MAKING ECG’S EASYMAKING ECG’S EASY

APPLICATION FOR THE ECGAPPLICATION FOR THE ECG

EVALUATING THE ECG EVALUATING THE ECG

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Upon completion one Upon completion one will be able to:will be able to:• Describe what an ECG is.Describe what an ECG is.• Describe the proper hook-up Describe the proper hook-up

procedure for a 12-Lead ECGprocedure for a 12-Lead ECG• Identify basic normal ECG Identify basic normal ECG

waveform morphology. waveform morphology. • Distinguish between basic ECG Distinguish between basic ECG

arrhythmia and artifact. arrhythmia and artifact.

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QUICK REVIEW OF HEART QUICK REVIEW OF HEART

Purpose Purpose • Pumps bloodPumps blood

Basic AnatomyBasic Anatomy• 4 chambers4 chambers• 2 sides 2 sides • 4 valves4 valves

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THE CONDUCTINGY THE CONDUCTINGY SYSTEM SYSTEM

• SA NodeSA Node• Inter-nodal Inter-nodal

pathwaypathway• AV NodeAV Node• Bundle of HISBundle of HIS• Bundle BranchesBundle Branches• Purkinje Fibers Purkinje Fibers

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RELATIONSHIP RELATIONSHIP

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CARDIAC CYCLES CARDIAC CYCLES

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12 LEAD ECG12 LEAD ECG

Learning objectives: Learning objectives:

Describe the correct Describe the correct placement of all electrodes placement of all electrodes Proper Skin preparationProper Skin preparation Care of the ECG machine, wires and Care of the ECG machine, wires and

electrodeselectrodes

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Principles of Principles of ElectrocardiographElectrocardiograph

• Electrocardiograph – is the Electrocardiograph – is the instrument that records the instrument that records the electrical activity of the heartelectrical activity of the heart

• Electrocardiogram (ECG) is the Electrocardiogram (ECG) is the record of that activityrecord of that activity

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HOOKING UP THE HOOKING UP THE 12-LEAD ECG12-LEAD ECG

• Proper skin prepProper skin prep• Placement of the limb electrodesPlacement of the limb electrodes• Placement of the chest electrodesPlacement of the chest electrodes

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SKIN PREPARATIONSKIN PREPARATION

• REASON FOR SKIN PREPARATIONREASON FOR SKIN PREPARATION

• 5 STEP METHOD5 STEP METHOD• 2 STEP METHOD 2 STEP METHOD

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ELECTRODE PLACEMENTELECTRODE PLACEMENT

• LIMB LEADSLIMB LEADS

• CHEST LEADCHEST LEAD

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LIMB LEADS LIMB LEADS

• Bipolar leadsBipolar leads

I II IIII II III

• Augment leadsAugment leads

Avr Avl AvfAvr Avl Avf

  

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CHEST LEADS CHEST LEADS

• 6 UNIPOLAR 6 UNIPOLAR LEADSLEADS

• V1V1• V2 V2 • V3V3• V4 V4 • V5V5• V6V6

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LETS REVIEW LETS REVIEW

• What is an ECGWhat is an ECG• What are the limb leads?What are the limb leads?• What are the chest leads?What are the chest leads?• Why do skin prep?Why do skin prep?

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12-LEAD ECG LAYOUT12-LEAD ECG LAYOUT

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INFORMATION ON THE INFORMATION ON THE ECG ECG

• Patients demographicsPatients demographics• Heart rate and measurementsHeart rate and measurements• Speed ECG is recorded atSpeed ECG is recorded at• Voltage ECG is recorded atVoltage ECG is recorded at• What the filter is set onWhat the filter is set on

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INFORMATION ON THE 12-INFORMATION ON THE 12-LEAD ECG LEAD ECG

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WHAT YOU NEED TO LOOK WHAT YOU NEED TO LOOK FORFOR

• Are the limb leads hooked up Are the limb leads hooked up correctly?correctly?

• Are the chest leads hooked up Are the chest leads hooked up correctly?correctly?

• Is the ECG free of artifact.Is the ECG free of artifact.• Is this ECG a Critical Value Is this ECG a Critical Value

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IS the ECG HOOKED UP IS the ECG HOOKED UP CORRECTLY?CORRECTLY?

LIMB LEADSLIMB LEADSNormal 12-lead Normal 12-lead • AVR – always AVR – always

negativenegative• Lead I – always Lead I – always

positive positive • Lead II, III – Lead II, III –

positive or positive or biphasicbiphasic

CHEST LEADS CHEST LEADS

COLUMN IIICOLUMN III• R wave progression R wave progression • Small to Tall Small to Tall

COLUMN IVCOLUMN IV• R wave progression R wave progression • Tall to Small Tall to Small

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RULING OUT LIMB LEAD RULING OUT LIMB LEAD REVERSAL REVERSAL

• Avr is always negativeAvr is always negative

• Lead I is always positive Lead I is always positive

• Lead II and III positive for the P Lead II and III positive for the P wave and usually the QRS complexwave and usually the QRS complex

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CHEST LEADS CHEST LEADS

CHEST LEADS CHEST LEADS

COLUMN IIICOLUMN III• R wave progression R wave progression • Small to Tall Small to Tall

COLUMN IVCOLUMN IV• R wave progression R wave progression • Tall to Small Tall to Small

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LIMB LEADS LIMB LEADS

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CHEST LEADS CHEST LEADS

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OTHER PROBLEMS WITH OTHER PROBLEMS WITH THE ECGTHE ECG

• ArtifactArtifact• Electrical interferenceElectrical interference• Somatic tremorSomatic tremor• Wandering baselineWandering baseline

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EINTHOVENS TRIANGLEEINTHOVENS TRIANGLE

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ARTIFACT ON THE ECGARTIFACT ON THE ECG

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FIND THE ARTEFACTFIND THE ARTEFACT

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WANDERIN BASELINEWANDERIN BASELINE

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SOMATIC TREMORSOMATIC TREMOR

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ELECTRICAL ELECTRICAL INTERFERANCEINTERFERANCE

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BASIC CRITICAL VALUESBASIC CRITICAL VALUES

• Bradycardia – HR Bradycardia – HR << 40bpm 40bpm• Tachycardia HR Tachycardia HR >> 120bpm 120bpm• PVC’s - 4 or more in a row PVC’s - 4 or more in a row • ST Elevation ST Elevation

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LOOKING AT THE RHYTHMLOOKING AT THE RHYTHM

• Evaluate the Evaluate the rhythm strip at rhythm strip at the bottom of the the bottom of the 12-lead for the 12-lead for the followingfollowing

• Is the rhythm Is the rhythm regular or regular or irregular?irregular?

• Is there a P wave Is there a P wave before every QRS before every QRS complexcomplex

• Are they any Are they any abnormal beats.abnormal beats.

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FINDING THE HEART RATE FINDING THE HEART RATE

• 3 METHODS3 METHODS

• RATE RULERRATE RULER• COUNTINGCOUNTING• BOX METHOD BOX METHOD

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BOX METHOD BOX METHOD

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ECTOPIC BEATSECTOPIC BEATS

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ECTOPIC BEATS ECTOPIC BEATS

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LETS SUMMARIZELETS SUMMARIZE

How do we produce an excellent 12-How do we produce an excellent 12-lead ECG?lead ECG?

Proper skin prepProper skin prep

Correct electrode placementCorrect electrode placement

Recognize and know how to correct Recognize and know how to correct problemsproblems

Recognize basic critical values Recognize basic critical values