Basic Of ECG

Prepared by:
Zahid hussain
 Learning Objectives
At the completion of this class the students will be able to:

• Define electrocardiograph

• Discuss the purpose.

• Understand the different lead placement and purpose of

each placement of12 leads ECG.

• Review the ECG graph paper

• Utilize a systematic process when approaching the

interpretation of the ECG.
 Introduction

• Willem Einthoven (1860 -1927) was the first to

develop ECG Machine in 1903. He, for the first time,
recorded electrical activity of heart from body surface.
He named it ‘Elektrokardiogramme’ (EKG) which
later on anglicized to ‘Electrocardiogram’ (ECG). He
won Noble Prize in 1924.
 ECG
• The ECG is a test that measures the
electrical activity of the heart, is
comprised of 3 primary parts...

• 1. P wave---electrical depolarization of
the atria

• 2. QRS COMPLEX---electrical
depolarization of the ventricles

• 3. T wave---electrical repolarization of
the ventricles.
 Purpose
• Check the heart's electrical activity.

• Find the cause of unexplained chest pain, which could be caused by

a heart attack, inflammation of the sac surrounding the heart
(pericarditis), or angina.

• Find out if the walls of the heart chambers are too thick
(hypertrophied).

• Check how well medicines are working and whether they are
causing side effects that affect the heart.

• Check how well mechanical devices that are implanted in the heart,
such as pacemakers, are working to control a normal heartbeat.

• Screening tool for ischemic heart disease during stress tests.

 Types of leads
• Standard leads OR Limb leads
• Chest leads
STANDARD LEADS
• Bipolar
• Unipolar
• I, II, III
• AVR, AVL, AVF
CHEST LEADS
• V1 -- V6
The chest leads is attached to chest wall.

6
 Placement of ECG lead
• V1 -- Right side of Sternum 4th Inter Costal space
• V2 -- Left side of Sternum 4th Inter Costal space
• V3 -- Between V2 and V4
• V4 -- Mid clavicular line 5th Inter Costal space
• V5 -- Anterior Axillary line 5th Inter Costal space
• V6 -- Mid Axillary line
 Nursing Procedure
 The purpose and procedure of the ECG should be
explained to patient.
 The ECG is not a painful technique neither it produces any
discomfort.
 The patient should lie in dorsal position undressing from
chest.
 The patient is asked to reflex, quite and breath normally.
 The patient should not talk during procedure
 The operator places electrodes at different sites on chest
and limbs and takes recording.
 ECG graph Paper
• The horizontal lines measure time

• Vertical lines measure amplitude of voltage

• Runs at a paper speed of 25 mm/sec

• Width of each small square = 0.04 seconds

• Width of one large square = 0.20 seconds (200 ms)

• Five large boxes = one second

• Voltage: 1 mm = 0.1 mV between each block vertically

• One large box = 5 mm high = 0.5 millivolt

 ECG Interpretation
What is your approach to reading an ECG?
•Rhythm
•Rate
•Axis
•Intervals
•P wave
•QRS complex
•T wave
•ST segment
 Rhythm
• The easiest way to tell is to take a sheet of paper and line
up one edge with the tips of the R waves on the rhythm
strip.

• Mark off on the paper the positions of 3 or 4 R wave tips

• Move the paper along the rhythm strip so that your first
mark lines up with another R wave tip

• See if the subsequent R wave tips line up with the

subsequent marks on your paper

• If they do line up, the rhythm is regular. If not, the rhythm

is irregular
 Rhythm
• Sinus ( Regular Rhythm )
• Originating from SA node
• P wave before every QRS
• P wave in same direction as QRS
• P waves and QRS complexes regular
• PR interval is constant
 Rhythm

• Regular rhythm means that each heart beat's R-R

interval is equal.
 Irregular Rhythm
• Irregular rhythm/arrhythmia

• For example is there a pattern, such as increasing R-R

durations Or R-R intervals completely irregular.
What is this rhythm?
What is this rhythm?
What is this rhythm?
 Rate

There are several methods for calculating the heart rate.

 The six second count
• This method can be used with an irregular rhythm to
estimate the rate. Count the number of R waves in a 6
second strip and multiply by 10.
• For example, if there are 7 R waves in a 6 second strip, the
heart rate is 70 (7x10=70).

• Calculate the rate.

 The triplicate method

• When the rhythm is regular, the heart rate is 300

divided by the number of large squares between the
QRS complexes.
• For example, if there are 4 large squares between regular
QRS complexes, the heart rate is 75 (300/4.5=67)
 The caliper method
• The second method uses small boxes. Count the number
of small boxes for a typical R-R interval. Divide this
number into 1500 to determine heart rate.

• The number of small boxes for the R-R interval is 22.

• The heart rate is 1500/22, which is 68.

•
Formula
ECG Review(Intervals)
 Conti…
• P wave:
• The P wave represents atrial depolarization
• Low voltage (2-3mm in amplitude)
• Duration <.11 seconds
• PR Interval:
• The PR interval is measured between the start of the P
wave to the start of the QRS
• A normal PR interval is between 0.12 and 0.20 seconds
( 3-5 small squares)
 Cont…
• QRS Complex
• Ventricles depolarization
• Normal QRS complex(interval) is 0.08 – 0.10 sec (1-2
small boxes)

• Q wave: First negative deflection

• R Wave: First positive deflection
• S Wave: Next negative deflection
 Conti…
ST segment:
• The ST segment should sit on the isoelectric line

• It is abnormal if there is elevation or depression of

the ST segment

• Connects the QRS complex and T wave

• Duration of 0.08-0.12 sec

 Cont…
T wave:
• Represents repolarization or recovery of ventricles

QT Interval
• Measured from beginning of QRS to the end of the T
wave
• Normal QT is usually about 0.36-0.44 sec
• QT interval varies based on heart rate
 Cont…
• U wave
• U waves occur after the T wave and are often difficult to see

• The source of the U wave is unknown. Three common theories

regarding its origin are:

• Delayed repolarisation of Purkinje fibres

• Prolonged repolarisation of mid-myocardial “M-cells”

• U waves generally become visible when the heart rate falls below 65
bpm
 J-point

• The point at which the QRS meets the ST segment

• The J point is at the end of Ventricular depolarization

• An essential landmark for measuring QRS duration

Anatomy of a 12-Lead EKG

I Lateral aVR V1 Septal V4 Anterior

II Inferior aVL Lateral V2 Septal V5 Lateral

III Inferior aVF Inferior V3 Anterior V6 Lateral

Questions
 Additional Resources
Websites:
• http://en.ecgpedia.org/
• http://ecg.utah.edu
• http://ecg.bidmc.harvard.edu/maven/

Apps:
• ECG Guide by QxMD (iPad and iPhone)
• ECG Interpret (iPhone)

Books:
• 12-Lead ECG: The Art of Interpretation, Tomas Garcia
(perhaps the best book on ECGs with detailed explanations
and physiology.)
• Arrhythmia Recognition, Tomas Garcia