Electrocardiogram

Clinical Skills III

NYIT Physician Assistant Studies

Electrocardiogram: (ECG or EKG)

ECG is a graphic record of electric currents that are
generated by the heart muscles.
Electrical impulses are picked up by a surface electrode
which are placed at various points on the body and
connected the ECG machine.

Indications for Electrocardiogram:

Baseline evaluation
Response to therapy
Prior to surgery
Medication overdose
Electrical injury (arrhythmia)
Syncope (bradycardia)
Pain, Dyspnea

Cardiac Pathology Diagnosed by EKG:

Arrhythmias ( slow, rapid, irregular heart beat)
Myocardial ischemia and infarction
Chamber hypertrophy
Congenital heart defects involving the conducting (electrical)
system
Abnormal position of the heart
Pericarditis or myocarditis
Cardiac Arrest
Disturbances of the hearts conducting system (heart blocks)
Electrolyte disturbances
Drug Toxicity

Assessment
Assess age, gender, current medication history (meds with
possible cardiac or hemodynamic effects). Other data that may
be required such as height, weight, blood pressure.
Determine that the patient is able to tolerate a supine position
and that adequate exposure of chest and limbs is possible for
electrode placement.
Determine presence of neck, arm, jaw, or other pain with
possible cardiac origin. Chest or other pain may provide
additional information useful in serial comparison of ECGs.
Assess patient need for information about the procedure purpose
and requirements and ability to cooperate:

Equipment Needed
Twelve-lead ECG machine with charged battery,
cables and leads, graph paper
Disposable electrodes
Alcohol wipes
Pillows
Sheet or drape
Disposable razor if needed

Complications of EKG:
-

Safe procedure
No known risks
No electric current sent to body
Possible allergic or sensitivity to electrodes
(local skin reaction)

Normal Conduction System of

Heart:

Basic Electrical Activity of the Heart:

Myocardial cells (muscle cells) of heart:
interior cells - negatively charge at rest
the surface - positively charged

Contraction of heart muscle:

Electrical stimulation positively charges cells
Cells prepare to contract depolarization occurs
Depolarization passes through heart contraction of myocardium

Depolarization : stimulates myocardial cells to contract and

cell changes to positive
Repolarization : gain negative charge

P wave: (depolarization) of the right and left atria

QRS complex: right and left ventricular depolarization
ST-T wave: ventricular repolarization
U wave: origin for this wave is not clear
(probably septal repolarization)
PR interval: time interval from onset of atrial
depolarization (P wave) to onset of
ventricular depolarization (QRS complex)
QRS duration: duration of ventricular depolarization
QT interval: duration of ventricular depolarization and repolarization
RR interval: duration of ventricular cardiac cycle (ventricular rate)
PP interval: duration of atrial cycle (atrial rate)
R wave - first positive deflection after p wave
Q wave - first negative deflection after p wave BEFORE positive deflection of R wave
Pathologic:>1mm wide (.04sec) or >1/3 amplitude of QRS complex
Old Qs remain
S wave - negative deflection after R wave

12 Lead ECG:
The 12-lead ECG provides views of cardiac electrical
activity from 12 different vantage points on the body surface.
Composed of 12 separate leads: 6 limb leads ( 3 standard
and 3 augmented leads) and 6 chest leads (precordial leads)
Displays the cardiac cycle in four lead groups that describe
the cardiac cycle in relation to lead placement
Lead groups:

Lateral ( I, aVL, V5 and V6)

Inferior (II, III and aVF)
Septal (V1 and V2)
Anterior (V3 and V4)

ECG LEADS:

Anatomical Groups:

Precordial
Leads
(chest
leads)

Identify /Placement of Chest Leads (Precordial):

V1 = 4th intercostal space right of sternal
border
V2 = 4th intercostal space left of sternal
border
V3 = midway between leads V2 and V4
V4 = mid-clavicular line, at the 5th
interspace
V5 = anterior axillary line at the 5th
interspace
V6 = mid-axillary line at the 5th interspace

Identify/Placement Limb Leads

RL - Anywhere above the ankle and below the torso
RA - Anywhere between the shoulder and the elbow
LL - Anywhere above the ankle and below the torso
LA - Anywhere between the shoulder and the elbow

12 Lead EKG

Artifacts on ECG:
Sweat: shorts electrodes
Pulse artifact: electrode on pulse and moves
Movement artifacts: patient moves
Electrical artifact: electrical activity near patient

Rhythm Strips:
Rhythm strip longer look at rate and rhythm
Each machine - set at certain lead but can be changed
Set multiple leads -multiple rhythm strips at a time

ECG Variations
15 lead ECG adds 3 additional chest leads
across the right precordium
Valuable tool for the early diagnosis of right
ventricular and posterior left ventricular
infarction.
18-lead ECG adds 3 posterior leads to the 15lead ECG
Very useful for early detection of myocardial
ischemia and injury

Holter Monitor:

Portable EKG
Electrodes placed on chest - patient wears recorder
around neck or waist for 24-48 hours
A diary - times symptoms occur and readings
Helps identify conditions - sporadic and not captured on
EKG

Video on How to Perform EKG:

https://youtu.be/RQQ-DCDE4-Q

Inferior MI
Pathologic Q waves and evolving ST-T changes in leads
II, III, aVF.
Q waves usually largest in lead III, next largest in lead
aVF, and smallest in lead II

Inferoposterior MI
ECG changes are seen in anterior precordial leads V1-3, but are
the mirror image of an anteroseptal MI,
Increased R wave amplitude and duration (i.e., a "pathologic R
wave" is a mirror image of a pathologic Q).
Hyperacute ST-T wave changes: i.e., ST depression and large,
inverted T waves in V1-3.
Late normalization of ST-T with symmetrical upright T waves in
V1-3.
Often seen with inferior MI (i.e., "inferoposterior MI")

Right Ventricular MI
Right Ventricular MI (seen with proximal right coronary
occlusion)
ECG findings usually require additional leads on right
chest (V1R to V6R, analogous to the left chest leads)
ST elevation, >1mm, in right chest leads, especially
V4R.

Anterior MI

High Lateral MI