ElectroCardioGraphy ECG made extra easy… medics.cc

ElectroCardioGraphy ECG made extra easy medics.cc

Overview Objectives for this tutorial What is an ECG? Overview of performing electrocardiography on a patient Interpreting Simple physiologythe ECG medics.cc

Objectives By the end of this tutorial the student should be able to: State a definition of electrocardiogram Perform an ECG on a patient, including explaining to the patient what is involved Draw a diagram of the conduction pathway of the heart Draw a simple labelled diagram of an ECG tracing List the steps involved in interpreting an ECG tracing in an orderly way Recite the normal limits of the parameters of various parts of the ECG Interpret ECGs showing the following pathology: MI, AF, 1st 2nd and 3rd degree heart block, p pulmonale, p mitrale, WolffParkinson-White syndrome, LBBB, RBBB, Left and Right axis deviation, LVH, pericarditis, Hyper- and hypokalaemia, prolonged QT. medics.cc

What is an ECG? ECG Electrocardiogram Tracing of heart’s electrical activity medics.cc

Recording an ECG medics.cc

Overview of procedure GRIP Greet, rapport, introduce, identify, privacy, explain procedure, permission Lay patient down Expose chest, wrists, ankles Clean electrode sites May need to shave Apply electrodes Attach wires correctly Turn on machine Calibrate to 10mm/mV Rate at 25mm/s Record and print Label the tracing Name, DoB, hospital number, date and time, reason for recording Disconnect if adequate and remove electrodes medics.cc

Electrode placement 10 electrodes in total are placed on the patient Firstly self-adhesive ‘dots’ are attached to the patient. These have single electrical contacts on them The 10 leads on the ECG machine are then clipped onto the contacts of the ‘dots’ medics.cc

Electrode placement in 12 lead ECG 6 are chest electrodes Called V1-6 or C1-6 4 are limb electrodes Right arm Left arm Left leg Right leg Ride Your Green Bike Remember The right leg electrode is a neutral or “dummy”! medics.cc

Electrode placement For the chest electrodes V1 4th intercostal space right sternal edge V2 4th intercostal space left sternal edge (to find the 4th space, palpate the manubriosternal angle (of Louis) Directly adjacent is the 2nd rib, with the 2nd intercostal space directly below. Palpate inferiorly to find the 3rd and then 4th space V4 over the apex (5th ICS mid-clavicular line) V3 halfway between V2 and V4 V5 at the same level as V4 but on the anterior axillary line V6 at the same level as V4 and V5 but on the mid-axillary line medics.cc

Recording the trace Different ECG machines have different buttons that you have to press. Ask one of the staff on the ward if it is a machine that you are unfamiliar with. Ask the patient to relax completely. Any skeletal muscle activity will be picked up as interference. If the trace obtained is no good, check that all the dots are stuck down properly – they have a tendency to fall off. medics.cc

Electrophysiology medics.cc

Electrophysiology Pacemaker sinoatrial node Impulse travels across atria Reaches AV node Transmitted along interventricular septum in Bundle of His Bundle splits in two (right and left branches) Purkinje fibres medics.cc

Overall direction of cardiac impulse medics.cc

How does the ECG work? Electrical impulse (wave of depolarisation) picked up by placing electrodes on patient The voltage change is sensed by measuring the current change across 2 electrodes – a positive electrode and a negative electrode If the electrical impulse travels towards the positive electrode this results in a positive deflection If the impulse travels away from the positive electrode this results in a negative deflection medics.cc

Away from the electrode Towards the electrode negative deflection positive deflection Direction of impulse (axis) medics.cc

Types of Leads Coronal plane (Limb Leads) 1. Bipolar leads — l , l l , l l l 2. Unipolar leads — aVL , aVR , aVF Transverse plane 1 V1 Leads) — V6 (Chest medics.cc

Electrodes around the heart

Leads How are the 12 leads on the ECG (I, II, III, aVL, aVF, aVR, V1 – 6) formed using only 9 electrodes (and a neutral)? - Lead I Lead I is formed using the right arm electrode (red) as the negative electrode and the left arm (yellow) electrode as the positive medics.cc

Leads - Lead I medics.cc

Leads Lead II is formed using the right arm electrode (red) as the negative electrode and the left leg electrode as the positive Lead II medics.cc

Lead II medics.cc

Leads Lead III is formed using the left arm electrode as the negative electrode and the left leg electrode as the positive aVL, aVF, and aVR are composite leads, computed using the information from the other leads medics.cc

Leads and what they tell you Limb leads Limb leads look at the heart in the coronal plane aVL, I and II lateral II, III and aVF inferior aVR right side of the heart medics.cc

Leads look at the heart from different directions axis

Leads and what they tell you Each lead can be thought of as ‘looking at’ an area of myocardium Chest leads V1 heart on the transverse 1 to V6 ‘look’ at the plain 1 and V2 look at the anterior of the heart and V1 R ventricle V3 3 and V4 anterior and septal V5 5 and V6 lateral and left ventricle medics.cc

Elements of the trace medics.cc

What do the components represent? P wave atrial depolarisation QRS T ventricular depolarisation repolarisation of the ventricles medics.cc

Interpreting the ECG medics.cc

Interpreting the ECG Check Name DoB Time and date Indication e.g. “chest pain” or “routine pre-op” Any previous or subsequent ECGs Is it part of a serial ECG sequence? In which case it may be numbered Calibration Rate Rhythm Axis Elements of the tracing in each lead medics.cc

Calibration Check that your ECG is calibrated correctly Height 10mm 1mV Look for a reference pulse which should be the rectangular looking wave somewhere near the left of the paper. It should be 10mm (10 small squares) tall Paper speed 25mm/s 25 mm (25 small squares / 5 large squares) equals one second medics.cc

Rate If the heart rate is regular Count the number of large squares between R waves i.e. the RR interval in large squares Rate 300 RR e.g. RR 4 large squares 300/4 75 beats per minute medics.cc

Rate If the rhythm is irregular (see next slide on rhythm to check whether your rhythm is regular or not) it may be better to estimate the rate using the rhythm strip at the bottom of the ECG (usually lead II) The rhythm strip is usually 25cm long (250mm i.e. 10 seconds) If you count the number of R waves on that strip and multiple by 6 you will get the rate medics.cc

Rhythm Is the rhythm regular? 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 medics.cc

Rhythm Definition Sinus Rhythm Cardiac impulse originates from the sinus node. Every QRS must be preceded by a P wave. (This does not mean that every P wave must be followed by a QRS – such as in 2nd degree heart block where some P waves are not followed by a QRS, however every QRS is preceded by a P wave and the rhythm originates in the sinus node, hence it is a sinus rhythm. It could be said that it is not a normal sinus rhythm) medics.cc

Rhythm Sinus arrhythmia There is a change in heart rate depending on the phase of respiration Q. If a person with sinus arrhythmia inspires, what happens to their heart rate? A. The heart rate speeds up. This is because on inspiration there is a decrease in intrathoracic pressure, this leads to an increased venous return to the right atrium. Increased stretching of the right atrium sets off a brainstem reflex (Bainbridge’s reflex) that leads to sympathetic activation of the heart, hence it speeds up) This physiological phenomenon is more apparent in children and young adults medics.cc

Rhythm Sinus bradycardia Rhythm originates in the sinus node Rate of less than 60 beats per minute Sinus tachycardia Rhythm originates in the sinus node Rate of greater than 100 beats per minute medics.cc

Axis The axis can be though of as the overall direction of the cardiac impulse or wave of depolarisation of the heart An abnormal axis (axis deviation) can give a clue to possible pathology medics.cc

Axis or extreme axis deviation right axis deviation An axis falling outside the normal range can be left axis deviation A normal axis can lie anywhere between -30 and 90 degrees or 120 degrees according to some

Axis deviation - Causes Wolff-Parkinson-White syndrome can cause both Left and Right axis deviation A useful mnemonic: “RAD RALPH the LAD from VILLA” Left Axis Deviation Right Axis Deviation Ventricular tachycardia Inferior MI Right ventricular hypertrophy Left ventricular hypertrophy Anterolateral MI Left Anterior hemiblock Left Posterior Hemiblock medics.cc

The P wave The P wave represents atrial depolarisation It can be thought of as being made up of two separate waves due to right atrial depolarisation and left atrial depolarisation. Which occurs first? Right atrial depolarisation Sum of right and left waves right atrial depolarisation left atrial depolarisation medics.cc

The P wave Dimensions No hard and fast rules Height a P wave over 2.5mm should arouse suspicion Length a P wave longer than 0.08s (2 small squares) should arouse suspicion medics.cc

The P wave Height A tall P wave (over 2.5mm) can be called P pulmonale Occurs due to R atrial hypertrophy Causes include: normal P pulmonale 2.5mm pulmonary hypertension, pulmonary stenosis tricuspid stenosis medics.cc

The P wave Length A P wave with a length 0.08 seconds (2 small squares) and a bifid shape is called P mitrale It is caused by left atrial hypertrophy and delayed left atrial depolarisation normal P mitrale Causes include: Mitral valve disease LVH medics.cc

The PR interval The PR interval is measured between the start of the P wave to the start of the QRS complex (therefore if there is a Q wave before the R wave the PR interval is measured from the start of the P wave to the start of the Q wave, not the start of the R wave) medics.cc

The PR interval The PR interval corresponds to the time period between depolarisation of the atria and ventricular depolarisation. A normal PR interval is between 0.12 and 0.2 seconds ( 3-5 small squares) medics.cc

The PR interval If the PR interval is short (less than 3 small squares) it may signify that there is an accessory electrical pathway between the atria and the ventricles, hence the ventricles depolarise early giving a short PR interval. One example of this is Wolff-Parkinson-White syndrome where the accessory pathway is called the bundle of Kent. See next slide for an animation to explain this medics.cc

Depolarisation begins at the SA node The wave of depolarisation spreads across the atria It reaches the AV node and the accessory bundle Conduction is delayed as usual by the in-built delay in the AV node However, the accessory bundle has no such delay and depolarisation begins early in the part of the ventricle served by the bundle As the depolarisation in this part of the ventricle does not travel in the high speed conduction pathway, the spread of depolarisation across the ventricle is slow, causing a slow rising delta wave Until rapid depolarisation resumes via the normal pathway and a more normal complex follows

The PR interval If the PR interval is long ( 5 small squares or 0.2s): If there is a constant long PR interval 1st degree heart block is present First degree heart block is a longer than normal delay in conduction at the AV node medics.cc

The PR interval If the PR interval looks as though it is widening every beat and then a QRS complex is missing, there is 2nd degree heart block, Mobitz type I. The lengthening of the PR interval in subsequent beats is known as the Wenckebach phenomenon (remember (w)one, Wenckebach, widens) If the PR interval is constant but then there is a missed QRS complex then there is 2nd degree heart block, Mobitz type II medics.cc

The PR interval If there is no discernable relationship between the P waves and the QRS complexes, then 3rd degree heart block is present medics.cc

Heart block (AV node block) Summary 1st degree constant PR, 0.2 seconds 2nd degree type 1 (Wenckebach) PR widens over subsequent beats then a QRS is dropped PRtype is constant then a QRS is dropped 2nd degree 2 3rd degree No discernable relationship between p waves and QRS complexes medics.cc

The Q wave Are there any pathological Q waves? A Q wave can be pathological if it is: Deeper than 2 small squares (0.2mV) and/or Wider than 1 small square (0.04s) and/or In a lead other than III or one of the leads that look at the heart from the left (I, II, aVL, V5 and V6) where small Qs (i.e. not meeting the criteria above) can be normal Normal if in I,II,III,aVL,V5-6 Pathological anywhere medics.cc

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The QRS height If the complexes in the chest leads look very tall, consider left ventricular hypertrophy (LVH) If the depth of the S wave1inadded V1 to the height of the R wave6 in V6 to comes more than 35mm, LVH is present medics.cc

QRS width The width of the QRS complex should be less than 0.12 seconds (3 small squares) Some texts say less than 0.10 seconds (2.5 small squares) If the QRS is wider than this, it suggests a ventricular conduction problem – usually right or left bundle branch block (RBBB or LBBB) medics.cc

LBBB If left bundle branch block is present, the QRS complex may look like a ‘W’ in V1 1 and/or an ‘M’6. shape in V6. New onset LBBB with chest pain consider Myocardial infarction Not possible to interpret the ST segment. medics.cc

RBBB It is also called RSR pattern If right bundle branch block is present, there may be an ‘M’ in V1 and/or a ‘W’ in V6. Can occur in healthy people with normal QRS width – partial RBBB medics.cc

QRS width It is useful to look at leads V1 1 and V6 LBBB and RBBB can be remembered by the mnemonic: WiLLiaM MaRRoW Bundle branch block is caused either by infarction or fibrosis (related to the ageing process) medics.cc

The ST segment The ST segment should sit on the isoelectric line It is abnormal if there is planar (i.e. flat) elevation or depression of the ST segment Planar ST elevation can represent an MI or Prinzmetal’s (vasospastic) angina Planar ST depression can represent ischaemia medics.cc

Myocardial infarction Within hours: T wave may become peaked ST segment may begin to rise Within 24 hours: T wave inverts (may or may not persist) ST elevation begins to resolve If a left ventricular aneurysm forms, ST elevation may persist Within a few days: pathological Q waves can form and usually persist medics.cc

Myocardial infarction The leads affected determine the site of the infarct Inferior II, III, aVF Anteroseptal V1-V4 Anterolateral V4-V6, I, aVL Posterior Tall wide R and STĻ in V1 and V2 medics.cc

Acute Anterior MI ST elevation c

Inferior MI ST elevation m

The ST segment If the ST segment is elevated but slanted, it may not be significant If there are raised ST segments in most of the leads, it may indicate pericarditis – especially if the ST segments are saddle shaped. There can also be PR segment depression medics.cc

Pericarditis medics.cc

The T wave Are the T waves too tall? No definite rule for height T wave generally shouldn’t be taller than half the size of the preceding QRS Causes: Hyperkalaemia Acute myocardial infarction medics.cc

The T wave If the T wave is flat, it may indicate hypokalaemia If the T wave is inverted it may indicate ischaemia medics.cc

The QT interval The QT interval is measured from the start of the QRS complex to the end of the T wave. The QT interval varies with heart rate As the heart rate gets faster, the QT interval gets shorter It is possible to correct the QT interval with respect to rate by using the following formula: QTc QT/ RR (QTc corrected QT) medics.cc

The QT interval The normal range for QTc is 0.38-0.42 A short QTc may indicate hypercalcaemia A long QTc has many causes Long QTc increases the risk of developing an arrhythmia medics.cc

The U wave U waves occur after the T wave and are often difficult to see They are thought to be due to repolarisation of the atrial septum Prominent U waves can be a sign of hypokalaemia, hyperthyroidism medics.cc

Supraventricular tachycardias These are tachycardias where the impulse is initiated in the atria (sinoatrial node, atrial wall or atrioventricular node) If there is a normal conduction pathway when the impulse reaches the ventricles, a narrow QRS complex is formed, hence they are narrow complex tachycardias However if there is a conduction problem in the ventricles such as LBBB, then a broad QRS complex is formed. This would result in a form of broad complex tachycardia medics.cc

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Atrial Fibrillation Features: There maybe tachycardia The rhythm is usually irregularly irregular No P waves are discernible – instead there is a shaky baseline This is because there is no order to atrial depolarisation, different areas of atrium depolarise at will medics.cc

Atrial Fibrillation medics.cc

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Atrial flutter There is a saw-tooth baseline which rises above and dips below the isoelectric line. Atrial rate 250/min This is created by circular circuits of depolarisation set up in the atria m s.cc

Ventricular Tachycardia medics.cc

Ventricular Tachycardia QRS complexes are wide and irregular in shape Usually secondary to infarction Circuits of depolarisation are set up in damaged myocardium This leads to recurrent early repolarisation of the ventricle leading to tachycardia As the rhythm originates in the ventricles, there is a broad QRS complex Hence it is one of the causes of a broad complex tachycardia Need to differentiate with supraventricular tachycardia with aberrant conduction medics.cc

Ventricular Fibrillation medics.cc

Ventricular fibrillation Completely disordered ventricular depolarisation Not compatible with a cardiac output Results in a completely irregular trace consisting of broad QRS complexes of varying widths, heights and rates medics.cc

Elements of the tracing P wave Magnitude and shape, e.g. P pulmonale, P mitrale PR interval (start of P to start of QRS) Normal 3-5 small squares, 0.12-0.2s ST segment Should be isoelectric T wave Magnitude and direction QT interval(Start QRS to end of T) Pathological Q waves? QRS complex Magnitude, duration and shape 3 small squares or 0.12s duration Normally 2 big squares or 0.4s at 60bpm Corrected to 60bpm (QTc) QT/ RRinterval medics.cc

Further work Check out the various quizzes / games available on the Imperial Intranet Get doctors on the wards to run through a patient’s ECG with you medics.cc