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ECG Basics forNursesProf. Dr. Aswinikumar Surendran. MD

Professor, Department of MedicineGovernment medical College Hospital

Thiruvananthapuram, South India.+9147124699824, +9194447799984

draswinikumars@gmail.co m

mailto:draswinikumars@gmail.commailto:draswinikumars@gmail.commailto:draswinikumars@gmail.commailto:draswinikumars@gmail.com

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What is ECG?Graphical Depiction of Electrical Forces

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Importance of ECGLife Line of the Patient

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NursesRole in the ICU

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Why Learn ECG?Valuable Easily Attained Skill

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Uses of ECGSpecific for Nurses

Heart RateNormal / Tachycardia /

Bradycardia

ArrhythmiasVentricular /

Supraventricular

Heart BlocksAV Nodal / RBBB /

LBBB

Electrolyte ImbalanceHypokalemia /Hyperkalemia

CarditisMyocarditis /Pericarditis

Drug EffectDigoxin / Quinidine /

Adriamycin

Coronary Circulation

Ischemia / Injury /Infarct

Electrical AxisNormal / Right axis /Left axis

Chamber EnlargementLAE / RAE / LVH / RVH

ICU monitoringEarly detection of arrhythmia

Stress testing

Early detection of Ischemia

Holter monitoringAarrhythmia testing

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Conduction PathwayFrom SA Node to Ventricular Muscle

SA Node

Right Atrial muscle

Left Atrial muscle

His Bundle

AV Node

Right Bundle Branch Left Bundle Branch

Right Ventricular Muscle Left Ventricular Muscle

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Pacemakers of HearrrrrtIf one fails, the other will take over

Inherent Rate60-80

Inherent Rate

40-60

Inherent Rate

20-40

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InventorEinthoven

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ECG MachineModified Galvanometer

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ECG PaperMoves at a spped of 25mm/sec

Black paper

Cheap: Rs1/- per ECGHeat sensitive substance coated

Erased by heated stylus

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ECGRecording

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6 Limb LeadsOriented to frontal plane

II III and aVF Inferior Wall

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6 Chest LeadsOriented to horizontal plane

1 aVL V5V6 Lateral Wall

V1V2V3V4 Anterior Wall

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Standardization1 mv of current produces 10mm deflection

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StandardizationHalf Standardization

1 mV

10 sd

1 mV

5 sd

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RestOnly multiples

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ECG WavesPQRSTU named by Einthoven

P: First positive wave of cardiac cycleQ: First negative deflection of the cycleR: First positive deflection of the cycleS: 2 nd negative deflection of the cycleS: can also be a 1 st -ve wave following RT: Positive wave following QRS complexU: Small +ve wave following the T wave

PQ

T U

R

S

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IntervalsFor Calculation of Heart rate

PR Interval QT interval

RR interval

QRS duration

PR: AV nodal delayQRS: Vent Conduction

RR interval for heart rate calculation

QT: Total time, Cardiac Cycle

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PQRSTElectrical correlation

P wave T wave

U wave

QRS

Atrial depolarization

Ventricular depolarization

Ventricular repolarization

Ventricular repolarization

Atrial repolarization?

PR/QRS

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P WaveShape - Widening

Wide and notched

Normal P P Mitrale

Left Atrial Enlargement

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P WaveShape peaked

Tall and Peaked

Normal P P Pulmonale Signifies RAE

Right Atrial Enlargement

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PR IntervalDenotes AV nodal delay

PR Interval Normal 3-5 SD

PR interval A physiological necessity

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PR IntervalAbnormalities

Prolonged PR:0.21sRheumatic Fever I0 Heart Block

Short PR:

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QRS DurationTime for Ventricular contraction

Normal 0.06 to 0.10 sec Abnormal > 0.11 sec

Prolonged QRS Ventricular contraction Delay

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Right Bundle Branch BlockConduction Delay in Right Ventricle

RBBB

R

r

S

T R

q

Deep slurred S

V1 V6

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RBBBECG

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Left Bundle Branch BlockConduction Delay in Left Ventricle

LBBB LBBB

T

V1 V6

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LBBBECG

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Q WaveComes After PR Interval

P QRS P

No Q T

Normally No Q 1 st negative deflection

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Q WaveAbnormal Dimensions

P Q P Q

>0.04sec

Width >0.04sec Depth > 1/4th

of height

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Importance of Q WaveIndicates Heart Attack

.

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Normal ST segment

PR

ST

ST SegmentFrom End of S to Beginning of T

ST segment elevationPR

ST

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ST Segment ElevationStraight and Coving

Coving ST segment elevationStraight ST segment elevation

PRPR

ST

Coving ST

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ST Segment ElevationActual Measurement

0.08 sec to the right of J point

PR

ST

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STEMI and NSTEMIChanges in ST segment

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ST Segment ElevationImportance

.

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ST Segment DepressionSuggestive of Angina

Normal ST segment ST segment Depression

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T WaveNormal And Abnormal

Normal T Peaked T Symm T Biphasic T

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Tall peaked T WaveAcute myocardial Infarction

Tall peaked T wave

Hyperacute MI

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Tall peaked T WaveAcute myocardial Infarction ECG

.

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Tall Peaked T WaveHyperkalemia (High potassium)

Hyperkalemia

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Tall peaked T WaveHyperkalemia ECG

.

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T InversionSuggestive of Ischemia

Symmetrical T InversionBiphasic T wave

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T InversionIn Anterior and Inferior Leads

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Acute Myocardial InfarctionProgressive Changes

Early changesof AMI

VAT

Peak T

ST

ST

T Biphasic

Q appears

ST downs

ST Normal

T upright

Acute Myocardialinfraction

Healing and oldinfarction

15 min

30 min

1 hour

2 hours

3 hours

4 hours

1 week

1 month

1 year

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Myocardial InfarctionAnterior Wall

Seen in V2 to V4If in V1 - Anteroseptal

Thrombus

Anterior descending branch

Left coronary artery

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ECGAcute Anterior Wall MI

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Myocardial InfarctionLateral Wall

Changes of Acute MI , when seen in the lateral chest leads, 1, aVL,V5 V6, is diagnostic of Lateral Wall Myocardial Infarction

Thrombus

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Myocardial InfarctionAntero Lateral MI

Changes of Acute MI are seen in all the anterior chest leads, fromV1 through V6; diagnostic of Antero-lateral Wall MI

Thrombus

Thrombus

Thrombus

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Myocardial InfarctionAntero Lateral MI - ECG

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ECGInferior Wall MI

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Sh Q

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Short QTIncreased susceptibility to Torsade de

Short QT

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Ri h V i l H h

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Right Ventricular HypertrophyR/S in V1 is > 1

..

S i V1 R i V6

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S in V1 + R in V6Normally less than 35mm

Lead V1

Lead V6

20mm

25mm

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