Anteroseptal

Anterior descending branch

Left coronary artery

ECG
Acute Anterior Wall MI

Myocardial Infarction
Lateral Wall

Thrombus

Changes of Acute MI , when seen in the lateral chest leads, 1, aVL, V5 V6, is diagnostic of Lateral Wall Myocardial Infarction

Myocardial Infarction
Lateral Wall - ECG

Myocardial Infarction
Antero Lateral MI

Thrombus Thrombus

Thrombus

Changes of Acute MI are seen in all the anterior chest leads, from V1 through V6; diagnostic of Antero-lateral Wall MI

Myocardial Infarction
Antero Lateral MI - ECG

Myocardial Infarction
Inferior Wall

Thrombus

Changes in II, III and aVF Diaphragmatic surface

Right coronary artery Diaphragmatic surface

ECG
Inferior Wall MI

Right Ventricular MI
Changes seen in V3R V4R

QT Interval
Time taken for Ventricular Re-polarization

QT Interval

QTC

Normal QT <0.44

Corrected QT <0.44

Prolonged QT
Congenital Long QT Syndrome

Short QT
Increased susceptibility to Torsade de

Short QT

U Wave
Small wave following T

New Wave of Repolarization

R/S in V1
Normally less than 1

Lead V1

Normal

RVH

R in V1 is < of S in V1

R in V1 is > S in V1

Right Ventricular Hypertrophy

R/S in V1 is > 1

..

S in V1 + R in V6
Normally less than 35mm

25mm

20mm

Lead V6

Lead V1

Left Ventricular Hypertrophy

SV1 + RV6 = >35