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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.
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.
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
Contd..
Location Amplitude Duration : Precedes the QRS complex : 2 to 3 mm high : 0.06 to 0.12 second upright
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
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
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
Heart block
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
Understanding ECG. In: Williams L,editor, Lippincotts manual of nursing practice series ECG interpretation. Lippincott Williams & Wilkins;2008.p20-38
Contd..
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
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
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
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.
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
V1
V2
V3
V4 V5 V6
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.
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
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
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
P wave
: Normal
Arrhythmias originating in sinus node. In: Conover MB, editor. Understanding electrocardiography. Mosby; 2002.p.45-60.
Sinus Bradycardia
Rhythm
P:QRS
:1:1 relationship, although the P wave may often be hidden in the QRS complex or T wave
Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.
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
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
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.
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
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
Hillel Z, Thys DM. Electrocardiography. In: Miller RD editor. Millers anesthesia. Churchil Livingstone;2005. p.1389-1412.
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.
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.
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
Performing an ECG. In: Phlebotomy technician specialist: a practical guide to phlebotomy Kalanick KA, editors. 2004. Page no.-292-293. .
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
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
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
Measurement of heart rate and intervals. In: Understanding electrocardigraphy. Brown SC, Anderson C, editors. (8th edition); 1996. Page no. 41-42.
Waves and intervals. In: Understanding ECG. Mehta PJ, editors. (6th edition). Mesh publishing house ltd; 2002. Page no.-10-15.
Waves and intervals. In: Understanding ECG. Mehta PJ, editors. (6th edition). Mesh publishing house ltd; 2002. Page no.-10-15.
Waves and intervals. In: Understanding ECG. Mehta PJ, editors. (6th edition). Mesh publishing house ltd; 2002. Page no.-10-15.
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