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The electrocardiogram (ECG) is a diagnostic tool that measures and records the electrical
activity of the heart in detail. Being able to interpretate these details allows diagnosis of a wide
range of heart problems.
ECG Electrodes
Skin Preparation:
Clean with an alcohol wipe if necessary. If the patients are very hairy – shave the electrode areas.
Lead I: is between the right arm and left arm electrodes, the left arm
being positive.
Lead II: is between the right arm and left leg electrodes, the left leg
being positive.
Lead III: is between the left arm and left leg electrodes, the left leg
again being positive.
ECG Interpretation
The graph paper that the ECG records on is standardised to run at 25mm/second, and is marked
at 1 second intervals on the top and bottom. The horizontal axis correlates the length of each
electrical event with its duration in time. Each small block (defined by lighter lines) on the
horizontal axis represents 0.04 seconds. Five small blocks (shown by heavy lines) is a large
block, and represents 0.20 seconds.
Duration of a waveform, segment, or interval is determined by counting the blocks from the
beginning to the end of the wave, segment, or interval.
P-Wave: represents atrial depolarization - the time necessary for an electrical impulse from the
sinoatrial (SA) node to spread throughout the atrial musculature.
P-R Interval: represents the time it takes an impulse to travel from the atria through the AV node,
bundle of His, and bundle branches to the Purkinje fibres.
• Location: Extends from the beginning of the P wave to the beginning of the QRS
complex
Duration: 0.12 to 0.20 seconds.
QRS Complex: represents ventricular depolarisation. The QRS complex consists of 3 waves: the
Q wave, the R wave, and the S wave.
• Location: Extends from the beginning of the QRS complex to the end of the T wave
(includes the QRS complex, S-T segment, and the T wave)
T Wave: represents the repolarization of the ventricles. On rare occasions, a U wave can be seen
following the T wave. The U wave reflects the repolarization of the His-Purkinje fibres.
S-T Segment: represents the end of the ventricular depolarization and the beginning of
ventricular repolarization.
• Location: Extends from the end of the S wave to the beginning of the T wave
Duration: Not usually measured
The ECG and Myocardial Infarction
During an MI, the ECG goes through a series of abnormalities. The initial abnormality is called a
hyperacute T wave. This is a T wave that is taller and more pointed than the normal T wave.
Hyperacute T Wave
The abnormality lasts for a very short time, and then elevation of the ST segment occurs. This is
the hallmark abnormality of an acute MI. It occurs when the heart muscle is being injured by a
lack of blood flow and oxygen and is also called a current of injury.
ST Elevation
An ECG can not only tell you if an MI is present but can also show the approximate location of
the heart attack, and often which artery is involved. When the ECG abnormalities mentioned
above occur, then the MI can be localized to a certain region of the heart. For example, see the
table below:
ECG leads Location of MI Coronary Artery
II, III, aVF Inferior MI Right Coronary Artery
Anterior or
V1-V4 Left Anterior Descending Artery
Anteroseptal MI
V5-V6, I,aVL Lateral MI Left Circumflex Artery
ST depression in Left Circumflex Artery or Right
Posterior MI
V1, V2 Coronary Artery
ECG Rhythms
This section will cover some of the most common ECG patterns that you'll come across on an
ambulance.
• Rhythm - Regular
• Rate - (60-100 bpm)
• QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree block)
• Indicates that the electrical signal is generated by the sinus node and travelling in a normal
fashion in the heart.
•
• Sinus Bradycardia
A heart rate less than 60 beats per minute (BPM). This in a healthy athletic person may
be 'normal', but other causes may be due to increased vagal tone from drug abuse,
hypoglycaemia and brain injury with increase intracranial pressure (ICP) as examples
• Rhythm - Regular
• Rate - less than 60 beats per minute
• QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal
• Usually benign and often caused by patients on beta blockers
•
• Sinus Tachycardia
An excessive heart rate above 100 beats per minute (BPM) which originates from the SA
node. Causes include stress, fright, illness and exercise. Not usually a surprise if it is
triggered in response to regulatory changes e.g. shock. But if their is no apparent trigger
then medications may be required to suppress the rhythm
• Rhythm - Regular
• Rate - More than 100 beats per minute
• QRS Duration - Normal
• P Wave - Visible before each QRS complex
• P-R Interval - Normal
• The impulse generating the heart beats are normal, but they are occurring at a faster pace than
normal. Seen during exercise
•
• Supraventricular Tachycardia (SVT) Abnormal
A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is
not under direct control from the SA node. SVT can occur in all age groups
Looking at the ECG you'll see that:
• Rhythm - Regular
• Rate - 140-220 beats per minute
• QRS Duration - Usually normal
• P Wave - Often buried in preceding T wave
• P-R Interval - Depends on site of supraventricular pacemaker
• Impulses stimulating the heart are not being generated by the sinus node, but instead are
coming from a collection of tissue around and involving the atrioventricular (AV) node
•
• Atrial Fibrillation
Many sites within the atria are generating their own electrical impulses, leading to
irregular conduction of impulses to the ventricles that generate the heartbeat. This
irregular rhythm can be felt when palpating a pulse
1st Degree AV block is caused by a conduction delay through the AV node but all
electrical signals reach the ventricles. This rarely causes any problems by itself and often
trained athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s
in length, or 3-5 small squares on the ECG.
• Rhythm - Regular
• Rate - Normal
• QRS Duration - Normal
• P Wave - Ratio 1:1
• P Wave rate - Normal
• P-R Interval - Prolonged (>5 small squares)
•
• 2nd Degree Block Type 1 (Wenckebach)
Another condition whereby a conduction block of some, but not all atrial beats getting
through to the ventricles. There is progressive lengthening of the PR interval and then
failure of conduction of an atrial beat, this is seen by a dropped QRS complex.
When electrical excitation sometimes fails to pass through the A-V node or bundle of
His, this intermittent occurance is said to be called second degree heart block. Electrical
conduction usually has a constant P-R interval, in the case of type 2 block atrial
contractions are not regularly followed by ventricular contraction
• Rhythm - Regular
• Rate - Normal or Slow
• QRS Duration - Prolonged
• P Wave - Ratio 2:1, 3:1
• P Wave rate - Normal but faster than QRS rate
• P-R Interval - Normal or prolonged but constant
•
• 3rd Degree Block
3rd degree block or complete heart block occurs when atrial contractions are 'normal' but
no electrical conduction is conveyed to the ventricles. The ventricles then generate their
own signal through an 'escape mechanism' from a focus somewhere within the ventricle.
The ventricular escape beats are usually 'slow'
Abnormal conduction through the bundle branches will cause a depolarization delay
through the ventricular muscle, this delay shows as a widening of the QRS complex.
Right Bundle Branch Block (RBBB) indicates problems in the right side of the heart.
Whereas Left Bundle Branch Block (LBBB) is an indication of heart disease. If LBBB is
present then further interpretation of the ECG cannot be carried out.
• Rhythm - Regular
• Rate - Normal
• QRS Duration - Prolonged
• P Wave - Ratio 1:1
• P Wave rate - Normal and same as QRS rate
• P-R Interval - Normal
•
• Premature Ventricular Complexes
• Rhythm - Regular
• Rate - Normal
• QRS Duration - Normal
• P Wave - Ratio 1:1
• P Wave rate - Normal and same as QRS rate
• P-R Interval - Normal
• Also you'll see 2 odd waveforms, these are the ventricles depolarising prematurely in response
to a signal within the ventricles.(Above - unifocal PVC's as they look alike if they differed in
appearance they would be called multifocal PVC's, as below)
Junctional Rhythms
• Rhythm - Regular
• Rate - 40-60 Beats per minute
• QRS Duration - Normal
• P Wave - Ratio 1:1 if visible. Inverted in lead II
• P Wave rate - Same as QRS rate
• P-R Interval - Variable
• Below - Accelerated Junctional Rhythm
Ventricular Tachycardia (VT) Abnormal
• Rhythm - Regular
• Rate - 180-190 Beats per minute
• QRS Duration - Prolonged
• P Wave - Not seen
• Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm.
Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac
arrest. Shock this rhythm if the patient is unconscious and without a pulse
•
• Ventricular Fibrillation (VF) Abnormal
• Rhythm - Irregular
• Rate - 300+, disorganised
• QRS Duration - Not recognisable
• P Wave - Not seen
• This patient needs to be defibrillated!! QUICKLY
•
• Asystole - Abnormal
• Rhythm - Flat
• Rate - 0 Beats per minute
• QRS Duration - None
• P Wave - None
• Carry out CPR!!
•
• Myocardial Infarct (MI)
• Rhythm - Regular
• Rate - 80 Beats per minute
• QRS Duration - Normal
• P Wave - Normal
• S-T Element does not go isoelectric which indicates infarction
Info
ECG Component Time(sec) Small Squares
P Wave 0.10
up to 2.5
QRS 0.10
1.5-2.5
ECG Rules
To be able to diagnose problems on an ECG is not a matter of just looking at the strip, an ECG
needs to be read to see what is being shown. If you follow Professor Chamberlains 10 rules
they'll give you an understanding of what is normal.
•
• The width of the QRS complex should not exceed 110 ms, less than 3 little squares
• Rule 3
QRS and T waves tend to have the same general direction in the limb leads
Rule 5
1. The R wave in the precordial leads must grow from V1 to at least V4 (See
Below)
2. The S wave in the precordial leads must grow from V1 to at least V3 and
disappear in V6. (See Below)
Rule 8
There should be no Q wave or only a small q less than 0.04 seconds in width in I, II,
V2 to V6
Rule 10