TECHNICAL SKILLS TECHNICAL SKILLS

HOW TO DOHOW TO DOAN ECGAN ECG

Dr D Byrne 2015References available on requestReferences available on request

PLEASE VIEW THE PLEASE VIEW THE TUTORIAL IN SLIDE SHOW TUTORIAL IN SLIDE SHOW

FORMATFORMAT

LEARNING OBJECTIVES LEARNING OBJECTIVES

At the end of this tutorial you should be able to: At the end of this tutorial you should be able to:

1. Use the ECG machine1. Use the ECG machine

2.2. Perform an ECGPerform an ECG

3. Interpret an ECG in a systematic manner3. Interpret an ECG in a systematic manner

TUTORIAL OUTLINETUTORIAL OUTLINE

Understanding the ECGUnderstanding the ECG

Indications and usesIndications and uses

How to do an ECGHow to do an ECG

FAQsFAQs

System for easy interpretation of the ECGSystem for easy interpretation of the ECG

UNDERSTANDING THE UNDERSTANDING THE ELECTROCARDIOGROMELECTROCARDIOGROM

(ECG or EKG) (ECG or EKG)

Introduction: Introduction: The ECG is a The ECG is a transthoracic interpretation of the transthoracic interpretation of the electrical activity of the heart electrical activity of the heart captured over time and externally captured over time and externally recorded by skin electrodes.recorded by skin electrodes. It is the It is the best way to measure and diagnose best way to measure and diagnose abnormal rhythms of the heart and abnormal rhythms of the heart and to diagnose if heart muscle has to diagnose if heart muscle has been damaged in specific areas been damaged in specific areas during a myocardial infarction (MI).during a myocardial infarction (MI).

UNDERSTANDING THE ECGUNDERSTANDING THE ECG‘‘LEADSLEADS’’

A 12 lead ECG is one in which 12 different electrical A 12 lead ECG is one in which 12 different electrical signals are recorded at approximately the same time signals are recorded at approximately the same time and is typically printed out onto paper.and is typically printed out onto paper. There are 10 electrodes in a 12 lead ECG.There are 10 electrodes in a 12 lead ECG.The electrodes are combined into pairs and the output The electrodes are combined into pairs and the output form each pair is known as a LEAD.form each pair is known as a LEAD.The tracing of the voltage difference between 2 of the The tracing of the voltage difference between 2 of the electrodes, as produced by the ECG recorder, is what electrodes, as produced by the ECG recorder, is what the term LEAD refers to and each will have a specific the term LEAD refers to and each will have a specific name e.g. Lead 1 is the voltage difference between the name e.g. Lead 1 is the voltage difference between the right arm electrode and the left arm electroderight arm electrode and the left arm electrode..

UNDERSTANDING THE ECGUNDERSTANDING THE ECG‘‘GRAPH PAPERGRAPH PAPER’’

An ECG machine will print onto graph paper which has An ECG machine will print onto graph paper which has a background pattern of 1mm squares in red or green a background pattern of 1mm squares in red or green with bold divisions every 5mm in both horizontal and with bold divisions every 5mm in both horizontal and vertical directionsvertical directions. . One small block on ECG paper One small block on ECG paper translates into 40ms and one large block (5 small translates into 40ms and one large block (5 small blocks) translates into 200ms.blocks) translates into 200ms.

UNDERSTANDING THE ECGUNDERSTANDING THE ECG‘‘LAYOUTLAYOUT’’

The 12 lead ECG will show a short segment of the The 12 lead ECG will show a short segment of the recording of each of the 12 leads.recording of each of the 12 leads.This is arranged into 4 columns, each containing 3 rows.This is arranged into 4 columns, each containing 3 rows.

• First Column: First Column: Limb leads (I, II, III)Limb leads (I, II, III)• Second Column: Second Column: Augmented limb leads (aVR, aVL, aVF)Augmented limb leads (aVR, aVL, aVF)• Third and Fourth Column: Third and Fourth Column: Chest leads (V1 – 3, V4 – 6)Chest leads (V1 – 3, V4 – 6)

To help analysis a rhythm strip is also recorded which To help analysis a rhythm strip is also recorded which shows the rhythm for the whole time the ECG was shows the rhythm for the whole time the ECG was recorded (5 or 6 seconds). recorded (5 or 6 seconds).

INDICATIONS AND USES INDICATIONS AND USES Cardiac murmersCardiac murmers

Syncope or collapse Syncope or collapse

SeizuresSeizures

Perceived cardiac dysrhythmiasPerceived cardiac dysrhythmias

Symptoms of myocardial infarctionSymptoms of myocardial infarction

Suspected pulmonary embolusSuspected pulmonary embolus

The assessment of patients with systemic diseaseThe assessment of patients with systemic disease

The pre operative assessment of patientsThe pre operative assessment of patients

Monitoring during anaesthesia and critically ill patientsMonitoring during anaesthesia and critically ill patients

HOW TO DO AN ECGHOW TO DO AN ECG

Review the indications for the ECGReview the indications for the ECG.

Preparation:Preparation:

Practice hand hygiene and introduce yourself to the patientPractice hand hygiene and introduce yourself to the patient

HOW TO DO AN ECGHOW TO DO AN ECGSay:Say:

“Hello Mr. Smith, My name is Dr. O Brien and I would like to carry out a simple test on your heart. It is called an electrocardiogram or an ECG. It is a recording of your heart’s activity. The reason for this test is……. It is painless. I will have to put stickers onto your chest, arms and legs. I will attach wires to these stickers and the ECG machine will print out a reading onto a piece of paper. I will ask you to sit up in the bed so that you are comfortable and to remove your top. Please ask me any questions that you may have”.

HOW TO DO AN ECGHOW TO DO AN ECGElectrode (dot) Placement:Electrode (dot) Placement:

The electrodes consist of a conducting gel embedded in the The electrodes consist of a conducting gel embedded in the middle of a self adhesive pad to which the wires clip.middle of a self adhesive pad to which the wires clip.Ensure that the chest is dry and if the patient is very hairy, Ensure that the chest is dry and if the patient is very hairy, you may have to shave the area where the electrodes will be you may have to shave the area where the electrodes will be placed.placed.

Practice Hand HygienePractice Hand Hygiene

Open a packet of electrodes.Open a packet of electrodes. Peel off the backing from each Peel off the backing from each electrode and place as follows:electrode and place as follows:

HOW TO DO AN ECGHOW TO DO AN ECGThe Six Chest Electrodes:The Six Chest Electrodes:

The electrodes for the chest leads MUST go in the standard positionsThe electrodes for the chest leads MUST go in the standard positions

V1 - Fourth intercostal space,V1 - Fourth intercostal space, right sternal borderright sternal border

Fourth intercostal space

Right sternal border

HOW TO DO AN ECGHOW TO DO AN ECGThe Six Chest Electrodes :The Six Chest Electrodes :

The electrodes for the chest leads MUST go in the standard positionsThe electrodes for the chest leads MUST go in the standard positions

V2 - Fourth intercostal space,left sternal border.V2 - Fourth intercostal space,left sternal border.

Fourth intercostal space,left

sternal border.

HOW TO DO AN ECGHOW TO DO AN ECGThe Six Chest Electrodes:The Six Chest Electrodes:

The electrodes for the chest leads MUST go in the standard positionsThe electrodes for the chest leads MUST go in the standard positions

V4 - Fifth intercostal space, left midclavicular line.V4 - Fifth intercostal space, left midclavicular line.

V4 - Fifth intercostal

space

Left midclavicular

line

HOW TO DO AN ECGHOW TO DO AN ECGThe Six Chest Electrodes:The Six Chest Electrodes:

The electrodes for the chest leads MUST go in the standard positionsThe electrodes for the chest leads MUST go in the standard positions

V3 - Midway between V2 and V4V3 - Midway between V2 and V4

V3 - Midway between V2 and V4

HOW TO DO AN ECGHOW TO DO AN ECGThe Six Chest Electrodes:The Six Chest Electrodes:

The electrodes for the chest leads MUST go in the standard positionsThe electrodes for the chest leads MUST go in the standard positions

V6 - Level with V4, left mid axillary line. V6 - Level with V4, left mid axillary line.

V6 - Level with V4, left mid axillary

line.

HOW TO DO AN ECGHOW TO DO AN ECGThe Six Chest Electrodes:The Six Chest Electrodes:

The electrodes for the chest leads MUST go in the standard positionsThe electrodes for the chest leads MUST go in the standard positions

V5 - Level with V4, left anterior axillary line. V5 - Level with V4, left anterior axillary line.

V5 - Level with V4, left

anterior axillary line.

HOW TO DO AN ECGHOW TO DO AN ECGThe Limb Electrodes:The Limb Electrodes:

These can be placed along the arms and legs at any point provided These can be placed along the arms and legs at any point provided they are below the shoulder in the upper limb and below the inguinal they are below the shoulder in the upper limb and below the inguinal fold in the lower limbs. In the case of recording serial data, consistency fold in the lower limbs. In the case of recording serial data, consistency for the limb lead placement is important.for the limb lead placement is important.

HOW TO DO AN ECGHOW TO DO AN ECGThe 10 electrodes :The 10 electrodes :

HOW TO DO AN ECGHOW TO DO AN ECGAttach The Cables:Attach The Cables:

Untangle the cables before clipping them onto the electrodesUntangle the cables before clipping them onto the electrodes

Attach the appropriate cables to the dots by opening the crocodile Attach the appropriate cables to the dots by opening the crocodile jaws and grasping the metal button on the electrodejaws and grasping the metal button on the electrode

Try to avoid crossing wiresTry to avoid crossing wires

HOW TO DO AN ECGHOW TO DO AN ECGCable Colours And Chest Electrodes To Which They Attach:Cable Colours And Chest Electrodes To Which They Attach:

White/Red – White/Red – C1/V1. C1/V1.

HOW TO DO AN ECGHOW TO DO AN ECGCable Colours And Chest Electrodes To Which They Attach:Cable Colours And Chest Electrodes To Which They Attach:

White/Yellow – C2/V2 White/Yellow – C2/V2

HOW TO DO AN ECGHOW TO DO AN ECGCable Colours And Chest Electrodes To Which They Attach:Cable Colours And Chest Electrodes To Which They Attach:

White/Green – C3/V3. White/Green – C3/V3.

HOW TO DO AN ECGHOW TO DO AN ECGCable Colours And Chest Electrodes To Which They Attach:Cable Colours And Chest Electrodes To Which They Attach:

White/Brown – C4/V4.White/Brown – C4/V4.

HOW TO DO AN ECGHOW TO DO AN ECGCable Colours And Chest Electrodes To Which They Attach:Cable Colours And Chest Electrodes To Which They Attach:

White/Black – C5/V5. White/Black – C5/V5.

HOW TO DO AN ECGHOW TO DO AN ECGCable Colours And Chest Electrodes To Which They Attach:Cable Colours And Chest Electrodes To Which They Attach:

White/Violet – C6/V6.White/Violet – C6/V6.

HOW TO DO AN ECGHOW TO DO AN ECG

Limb Cables: Remember Limb Cables: Remember RRed For ed For RRight Arm. ight Arm. YYellow for Left Arm ellow for Left Arm

(Think of (Think of Lemon Yellow/LeftLemon Yellow/Left).).

BBlack and lack and GGreen reen Are Lower Limb Leads.Are Lower Limb Leads.

((Think Think EarthEarth and and GrassGrass Colours). Colours).

HOW TO DO AN ECGHOW TO DO AN ECGThe 10 CablesThe 10 Cables

HOW TO DO AN ECGHOW TO DO AN ECGTurn on the machineTurn on the machine

Check that paper insertedCheck that paper inserted

Insert the patientInsert the patient’’s details into the machines details into the machine

Press the record buttonPress the record button

Review the ECG and ensure that all 12 leads Review the ECG and ensure that all 12 leads and rhythm strip are recordedand rhythm strip are recorded

Tear off ECG and check patientTear off ECG and check patient’’s name, medical s name, medical record number, date and time. record number, date and time. Write symptoms at time of recording on the tracing Write symptoms at time of recording on the tracing e.g. chest pain….e.g. chest pain….

HOW TO DO AN ECGHOW TO DO AN ECGTurn off the machine Turn off the machine

Remove the cablesRemove the cables

Remove the electrodes (dots) Remove the electrodes (dots) and dispose in clinical waste and dispose in clinical waste

Practice hand hygienePractice hand hygiene

Thank the patientThank the patient

Document date, time, indication and findings Document date, time, indication and findings in the patientin the patient’’s notess notes

FAQsFAQs

Q.Q. The patient has a very hairy chest and the electrodes (dots) will not stick.The patient has a very hairy chest and the electrodes (dots) will not stick.

Ans: Shave the chest in the areas for electrode placement.

Q.Q. The patient has a lot of piercings, including nipple piercings. The patient has a lot of piercings, including nipple piercings. Will I remove them? Will I remove them?

Ans: No. Be sure not to put an electrode (dot) over the piercing though. Just work around them.

FAQsFAQsQ.Q. The patient is a female. Can I place the electrodes on her breasts? The patient is a female. Can I place the electrodes on her breasts?

Ans: No. Place the electrodes on the chest wall by lifting up the breast.

Q.Q. The patient is a lady. Can she leave her bra on? The patient is a lady. Can she leave her bra on?

Ans: No. Place the electrodes on the chest wall by lifting up the breast.

Q.Q. The tracing is very shaky or parts of it are missing. The tracing is very shaky or parts of it are missing.

Ans: Ensure the patient stays still during the recording and check that all electrodes are in good contact with the skin. If the skin is damp, they will not stick.

ECG Interpretation: A Systematic ECG Interpretation: A Systematic ApproachApproach

We Recommend You We Recommend You Download a Copy of WithamDownload a Copy of Witham‘‘ECG interpretation’ at This ECG interpretation’ at This

Web Address:Web Address:http://sichon.wu.ac.th/file/pt-shh-20110612-135010-XwBq1.pdf

Thank you

We hope that you enjoyed the We hope that you enjoyed the presentation.presentation.

Thanks to the interns in Network West Thanks to the interns in Network West Northwest for their help and Northwest for their help and

enthusiasm.enthusiasm.