Practical ECG

Cholid T Tjahjono,
MD
Heny Martini, MD
Upon completion one
will be able to:
Describe what an ECG is.
Describe the proper hook-up
procedure for a 12-Lead ECG
Identify basic normal ECG
waveform morphology.
Distinguish between basic ECG
arrhythmia and artifact.

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QUICK REVIEW OF
HEART
Purpose
Pumps blood

Basic Anatomy
4 chambers
2 sides
4 valves
3
THE CONDUCTINGY
SYSTEM
SA Node
Inter-nodal
pathway
AV Node
Bundle of HIS
Bundle Branches
Purkinje Fibers

4
RELATIONSHIP

5
CARDIAC CYCLES

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12 LEAD ECG

Learning objectives:

Describe the correct

placement of all electrodes
Proper Skin preparation
Care of the ECG machine, wires
and electrodes
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Principles of
Electrocardiograph

Electrocardiograph is the
instrument that records the
electrical activity of the heart
Electrocardiogram (ECG) is the
record of that activity

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HOOKING UP THE
12-LEAD ECG

Proper skin prep

Placement of the limb
electrodes
Placement of the chest
electrodes

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SKIN PREPARATION

REASON FOR SKIN

PREPARATION

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ELECTRODE
PLACEMENT

LIMB LEADS

CHEST LEAD

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LIMB LEADS

Bipolar leads
I II III

Augment leads
aVR aVL aVF

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CHEST LEADS
6 UNIPOLAR
LEADS
V1
V2
V3
V4
V5
V6
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LETS REVIEW

What is an ECG
What are the limb leads?
What are the chest leads?
Why do skin prep?

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12-LEAD ECG LAYOUT

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INFORMATION ON THE
ECG

Patients demographics
Heart rate and measurements
Speed ECG is recorded at
Voltage ECG is recorded at
What the filter is set on

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INFORMATION ON THE 12-
LEAD ECG

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WHAT YOU NEED TO
LOOK FOR

Are the limb leads hooked up

correctly?
Are the chest leads hooked up
correctly?
Is the ECG free of artifact.
Is this ECG a Critical Value

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IS the ECG HOOKED UP
CORRECTLY?
LIMB LEADS CHEST LEADS
Normal 12-lead COLUMN III
AVR always R wave progression
negative Small to Tall
Lead I always
positive COLUMN IV
Lead II, III R wave progression
positive or Tall to Small
biphasic

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RULING OUT LIMB LEAD
REVERSAL

aVR is always negative

Lead I is always positive

Lead II and III positive for the P

wave and usually the QRS
complex
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CHEST LEADS
CHEST LEADS
COLUMN III
R wave progression
Small to Tall

COLUMN IV
R wave progression
Tall to Small

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LIMB LEADS

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CHEST LEADS

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The eight-step method
to read an ECG
Step 1: Determine rhythm

Step 2: Calculate rate

Step 3: Evaluate P wave

Step 4: Determine PR-interval

The eight-step method
to read an ECG
Step 5: Determine QRS-complex
duration
Step 6: Evaluate T wave

Step 7: Determine QT-interval

duration
Step 8: Evaluate other
components
The eight-step method
to read an ECG
Step 1: Determine rhythm
paper -andpencil method
Caliper method

Step 2: Calculate rate

Times-10 method
1,500 method
Sequence method
BOX METHOD

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BASIC CRITICAL
VALUES

Bradycardia HR < 60bpm

(adult)
Tachycardia HR > 100bpm
(adult)

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The eight-step method
to read an ECG
Step 3: Evaluate P wave
Are P waves present?
Do the P waves have a normal
configuration?
Do all the P waves have a
similar size and shape?
Is there one P wave for every
QRS complex?
The eight-step method
to read an ECG
Step 4: Determine PR-interval
Does the duration of the PR
interval fall within normal limits,
0.12 to 0.20 second (or 3 to 5
small squares)?
Is the PR interval constant?
The eight-step method
to read an ECG
Step 5: Determine QRS-complex
duration
Does the duration of the QRS
complex fall within normal
limits, 0.06 to 0.10 second?
Are all QRS complexes the same
size and shape?
Does a QRS complex appear
after every P wave?
The eight-step method
to read an ECG
Step 6: Evaluate T wave
Are T waves present?
Do all of the T waves have a
normal shape?
Could a P wave be hidden in a T
wave?
Do all T waves have a normal
amplitude?
The eight-step method
to read an ECG
Step 7: Determine QT-interval
duration
Does the duration of the QT
interval fall within normal limits,
0.36 to 0.44 second?
The eight-step method
to read an ECG
Step 8: Evaluate other
components
Normal ECG
Abnormal ECG
Abnormal ECG
Left Bundle Branch Block
Acute ST Depression
Acute ST Elevation Inferior MI
Acute ST Elevation Posterior MI
Atrial Flutter
Atrial Fibrillation
Ventricular Fibrillation
OTHER PROBLEMS
WITH THE ECG

Artifact
Electrical interference
Somatic tremor
Wandering baseline

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EINTHOVENS TRIANGLE

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ARTIFACT ON THE ECG

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FIND THE ARTEFACT

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WANDERIN BASELINE

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SOMATIC TREMOR

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ELECTRICAL
INTERFERANCE

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Ventricular Tachycardia

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LBBB and Old anteroseptal MI

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ECTOPIC BEATS

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ECTOPIC BEATS

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LETS SUMMARIZE
How do we produce an excellent
12-lead ECG?
Proper skin prep
Correct electrode placement
Recognize and know how to
correct problems
Recognize basic critical values

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