Electrocardiography
(ECG)
Recording and interpretation
Definition:
The 12 lead ECG is a recording of the electrical
activity of the heart, and is an essential diagnostic
tool in the management and treatment of heart
disease - (Jevon 2000)
ECG provides graphical representation of electrical
forces which appears in graph as a series of positive
and negative deflections
Indications of ECG recording:
Chest pain
Myocardial infarction
Palpitations
After successful CPR
History of syncope (fainting)
Screening due to multiple risk factors of
CVD
Purposes of ECG
Measure the rate and regularity
heartbeats
Size and position of the chambers,
Presence of any damage to the heart
Effects of drugs
Conduction system of heart
Effects of electrolyte imbalace
Points kept in mind before
ECG recording:
Although recording an ECG is a relatively easy
procedure, it is vital that it is recorded
accurately to avoid misinterpretation to ensure
an accurate reading:
It is important that the
comfortable as possible .
patient
is
as
Contd
The temperature of the room should be
adequate .
The patient should preferably be in a
supine position
In order to facilitate contact with the
electrode pads, it is necessary to clean
the skin with an alcohol swab to remove
any body lotion or sweat
Equipments required for ECG
recording:
ECG machine
Alcohol swabs
Shaving set (optional)
ECG jelly
Disposable paper/ tissue
Screen
Procedure ECG recording:
Procedure of ECG recording:
Explain procedure to patient and confirm
consent
Wash hands as per protocol
Ensure patient is comfortably positioned
Prepare skin and electrode sites by
cleaning with alcohol swabs
Apply electrodes ensuring adequate
adhesion
Limb leads:
Red (RA) inner right wrist
Yellow (LA) inner left wrist
Green (LL) inner left leg just above ankle
Black (RL) inner right leg just above
ankle
(Starting at right arm, in a clockwise
direction Ride Your Green Bike)
Chest leads:
V1 fourth intercostal space, rt of
sternum
V2 fourth intercostal space, lt of sternum
V3 midway between V2 and V4
V4 5th intercostal space, mid clavicular
V5 5th intercostal space , anterior axilla)
V6 5th intercostal space, midpoint of
armpit
Chest leads
Contd
switch on machine
Check calibration is 10mm/millivolt
Input patient/client data
Ask patient/client to relax and refrain
from movement
Start recording 12 lead ECG
Reassure
patient/client
throughout
recording
After procedure:
Detach recording and ensure labelling is
correct
Remove the electrodes
Provide tissue paper to patient to clean
jelly
Clean ECG leads with tissue paper and
spirit swabs
Correctly file ECG recording & report to
physician
ECG graph paper:
In the ECG Graph Paper there
Horizontal axis and vertical axis.
are
The horizontal axis represents time in
milliseconds (ms) and vertical axis
represents amplitude or voltage in millivolts
(mV).
Interpretation of ECG
recording
In ECG graph there are small and large
boxes. If we see ECG graph :
Horizontally:
- One small box - 0.04 s, = 1mm
One large box - 0.20 s = 5mm
Vertically :
- One large box - 0.5 mV
2 large boxes 1mV
Two 5-mm-divisions on the vertical axis
are calibrated to represent 1 mV
Contd
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
Contd
ECG waves and intervals
Certain important facts about the direction and
magnitude of ECG waves:
Provides graphical depiction of electrical
forces
Graph appears as a series of deflections
Deflections above isoelectric line are positive
Isoelectric line period of electric inactivity,
during which no deflections are observed
Deflection mainly depends- 2 factors
spread of electric force
location of recording electrode
Contd
Electrical impulses moving towards an
electrode- positive deflection
Away negative
Magnitude of deflection- muscle mass
Activation of atria occur- longitudinallyreflects atrial enlargement
Ventricles-transversely-hypertrophy
Contd
a current surging directly in
the direction -recording
electrode-positive deflection
a current flowing in the
direction but not directly
toward the recording
electrode -positive deflection
of lower amplitude
running at right angle recording electrode -no
deflection or a biphasic
deflection;
flowing away -recording
electrode -negative
deflection
Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Impulse Conduction & the ECG
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
The PQRST
P wave - Atrial
depolarization
QRS - Ventricular
depolarization
T wave - Ventricular
repolarization
The P Wave
The first deflection is the P wave associated
with right and left atrial depolarization. Wave
of atrial repolarization is invisible because of
low amplitude
PR interval
Interval: 0.12 to 0.20
Prolonged PR Interval
AV Node Block
Hyperthyroidism
Shortened PR Interval Wolf-ParkinsonWhite Syndrome (WPW Syndrome)
Hypertension
QRS Complex
Normal findings: DurationLimb leads (I, II, III):
0.05 to 0.10
Precordial leads (V1 to V6): 0.06 to 0.12
Wide QRS or Prolonged QRS -Left Bundle
Branch Block
Medications ( Toxin Ingestion)
Low QRS amplitude (<5 mm in limb
leads)Diffuse Coronary Artery Disease
Congestive Heart Failure
Pericardial Effusion
High QRS amplitude- Left Ventricular Hypertrophy
ST segment
Measurement
Measure at 0.04 sec (1 mm) after the JPoint
Causes( ST elevation)
Acute Myocardial Infarction
Pericarditis
Left Bundle Branch Block
- Left Ventricular Hypertrophy
Early Repolarization
T wave
Findings: Normal
Upright: I, II, V3, V4, V5, V6
Inverted: aVR, V1
Increased Amplitude: aVL and aVF
Findings: T Wave Shape
Smooth: Normal
Notched: Pericarditis
Pointed: Myocardial Infarction
Contd
Findings: T Wave Height
Normal
Limb leads: <5 mm
Precordial leads: < 10 mm
Tall T Wave Causes
Hyperkalemia
Myocardial Infarction
Myocardial Ischemia
Cerebrovascular Accident
Contd
Causes: T Wave Inversion in anterior
leads (V2 to V4)
Anterior Myocardial Ischemia
Posterior Myocardial Infarction
Pulmonary Embolism
U- wave
Deflections in different leads:
Intervals
Atrial and ventricular depolarization and
repolarization are represented on the ECG
Contd
Feature
Description
Duration
RR interval
The interval between an R 0.6 to 1.2s(3-6 large
wave and the next R wave boxes)
P wave
SA node towards the AV
node, and spreads from
the right atrium to the left
atrium
80-120ms( 2-3small box)
PR interval
reflects the time the
electrical impulse takes to
travel from the sinus node
through the AV node and
entering the ventricles
120 to 200ms(1 large box)
Contd
feature
description
duration
PR segment
The impulse vector is
from the AV node to the
bundle of His to the
bundle branches and
then to the Purkinje
fibers
50 to 120ms(1-3 small
boxes)
QRS complex
The QRS complex
reflects the rapid
depolarization of the
right and left ventricles
80 to 120ms(2-3 small
boxes)
J-point
point at which the QRS
complex finishes & ST
segment begins, used to N/A
measure ST elevation /
depression
Features
Description
Duration
ST segment
represents the period
when the ventricles are
depolarized. It is
isoelectric.
80 to 120ms(2- 3 smll
boxes)
T wave
The T wave represents
the repolarization of the
ventricles
160ms (4 small boxes)
ST interval
The ST interval is
measured from the J
point to the end of the T
wave.
320ms( 1 large box & 3
small boxes)
QT interval
measured from the
beginning of the QRS
complex to the end of the
T wave .It varies with
heart rate ,for clinical
relevance requires a
correction for this, giving
the QTc.
Up to 420ms in heart rate
of 60 bpm
Calculation of heart rate
Method 1
Ecg strip of 6 sec
Count QRS
complexes
To get 1min HR
multiply it by 10
Method 2
Paper speed=
25mm/ sec
means 25 small
boxes / sec
Small boxes in 1
min = 25multiply
60= 1500
1500/no. of small
boxes in P-P interval
& R-R interval
Abnormal ECG findings
SA node dysrhythmias
Sinus bradycardia- HR- less than 60b/m
Venrtricular & atrial rhythm - regular
Sinus tachycardia
HR- more than 100 & less than 120b/m
Ventricular & atrial rhythm - regular
Contd
Sinus aarhythmias
HR- b/w 60-100b/m
Ventricular & atrial rhythm irregular
Atrial dysrhythymias
Premature atrial complex:early p wave & shorter
Ppintetval
Atrial flutter
Contd
Atrial fibrillation
Ventricular tachycardia
Electrolyte abnormalities
Serum potassium - major intracellular ion
participates in- depolarization and repolarization
of myocardial cells
serum concentration- effect on the QRS and STT complex.
Hyperkalemia
Peaked T wave
QRS wide
prolonged PR
QT short
Hypokalemia
T wave -flattened or inverted
Appearance of a prominent- U wave
ST segment - depressed
Calcium
hypercalcemia- is associated with short
QT interval
hypocalcemia- with long QT interval
Drug effects
At toxic levels digoxin- causes sinus
bradycardia
Amiodarone increases PR,QRS,QT
intervals
Quinidine , procainamide- prolong QRS
duration & QT interval
References:
[Link] [Link]. ECG- simplified.
Aswini Kumar M.D. Retrieved 2013-11-11.
Bazett HC. (1920). "An analysis of the timerelations of electrocardiograms". Heart (7):
353370
[Link]
Einthoven's Triangle .Retrieved 2013-11-11
Contd
Luthra A. ECG for nurses. Japee brothers.p3-127
Bazett HC. (1920). "An analysis of the timerelations of electrocardiograms". Heart (7):
353370.
