ECG Basics

A guide for entry level providers

D. Robert Handy, BSRT, CRT, EMT-I

Synopsis
ECG Monitoring Basics Components & Measurements of the ECG Complex ECG Analysis Basic Rhythms Recognition Questions

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ECG Monitoring

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ECG Monitoring

The purpose of ECG monitoring is to Measure and diagnose heart rhythms by Recording the electrical activity of the heart

DOES NOT RECORD MECHANICAL ACTIVITY

Monitoring for electrical abnormalities

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ECG Monitoring
ECG Lead placement A three lead ECG is the most common, basic recording method Leads are placed as shown to obtain up to 5 views of the heart The most common lead to read and interpret from in ECG Basics - 2011 55 HANDY Click to edit Master text styles Second level Third level Fourth level Fifth level

ECG Monitoring
Bipolar Leads
1 positive and 1 negative electrode

RA always negative LL always positive

Traditional limb leads are examples of these

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Lead I Lead II Lead III

Provide a view from a vertical plane

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ECG Monitoring
Einthovens Triangle
Each lead looks from a different perspective Can determine the direction of electrical impulses Upright electrical recording indicates electricity flowing towards the + electrode

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positive deflection
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ECG Monitoring
ECG Graph Paper

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Every 5 lines (boxes) are bolded Horizontal axis - 1 and 3 sec marks

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Components of the ECG

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Components of the ECG Complex

Components & Their Representation
P, Q, R, S, T Waves PR Interval QRS Interval ST Segment

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Components of the ECG Complex

P Wave
first upward deflection represents atrial depolarization usually 0.10 seconds or less usually followed by QRS complex

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Components of the ECG Complex

QRS Complex
Composition of 3 Waves

Q, R & S represents ventricular depolarization

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much variability

usually < 0.12 sec

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Components of the ECG Complex

Q Wave
first negative deflection after P wave depolarization of septum not always seen

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Components of the ECG Complex

R Wave
first positive deflection following P or Q waves subsequent positive deflections are R, R, etc

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Components of the ECG Complex

S Wave
Negative deflection following R wave subsequent negative deflections are S, S, etc may be part of QS complex

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absent R wave in aberrant conduction

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Components of the ECG Complex

PR Interval
time impulse takes to move through atria and AV node from beginning of P wave to next deflection on baseline (beginning of QRS complex) normally 0.12 - 0.2 sec may be shorter with faster rates
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Components of the ECG Complex

QRS Interval
time impulse takes to depolarize ventricles from beginning of Q wave to beginning of ST segment usually < 0.12 sec

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Components of the ECG Complex

J Point
point where QRS complex returns to isoelectric line beginning of ST segment critical in measuring ST segment elevation

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Components of the ECG Complex

ST Segment
early repolarization of ventricles measured from J point to onset of T wave elevation or depression may indicate abnormality

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Components of the ECG Complex

T Wave
repolarization of ventricles concurrent with end of ventricular systole

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Components of the ECG Complex

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Bringing it all together

A look at the waves with the measurements

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Components of the ECG Complex

Bringing it all together Follow the path of the electrical activity through the chambers and see how it corresponds with the ECG tracing
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ECG Analysis

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ECG Analysis
Look at 5 things Rate Rhythm/Regularity QRS Complex P Waves Relationships & Measurements

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ECG Analysis
Rate Normal 60-100 bpm Bradycardic (slow) - <60 bpm Tachycardic (fast) - >100 bpm Measure R-R interval Box short cut
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ECG Analysis
Rhythm/Regularity Should find regular distance between R waves Classification

Regular Irregular

Regularly irregular Irregularly irregular

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ECG Analysis
QRS Complex Narrow

< 0.12 seconds (3 small boxes) is normal indicates supraventricular origin (AV node or above) of pacemaker

Wide

> 0.12 seconds is wide indicates ventricular or supraventricular w/aberrant conduction

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ECG Analysis
P Waves Present? Do they all look alike? Regular interval Upright or inverted in Lead II?

Upright = atria depolarized from top to bottom Inverted = atria depolarized from bottom to top

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ECG Analysis
Relationships/Measurements PR Interval

Constant? Less than 0.20 seconds (1 large box)

P to QRS Relationship

P wave before, during or after QRS? 1 P wave for each 1 QRS? Regular relationship?
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ECG Analysis
A monitoring lead can tell you:
How often the myocardium is depolarizing How regular the depolarization is How long conduction takes in various areas of the heart Right vs. Left bundle branch The origin of the impulses that are depolarizing the myocardium blocks Quality of pumping action
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A monitoring lead can not tell you:

Presence or absence of a myocardial infarction Axis deviation Chamber enlargement

Basic Rhythms

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Normal Sinus Rhythm (NSR)

Rate: 60-100 per minute Rhythm: R - R = P waves: Upright, similar P-R: 0.12 - 0 .20 second & consistent qRs: 0.04 0.10
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Sinus Tachycardia
Rate: > 100 Rhythm: R - R = P waves: Upright, similar P-R: 0.12 - 0 .20 second & consistent qRs: 0.04 0.10 second P:qRs: 1P:1qRs
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Sinus Bradycardia
Rate: < 60 Rhythm: R - R = P waves: Upright; similar P-R: 0.12 - 0 .20 second & consistent qRs: 0.04 0.10
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Premature Atrial Contraction (PAC)

Rate: usually < 100, dependant on underlying rhythm Rhythm: irregular P waves: Early & upright, different from Sinus PR: 0.12 0.20 second; different from Sinus qRs: 0.04 0.10

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Atrial Flutter
Rate: Atrial rate 250-350 Vent 150 common Rhythm: Atrial = Regular Vent = Reg. or irreg P waves: Not identifiable F waves: Uniform (sawtooth or picket fence ) PRI: not measurable qRs: 0.04 0.10 second
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Atrial Fibrillation
Rate: Atrial: 400-700 Vent. 160-180/minute Rhythm: Atrial: irregular; Vent.: irregular P waves: No identifiable Ps f waves: may be seen. PRI: unable to measure (No identifiable P) qRs: usually normal
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Junctional Escape Rhythm

Rate: 4060, 61100 (accelerated) Rhythm: Regular P waves: Inverted before or after qRs or not visible PR interval: < 0.12 second when inverted P is before qRs qRs: 0.04 0.10 second P:qRs 1:1 if Ps are visible
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Junctional Tachycardia
Rate: 101-200 Rhythm: Regular P waves: Inverted before or after qRs or not visible PR interval: < 0.12 second when inverted P is before qRs qRs: 0.04 0.10 second P:qRs 1:1 if Ps are visible
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Supraventricular Tachycardia (SVT)

Rhythm: Absolutely regular Rate: > 150 per minute P Waves: Not visible (PRI not measurable) qRs: normal 0.04 0.10 sec
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Premature Ventricular Complex (PVC)

Rate: Dependent upon underlying rhythm Rhythm: R R P waves: Usually absent, if present, not associated with PVC qRs: 0.12 second or greater; bizarre and notched ST & T: Often opposite in direction to the qRs.
Cont. on next slide

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Premature Ventricular Complex (PVC) cont.

Timing One on a strip = Rare One in a row = Isolated Two in a row = Pair, couplet Three in a row = V Tachycardia Pattern Every other = Bigeminy Every third = Trigeminy Morphology Similar shape = Uniformed Different shape = Multiformed Location R on T = PVC falls on the T wave

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Ventricular Tachycardia
Rate: > 100 per minute and usually not > 220 Rhythm: Usually regular P Waves: P waves or if present, not associated with qRs qRs: Wide ( 0.12 sec), bizarre ST/T wave: Opposite direction of qRs A group of three PVCs in a row or more at a HANDY - ECG Basics - 2011 rate 4343
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Ventricular Fibrillation
Rate: Rhythm: regularity, chaotic undulating waves P Waves: qRs: ST/T Wave: Organized activity: No Cardiac Output or Pulse
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Idioventricular Rhythm (IVR)

Rate: 20-40 per minute Rhythm: R R = P waves: No P waves associated to qRs qRs: > 0.12 sec, notched, bizarre appearance ST/T : Opposite direction of qRs Rate > 40 to 100 = Accelerated
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Asystole
Rate: Ventricular rate = 0 Rhythm: unless Ps are present, then regular or irregular P waves: may be present qRs: P:qRs

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1st degree AV Block

1P : 1 qRs Prolonged PRI (> 0.20 sec not > 0.40 sec)

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2nd degree AV Block, type I (Wenckebach)

More P waves than qRs PRI progressively increases in a cycle until P appears w/o qRs. Cyclic pattern reoccurs RR
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2nd degree AV Block, type II (Mobitz II)

More P waves than qRs PRI consistent qRs normal or wide (bundle branch block) R - R or R R =
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3rd degree AV Block (complete heart block)

More P waves than qRs P not r/t qRs (P too close, P too far) PRI varies greatly qRs normal or wide RR= A divorced rhythm
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Bundle Branch Block Pattern

Inappropriate conduction of electricity through Bundle of HIS, usually due to injury, affecting either right or left side Cannot diagnose right vs. left using only one lead, may look similar to PVCs or V-Tach Can be charted/documented as Bundle Branch Block Pattern or BBB Pattern

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Left Bundle Branch Block Right Bundle Branch Block

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Et Cetera

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Extra Resources
Videos for Review
ECG Dance (Living Arrhythmias) with Dr. John C. Grammer

Web Content
www.skillstat.com Tools ECG Simulator

Dr. Grammer ECG Dance

Therapists Sacred Lung Hospital with Handy

Library.med.utah.edu/kw/ecg

or type ECG Learning Center into your favorite search engine

Therapists - Sacred Lung Hospital

Both videos are available on YouTube 5454 HANDY - ECG Basics - 2011

???

Questions? Comments? Answers?

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Thank you for your time

D. Robert Handy
BSRT, CRT, EMT-I 801-497-1075 emtman@live.com

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th fixed wi be rs in g c a n Anyth ma shea au e and tr 2 tap

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