ECG

Performing 12 Lead ECG
Copyright Parkway College of Nursing and Allied Health September 2009
Objectives
By the end of this session, the students will be able to: Will be able to record good technical E.C.G Understand basic trouble-shooting Identify normal ECG wave.
Electrocardiogram Introduction
The electrocardiogram (ECG) is a diagnostic tool that measures and records the electrical activity of the heart in exquisite detail. Interpretation of these details allows diagnosis of a wide range of heart conditions. These conditions can vary from minor to life threatening.
The term electrocardiogram was introduced by Willem Einthoven in 1893 at a meeting of the Dutch Medical Society. In 1924, Einthoven received the Nobel Prize for his life's work in developing the ECG.
The ECG has evolved over the years

The standard 12-lead ECG that is used throughout the world was introduced in 1942.
It is called a 12-lead ECG because it examines the electrical activity of the heart from 12 points of view.
This is necessary because no single point (or even 2 or 3 points of view) provides a complete picture of what is going on.
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To fully understand how an ECG reveals useful information about the condition of your heart requires a basic understanding of the anatomy (that is, the structure) and physiology (that is, the function) of the heart.
Conducting Tissues
Sino-atrial node (SAN) Fibrous septum Atrio-ventricular node Specialised Conducting Tissue
The Electrical Events of the Cardiac Cycle (1)
SAN Depolarisation The events of the cardiac cycle are initiated by depolarisation of the sinoatrial node Atrial Depolarisation The wave of electrical depolarisation is conducted through the cardiac muscle of both atria
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SAN Depolarisation
Atrial Depolarisation
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Atrial Contraction The depolarising wave causes contraction of the atria puching blood into the ventricles AVN Depolarisation The wave of depolarisation reaches: The fibrous septum which does not contract The AVN which depolarises and conducts but slows the wave
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Atrial Contraction
AVN Depolarisation
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Specialised Conducting Tissue The AVN conducts the depolarisation to the Bundle of HIS The Bundle of HIS bifurcates into the left and right bundle branches The impulse is rapidly conducted through these tissues
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Ventricular Depolarisation The wave of depolarisation moves quickly through the specialised conductive tissues Ventricular muscle is depolarised in a cocoordinated, synchronised manner
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Ventricular Contraction The co-coordinated synchronised depolarisation produces an effective contraction of both ventricles Blood is pushed into the aorta and pulmonary arteries
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Ventricular Repolarisation After depolarisation and contraction the ventricles repolarise The bulk of the ventricle means that this electrical event is easily identified on the ECG Repolarisation returns the ventricles back to their resting potential
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SAN Depolarisation The events of the cardiac cycle are initiated by depolarisation of the sinoatrial node
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Atrial Depolarisation The wave of electrical depolarisation is conducted through the cardiac muscle of both atria
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Atrial Contraction The depolarising wave causes contraction of the atria pushing blood into the ventricles
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AVN Depolarisation The wave of depolarisation reaches: The fibrous septum which does not contract The AVN which depolarises and conducts but slows the wave
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Specialised Conducting Tissue The AVN conducts the depolarisation to the Bundle of HIS The Bundle of HIS bifurcates into the left and right bundle branches The impulse is rapidly conducted through these tissues
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Waves of an ECG
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Intervals of an ECG
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File:ECG principle slow.gif - Wikipedia, the free encyclopedia
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ECG Paper
The ECG is recorded on a moving paper ruled at 1mm intervals with darker lines every 5mm At the standard paper speed of 25mm/sec each 1mm horizontally represents 40msec and each 5mm interval 200msec The space between the vertical lines from the top of the paper is 25mm which is equal to 1 second In the vertical dimension, each 10mm represents 0.1mv of electrical potential
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Methods to Determine Rate (1)

Number of squares between R-R: 1 large square = 300/min 2 large square = 150/min 3 large square = 100/min 4 large square = 75/min 5 large square = 60/min 6 large square = 50/min
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Methods to Determine Rate (2)

6 - second strip
300 divided by number of large squares between R-R 1500 divided by number of small squares between R-R
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12 Lead ECG (1)

Depiction of 12 different views of the same electrical activity in the clients heart Provides information about the site of any damage to the myocardium as well as the type of damage that may be occurring. Positive deflection on the ECG: A wave of depolarization moving toward an electrode Negative deflection on the ECG: A wave of depolarization is travelling away from the electrode. No deflection or a very small deflection: A wave of depolarization is at right angles to the electrode
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12 Lead ECG (2)
Atrial depolarization Lead II will have the tallest P wave AVR will have a negative P wave lead III or AVL will have the smallest P wave. Ventricular repolarization T waves should be upright in leads I, II, AVL, AVF, V2-V6 inverted in AVR T waves are variable in leads III and V1.
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Tips for Electrode Placement

Electrode site preparation Conductive gel No pulling Avoid bony prominences For woman with large breast, place V3 on the breast and V4 through V6 below the breast. Pt with surgical dressing
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Types of Monitoring Lead System: Three Lead Wire

RA (white) below Right clavicle LA (black) below Left clavicle LL (red) below Left rib cage OR modified chest lead (MCL1- 6)
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Types of Monitoring Lead System: Five Lead Wire

RA (white) - below Right clavicle LA (black) - below Left clavicle LL (red) - below Left rib cage RL (green) - below Right rib cage V lead (brown)- precordial leads V1 - V6 position
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Limbs Lead
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Positioning the Limb Leads
Right wrist = aVR Left wrist = aVL Left leg = aVF Right leg (earth)
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Positioning the Chest Leads
V1 - 4th ICS RSE (Red) V2 - 4th ICS LSE (Yellow) V3 - midway between V2 & V4 (Green) V4 - 5th ICS MCL ( Brown) V5 - 5th ICS AAL (Black) V6 - 5th ICS MAL (Purple)
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Relationship Between Limb and Chest Leads
The chest leads look at the heart across the horizontal plane The limb leads look at the heart in the vertical plane Leads aVR, aVL and aVF look from three separate directions Leads I,II and III are summation of potential differences between limb leads
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What Do the 12 Leads Represent (1)
Inferior leads: leads II, III and aVF Look at electrical activity from the inferior or diaphragmatic wall of the left ventricle Septal leads: Leads V1 and V2 looks at electrical activity from the septal wall of the left ventricle. They are often grouped together with the anterior leads
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What Do the 12 Leads Represent (2)

Lateral leads: Leads I, aVL, V5 and V6 Look at the electrical activity from the lateral wall of left ventricle. As the positive electrode for leads I and aVL are located on the left shoulder, these leads are sometimes referred to as high lateral leads. As the positive electrodes for leads V5 and V6 are on the patient's chest, these leads are sometimes referred to as low lateral leads.
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What Do the 12 Leads Represents (3)

Anterior leads, V3 and V4: Looks at electrical activity from the vantage point of the anterior wall of the left ventricle. In addition, any two precordial leads that are next to one another are considered to be contiguous. In other words, even though V4 is an anterior lead and V5 is a lateral lead, they are contiguous because they are next to one another. Lead aVR offers no specific view of the left ventricle, but views the endocardial wall from the right shoulder.
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Normal 12 Lead ECG
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Common Rhythms (1)
Normal Sinus Rhythm
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Normal Sinus Rhythm
Rate: 60 to 100/mins Regularity: regular PQRS relationship: present G/C: alert, restful Rx: observe
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Common Rhythms (2)
Sinus Bradycardia
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Sinus Bradycardia
Rate: < 60/mins Regularity: regular PQRS relationship: present G/C: May be symptomatic i.e. fainting Causes: Sleep, well conditioned athletes, druginduced, SSS or hypothyroidism Rx: Observe, may need IV Atropine
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Common Rhythms (3)
Sinus Tachycardia
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Sinus Tachycardia
Rate: > 100/mins Regularity: regular PQRS relationship: present Causes : Anxiety, exercise, fever, drug-induced, pain or medical condition - CCF, AMI, etc Rx: Treat underlying cause(s)
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Common Rhythms (4)
Fine Ventricular Fibrillation
Course Ventricular Fibrillation
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Ventricular Fibrillation
Rate: undeterminable Regularity: chaotic PQRS relationship: absent Causes: MI, drug induced, lightning injury, electrocution Rx: DC shock, AICD
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Ventricular Tachycardia
Rate: > 150/min Regularity: regular PQRS relationship: absent Causes: CAD, MI, dilated cardiomyopathy, electrolytes disturbances, sepsis, etc Rx: If pulseless treat as VF. Pulse VT is unstable, treat with cardio-version, or antiarrhythmias, electrolytes replacement, override pacing
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Common Rhythms (5)
Asystole
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Artefacts / Interferences in an ECG (1)

Artefacts One of the most common causes for alarms Looks like fuzzy complexes This can be due to poor electrode contact or patient movement.
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AC Interference My be seen if the bed or other nearby equipment is not earthed
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Wandering baseline May be seen in ECG for a variety of reasons, such as: clients respirations, poor electrode contact (oily, dirty skin) and excessive hair on the clients chest
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Questions?
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ECG machine
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ECG machine
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ECG machine
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ECG machine
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End Of Presentation
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Performing 12 Lead ECG

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

The ECG has evolved over the years

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

The Electrical Events of the Cardiac Cycle (1)

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

The Electrical Events of the Cardiac Cycle (2)

Copyright Parkway College of Nursing and Allied Health September 2009

The Electrical Events of the Cardiac Cycle (3)

Copyright Parkway College of Nursing and Allied Health September 2009

The Electrical Events of the Cardiac Cycle (4)

The Electrical Events of the Cardiac Cycle (5)

Copyright Parkway College of Nursing and Allied Health September 2009

The Electrical Events of the Cardiac Cycle (6)

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

File:ECG principle slow.gif - Wikipedia, the free encyclopedia

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Methods to Determine Rate (1)

Copyright Parkway College of Nursing and Allied Health September 2009

Methods to Determine Rate (2)

12 Lead ECG (1)

12 Lead ECG (2)

Tips for Electrode Placement

Copyright Parkway College of Nursing and Allied Health September 2009

Types of Monitoring Lead System: Three Lead Wire

Copyright Parkway College of Nursing and Allied Health September 2009

Types of Monitoring Lead System: Five Lead Wire

Copyright Parkway College of Nursing and Allied Health September 2009

Positioning the Limb Leads

Copyright Parkway College of Nursing and Allied Health September 2009

Positioning the Chest Leads

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Relationship Between Limb and Chest Leads

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

Copyright Parkway College of Nursing and Allied Health September 2009

What Do the 12 Leads Represent (1)

Copyright Parkway College of Nursing and Allied Health September 2009

What Do the 12 Leads Represent (2)

Copyright Parkway College of Nursing and Allied Health September 2009

What Do the 12 Leads Represents (3)

Copyright Parkway College of Nursing and Allied Health September 2009

Normal 12 Lead ECG

Copyright Parkway College of Nursing and Allied Health September 2009

Common Rhythms (1)