ECG Basics

1. ECG Basics

2. What is an ECG? The electrocardiogram (ECG) is a representation of the electrical events of the cardiac cycle. Each event has a distinctive waveform, the study of which can lead to greater insight into a patient’s cardiac pathophysiology.

3. Electrocardiogram (ECG/EKG) 13-60

5. ECG Leads Leads are electrodes which measure the difference in electrical potential. They can be of two types: 1. Two different points on the body (bipolar leads) 2. One point on the body and a zero electrical potential.

6. EKG Leads The standard EKG has 12 leads: 3 Standard Limb Leads 3 Augmented Limb Leads 6 Precordial Leads The axis of a particular lead represents the viewpoint from which it looks at the heart.

9. Standard Limb Leads

10. Types of ECG Recordings • Bipolar leads record voltage between electrodes placed on wrists & legs (right leg is ground) • Lead I records between right arm & left arm • Lead II: right arm & left leg • Lead III: left arm & left leg 13-61

12. Summary of Leads

13. Arrangement of Leads on the EKG

14. Precordial Leads Adapted from: www.numed.co.uk/electrodepl.html

15. Precordial Leads

16. ECG Graph Paper • one small block equals 0.04 s • Five small blocks make up 1 large block which translates into 0.20 s (200 msec)

17. Normal conduction pathway: SA node -> atrial muscle -> AV node -> bundle of His -> Left and Right Bundle Branches -> Ventricular muscle

20. ECG • 3 distinct waves are produced during cardiac cycle • P wave caused by atrial depolarization • QRS complex caused by ventricular depolarization • T wave results from ventricular repolarization

21. Elements of the ECG: • P wave: Depolarization of both atria; • Shape and duration of P may indicate atrial enlargement • Relationship between P and QRS helps distinguish various cardiac arrhythmias

23. Waveforms and Intervals

26. QRS complex: Ventricular depolarization • Larger than P wave because of greater muscle mass of ventricles • Normal duration = 0.08-0.12 seconds • Its duration, amplitude, and morphology are useful in diagnosing cardiac arrhythmias, ventricular hypertrophy, MI, electrolyte derangement, etc. • Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec are abnormal and may represent MI

27. PR interval: from onset of P wave to onset of QRS • Normal duration = 0.12-2.0 sec (120-200 ms) (3-4 horizontal boxes) • Represents atria to ventricular conduction time (through His bundle) • Prolonged PR interval may indicate a 1st degree heart block

28. ST segment: • Connects the QRS complex and T wave • Duration of 0.08-0.12 sec (80-120 msec • T wave: • Represents repolarization • QT Interval • Measured from beginning of QRS to the end of the T wave • Normal QT is usually about 0.40 sec • QT interval varies based on heart rate

36. Determining the Heart Rate • Rule of 300 • 10 Second Rule

37. Rule of 300 Count the number of “big boxes” between neighboring QRS complexes, and divide 300 by this number. The result will be approximately equal to the rate Although fast, this method only works for regular rhythms.

38. What is the heart rate? www.uptodate.com (300 / 6) = 50 bpm

39. What is the heart rate? www.uptodate.com (300 / ~ 4) = ~ 75 bpm

40. What is the heart rate? (300 / 1.5) = 200 bpm

41. The Rule of 300 It may be easiest to memorize the following table:

42. 10 Second Rule As most EKGs record 10 seconds of rhythm per page, one can simply count the number of beats present on the EKG and multiply by 6 to get the number of beats per 60 seconds. This method works well for irregular rhythms.

43. The QRS Axis The QRS axis represents the net overall direction of the heart’s electrical activity. Abnormalities of axis can hint at: Ventricular enlargement Conduction blocks (i.e. hemiblocks)