BASIC ECG

Alan W. Vespie, MEd, CNMT, RT(N)

Advanced Medical Imaging Technology Program
College of Allied Health Sciences
University of Cincinnati
Whitney Bowen, BS, CNMT, RT(MR)

CARDIAC PATHOLOGY

Heart Disease is the Number 1

killer in America

http://www.drorestesg.com/blog/heart-disease-is-preventable-and-reversible

CARDIAC PATHOLOGY

Heart
Disease is
the Number 1
killer in
America

Recent data
reflects similar
trend
http://www.nimh.nih.gov/statistics/3AGES185.shtml
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CARDIAC PATHOLOGY
Number of deaths for leading causes of death (2014):
Heart disease: 614,348
Cancer: 591,699
Chronic lower respiratory diseases: 147,101
Accidents (unintentional injuries): 136,053
Stroke (cerebrovascular diseases): 133,103
Alzheimer's disease: 93,541
Diabetes: 76,488
Influenza and Pneumonia: 55,227
Nephritis, nephrotic syndrome and nephrosis: 48,146
Intentional self-harm (suicide): 42,773
http://www.cdc.gov/nchs/fastats/deaths.htm

CARDIAC PATHOLOGY

http://www.cdc.gov/nchs/data/databriefs/db229_fig3.png

CARDIAC PATHOLOGY

http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_02.pdf

CARDIAC PATHOLOGY

http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_02.pdf

CARDIAC PATHOLOGY

http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_02.pdf

CARDIAC PATHOLOGY

Approximately 40,000 children are

born each year with some type of
congenital cardiac abnormality
(cdc.gov)

Leading cause of birth defects

A leading cause of infant death

Approximately 2,000,000 people are

living in the United States with some
type of congenital cardiac anomaly
(2010)

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CARDIAC PATHOLOGY

Acquired heart or blood vessel disease

affects approximately 58,800,000
Americans have one or more types of
cardiovascular disease (CVD) according
to current estimates (2008).
Every 43 second someone in the US
has a Myocardial Infarction (Heart
Attack)
Myocardial Infarctions account for over
735,000 deaths annually (2015)

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CARDIAC PHYSIOLOGY

To pump blood in sufficient amounts to

meet the varying needs of the cells of
the body

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CARDIAC ANATOMY

Four chambered organ roughly the size of

a human fist
Located within mediastinum, slightly left
of center (2/3rds)
Inferior surface rests on the diaphragm
Located between the second and fifth or
sixth rib anteriorly
Held in place by the great vessels and the
pericardium
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CARDIAC ANATOMY

http://www.vhlab.umn.edu/atlas/anatutorial/anatutorial3.shtml

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CARDIAC ANATOMY

Interventricular septum separates the

heart into right and left halves
Each lateral half contains a transverse
constriction that divides each half into
two cavities (atrium & ventricle)

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CARDIAC ANATOMY

Ventricles are
thicker walled
than atria due to
greater pumping
burden
Similarly, LV is
thicker than RV for
the same reason
(systemic versus
pulmonary
http://www.chelation.co.uk/heart-structure.html
circulation)

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CORONARY ARTERIES

Continuous action of the heart requires

a constant supply of oxygen rich blood
This need is serviced by the right and
left coronary arteries
Approximately 5% of the cardiac output
flows through the coronary arteries
Coronary arteries are the first to branch
off the aorta
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CORONARY ARTERIES

Right coronary
artery

Right atrium and

ventricle
Posterior
interventricular
septum
Inferior portion of
the left ventricle

http://www.clevelandclinic.org/heartcenter/images/guide/heartworks/coronary%20arteries.JPG
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CORONARY ARTERIES

Left coronary artery

Left anterior
descending (LAD)

Anterior of RV and LV
Interventricular
septum

Left circumflex

Posterior, inferior,
and lateral walls

http://www.clevelandclinic.org/heartcenter/images/guide/heartworks/coronary%20arteries.JPG
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CORONARY ARTERIES

Notice that each ventricle has receives

blood from both the right and left
coronary arteries
Allows a greater blood supply
(ventricles work harder than atria)
Protective function in that certain areas
of heart are not entirely dependent
upon a single blood supply
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ELECTRICAL CONDUCTING SYSTEM

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ELECTRICAL CONDUCTION SYSTEM

Sinoatrial Node (SA node)

Atrioventricular Node (AV node)
Atrioventricular Bundles (Bundle of His)

right bundle branch

left bundle branch

Purkinje fibers

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ELECTRICAL CONDUCTION SYSTEM

All are made of

modified cardiac
muscle
Muscle is capable of
conducting electrical
pulses
These structures no
longer have a
contractile function.
They only conduct
electrical pulses
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ELECTRICAL CONDUCTION SYSTEM

http://www.guthrie.org/services/cardiac/procedures/ekg.asp

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ELECTRICAL CONDUCTION SYSTEM

SA Node

Located in the atrial

wall near vena cava
Supplied with fibers
from autonomic
nervous system
Known as the
pacemaker node
since it is the initiator
of the heart beat

AV Node

Located in septum
separating right
and left atria
Temporarily holds
electrical signal

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ELECTRICAL CONDUCTION SYSTEM

Bundle of His
(hiss)

Originates in AV
Node and divides
into the right and
left bundle
branches
Branches extend
down the sides of
the septum

Purkinje Fibers

Extend from the

apex to the walls
and muscles of
the ventricles

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ELECTRICAL CONDUCTION SYSTEM

http://what-when-how.com/paramedic-care/principles-of-electrocardiography-clinical-essent
ials-paramedic-care-part-1/

27

ELECTRICAL CONDUCTION SYSTEM

SA Node

Spreads electrical
impulse
throughout both
atria
Results in atrial
contraction

AV Node

Temporarily holds
electrical signal
until completion of
atrial contraction

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ELECTRICAL CONDUCTION SYSTEM

Bundle of His (hiss)

Carries electrical
pulse to Purkinje
fibers

Purkinje Fibers

Carries electrical
pulse from the
apex to the walls
and muscles of the
ventricles

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ELECTRICAL CONDUCTION SYSTEM

The signal for ventricular contraction

causes the ventricles to contract from
the apex up. This insures that blood is
pumped out of the ventricle

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ELECTROCARDIOGRAM

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ELECTROCARDIOGRAM

ECG or EKG

Diagnostic tool that measures the

electrical impulses of the heart
The body contains a large quantity of
water with solutes which is ideal for
conducting electrical impulses
Electrical impulses to the heart are altered
by many different conditions.

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ELECTROCARDIOGRAM

ECG or EKG

Evolved over the years

3 or 4 lead

Good for identifying R-wave

Current diagnostics

12 lead

Useful for detecting cardiac pathology

Deceptive because it only requires the use of 10 contacts

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ELECTROCARDIOGRAM

12 lead

Views from the pads located on chest

V1, V2, V3, V4, V5, V6

Remaining 6 views generated by pads on

arms and legs

I, II, III, aVR, aVL, aVF

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ELECTROCARDIOGRAM

12 lead

Combines
information
from 10
contacts to
provide 12
views

http://www.nuclearcardiologyseminars.net/electrocardiography.htm

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ELECTROCARDIOGRAM

ECG Components

P-wave
PR interval
QRS complex
T wave
U-wave (not always demonstrated)

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ELECTROCARDIOGRAM

P-wave - Atrial Excitation

PR interval - Atrial Systole
QRS Complex - Ventricular
Excitation

T-wave - Ventricular Systole

U-wave-Ventricular Diastole
(80-90% Ventricular Filling)

http://www.math.utah.edu/~keener/lectures/AMS/slide1.html

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ELECTROCARDIOGRAM

P-wave - Atrial Excitation

PR interval - Atrial Systole
QRS Complex - Ventricular
Excitation

T-wave - Ventricular Systole

U-wave-Ventricular Diastole
(80-90% Ventricular Filling)

http://en.wikipedia.org/wiki/File:ECG_principle_slow.gif

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ELECTROCARDIOGRAM

Systole - Contraction of the heart,

especially the ventricles
Diastole - Normal post-systolic dilation
of the heart cavities during which they
fill with blood

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ELECTROCARDIOGRAM

Cardiac Cycle - A complete heart beat

that involves contraction & relaxation
of both atria & both ventricles
Sinus Rhythm p-wave preceding and
driving the QRS complex

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ELECTROCARDIOGRAM

Irregularities appear as

Cardiac Arrhythmias

Abnormal but not necessarily irregular

ST-T wave changes

Consistent with impending myocardial

infarction

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ELECTROCARDIOGRAM

Cardiac Arrhythmia - a variation of the

normal heartbeat

Tachycardia - unusually rapid heart rate

(>100 bpm). Ventricular tachycardia is a
very serious form.
Bradycardia - unusually slow heart rate(<
60 bpm)

Exception being trained athletes

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ELECTROCARDIOGRAM

Cardiac Arrhythmia

Premature Ventricular Contractions (PVCs)

Ventricular fibrillation - a fluttering of the
ventricles

Consistent with imminent death if not quickly

resolved

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ELECTROCARDIOGRAM

Common indications

Chest pain
SOB shortness of breath
Palpitations
Nausea (with other cardiac related signs and
symptoms
Weakness
Syncope (fainting)
Pre-surgical workup
People who undergo repeated cardiac stress (athletes)
Middle age patients receiving physicals.
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WHY DO I NEED TO KNOW

THIS IN NUCLEAR MEDICINE??

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ELECTROCARDIOGRAM

Determining rate

Note the boxes on an ECG

Small boxes are 0.04 sec each.
Big, bolder boxes are 0.2 sec each

http://www.mauvila.com/ECG/ecg_fundamentals.htm

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ELECTROCARDIOGRAM

Determining rate

Heart rate can be determined by counting

the number of big boxes between R-waves
and dividing into 300. What is the heart
rate below?
300 / 4 = 75

http://www.mauvila.com/ECG/ecg_fundamentals.htm

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ELECTROCARDIOGRAM

Determining
rhythm

Measure the
distance between
R-waves.
Does it remain
steady?

http://www.medcatalog.com/M/MackinManuf.htm
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ELECTROCARDIOGRAM

Determining existence of p-wave

Should exist with a QRS complex

Distance between P and R (PR interval) should

be less than 0.2 sec (one big box)

http://www.mauvila.com/ECG/ecg_fundamentals.htm

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ELECTROCARDIOGRAM

QRS Complex

Needs to be less than 3 little boxes (0.12

seconds)

In this example it appears to be 2 little boxes so

it is okay

http://www.mauvila.com/ECG/ecg_fundamentals.htm

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ELECTROCARDIOGRAM

Sample ECGs

What is the heart rate?

About 48 bpm

http://medicine-science.com/sinus-bradycardia/

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ELECTROCARDIOGRAM

Sample ECGs

Bradycardia has a resting rate less than 60

bpm.
Can indicate pathology but may be normal
in the conditioned athlete.

http://medicine-science.com/sinus-bradycardia/

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ELECTROCARDIOGRAM

Sample ECGs

May reflect disease of the SA node or drug

effects
May result in decreased cardiac output,
hypotension, angina.

http://medicine-science.com/sinus-bradycardia/

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ELECTROCARDIOGRAM

Sample ECGs

What is the heart rate?

About 150 bpm

Website referenced on next slide.

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ELECTROCARDIOGRAM

Sample ECGs

Tachycardia has a resting heart rate

greater than 100 bpm.
Compensatory mechanism

http://www.cardionetics.com/cardiology/sinus-tachycardia.php
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ELECTROCARDIOGRAM

Sample ECGs

Caused by increased rate of SA node

discharge

Exercise, anxiety, anemia, hypoxia, heart

failure, fever and others
Very rapid rates can precipitate ischemia or
infarct

http://www.cardionetics.com/cardiology/sinus-tachycardia.php
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ELECTROCARDIOGRAM

Sample ECGs

What is the heart rate?

Hard to say . . . irregularly irregular

Hey! Where is that p-wave?

Website referenced on next slide

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ELECTROCARDIOGRAM

Sample ECGs

Atrial fibrillation

Signal to contract coming from many places

besides the SA node hence, no p-wave
Rhythm characterized as being irregularly
irregular

http://afib.utorontoeit.com/images/pic1afib.jpg

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ELECTROCARDIOGRAM

Sample ECGs

Often times points of excitation can be

identified near the pulmonary artery

Surgical intervention tries to scar tissue near PA

hoping to disrupt the source of additional
discharges

Fatigue and risk of embolism

http://afib.utorontoeit.com/images/pic1afib.jpg

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ELECTROCARDIOGRAM

Sample ECGs

What is the heart rate?

About 200 bpm

http://www.emedu.org/ecg/crapsanyall.php
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ELECTROCARDIOGRAM

Sample ECGs

Ventricular tachycardia (v-tach)

Not the same as ventricular fibrillation

Note the waves are very wide. (Wider than 3
little boxes)

http://www.emedu.org/ecg/crapsanyall.php
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ELECTROCARDIOGRAM

Sample ECGs

Caused by myocardial ischemia, hypoxia,

acid-base disturbances, electrolyte
imbalance
Potentially life threatening

http://www.emedu.org/ecg/crapsanyall.php
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ELECTROCARDIOGRAM
Normal Sinus
Rhythm

Sinus
Tachycardia
http://www.mei.com/resource/arrhythm/111.gif
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ELECTROCARDIOGRAM
Normal Sinus
Rhythm

Sinus
Bradycardia
http://www.mei.com/resource/arrhythm/111.gif
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ELECTROCARDIOGRAM
Ventricular
Flutter
180 250 bpm
but still
regularly
occurring
http://ibmi.mf.uni-lj.si/mmd/cardio-a/eng/sz-50/sldr00026.html

Ventricular
Fibrillation

http://personalwebs.myriad.net/dan/EKG/mfpvc.gif

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ELECTROCARDIOGRAM
Premature
Ventricular
Contraction

Ventricular
Fibrillation

http://personalwebs.myriad.net/dan/EKG/mfpvc.gif

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ELECTROCARDIOGRAM

S-T
Segment
Depression

http://medstat.med.utah.edu/kw/ecg/mml/ecg_12lead006.gif
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Intro to EKG Interpretation Part 1. Downloaded October 11, 2001

from
http://youtu.be/ex1k_MPF-w4

Intro to EKG Interpretation Part 2. Downloaded 10/11/2011 from

http://www.4shared.com/video/ukmWT6KP/Intro_EKG_Interpretati
on_Part_.html

Intro to EKG Interpretation Part 3. Downloaded 10/11/2011

from http://youtu.be/Z5w8N6NBDys

March of Dimes Birth Defects. Downloaded 9/21/2012 from http:

//www.marchofdimes.com/baby/birthdefects_congenitalheart.html

Sinus bradycardia. Downloaded October 11, 2011 from http

://medicine-science.com/sinus-bradycardia/

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ECG LEAD PLACEMENT

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ECG LEAD PLACEMENT

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ECG LEAD PLACEMENT

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ECG LEAD PLACEMENT

12 Lead Placement
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ECG LEAD PLACEMENT

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LEAD PLACEMENT PRACTICE

http://
www.m2hnursing.com/ecg_demo/12lea
d.php

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