Electrocardiography

(ECG)
Recording and interpretation

Definition:
The 12 lead ECG is a recording of the electrical
activity of the heart, and is an essential diagnostic
tool in the management and treatment of heart
disease - (Jevon 2000)

ECG provides graphical representation of electrical

forces which appears in graph as a series of positive
and negative deflections

Indications of ECG recording:

Chest pain
Myocardial infarction
Palpitations
After successful CPR
History of syncope (fainting)
Screening due to multiple risk factors of
CVD

Purposes of ECG
Measure the rate and regularity
heartbeats
Size and position of the chambers,
Presence of any damage to the heart
Effects of drugs
Conduction system of heart
Effects of electrolyte imbalace

Points kept in mind before

ECG recording:
Although recording an ECG is a relatively easy
procedure, it is vital that it is recorded
accurately to avoid misinterpretation to ensure
an accurate reading:
It is important that the
comfortable as possible .

patient

is

as

Contd
The temperature of the room should be
adequate .
The patient should preferably be in a
supine position
In order to facilitate contact with the
electrode pads, it is necessary to clean
the skin with an alcohol swab to remove
any body lotion or sweat

Equipments required for ECG

recording:

ECG machine
Alcohol swabs
Shaving set (optional)
ECG jelly
Disposable paper/ tissue
Screen

Procedure ECG recording:

Procedure of ECG recording:

Explain procedure to patient and confirm
consent
Wash hands as per protocol
Ensure patient is comfortably positioned
Prepare skin and electrode sites by
cleaning with alcohol swabs
Apply electrodes ensuring adequate
adhesion

Limb leads:

Red (RA) inner right wrist

Yellow (LA) inner left wrist
Green (LL) inner left leg just above ankle
Black (RL) inner right leg just above
ankle
(Starting at right arm, in a clockwise
direction Ride Your Green Bike)

Chest leads:
V1 fourth intercostal space, rt of
sternum
V2 fourth intercostal space, lt of sternum
V3 midway between V2 and V4
V4 5th intercostal space, mid clavicular
V5 5th intercostal space , anterior axilla)
V6 5th intercostal space, midpoint of
armpit

Chest leads

Contd

switch on machine
Check calibration is 10mm/millivolt
Input patient/client data
Ask patient/client to relax and refrain
from movement
Start recording 12 lead ECG
Reassure
patient/client
throughout
recording

After procedure:
Detach recording and ensure labelling is
correct
Remove the electrodes
Provide tissue paper to patient to clean
jelly
Clean ECG leads with tissue paper and
spirit swabs
Correctly file ECG recording & report to
physician

ECG graph paper:

In the ECG Graph Paper there
Horizontal axis and vertical axis.

are

The horizontal axis represents time in

milliseconds (ms) and vertical axis
represents amplitude or voltage in millivolts
(mV).

Interpretation of ECG
recording

 In ECG graph there are small and large

boxes. If we see ECG graph :
Horizontally:
- One small box - 0.04 s, = 1mm
One large box - 0.20 s = 5mm

Vertically :
- One large box - 0.5 mV
2 large boxes 1mV

Two 5-mm-divisions on the vertical axis

are calibrated to represent 1 mV

Contd
Horizontally
One small box - 0.04 s
One large box - 0.20 s

Vertically
One large box - 0.5 mV

Contd

ECG waves and intervals

Certain important facts about the direction and

magnitude of ECG waves:
Provides graphical depiction of electrical
forces
Graph appears as a series of deflections
Deflections above isoelectric line are positive
Isoelectric line period of electric inactivity,
during which no deflections are observed
Deflection mainly depends- 2 factors
spread of electric force
location of recording electrode

Contd
Electrical impulses moving towards an
electrode- positive deflection
Away negative
Magnitude of deflection- muscle mass
Activation of atria occur- longitudinallyreflects atrial enlargement
Ventricles-transversely-hypertrophy

Contd
a current surging directly in
the direction -recording
electrode-positive deflection
a current flowing in the
direction but not directly
toward the recording
electrode -positive deflection
of lower amplitude
running at right angle recording electrode -no
deflection or a biphasic
deflection;
flowing away -recording
electrode -negative
deflection

Normal Impulse Conduction

Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers

Impulse Conduction & the ECG

Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers

The PQRST
P wave - Atrial

depolarization

QRS - Ventricular
depolarization
T wave - Ventricular
repolarization

The P Wave
The first deflection is the P wave associated
with right and left atrial depolarization. Wave
of atrial repolarization is invisible because of
low amplitude

PR interval
Interval: 0.12 to 0.20
Prolonged PR Interval
AV Node Block
Hyperthyroidism
Shortened PR Interval Wolf-ParkinsonWhite Syndrome (WPW Syndrome)
Hypertension

QRS Complex
Normal findings: DurationLimb leads (I, II, III):
0.05 to 0.10
Precordial leads (V1 to V6): 0.06 to 0.12
Wide QRS or Prolonged QRS -Left Bundle
Branch Block
Medications ( Toxin Ingestion)
Low QRS amplitude (<5 mm in limb
leads)Diffuse Coronary Artery Disease
Congestive Heart Failure
Pericardial Effusion
High QRS amplitude- Left Ventricular Hypertrophy

ST segment
Measurement
Measure at 0.04 sec (1 mm) after the JPoint

Causes( ST elevation)
Acute Myocardial Infarction
Pericarditis
Left Bundle Branch Block
- Left Ventricular Hypertrophy
Early Repolarization

T wave
Findings: Normal
Upright: I, II, V3, V4, V5, V6
Inverted: aVR, V1
Increased Amplitude: aVL and aVF

Findings: T Wave Shape

Smooth: Normal
Notched: Pericarditis
Pointed: Myocardial Infarction

Contd
Findings: T Wave Height
Normal
Limb leads: <5 mm
Precordial leads: < 10 mm

Tall T Wave Causes

Hyperkalemia
Myocardial Infarction
Myocardial Ischemia
Cerebrovascular Accident

Contd
Causes: T Wave Inversion in anterior
leads (V2 to V4)
Anterior Myocardial Ischemia
Posterior Myocardial Infarction
Pulmonary Embolism

U- wave

Deflections in different leads:

Intervals
Atrial and ventricular depolarization and
repolarization are represented on the ECG

Contd
Feature

Description

Duration

RR interval

The interval between an R 0.6 to 1.2s(3-6 large

wave and the next R wave boxes)

P wave

SA node towards the AV

node, and spreads from
the right atrium to the left
atrium

80-120ms( 2-3small box)

PR interval

reflects the time the

electrical impulse takes to
travel from the sinus node
through the AV node and
entering the ventricles

120 to 200ms(1 large box)

Contd
feature

description

duration

PR segment

The impulse vector is

from the AV node to the
bundle of His to the
bundle branches and
then to the Purkinje
fibers

50 to 120ms(1-3 small
boxes)

QRS complex

The QRS complex

reflects the rapid
depolarization of the
right and left ventricles

80 to 120ms(2-3 small
boxes)

J-point

point at which the QRS

complex finishes & ST
segment begins, used to N/A
measure ST elevation /
depression

Features

Description

Duration

ST segment

represents the period

when the ventricles are
depolarized. It is
isoelectric.

80 to 120ms(2- 3 smll
boxes)

T wave

The T wave represents

the repolarization of the
ventricles

160ms (4 small boxes)

ST interval

The ST interval is
measured from the J
point to the end of the T
wave.

320ms( 1 large box & 3

small boxes)

QT interval

measured from the

beginning of the QRS
complex to the end of the
T wave .It varies with
heart rate ,for clinical
relevance requires a
correction for this, giving
the QTc.

Up to 420ms in heart rate

of 60 bpm

Calculation of heart rate

Method 1
Ecg strip of 6 sec
Count QRS
complexes
To get 1min HR
multiply it by 10

Method 2
Paper speed=
25mm/ sec
means 25 small
boxes / sec
Small boxes in 1
min = 25multiply
60= 1500
1500/no. of small
boxes in P-P interval
& R-R interval

Abnormal ECG findings

SA node dysrhythmias
Sinus bradycardia- HR- less than 60b/m
Venrtricular & atrial rhythm - regular

Sinus tachycardia
HR- more than 100 & less than 120b/m
Ventricular & atrial rhythm - regular

Contd

Sinus aarhythmias
HR- b/w 60-100b/m
Ventricular & atrial rhythm irregular

Atrial dysrhythymias
Premature atrial complex:early p wave & shorter
Ppintetval

Atrial flutter

Contd

Atrial fibrillation

Ventricular tachycardia

Electrolyte abnormalities
Serum potassium - major intracellular ion
participates in- depolarization and repolarization
of myocardial cells
serum concentration- effect on the QRS and STT complex.

Hyperkalemia
Peaked T wave
QRS wide
prolonged PR
QT short

Hypokalemia
T wave -flattened or inverted
Appearance of a prominent- U wave
ST segment - depressed

Calcium
hypercalcemia- is associated with short
QT interval
hypocalcemia- with long QT interval

Drug effects
At toxic levels digoxin- causes sinus
bradycardia
Amiodarone increases PR,QRS,QT
intervals
Quinidine , procainamide- prolong QRS
duration & QT interval

References:
http://www. lifehugger.com. ECG- simplified.
Aswini Kumar M.D. Retrieved 2013-11-11.
Bazett HC. (1920). "An analysis of the timerelations of electrocardiograms". Heart (7):
353370
http://library.med.utah.edu/kw/ecg
Einthoven's Triangle .Retrieved 2013-11-11

Contd
Luthra A. ECG for nurses. Japee brothers.p3-127
Bazett HC. (1920). "An analysis of the timerelations of electrocardiograms". Heart (7):
353370.