Introduction to ECGs

Terry White, RN

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Discussion Topics
 ECG Monitoring Basics
 Standardized Methods & Devices
 Components & Measurements of
the ECG Complex

 ECG Analysis

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ECG Monitoring

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 ECG Monitoring
 Recording of Electrical Activity
 Uses Bipolar or Unipolar leads

The ECG DOES NOT provide a recording

or evaluation of Mechanical Activity!!!

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ECG Monitoring
 Bipolar Leads
 1 positive and 1
negative electrode
 RA always negative
 LL always positive

 Traditional limb leads

are examples of these
 Lead I
 Lead II

 Lead III

 Provide a view from a

vertical plane
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ECG Monitoring
 Unipolar Leads
 1 positive electrode
 1 negative “reference point”
 calculated by using
summation of 2 negative
leads
 Augmented Limb Leads
 aVR, aVF, aVL
 vertical plane

 Precordial or Chest Leads

 V1-V6
 horizontal plane

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ECG Monitoring
 Einthoven’s Triangle
 Each lead “looks” from a
different perspective
 Can determine the
direction of electrical
impulses
 Upright electrical
recording indicates
electricity flowing towards
the + electrode
 positive deflection

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Standardized Methods
& Devices

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Standardized Methods &
Devices
 ECG Paper
 Device Paper Speed
 Device Calibration
 Electrode Placement

 Variations Do Exist!

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Standardized Methods &
Devices
 ECG Graph Paper
 Vertical axis- voltage
1 small box = 1 mm = 0.1 mV

 Horizontal axis - time

1 small box = 1 mm = 0.04 sec.

 Every 5 lines (boxes) are bolded

 Horizontal axis - 1 and 3 sec marks

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Standardized Methods &
Devices
 ECG Paper Examples
 Vertical Axis
 No. of mm in 10 small boxes?
 No. of small boxes in 2 mm?

 Horizontal Axis
 No. of seconds in 5 small boxes?
 No. of small boxes in 0.2 second?

 No. of small boxes in 1 second?

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Standardized Methods &
Devices
 Paper Speed & Calibration
 Paper Speed - 25 mm/sec standard
 Calibration of Voltage is Automatic
 Both Speed and voltage calibration
can be changed on most devices

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Standardized Methods &
Devices
 Electrode Placement
 Standardization improves accuracy of
comparison ECGs
 3 Lead and 12 Lead Placement are most
common
 Assure good conduction gel
 Prep area with alcohol prep
 Avoid
 Bone
 Large muscles or hairy areas

 Limb vs. Chest placement

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Standardized Methods &
Devices
 Electrode Placement
 Poor placement or preparation
 Often results in artifact
 Stray energy from other sources can also lead to
poor ECG tracings (noise)
 60 cycle interference

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Components of the
ECG

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Components of the ECG
Complex
 Components & Their
Representation
 P, Q , R, S, T Waves

 PR Interval

 QRS Interval

 ST Segment

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Components of the ECG
Complex
 P Wave
 first upward
deflection
 represents atrial
depolarization
 usually 0.10 seconds
or less
 usually followed by
QRS complex

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Components of the ECG
Complex
 QRS Complex
 Composition of 3
Waves
 Q, R & S
 represents ventricular
depolarization
 much variability

 usually < 0.12 sec

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Components of the ECG
Complex
 Q Wave
 first negative
deflection after P
wave
 depolarization of
septum
 not always seen

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Components of the ECG
Complex
 R Wave
 first positive
deflection following P
or Q waves
 subsequent positive
deflections are R’,
R”, etc

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Components of the ECG
Complex
 S Wave
 Negative deflection
following R wave
 subsequent negative
deflections are S’,
S”, etc
 may be part of QS
complex
 absent R wave in
aberrant conduction

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Components of the ECG
Complex
 PR Interval
 time impulse takes to
move through atria and
AV node
 from beginning of P
wave to next deflection
on baseline (beginning
of QRS complex)
 normally 0.12 - 0.2 sec
 may be shorter with
faster rates

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Components of the ECG
Complex
 QRS Interval
 time impulse takes to
depolarize ventricles
 from beginning of Q
wave to beginning of
ST segment
 usually < 0.12 sec

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Components of the ECG
Complex
 J Point
 point where QRS
complex returns to
isoelectric line
 beginning of ST
segment
 critical in measuring
ST segment elevation

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Components of the ECG
Complex
 ST Segment
 early repolarization of
ventricles
 measured from J point
to onset of T wave
 elevation or
depression may
indicate abnormality

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Components of the ECG
Complex
 T Wave
 repolarization of
ventricles
 concurrent with end of
ventricular systole

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ECG Analysis

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ECG Analysis
 Rate
 Rhythm/Regularity
 QRS Complex
 P Waves
 Relationships & Measurements

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ECG Analysis
 Ventricular Rate
 Triplicate method
 300-150-100-75-60-50

 R-R method
 divide
300 by # of large squares
between consecutive R waves
6 Second method
 multiply # of R waves in a 6 second
strip by 10
 Rate meter unreliable!!!
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ECG Analysis
 Rhythm
 Measure R-R intervals across strip
 Should find regular distance
between R waves
 Classification
 Regular

 Irregular
• Regularly irregular
• Irregularly irregular

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ECG Analysis
 QRS Complex
 Narrow
< 0.12 seconds (3 small boxes) is
normal
 indicates supraventricular origin (AV
node or above) of pacemaker
 Wide
> 0.12 seconds is wide
 indicates ventricular or
supraventricular w/aberrant
conduction
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ECG Analysis
 P Waves
 Present?
 Do they all look alike?
 Regular interval
 Upright or inverted in Lead II?
 Upright = atria depolarized from top
to bottom
 Inverted = atria depolarized from
bottom to top

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ECG Analysis
 Relationships/Measurements
 PR Interval
 Constant?

 Less than 0.20 seconds (1 large bx)

P to QRS Relationship
P wave before, during or after QRS?
 1 P wave for each 1 QRS?

 Regular relationship?

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ECG Analysis
 A monitoring lead can tell you:
 How often the myocardium is
depolarizing
 How regular the depolarization is
 How long conduction takes in
various areas of the heart
 The origin of the impulses that are
depolarizing the myocardium

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ECG Analysis
 A monitoring lead can not tell you:
 Presence or absence of a
myocardial infarction
 Axis deviation
 Chamber enlargement
 Right vs. Left bundle branch blocks
 Quality of pumping action
 Whether the heart is beating!!!

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 ECG Analysis
 An ECG is a diagnostic tool, NOT a
treatment
 No one was ever cured by an ECG!!

Treat the PATIENT not the Monitor!!!

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