BASIC ECG

in the eyes of NURSE

Christopher S. Mallari, R.N.
Clinical Instructor
Certified IV Therapist
BLS/ACLS Certified Provider (UP-PGH/AHA)
Objective
1. To provide a thorough understanding of
both the fundamental principles of clinical
electrocardiography.
2. Basics of electrical therapy
 LAYERS OF THE HEART WALL

Epicardium
– Coronary arteries are
found in this layer

Myocardium
– Responsible for
contraction of the heart

Endocardium
– Lines the inside of the
myocardium
– Covers the heart valves
CONDUCTION SYSTEM OF THE HEART

SA Node

Atrial Muscle
AV Node

Bundle of His
Bundle Branches
Purkinje Fibers
Ventricular Muscle
 ELECTROCARDIOGRAM

The electrocardiogram (ECG) is a graphic

recording of the electrical potentials produced
by the cardiac tissue.
– Electrical impulse formation occurs within the
conduction system of the heart.
– Excitation of the muscle fibers throughout the
myocardium results in cardiac contraction.
The ECG is recorded by applying electrodes to
various locations on the body surface and
connecting them to a recording apparatus.
 ELECTROCARDIOGRAM

Clinical Value of the ECG

– Atrial and ventricular hypertrophy
– Myocardial ischemia and infarction
– Systemic diseases that affect the heart
– Determination of the effect of cardiac drugs
– Disturbances in electrolyte balance
– Evaluation of function of cardiac pacemakers
 ELECTROPHYSIOLOGY OF THE HEART

Four Electrophysiologic Events Involved in the

Genesis of the ECG
– Impulse formation
– Transmission of the impulse
– Depolarization
– Repolarization
 12 LEAD ECG

Limb Leads
RA Red Right arm
LA Yellow Left arm
LL Green Left leg
RL Black Right
Chest Leads 12 LEAD ECG
V1 Red 4th ICS RPSB
V2 Yellow 4th ICS LPSB
V3 Green Midway between V2 and V4
V4 Brown 5th ICS LMCL
V5 Black LAAL Lateral & horizontal to V4
V6 Violet LMAL Lateral & horizontal to V4
ECG PAPER
 TERMINOLOGY

Definition of Terms

Waveform
– Movement away from the baseline
in either a positive or negative
direction
 TERMINOLOGY

Definition of Terms

Segment
– A line between wave forms
 TERMINOLOGY

Definition of Terms

Interval
– A waveform + segment
 THE NORMAL ELECTROCARDIOGRAM

P wave
– Generated by activation of the atria
PR segment
– Represents the duration of atrioventricular (AV)
conduction
QRS complex
– Produced by activation of both ventricles
ST-T wave
– Reflects ventricular recovery
 STANDARD 12 LEAD ECG

The P wave
– Atrial activation
– Height < 2 mm
– Duration < 0.12 sec
ECG PAPER
 STANDARD 12 LEAD ECG

P-R Interval
– Intraatrial, internodal, His purkinje conduction
– Duration 0.12 to 0.20 sec
ECG PAPER
 STANDARD 12 LEAD ECG

The QRS Complex

– Ventricular activation
– Duration of <0.10 sec
ECG PAPER
 STANDARD 12 LEAD ECG

The ST-segment

– Isoelectric in normal subjects

 STANDARD 12 LEAD ECG

The T wave
– Ventricular relaxation
- Normally upright
The QT Interval
– From beginning of QRS to end of T wave
– Reflects the duration of depolarization and
repolarization
 ANALYZING ECG

I. Rate
II. Rhythm
III. Axis
IV. Hypertrophy
V. Ischemia and Infarction
VI. Miscellaneous

Mnemonic: RRAHIM
The Normal ECG
 ANALYZING ECG

I. RATE
 ANALYZING A RHYTHM STRIP

I. RATE
a) 3 Possibilities:
- Bradycardia (<60 beats/minute)
- Normal Rate (60-100 beats/minute)
- Tachycardia (>100 beats/minute)
 ANALYZING A RHYTHM STRIP

I. RATE
b)Rate Analysis

1. Mnemonic – using # of big squares between R-

R intervals
300, 150, 100, 75, 60, 50, 40, 30

2. Formula
HR = 1500/# of small boxes between the R-R
interval
or
HR = 300/# of big boxes between the R-R
interval
 What Is The Rate?

I. Rate
– 1500/#Small squares (R-R Interval)
– 300/#Big squares (R-R Interval)

R R
Normal Rate
Bradycardia
Tachycardia
 ANALYZING ECG

II. RHYTHM
 ANALYZING A RHYTHM STRIP

II. Rhythm
Tips
- Identify the P wave
- Identify the relationship of P wave to the
QRS
- Check the PR interval
- Check QRS duration
- Check the R-R interval and P-P interval
 STANDARD 12 LEAD ECG

Identify the P wave

– Atrial activation
– Height < 2 mm
– Duration < 0.12 sec
 STANDARD 12 LEAD ECG

The QRS Complex

– Ventricular activation
– Duration of <0.10 sec
– Identify the relationship of P wave to the QRS
 STANDARD 12 LEAD ECG

P-R Interval
– Intraatrial, internodal, His purkinje conduction
– Duration 0.12 to 0.20 sec
QRS duration
Rhythm Interpretations

Sinus rhythm
Normal Rate, Regular (sinus) Rhythm
Bradycardia, Regular (sinus) rhythm
Tachycardia, Regular (sinus) rhythm
Rhythm Interpretations

Atrial fibrillation
- HR = # of QRS in a 6 sec. Strip X 10

R R R R
Atrial Fribrillation
Rate Atrial rate usually greater than 350-400 beats per
minute; ventricular rate variable
Rhythm Ventricular rhythms usually very irregular

P waves No identifiable P waves; fibrillatory waves present.

Erratic wavy baseline.
PR interval Not measurable
QRS Usually less than 0.10 second but may be
widened if an intraventricular conduction defect
exists.
II. Rhythm Interpretations
Atrial Flutter

Sawtooth appearance

R R R R
 Atrial Rhythms
Atrial Flutter
Rate Atrial rate 250-350 beats per minute; ventricular
rate variable – determined by AV blockade. The
ventricular rate will usually not exceed 180 beats
per minute due to the intrinsic conduction rate of
the AV junction.
Rhythm Atrial regular
Ventricular may be regular or irregular
P waves No identifiable P waves; saw-toothed “flutter
waves”
PR interval Not measurable
QRS Usually less than 0.10 second but may be
widened if flutter waves are buried in the QRS
complex or if an intraventricular conduction
defect exists.
Rhythm Interpretations

Supraventricular Tachycardia
 Atrial Rhythms

Supraventricular Tachycardia
Rate 150-250 beats per minute
Rhythm Regular
P waves Atrial P waves may be seen which differ from sinus P
waves (may be flattened, notched, pointed, or
biphasic). P waves are usually identifiable at the
lower end of the rate range but are seldom identifiable
at rates above 200. May be lost in the preceding T
wave.
PR interval Usually not measurable because the P wave is difficult
to distinguish from the preceding T wave. If P waves
are seen, the RR interval will usually measure 0.12-
0.20 second.
QRS Less than 0.10 second unless an intraventricular
conduction defect exists.
 Atrial Rhythms

ELECTRICAL THERAPY – Synchronized Countershock

Description and Purpose
Synchronized countershock reduces the potential for delivery of
energy during the vulnerable period of the T wave (relative
refractory period). A synchronizing circuit allows the delivery of
a countershock to be “programmed”. The machine searches
for the peak of the QRS complex (R wave deflection) and
delivers the shock a few milliseconds after the highest part of
the R wave.
Indications:
• Supraventricular tachycardia
• Atrial fibrillation
• Atrial flutter
• Unstable ventricular tachycardia with pulse
 ANALYZING A RHYTHM STRIP

Rhythm Interpretation

Ventricular Arrhythmias
 Ventricular Rhythms

Premature Ventricular Complexes (PVC)

Rate Usually normal but depends on the underlying
rhythm
Rhythm Essentially regular with premature beats. If the
PVC is an interpolated PVC, the rhythm will be
regular.
P waves There is no P wave associated with the PVC
PR interval None with the PVCs because the ectopic beat
originates in the ventricle
QRS Greater than 0.12 second.
Wide and bizarre.
T wave frequently in opposite direction of the QRS
complex.
 Ventricular Rhythms

Patterns of PVCs
1. Isolated PVC - < 1/min
2. Multifocal PVCs – PVCs with different morphologies
3. Bigeminal PVCs – every other beat is a PVC
4. Trigeminal PVCs – every third beat is a PVC
5. Quadrigeminal PVCs – every fourth beat is a PVC
6. Pairs (couplets) – two sequential PVCs
7. Runs or bursts (salvos) – three or more sequential PVCs
The Normal ECG
Isolated PVC
Multifocal PVC
PVC in Bigeminy

2
PVC in Quadrigeminy
4 4
1 2 3 1 2 3
PVC in Couplets
PVC in Runs or Bursts
(salvos)
The Normal ECG
 Ventricular Rhythms

Common Causes of PVCs

• Normal variant
• Anxiety
• Exercise
• Hypoxia
• Digitalis toxicity
• Acid-base imbalance
• Myocardial ischemia
• Electrolyte imbalance (hypokalemia, hypocalcemia,
hypercalcemia, hypomagnesemia)
• Congestive heart failure
• Increased sympathetic tone
• Acute myocardial infarction
• Stimulants (alcohol, caffeine, tobacco)
• Drugs (sympathomimetics, cyclic antidepressants,
phenothiazines)
 Ventricular Rhythms

Warning Dysrhythmias
• Six or more PVCs per minute
• PVCs that occurred in pairs (couplets) or in runs or
three or more (ventricular tachycardia)
• PVCs that fell on the T wave of the preceding beat
(R-on T phenomenon)
• PVCs that differed in shape (multiformed PVCs)
Ventricular Tachycardia (VT)
 Ventricular Rhythms

Ventricular Tachycardia (VT)

Rate Atrial rate not discernible, ventricular rate 100-250
beats per minute
Rhythm Atrial rhythm not discernible
Ventricular rhythm is essentially regular
P waves May be present or absent; if present they have no
set relationship to the QRS complexes –
appearing between the QRS’s at a rate different
from that of the VT.
PR interval None
QRS Greater than 0.12 second.
Often difficult to differentiate between the QRS
and the T wave.
Torsade de pointes
 Ventricular Rhythms

Torsades de Pointes (TdP)

Rate Atrial rate not discernible, ventricular rate 150-250
beats per minute
Rhythm Atrial not discernible
Ventricular may be regular or irregular
P waves None
PR interval None
QRS Greater than 0.12 second.
Gradual alteration in the amplitude and direction of
the QRS
Ventricular Fibrillation
 Ventricular Rhythms

Ventricular Fibrillation
Rate Cannot be determined since there are no
discernible waves or complexes to measure
Rhythm Rapid and chaotic with no pattern or regularity
P waves Not discernible
PR interval Not discernible
QRS Not discernible
 Ventricular Rhythms

Defibrillation (Unsynchronized Countershock)

Description and Purpose:
The purpose of defibrillation is to produce momentary asystole. The
shock attempts to completely depolarize the myocardium and
provide an opportunity for the natural pacemaker centers of the
heart to resume normal activity. Defibrillation is a random
delivery of energy – there is no relation of the discharge of
energy to the cardiac cycle.

Indications:
• Pulseless ventricular tachycardia
• Ventricular fibrillation
• Sustained Torsade de pointes
 ELECTRICAL THERAPY

DEFIBRILLATOR
DEFIBRILLATION
Placement of Electrode
The following acronym directs AHA accepted actions after the
Primary ABCDs have been enacted and an AED or Manual
Defibrillator arrives and a shockable rhythm (VF or PVT) is
present: SCREAM LetterInterventionNote

S Shock360J* monophasic, 1st and subsequent shocks.

(Shock every 2 minutes if indicated) 200J biphasic

C CPR After shock, immediately begin chest compressions

followed by respirations (30:2 ratio) for 2 minutes. (Do not
check rhythm or pulse)

R RhythmRhythm check after 2 minutes of CPR (and after every 2

minutes of CPR thereafter) and shock again if indicated. Check
pulse only if an organized or non-shockable rhythm is
present.Implement the Secondary ABCD Survey. Continue this
algorithm if indicated. Give drugs during CPR before or after
shocking. Minimize interruptions in chest compressions to <10
seconds. Consider Differential Diagnosis.
E Epinephrine1 mg IV/IO q3-5 min. Or vasopressin 40
U IV/IO, once, in place of the 1st or 2nd dose of epi.
AM Antiarrhythmic Medications
Amiodarone 300mg IV/IO, may repeat once at
150mg in 3-5 min. if VF/PVT persists or
Lidocaine (if amiodarone unavailable) 1.0-1.5 mg/kg
IV/IO, may repeat X 2, q5-10 min. at 0.5-0.75 mg/kg,
(3mg/kg max. loading dose) if VF/PVT persists,or
Magnesium Sulfate1-2 g IV/IO diluted in 10mL D5W
(5-20 min. push) for torsades de pointes or
suspected/ known hypomagnesemia.* Biphasic
energy level is device dependent, follow the
manufacturer's recommendation. If recommendation
is unknown, use 200J for 1st shock and the same or
higher energy level for subsequent shocks
Asystole
 Ventricular Rhythms

Asystole
Rate Ventricular usually indiscernible but may see some
atrial activity.
Rhythm Atrial may be discernible.
Ventricular indiscernible.
P waves Usually not discernible
PR interval Not measurable
QRS Absent
FLAT LINE PROTOCOL
 ANALYZING ECG

ISCHEMIA AND
INFARCTION
 Atherosclerosis Timeline

Normal Anatomy Complicated

Foam Fatty Intermediate Atheroma Fibrous Lesion/
Cells Streak Lesion Plaque Rupture

Endothelial Dysfunction
From First From Third From Fourth
Decade Decade Decade
Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).
Coronary Heart Disease
 ANALYZING RHYTHM STRIP

Localization
I, AVL
– High lateral wall
II, III, AVF
– Inferior wall AVL

AVR

AVF
 ANALYZING THE RHYTHM STRIP

Localization
V1,V2
– Septal wall
V1-V6 - anterolateral wall MI
V3,V4 I,AVL,V5,V6 – Lateral wall
– Anterior wall
V5,V6
– Lateral wall
V1-V3 or V4
– Anteroseptal wall
V3 or V4-V6
– Anterolateral wall
ST T WAVE CHANGES
•ST elevation
-Myocardial infarction
•ST depression
-Myocardial ischemia
•T wave inversion (symmetrical)
-Myocardial ischemia
•Q waves
-old myocardial infarction
The Normal ECG
Ischemia (T-wave inversion),
lateral wall
 ANALYZING THE RHYTHM STRIP

Localization
V1,V2
– Septal wall
V1-V6 - anterolateral wall MI
V3,V4 I,AVL,V5,V6 – Lateral wall
– Anterior wall
V5,V6
– Lateral wall
V1-V3 or V4
– Anteroseptal wall
V3 or V4-V6
– Anterolateral wall
 Localizing the Lesion

1. V1, V2 = septal
2. V1 - V3 = anteroseptal
3. V1 - V4 = anterior
4. V1 – V6= anterolateral
5. I, AVL, V5, V6 = lateral
6. I, AVL = high lateral
7. II, III, AVF = inferior
Acute MI (ST elevation), inferior wall
 Localizing the Lesion

1. V1, V2 = septal
2. V1 - V3 = anteroseptal
3. V1 - V4 = anterior
4. V1 – V6= anterolateral
5. I, AVL, V5, V6 = lateral
6. I, AVL = high lateral
7. II, III, AVF = inferior
The Normal ECG
 ANALYZING ECG

VI. Miscellaneous
 ANALYZING ECG

Hypokalemia – presence of U waves

Hyperkalemia – peaked T waves, >5mm

in most leads

Hypocalcemia – prolonged QT-interval

Hypercalcemia – shortened QT-interval

Thank You