ECG Course

Education Team
 What is ECG

 Electrocardiography (ECG) is a graphic, noninvasive procedure

that represents of the electrical events of the cardiac cycle.

 Indications for ECG Monitoring

 Routine checkup

 Cardiac conditions such as (Chest pain; Palpitations)

 History of syncope or Shock

 To assess pacemaker performance

 Preoperative preparation

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 What does ECG reveal ?

 Different types of arrhythmia.

 Inflammations (e.g. pericarditis ,endocarditis).

 Electrolytes imbalances (e.g. hypokalemia ,hyperkalemia).

 Hypertrophy of the heart.( Ventricular and atrial enlargements)

 Conduction defects.

 Myocardial (Ischemia& infarction)

 Drug toxicity (i.e. digoxin).

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 Monitor leads placement

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 Types of ECG

 The two types of ECG recording are the 12-lead ECG and single-lead

ECG, commonly known as a rhythm strip.

 Both types give valuable information about heart function.

 Another types of ECG (Right side ECG, posterior ECG)

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 1) 12 Lead ECG

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 2) Single-lead ECG (a rhythm strip)

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 3) Left side ECG

Sites of Precordial leads

 V1 - Fourth intercostal, right sternal border.

 V2 - Fourth intercostal, left sternal border.

 V3 - Equal distance between V2 and V4.

 V4 - Fifth intercostal, left mid clavicular line.

 V5 - Anterior axillary line, same level with V4.

 V6 - Mid axillary line, same level with V4 & V5

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 4) Rt sided ECG

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 5) Posterior ECG

 As left sided ECG

 BUT:

 V4: in posterior axilla in 5th intercostal

 V5: in posterior midclavicular below scapula in 5th intercostal

 V6: in posterior 5th intercostal space beside the vertebral column

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 6) Atrial ECG

 As left sided ECG

 BUT:

 Connect V2 on the atrial epicardial pace maker wire.

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 7) Lewis Lead ECG

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 Standard criteria for ECG procedure

Criteria ‫المواصفا‬
‫ت‬
1. No artifact ‫ليس به مثل الشخبطة‬1-
‫مكتوب على‬2-
1. Paper speed: 25mm/sec ‫الورقة‬
Paper speed: 25mm/sec
‫مكتوب على‬3-
1. Voltage gain- 10mm/mV ‫الورقة‬
Voltage gain- 10mm/mV
1. AVR negative deflection ‫ألسفل‬AVR ‫ في‬R ‫اتجاه ال‬4-

1. Lead II: positive deflection ‫ ألعلى‬II ‫ في‬R ‫اتجاه ال‬5-

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 Conduction System

 SA node:

 Rate: 60 to 100 b/m

 Bundle of His:

 Rate: 40-60 b/m

 Purkinje Fibers:

 Rate: 20-40 b/m

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 ECG PAPER

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 ECG paper

 It records the speed and magnitude of electrical impulses on a grid.

 The ECG paper has a series of horizontal and vertical lines .

 The intersection of these lines produce boxes (large boxes and small boxes).

 Each large box is made up of five small boxes.

 The horizontal lines measure time or duration.

 The vertical lines measure amplitude or voltage.

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 ECG paper

 Horizontally

 1 small box = 0.04 sec

 1 large box (5 small box) = 0.2 sec

 5 large boxes (.20x5) = 1 sec

 300 large box (60x5) = 60sec

 Vertically

 Each small box represent 1mm (0.1mV).

 Each large box represent 5mm (0.5mV).

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 12 Leads

 Standard LL Augmented LL

Lead I AVR

Lead II AVL

Lead III AVF

 Chest /pericardial leads:

 V1, V2, V3, V4, V5, V6

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 Component of cardiac cycle

 P wave.

 PR interval.

 QRS complex.

 ST segment.

 T wave.

 QT interval

 U wave.

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 ECG waves characteristics:

 P wave:

 This represents the generation of an electrical impulse & depolarization of the atria.

 It determine that impulses started from SA node.

 Location: before every QRS complex.

 Amplitude: two and half small square(2.5mm).

 Duration : not more than 3 small square(.12 s).

 Deflection: positive except in (AVR &V1).

 Symmetrical (Why?).

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 PR interval:

 It represent the time for the electrical impulse to spread from the atrium to

the AV node ,bundle of his ,bundle branches and the purkinje fibers.

 Is measured from the beginning of the p wave to the beginning of QRS complex.

 Normally PR interval is (3 to 5 )small square

 (0.12 - 0.20 s) and it should be constant.

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 QRS Complex

 It represent ventricular muscle depolarization.

 From the beginning of Q or R to the end of S wave.

 It is referred to be complex as it consist of several different waves(Q,R,S).

 Duration:(0.04 - 0.10 s) not more than 2.5 small square.

 Amplitude: it differ but may be reach to 30 mm high

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 ST Segment

 The isoelectric segment following depolarization & preceding ventricular repolarization.

 From the end of the QRS complex to the beginning of the T wave.

 It’s duration not measured but shape and location are evaluated

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 T wave:

 It represent ventricular muscle repolarization.

 It follow QRS complex and is usually of

the same deflection of the QRS complex.

 No criteria for T wave amplitude.

 Tall T wave may be seen in Hyperkalemia.

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 U wave:

 Represents late ventricular repolarization.

 It may or may not be seen .

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 Rhythm Analysis

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 Calculation of heart rate

 First determine if it regular rhythm or irregular.

 If regular rhythm use one of the following:

 - Ten time method.

 - Rule of 300.

 If irregular only use:

 - Ten time method.

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 Ten time method

 Count the number of P waves in a 6 second strip (30 large

blocks) then multiply the number of P waves by 10 to get the

atrial rate.

 To calculate ventricular rate count R wave in a 6 second

strip then multiply this number by 10.

 In regular rhythm it become equal but in irregular rhythm it not equal

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 Rule of 300

 Take the number of big boxes between neighboring QRS complexes, and

divide this into 300. The result will be approximately equal to the rate.

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 Step 1: Calculate Rate

6 sec

 Option 1

 Count the # of R waves in a 6 second rhythm strip, then multiply by 10.

 Reminder: all rhythm strips in the Modules are 6 seconds in length.

 Interpretation? 90 b/m

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 Step 2: Determine regularity

R R

 Look at the R-R distances (using a caliper or markings on a pen or paper).

 Regular (are they equidistant apart)? Occasionally irregular?

Regularly irregular? Irregularly irregular?

 Interpretation? Regular

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 Step 3: Assess the P waves

 Are there P waves?

 Do the P waves all look alike?

 Do the P waves occur at a regular rate?

 Is there one P wave before each QRS?

 Interpretation? Normal P waves with 1 P wave for every QR

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 Step 4: Determine PR interval

Normal: 0.12 - 0.20 second

 (3 - 5 boxes)

Interpretation? 0.12 seconds

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 Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)

Interpretation? 0.08 seconds

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 Rhythm Summary

 Rate 90-95 bpm

 Regularity Regular

 P waves Normal

 PR interval 0.12 s

 QRS duration 0.08 s

 Interpretation? Normal Sinus Rhythm

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 NSR Parameters

 Rate 60 - 100 bp

 Regularity regular

 P waves normal

 PR interval 0.12 - 0.20 s

 QRS duration 0.04 - 0.12 s

 Any deviation from above is sinus tachycardia, sinus bradycardia or an arrhythmia

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 CARDIAC ARRHYTHMIA

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 Arrhythmia Formation

 Arrhythmias can arise from problems in the:

 Sinus node

 Atrial cells

 AV junction

 Ventricular cells

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 Sinus rhythms

 Normal sinus rhythm (NSR)

 Sinus bradycardia

 Sinus tachycardia

 Sinus pause

 Sinus arrest

 Sinus arrhythmia

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 SA Node Problems

 The SA Node can:

 fire too slow  Sinus Bradycardia

 fire too fast  Sinus Tachycardia

 Pause  Sinus arrest/pause

 Fire irregularly  Sinus arrhythmia

 Stop  A systole

 Pulseless electrical activity

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 Sinus Bradycardia

 Deviation from NSR

- Rate < 60 bpm (according to normal range of age group)

 Etiology: SA node is depolarizing slower than normal, impulse

is conducted normally (i.e. normal PR and QRS interval).

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 Rhythm #1

 Rate?  30 b/m

 Regularity?  regular

 P waves?  normal

 PR interval  0.12 s

 QRS duration?  0.10 s

 Interpretation?  Sinus Bradycardia
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 Management

 No treatment if patient asymptomatic.

 If symptomatic, correction of underlying cause.

 Bradycardia algorithm guidelines (ACLs).

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 Sinus Tachycardia

 Deviation from NSR

Rate > 100 bpm (according to normal range of age group)

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 Rhythm #2

 Rate? 130 b/m

 Regularity? regular

 P waves? Normal

 PR interval? 0.16 s

 QRS duration? 0.08 s

 Interpretation? Sinus Tachycardia

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 Management

 No treatment if patient asymptomatic.

 Correction of underlying cause.

 For cardiac ischemia: Beta-adrenergic blockers (propranolol, atenolol)

or calcium channel blockers (verapamil, diltiazem).

 Abstinence from triggers (alcohol, caffeine, nicotine).

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 Sinus Arrest

 Pause is equal or more than 3 seconds

 Etiology: SA node fails to depolarize & no compensatory mechanisms take over

 Sinus arrest is usually a transient pause in sinus node activity

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 Management

 No treatment if patient asymptomatic.

 If symptoms, follow bradycardia algorithm.

 As needed, discontinuation of drugs affecting SA node discharge or conduction,

such as beta-adrenergic blockers, calcium channel blockers, and digoxin.

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 Sinus pause

As sinus arrest but Pause is less than 3 seconds

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 Sinus arrhythmia

 Normal ECG but rhythm is irregular

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 Management

 Monitor heart rhythm.

 If sinus arrhythmia develops suddenly in patient taking digoxin, notify doctor.

 If induced by drugs (morphine or another sedative), notify doctor, who will decide

whether to continue giving the drug.

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 Asystole

 Ventricular standstill, no electrical activity, no cardiac output – no pulse!

 Cardiac arrest, may follow VF or PEA

 Remember! No defibrillation with Asystole

 Rate: absent due to absence of ventricular activity. Occasional P wave may be identified.

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 Pulseless electrical activity (PEA)

Any non shockable rhythm without pulse

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 Reversible Cause of Cardiac Arrest

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 Management

Refer To ACLS
Algorithm

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 Atrial Cell Problems

 Atrial cells can:

 fire occasionally from a focus  Premature Atrial Contractions (PACs)

 fire continuously due to a  Atrial Flutter

looping re-entrant circuit

 fire continuously from multiple foci  Atrial Fibrillation

 OR

 fire continuously due to  Atrial Fibrillation

multiple micro re-entrant
“wavelets”
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 Premature Atrial Contractions

 Deviation from NSR

 Rhythm – irregular when PAC’s present

 P wave of PAC is different in size shape and direction

 PR interval may be shorter or longer

 QRS is usually normal

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 Premature Atrial Contractions

 Etiology:
 Catecholamines
 Increased sympathetic tone
 Infections
 Emotions
 Stimulants
 Electrolyte imbalance
 Digitalis
 Open heart surgery
 Treatment
 Observe & Look for underlying cause
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 Atrial Fibrillation

 Deviation from NSR

 Irregularly irregular
 P: absent/ fine
 Heart rate is variable:
 Normal HR
 Bradycardia (slow AF)
 Tachycardia (rapid AF)
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 Rhythm #3

 Rate?  100 b/m

 Regularity?  irregularly irregular
 P waves?  None
 PR interval?  None
 QRS duration?  0.06 s
 Interpretation?  Atrial Fibrillation

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 Management

 Drug therapy to control ventricular response, or electrical cardioversion with drug therapy

 If patient hemo-dynamically unstable, immediate synchronized cardioversion

(most successful if done within 48 hours after atrial fibrillation onset)

 With A. Fib of more than 48 hours: TEE, anticoagulation before & after cardioversion

 With otherwise normal heart function: beta blockers, or calcium channel blockers

 With impaired heart function (heart failure or EF below 40%): digoxin or amiodarone

 Radio-frequency ablation therapy for unresponsive symptomatic atrial fibrillation.

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 Atrial Flutter

 Deviation from NSR  Etiology:

 P waves: frequent (2-4 before each
 CAD, mitral valve
QRS) and saw-toothed appearance.
disease, RHD, pulmonary
 Rhythm: regular/ irregular.

 HR: normal, brady, tachycardia. emboli, COPD,

 QRS: normal, become wide if p wave buried in it. hyperthyroidism

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 Treatment:
 Usually as AF 62
 Rhythm #4

 Rate?  70 b/m
 Regularity?  regular
 P waves?  flutter waves
 PR interval?  None
 QRS duration?  0.06 s
 Interpretation?  Atrial Flutter
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 AV Junction Problems

 The AV junction can:

 fire continuously due to a looping

 Paroxysmal Supraventricular Tachycardia

re-entrant circuit

 block impulses coming from the

 AV Junctional Blocks

SA Node

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 PSVT: Paroxysmal Supra Ventricular Tachycardia

 Deviation from NSR

 Regular rhythm

 Tachycardia

 P wave: absent/ retrograde

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 Rhythm #5

 Rate?  74 148 b/m

 Regularity?  Regular  regular

 P waves?  Normal  none

 PR interval?  0.16 s  none

 QRS duration?  0.08 s

 Interpretation?  Paroxysmal Supraventricular Tachycardia (PSVT)
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 Treatment

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 AV Nodal Blocks

 1st Degree AV Block

 2nd Degree AV Block, Type I

 2nd Degree AV Block, Type II

 3rd Degree AV Block

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 1st Degree AV Block

 Deviation from NSR

 PR Interval > 0.20 s

 Etiology: Prolonged conduction delay in the AV node or Bundle of His

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 Rhythm #6

 Rate?  60 b/m

 Regularity?  Regular

 P waves?  Normal

 PR interval?  0.36 s

 QRS duration?  0.08 s

 Interpretation?  1st Degree AV Block

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 2nd Degree AV Block, Type I

 Deviation from NSR

 PR interval progressively lengthens, then the impulse is completely

blocked (P wave not followed by QRS).

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 2nd Degree AV Block, Type II

 Deviation from NSR

 Multiple p before each QRS

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 3rd Degree AV Block

 Deviation from NSR

 The P waves are completely blocked in the AV junction; QRS

complexes originate independently from below the junction.

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 Comparing all types of H.B

Type P P-R P-P HR Management

 Prolonged  If asymptomatic: nothing
1st  Single fixed >0.2  Fixed  50: 60.  Medical TTT
sec  TTT of cause.

 TTT the cause

 Single except
 Gradual  Medical TTT (atropine,
2nd type 1 in dropped  Fixed  40:60
prolongation dopamine, epinephrine).
beat
 If no response: Pace maker

 Usually
2nd type2  Multiple normal  Fixed  30:40  As type I
 fixed

3rd  Multiple  Not fixed  Not fixed  30 …  Pace maker

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 Bundle branch block

 Look at R wave in V1, V6

 It may be abnormally W shape or M shape.

 If R wave in V1 like M shape, in V6

like W shape: RBBB

 If R wave in V1 like W shape, in V6

like M shape: RBBB

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 Management

 RBBB  LBBB

 If asymptomatic: no treatment.  If asymptomatic: no treatment.

 If symptomatic: pace maker  If symptomatic: CRTP insertion.

insertion.

 Healthy diet and life style.

 Healthy diet and life style.
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 Junctional Rhythm

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 Junctional Rhythm

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 Treatment

 Usually no treatment if patient asymptomatic

 If symptomatic, treatment of underlying cause

 If digoxin toxicity, discontinuation of drug

 If ectopic beats frequent because of caffeine, decrease of caffeine intake

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 Ventricular Cell Problems

 Ventricular cells can:

 Fire occasionally from 1 or more foci  Premature Ventricular Contractions (PVCs)

 Fire continuously from multiple foci

 Ventricular Fibrillation

 Fire continuously due to a

 Ventricular Tachycardia

looping re-entrant circuit

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 PVCs

 Wide bizarre QRS

 Types of PVC’s
 Unifocal–PVCs have same shape

 Multifocal–different shapes (from different foci)

 R on T–PVC falls on T wave of preceding beat

 Bigeminy, Trigeminy, Couplet

3 or more PVCs = VT
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 Forms of PVCs

 Uniform (Unifocal PVCs)

 Multiform PVCs

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 Forms of PVCs

 Coupled/ paired/ ventricular couplet

 Bigeminy PVCs

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 Ventricular Ectopic

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 R on T phenomenon

 In R-on-T phenomenon, a PVC occurs

so early that it falls on the T wave of the

preceding beat (see shaded area on

strip above). Because the cells haven’t

fully repolarized, VT or VF can result.

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 Management

 No treatment if patient asymptomatic and has no evidence of heart disease

 If symptomatic, or dangerous form of PVC occurs, treatment dependent on cause

 For PVCs of purely cardiac origin: drugs to suppress ventricular irritability, such as

amiodarone, lidocaine, procainamide

 For PVCs of noncardiac origin: treatment of cause

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 Ventricular Tachycardia

 Ventricular cells fire continuously due to a looping re-entrant circuit

 Rate usually regular, 100 - 250 bpm

 Pulse: present/ absent

 P wave: may be absent, inverted or retrograde

 QRS: complexes bizarre, > .12

 Rhythm: usually regular.

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 Types of Ventricular Tachycardia

 Monomorphic

 (one shape),

 Polymorphic

 (multiple shapes),

 Torsade's de pointe

 (twisting shape) due to low Mg .

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 Ventricular Fibrillation

 Rhythm:

 irregular-coarse or fine, wave form varies in size and shape

 Fires continuously from multiple foci

 No organized electrical activity

 No cardiac output

 Pulse: absent

 Types:

 Coarse

 Fine
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 Types of VF

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 Causes of V. Tach and V.F

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Management of V. Tach and V.F

Refer to
ACLS
Algorithms
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