ECG SUPPLEMENTAL ECG SUPPLEMENTAL TRAININGTRAINING

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BRAD CHAPMAN RCTBRAD CHAPMAN RCT

INTRODUCTIONINTRODUCTION

This supplemental course is to help RN’s, LPN’s and MRT’s to do This supplemental course is to help RN’s, LPN’s and MRT’s to do an accurate ECG in a hospital setting when a Cardiology an accurate ECG in a hospital setting when a Cardiology Technologist is not available. This course is not in anyway to Technologist is not available. This course is not in anyway to replace Cardiology Technologist but to give the best patient care replace Cardiology Technologist but to give the best patient care possible.possible.

New Brunswick is currently the only province in Canada that has New Brunswick is currently the only province in Canada that has legislation in place regarding ECG’s, Stress Testing, Holter legislation in place regarding ECG’s, Stress Testing, Holter Monitoring and Pacemakers. An ECG can only be done by Monitoring and Pacemakers. An ECG can only be done by someone other then a Cardiology Technologist if a Cardiology someone other then a Cardiology Technologist if a Cardiology Technologist is not available. Examples would be outer hospitals Technologist is not available. Examples would be outer hospitals and nights at some facilities where a Cardiology Technologist is not and nights at some facilities where a Cardiology Technologist is not present.present.

What is an ECG?What is an ECG?

An ECG is a test that measures An ECG is a test that measures the electrical activity of the the electrical activity of the heart from 12 different views.heart from 12 different views.

There are many things There are many things assessed through an ECGassessed through an ECG

1.1. RateRate

2.2. RhythmRhythm

3.3. RegularityRegularity

4.4. VoltageVoltage

5.5. Conduction (Axis)Conduction (Axis)

The result from these recordings The result from these recordings form an ECGform an ECG

The waves produced from these The waves produced from these electrical impulses are charted on electrical impulses are charted on

graph paper.graph paper.

What do all the lines mean?What do all the lines mean?

A typical ECG tracing of a normal A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a P heartbeat (or cardiac cycle) consists of a P wave, a QRS complex and a T wave. wave, a QRS complex and a T wave.

The BaselineThe Baseline

It’s the straight line in between It’s the straight line in between each waveeach wave

BaselineBaseline

It is important to have a clear steady It is important to have a clear steady baseline for interpretation of the ECG.baseline for interpretation of the ECG.

You want a nice horizontal line.You want a nice horizontal line. If the baseline is wandering, one can’t truly If the baseline is wandering, one can’t truly

assess for S-T elevations accurately.assess for S-T elevations accurately.Note the baseline wandering of this strip.Note the baseline wandering of this strip.

The “P” WaveThe “P” Wave Initial contraction (depolarization) of the atria.Initial contraction (depolarization) of the atria.The first wave to appear in a cardiac cycle.The first wave to appear in a cardiac cycle.Rounded and symmetrical.Rounded and symmetrical.Precedes QRS complexPrecedes QRS complexTypically upright in all leads except AVR.Typically upright in all leads except AVR.There should only be There should only be oneone “P” wave for every “P” wave for every

QRST (1:1 RATIO).QRST (1:1 RATIO).

QRS WavesQRS Waves Initial contraction or Initial contraction or

depolarization of the depolarization of the ventricle.ventricle.

The Q wave is located at The Q wave is located at the beginning of the the beginning of the complex. This is the first complex. This is the first negative (downward) negative (downward) deflection. Not all ECG’s deflection. Not all ECG’s will show a “Q” wave.will show a “Q” wave.

The R wave is the first The R wave is the first positive (upward) deflection positive (upward) deflection of the QRS.of the QRS.

The S wave is the negative The S wave is the negative (downward) deflection (downward) deflection following the R wave.following the R wave.

ST SegmentST Segment

Represents the beginning of ventricular Represents the beginning of ventricular repolarization (relaxation and refilling).repolarization (relaxation and refilling).

End of the S wave to the beginning of the T End of the S wave to the beginning of the T wave.wave.

The ST segment is often used in diagnosing The ST segment is often used in diagnosing infarcts, ischemia etc.infarcts, ischemia etc.

ST segment are observed for elevation, ST segment are observed for elevation, depression, T wave inversion, etc.depression, T wave inversion, etc.

““T” WaveT” WaveRepresents ventricular repolarization Represents ventricular repolarization

(electrical recovery).(electrical recovery).Follows ST segmentFollows ST segmentUsually rounded and symmetricalUsually rounded and symmetricalUpright in most leads, may be inverted Upright in most leads, may be inverted

in AVR and AVL.in AVR and AVL.

The paper from the ElectrocardiographThe paper from the ElectrocardiographECG paper is made up of small and large boxes. ECG paper is made up of small and large boxes. The small boxes measure .04 seconds while as the big boxes (5 small The small boxes measure .04 seconds while as the big boxes (5 small

boxes) measure 0.04 X 5 = .20 seconds.boxes) measure 0.04 X 5 = .20 seconds.An easy way to calculate the rate on your ECG is to count the number An easy way to calculate the rate on your ECG is to count the number

of large squares between R waves and count as follows:of large squares between R waves and count as follows:

10 Wires – 12 Angles???10 Wires – 12 Angles???

How can I get 12 different angles from an ECG with only 10 How can I get 12 different angles from an ECG with only 10 wires? Only the chest leads read what is going on directly wires? Only the chest leads read what is going on directly underneath them. The rest read as follows:underneath them. The rest read as follows:

Lead I: The electrical current moves from the Right Arm towards Lead I: The electrical current moves from the Right Arm towards the Left Armthe Left Arm

Lead II: The electrical current moves from the Right Arm Lead II: The electrical current moves from the Right Arm towards the Left Legtowards the Left Leg

Lead III: The electrical current moves from the Left Arm to the Lead III: The electrical current moves from the Left Arm to the Left LegLeft Leg

These leads will all have a positive deflection.These leads will all have a positive deflection.

The Unipolar LeadsThe Unipolar Leads

Leads AVR, AVL and AVF, they are called Leads AVR, AVL and AVF, they are called augmented leads.augmented leads.

AVR: Recording are from Right arm to the AVR: Recording are from Right arm to the midpoint of the chest.midpoint of the chest.

AVF: Recording are from left leg to the AVF: Recording are from left leg to the midpoint of the chest.midpoint of the chest.

AVL: Recording are from Left arm to the AVL: Recording are from Left arm to the midpoint of the chest.midpoint of the chest.

Lead PlacementLead Placement

Find the first intercoastal space by moving a Find the first intercoastal space by moving a finger down the right collar bone towards the finger down the right collar bone towards the sternum. Stop a ½ “ before the sternumsternum. Stop a ½ “ before the sternum

Rock fingers down chest counting the intercostal Rock fingers down chest counting the intercostal spacesspaces

Count down to the 4Count down to the 4thth intercostal space, this will intercostal space, this will be the V1 positionbe the V1 position

Repeat process on the Left side of the sternum Repeat process on the Left side of the sternum and place V2and place V2

Draw a vertical line Draw a vertical line from mid-clavicular to from mid-clavicular to under the breast and under the breast and place a sticker. This place a sticker. This will be V4.will be V4.

V3 would be on a V3 would be on a diagonal plane between diagonal plane between v2 and v4 and on top of v2 and v4 and on top of the breast.the breast.

Visually drop a Visually drop a horizontal straight line horizontal straight line down from v4 to mid-down from v4 to mid-auxilla and place a auxilla and place a sticker (v6)sticker (v6)

Place V5 between v4 Place V5 between v4 and v6and v6

Chest Lead PlacementChest Lead Placement

All chest leads are labelled v1, v2, v3,...v6.All chest leads are labelled v1, v2, v3,...v6.All leads are color coded.All leads are color coded.Chest leads are Chest leads are

RedRedYellowYellowGreenGreenBlueBlueOrangeOrangePurplePurple

Easy to rememberEasy to remember

Stop LightStop LightRRed, ed, YYellow, ellow, GGreenreen

BOPBOPBBLUE, LUE, OORANGE, RANGE,

PPURPLEURPLE

A Technically Accurate ECG!A Technically Accurate ECG!

LEAD I will always have a positive LEAD I will always have a positive deflection and the R wave will be upright.deflection and the R wave will be upright.

The “R” wave is the first “Positive” The “R” wave is the first “Positive” deflection after the “P” wave.deflection after the “P” wave.

The “R” wave will be small in V1 and get The “R” wave will be small in V1 and get larger as you go to V5. V6 will be slightly larger as you go to V5. V6 will be slightly smaller then V5.smaller then V5.

Standardization will be 10 mvStandardization will be 10 mv

What to look for on an ECGWhat to look for on an ECG

1: 1: Check for correct patient information, Check for correct patient information, ordering physician, location, time and date.ordering physician, location, time and date.

22: Paper speed (25 mm/ms): Paper speed (25 mm/ms) 3: 3: Standardization should be at (10 mm/mv) to Standardization should be at (10 mm/mv) to

check if this is accurate, check your squares at check if this is accurate, check your squares at the end of leads V4, V5 and V6 .the end of leads V4, V5 and V6 .

44: All leads are visible and without artifact.: All leads are visible and without artifact. 5: 5: You should have a positive R wave in lead I.You should have a positive R wave in lead I.

What to look for on an ECGWhat to look for on an ECG

6: 6: You should have a good R wave You should have a good R wave progression in the chest leads V1 to V6. progression in the chest leads V1 to V6. The R wave is small in V1 and becomes The R wave is small in V1 and becomes progressively larger as it continues to V6.progressively larger as it continues to V6.

7: 7: 1 P wave per QRS complex, 1:1 ratio. 1 P wave per QRS complex, 1:1 ratio. 8:8: Before removing your electrodes check Before removing your electrodes check

to make sure all limb leads and chest to make sure all limb leads and chest leads are situated in the right position.leads are situated in the right position.

R WAVE PROGRESSIONR WAVE PROGRESSION

R WAVE PROGRESSIONR WAVE PROGRESSIONNote “R” wave increases in positive deflection from leads V1 to V5 and then slightly smaller in V6. Proper lead hook-up.

POOR R WAVE PROGRESSIONPOOR R WAVE PROGRESSIONNote “R” wave progression from V1 to V3. It goes from tall R wave to shorter then small then to biphasic. V1 and V3 are reversed – most common mistake in lead reversal.

BIPHASIC EXAMPLESBIPHASIC EXAMPLES

Between V3 and V4 the lead will be “Biphasic” Between V3 and V4 the lead will be “Biphasic” (almost equally upward as downward)(almost equally upward as downward)

What to look for in an ECGWhat to look for in an ECGElectrode/lead placement is very important.  If Electrode/lead placement is very important.  If

one were to accidentally confuse the red and one were to accidentally confuse the red and white lead cables (i.e. place the white one white lead cables (i.e. place the white one where the red one should go, vice versa), he where the red one should go, vice versa), he might get an ECG that looks like below.might get an ECG that looks like below.

In this ECG, we can make out a normal sinus In this ECG, we can make out a normal sinus rhythm with all of the waves upside-down. rhythm with all of the waves upside-down. 

REVIEW QUIZ!REVIEW QUIZ!

Thank you for your time.Thank you for your time.