Electrocardiography

The ECG is a graphic representation of the electrical currents of the heart. It is obtained by placing disposable electrodes in standard positions on the skin of the chest wall and extremities. Recordings of the electrical current flowing between two electrodes is made on graph paper or displayed on a monitor. Several different recordings can be obtained by using a variety of electrode combinations, called leads. Simply stated, a lead is the specific view of the electrical activities of the heart. The standard ECG is composed of 12 leads or 12 different views, although it is possible to record 15 or 18 leads. The 12 lead ECG is used to diagnose: Dysrhythmias Conduction abnormalities Chamber enlargement Myocardial ischemia It can also suggest cardiac effects of electrolyte disturbances and the effects of antiarrhythmic medications. A 15 lead ECG adds three additional chest lead across the right precordium and is used for early diagnosis of right ventricular and left posterior (ventricular) infarction.

The 18 lead ECG adds three posterior leads to the 15 lead ECG and is useful for early detection of myocardial ischemia and injury. To enhance interpretation of the ECG, the patients age, gender, BP, height, weight, symptoms, and medications are noted on the ECG requisition.

Continuous Electrocardiographic Monitoring

It is the standard of care for patients who are at high risk for dysrhythmias. This form of cardiac monitoring detects abnormalities in heart rate and rhythm. There are two types of continuous ECG monitoring techniques used in health care settings:

1.Hardwire cardiac monitoring

It is used to continuously observe the heart for dysrhythmias and conduction disorders using 1 or 2 ECG leads. A real time ECG is displayed on a bedside monitor and at a central monitoring station. In critical care units, additional components can be added to the bedside monitor to continuously monitor hemodynamic and respiratory parameters. It is found in emergency departments, critical care units, and progressive care units.

2.Telemetry

It is the transmission of radiowaves from a battery-operated transmitter to a central bank of monitors. The primary benefit is that the system is wireless, which allows patient to ambulate while 1 or 2 ECG leads are monitored. Most transmitter batteries are changed every 24 to 48 hours. Hardwire cardiac monitoring and telemetry systems have the following features in common: Monitor more than one lead simultaneously Monitor ST segments Provide graded visual and audible alarms

Interpret and store alarms

Trend data over time Print a copy of rhythms from one or more specific ECG leads over a set of time

Lead Systems
The number of electrodes needed for hardwire cardiac monitoring and telemetry is dictated by the lead system used in the clinical setting. Electrodes needed to be securely and accurately placed on the chest wall. The two ECG leads most often selected for continuous ECG monitoring are leads II and V1. Lead II provides the best visualization of atrial depolarization

(represented by the P wave). Lead V1 best records ventricular depolarization and is most helpful when monitoring for certain dysrhythmias. The monitoring system requires an adequate electrical signal to analyze the patients cardiac rhythm. When applying electrodes, the following recommendations should be followed to optimized skin adherence and conduction of the hearts electrical current. Debride the skin surface of dead cells with soap and water and dry well Clip (do not shave) hair from around the electrode site if needed

If the patient is diaphoretic, apply a small amount of benzoin to the skin, avoiding the area under the center of the electrode

Connect the electrodes to the lead wires prior to placing them on the chest Peel the backing off the electrode and check to make sure the center is moist with electrode gel Locate the appropriate lead placement and apply the electrode to the skin, securing it in place with light pressure

 Change the electrodes every 24 to 48 hours (for as recommended by the manufacturer), examine the skin for irritation, and apply the electrodes to different locations If patient is sensitive to the electrodes, use hypoallergenic electrodes

Placement of electrodes Ten electrodes are used for a 12-lead ECG. The electrodes usually consist of a conducting gel, embedded in the middle of a self-adhesive pad onto which cables clip. Sometimes the gel also forms the adhesive. They are labeled and placed on the patient's body as follows: Electrode label (in the USA) RA LA RL LL V1 V2 Electrode placement

On the right arm, avoiding thick muscle. In the same location that RA was placed, but on the left arm. On the right leg, lateral calf muscle In the same location that RL was placed, but on the left leg In the fourth intercostal space (between ribs 4 & 5) just to the right of the sternum (breastbone). In the fourth intercostal space (between ribs 4 & 5) just to the left of the sternum.

V3 V4

Between leads V2 and V4. In the fifth intercostal space (between ribs 5 & 6) in the mid-clavicular line (the imaginary line that extends down from the midpoint of the clavicle (collarbone)). Horizontally even with V4, but in the anterior axillary line. (The anterior axillary line is the imaginary line that runs down from the point midway between the middle of the clavicle and the lateral end of the clavicle; the lateral end of the collarbone is the end closer to the arm.) Horizontally even with V4 and V5 in the midaxillary line. (The midaxillary line is the imaginary line that extends down from the middle of the patient's armpit.)

V5

V6

Ambulatory Electrocardiography

It is a form of continuous ECG monitoring used for diagnostic purposes in the outpatient setting. Electrodes are connected with lead wires to a cable that is inserted into a portable recorder that records the ECG onto a digital memory device. Data from the digital memory device are uploaded into a computer for analysis, and rhythms that need further evaluation by a clinician are identified. It is also used to identify the etiology of symptoms (eg. Syncope, palpitations) that may be caused by dysrhythmias, to detect episodes of myocardial ischemia, and to evaluate effectiveness of cardiac medication or pacemaker function.

Transtelephonic Monitoring
The patient attaches a specific lead system for transmitting the signals and places a telephone mouthpiece over the transmitter box. The ECG is recorded and evaluated at a remote location. This method is often used for diagnosing dysrhythmias and to evaluate pacemaker function.

Wireless Mobile Cardiac Monitoring System

This emerging technology allows health care professionals to monitor and transmit the ECG of patients outside of the hospital or office setting continuously. The wireless method has a number of advantages when compared with Holter and transtelephonic monitoring. It is a lightweight and can monitor the patient 24

hours a day 7 days a week. Patients wear a small sensing device that transmits each heartbeat to a small monitor. When a dysrhythmia is detected, the system automatically transmits the patients ECG to a monitoring center through either the patients telephone line when at home or through wireless communications systems when outside of the home. This system enhances detection and early treatment of dysrhythmias that might otherwise be diagnosed only after the patient develops serious symptoms.

Waves and intervals

A typical ECG tracing of the cardiac cycle (heartbeat) consists of a P wave, a QRS complex, a T wave, and a U wave which is normally visible in 50 to 75% of ECGs. The baseline voltage of the electrocardiogram is known as the isoelectric line. Typically the isoelectric line is measured as the portion of the tracing following the T wave and preceding the next P wave.
Featur Duratio Description e n RR The interval between an R wave and the next R wave. 0.6 to interva Normal resting heart rate is between 60 and 100 bpm 1.2s l During normal atrial depolarization, the main electrical vector is directed from the SA node towards the AV node, P wave 80ms and spreads from the right atrium to the left atrium. This turns into the P wave on the ECG. PR The PR interval is measured from the beginning of the P 120 to interva wave to the beginning of the QRS complex. The PR interval 200ms l reflects the time the electrical impulse takes to travel from the sinus node through the AV node and entering the ventricles. The PR interval is therefore a good estimate of AV

node function. The PR segment connects the P wave and the QRS complex. This coincides with the electrical conduction from the AV PR node to the bundle of His to the bundle branches and then 50 to segme to the Purkinje Fibers. This electrical activity does not 120ms nt produce a contraction directly and is merely traveling down towards the ventricles and this shows up flat on the ECG. The PR interval is more clinically relevant. The QRS complex reflects the rapid depolarization of the QRS right and left ventricles. They have a large muscle mass 80 to comple compared to the atria and so the QRS complex usually has a 120ms x much larger amplitude than the P-wave. The point at which the QRS complex finishes and the ST J-point segment begins. Used to measure the degree of ST N/A elevation or depression present. ST The ST segment connects the QRS complex and the T wave. 80 to segme The ST segment represents the period when the ventricles 120ms nt are depolarized. It is isoelectric. The T wave represents the repolarization (or recovery) of the ventricles. The interval from the beginning of the QRS complex to the apex of the T wave is referred to as the T wave 160ms absolute refractory period. The last half of the T wave is referred to as the relative refractory period (or vulnerable period). ST The ST interval is measured from the J point to the end of interva 320ms the T wave. l The QT interval is measured from the beginning of the QRS QT complex to the end of the T wave. A prolonged QT interval is 300 to interva a risk factor for ventricular tachyarrhythmias and sudden 430ms l death. It varies with heart rate and for clinical relevance requires a correction for this, giving the QTc. The U wave is hypothesized to be caused by the repolarization of the interventricular septum. They normally have a low amplitude, and even more often completely U wave absent. They always follow the T wave and also follow the same direction in amplitude. If they are too prominent we suspect hypokalemia, hypercalcemia or hyperthyroidism usually. The J wave, elevated J-Point or Osborn Wave appears as a late delta wave following the QRS or as a small secondary R J wave wave . It is considered pathognomonic of hypothermia or hypocalcemia.

There were originally four deflections, but after the mathematical correction for artifacts introduced by early amplifiers, five deflections were discovered. Einthoven chose the letters P, Q, R, S, and T to identify the tracing which was superimposed over the uncorrected labeled A, B, C, and D. In intracardiac electrocardiograms, such as can be acquired from pacemaker sensors, an additional wave that can be seen is the H deflection, which reflects the depolarization of the bundle of His. The H-V interval, in turn, is the duration from the beginning of the H deflection to the earliest onset of ventricular depolarization recorded in any lead.

Some pathological entities which can be seen on the ECG

Shortened QT Hypercalcemia, some drugs, certain genetic interval abnormalities. Prolonged QT Hypocalcemia, some drugs, certain genetic interval abnormalities. Flattened or Coronary ischemia, hypokalemia, left ventricular inverted T hypertrophy, digoxin effect, some drugs. waves Possibly the first manifestation of acute Hyperacute T myocardial infarction, where T waves become waves more prominent, symmetrical, and pointed. Prominent U Hypokalemia. waves