ECG

Basic principles An ECG is simply a representation of the electrical activity of the heart muscle as it changes with time, usually printed on paper for easier analysis. Like other muscles, cardiac muscle contracts in response to electrical depolarisation of the muscle cells. It is the sum of this electrical activity, when amplified and recorded for just a few seconds that we know as an ECG. Basic Electrophysiology of the Heart (see Figure 1) he normal cardiac cycle !egins with spontaneous depolarisation of the sinus node, an area of specialised tissue situated in the high right atrium "#A$. A wave of electrical depolarisation then spreads through the #A and across the inter%atrial septum into the left atrium "LA$. he atria are separated from the ventricles !y an electrically inert fi!rous ring, so that in the normal heart the only route of transmission of electrical depolarisation from atria to ventricles is through the atrioventricular "A&$ node. he A& node delays the electrical signal for a short time, and then the wave of depolarisation spreads down the interventricular septum "I&'$, via the !undle of (is and the right and left !undle !ranches, into the right "#&$ and left "L&$ ventricles. (ence with normal conduction the two ventricles contract simultaneously, which is important in ma)imising cardiac efficiency. After complete depolarisation of the heart, the myocardium must then repolarise, !efore it can !e ready to depolarise again for the ne)t cardiac cycle.

Figure 1. Basic electrophysiology of the heart Electrical axis and recording lead vectors (see Figures 2 and )

he ECG is measured !y placing a series of electrodes on the patient*s skin + so it is known as the ,surface* ECG. he wave of electrical depolarisation spreads from the atria down though the I&' to the ventricles. 'o the direction of this depolarisation is usually from the superior to the inferior aspect of the heart. he direction of the wave of depolarisation is normally towards the left due to the leftward orientation of the heart in the chest and the greater muscle mass of the left ventricle than the right. his overall direction of travel of the electrical depolarisation through the heart is known as the electrical axis. A fundamental principle of ECG recording is that when the wave of depolarisation travels toward a recording lead this results in a positive or upward deflection. -hen it travels away from a recording lead this results in a negative or downward deflection.

he electrical a)is is normally downward and to the left !ut we can estimate it more accurately in individual patients if we understand from which ,direction* each recording lead measures the ECG.

Figure 2. !rientation of the li"# leads sho$ing the direction fro" $hich each lead %loo&s% at the heart .y convention, we record the standard surface ECG using /0 different recording lead ,directions,* though rather confusingly only /1 recording electrodes on the skin are re2uired to achieve this. 'i) of these are recorded from the chest overlying the heart + the chest or precordial leads. 3our are recorded from the lim!s + the limb leads. It is essential that each of the /1 recording electrodes is placed in its correct position, otherwise the appearance of the ECG will !e changed significantly, preventing correct interpretation. he lim! leads record the ECG in the coronal plane, and so can !e used to determine the electrical a)is "which is usually measured only in the coronal plane$. he lim! leads are called leads I, II, III, A&#, A&L and A&3. 3igure 0 shows the relative directions from which they ,look* at the heart. A hori4ontal line through the heart and directed to the left "e)actly in the direction of lead I$ is conventionally la!elled as the reference point of 1 degrees "1 o$. he directions from which other leads ,look* at the heart are descri!ed in terms of the angle in degrees from this !aseline. he electrical a)is of depolarisation is also e)pressed in degrees and is normally in the range from %51 1 to 6 71 1. A detailed e)planation of how to determine the a)is is !eyond the scope of this article !ut the principles mentioned here should help readers to understand the concepts involved. he chest leads record the ECG in the transverse or hori4ontal plane, and are called &/, &0, &5, &8, &9 and &: "see 3igure 5$.

Figure . 'ransverse section of the chest sho$ing the orientation of the six chest leads in relation to the heart (oltage and ti"ing intervals It is conventional to record the ECG using standard measures for amplitude of the electrical signal and for the speed at which the paper moves during the recording. his allows;

Easy appreciation of heart rates and cardiac intervals and

<eaningful comparison to !e made !etween ECGs recorded on different occasions or !y different ECG machines.

he amplitude, or voltage, of the recorded electrical signal is e)pressed on an ECG in the vertical dimension and is measured in millivolts "m&$. =n standard ECG paper /m& is represented !y a deflection of /1 mm. An increase in the amount of muscle mass, such as with left ventricular hypertrophy "L&($, usually results in a larger electrical depolarisation signal, and so a larger amplitude of vertical deflection on the ECG. An essential feature of the ECG is that the electrical activity of the heart is shown as it varies with time. In other words we can think of the ECG as a graph, plotting electrical activity on the vertical a)is against time on the hori4ontal a)is. 'tandard ECG paper moves at 09 mm per second during real%time recording. his means that when looking at the printed ECG a distance of 09 mm along the hori4ontal a)is represents / second in time. ECG paper is marked with a grid of small and large s2uares. Each small s2uare represents 81 milliseconds "ms$ in time along the hori4ontal a)is and each larger s2uare contains 9 small s2uares, thus representing 011 ms. 'tandard paper speeds and s2uare markings allow easy measurement of cardiac timing intervals. his ena!les calculation of heart rates and identification of a!normal electrical conduction within the heart "see 3igure 8$.

Figure ). *a"ple of standard ECG paper sho$ing the scale of voltage+ "easured on the vertical axis+ against ti"e on the hori,ontal axis 'he nor"al ECG It will !e clear from a!ove that the first structure to !e depolarised during normal sinus rhythm is the right atrium, closely followed !y the left atrium. 'o the first electrical signal on a normal ECG originates from the atria and is known as the - $ave. Although there is usually only one > wave in most leads of an ECG, the > wave is in fact the sum of the electrical signals from the two atria, which are usually superimposed. here is then a short, physiological delay as the atrioventricular "A&$ node slows the electrical depolarisation !efore it proceeds to the ventricles. his delay is responsi!le for the ># interval, a short period where no electrical activity is seen on the ECG, represented !y a straight hori4ontal or ,isoelectric* line. ?epolarisation of the ventricles results in usually the largest part of the ECG signal "!ecause of the greater muscle mass in the ventricles$ and this is known as the ./* co"plex.

he @ wave is the first initial downward or ,negative* deflection he # wave is then the ne)t upward deflection "provided it crosses the isoelectric line and !ecomes ,positive*$ he ' wave is then the ne)t deflection downwards, provided it crosses the isoelectric line to !ecome !riefly negative !efore returning to the isoelectric !aseline.

In the case of the ventricles, there is also an electrical signal reflecting repolarisation of the myocardium. his is shown as the *' seg"ent and the ' $ave. he ' segment is normally isoelectric, and the wave in most leads is an upright deflection of varia!le amplitude and duration "see 3igures 9 and :$.

Figure 0. 'he "a1or $aves of a single nor"a

l ECG pattern

Figure 2. Exa"ple of a nor"al 12 lead ECG3 notice the do$n$ard deflection of all signals recorded fro" lead a(/. 'his is nor"al+ as the electrical axis is directly a$ay fro" that lead 4or"al intervals he recording of an ECG on standard paper allows the time taken for the various phases of electrical depolarisation to !e measured, usually in milliseconds. here is a recognised normal range for such ,intervals*;

-/ interval "measured from the !eginning of the > wave to the first deflection of the @#' comple)$. Aormal range /01 + 011 ms "5 + 9 small s2uares on ECG paper$. ./* duration "measured from first deflection of @#' comple) to end of @#' comple) at isoelectric line$. Aormal range up to /01 ms "5 small s2uares on ECG paper$. .' interval "measured from first deflection of @#' comple) to end of wave at isoelectric line$. Aormal range up to 881 ms "though varies with heart rate and may !e slightly longer in females$

Heart rate esti"ation fro" the ECG 'tandard ECG paper allows an appro)imate estimation of the heart rate "(#$ from an ECG recording. Each second of time is represented !y 091 mm "9 large s2uares$ along the hori4ontal a)is. 'o if the num!er of large s2uares !etween each @#' comple) is;

9 % the (# is :1 !eats per minute. 5 % the (# is /11 per minute. 0 % the (# is /91 per minute.

Helpful hints and rules to reading the 12 lead...

Always !e sure to check for an inverted or negative @#' comple) in A&#. his will ensure that the lead were correctly connected appropriately and your recordings shold !e accurate. Anali4e and evaluate the right chest leads. &/ B &0 will reveal more than any other two contigeous leads. his is where you check for a .undle .ranch .lock, Anterior and >osterior wall infarctions, and C#C wave progression, ect... -hen checking your a)is, always focus on Leads I B A&3. .e sure to check for .undle .ranch .lock. A)is vectors are inaccurate in their pressence. -hen checking for signs of infarct, omit A&#. It is of no diagnostic value due to the fact that it misrepresents pathological @ waves and o!scures them. Acute <yocardial Infarction cannot !e positively identified in the pressence of L...DDD It is prudent to suspect it per the patients presentation; however, serum en4yme tests among other things are needed to make the diagnosis. As a rule, standard criteria for diagnosing A<I dictates that ' elevation of / mm. or more in the presence of pathological @ waves in 0 or more contigous leads is sufficient. 5eads 6+ 66 7 666 7 8(/+ 8(5+ and 8(F.

69 5eft Chest 669 5eft :pper .uadrant 6669 /ight :pper .uadrant 8(/9 /ight lateral ar" 8(59 5eft lateral ar" 8(F9 /ight lateral lo$er leg

2) Augmented Leads

he four li"# leads go on the four e)tremities as follows; he upper e)tremities need placement of the electrodes on the area of the lateral humoral aspect of the arms. he lower e)tremities need placement of the electrodes on the lateral lower legs near the lateral mallelous. Lead aVR faces the heart from the right shoulder and is oriented to the cavity of the heart. Lead aVL faces the heart from the left shoulder and is oriented to the Left Ventriacle. Lead aVF face the heart from the left hip and is oriented to the inferior surface of the Left Ventricle.

3) Precordial Leads

*ix -recordial Electrode -lace"ent9 Records potential in the horizontal plane. ach lead is positive.

!he ma"or forces of depolariztion move from right to left. V# and V2 are negative deflections.

V3$ V%$ V& and V' (ecome more positive ) pea* positive is V3 or V% ). &/ % fourth intercostal, right strernal !order. &0 % fourth intercostal, left sternal !order. &5 % e2ual distance !etween &0 and &8. &8 % fifth intercostal, left mid clavicular line. &9 % anterior a)illary line, same level with &8. &: % mid a)illary line, same level with &8 and &9. +ategory one, A<I that clearly meets the criteria. E)ample; / mm or more of ' elevation in the inferior leads "II, III, A&3$ with reciprocal changes in the lateral leads "I, A&L, &9, &:$ #eciprocal changes not necesssary to make the diagnosis. -ther .ignals to use as a diagnostic tool,

!ac*ycardia, )heart rate a(ove #//) indicates damge to the left Ventricle and an 0anterior0 or 0lateral0 infarct. !he Left +ircumfle1 and or Left 2ecending +oronary Artery is occluded. Visa(le elevation in the +3 .! L A2., V43$ %$ &$ 5 '. 6radycardia, )heart rate (elo7 '/) indiactes damage to the Right Ventricle and an 0inferior0 or 0posterior0 infarct. !he Right +oronary Artery is occluded. levation in the L896 L A2., 88$ 888$ 5 AFV. .ystematic 8nfarct Recognition Approach 8ssure that a(/ is pria"arily negative. /ule out a 9eft Bundle Branch Bloc& (5BBB) in (1 and or (2... (erify in (2. Chec& all leads for patterns of ische"ia+ in1ury+ infarction and reciprocal changes.

A98 diagnosis criteria, 1"". or "ore of *' elevation in 2 or "ore contiguous leads. 8nterior $all re;ires 2"". or "ore of *' elevation ((1<()) Caution9 5BBB Lead :roups 8;FAR+! .! L-+A!8-;, L VA!8-; F-<;2 8;,

Anterior 4 V#$ V2$ V3$ and V% 44 /.2mV or .eptal more in leads Posterior 8nferior 3igh Lateral Lo7 Lateral V#$ and V2 44 /.2mV or more in leads 88$ 888$ and aVF 44 /.#mV or more in 2 leads 8$ and aVL 44 /.#mV or more in 2 leads V&$ and V' 44 /.#mV or more in 2 leads

0.! 2epression indicates Angina0

2iagrams (elo7 indicate 7hich part the heart is (eing affected and 7hat lead 7ould sho7 the changes.

Reciprocal +hanges Region of .! levation Region of .! 2epression Anterior )leads V#4V%) 8nferior )true posterior) Anterior )leads V#4V3 or lateral lead 8nferior )leads 88$ 888$ aVF) #. aVL) Lateral ) leads 8$ aVF$ V&$ 8nferior ) leads 88$ 888$ aVF) V') !rue Posterior Anterior )leads V#4V3) #2 lead rapid assessment (erify a(/ is negative 8ssess rate and rhyth" 8xis deter"ination % Leads I and a&3 Conduction a#nor"alities9 L... % seen in &/ (ypertrophy Aneurysm >ericarditis ?rugs or Electrolytes Early repolari4ation 6sche"ia+ 6n1ury+ 6nfarct signs9 %wave inversions ' segment elevation 'ignificant @ waves 8cute =6 pattern9 8nterior9 ' elevation in &/, &0, &5, &8 ' depression in II, III, a&3 6nferior9 ' elevation in II, III, a&3 ' depression in &/, &0, &5, or I, a&L 5ateral9 ' elevation in I, a&L, &9, &: ' depression in II, II, a&3

*eptal $all9 ' elevation in I, a&L, &/, &0 -osterior9 tall and wide # waves and ' depression in &/, &0 /ight (entricular9 ' elevations in &8#, &9#, &:# "9 additional right chest wall electrodes placed on the chest in the same positions as the precordial leads$ Clinical pressentaion 'reat"ent plan

Electrical Current9 lectricity al7ays flo7s from positive to negative. !he electrical current should flo7 from negative to positive in the normal healthy heart. .o$ if this pattern is disrupted (y a 0detour0 or as in the heart$ 0an infarct0 or 0in"ury0 the +: recording 7ill indicate the a(normal flo7 of current. =ith an infarcted heart$ the electrical current flo7s opposite of 7here it is e1pected to flo7. 3ence$ the elevated or depressed .! segment . For instance$ an inferior infaction 7ill sho7 an elevation in lead 88$ 888 and aVF. !he normal flo7 7ould (e 0isoelectrical0 and the .! segment 7ould (e e>ualized or level. 6ut$ since the flo7 is going (ac*7ards around the damaged heart muscle$ 7e see an elevation on the record. 8t is this precise measurement that can dictate e1actly 7here the infarct is located. 8f the .! segment is elevated in V2$ V3 and V%$ the infarct is anterior. !hese vie7s are loo*ing at the front or anterior area of the heart muscle. !he current is flo7ing to7ard the positive electrode on the patients chest. =hen the current is disrupted$ it 7ill sho7 as an elevation in the .! segment versus an isoelectric reading. !hin* of it li*e this, An ?ray film is placed (ehind the heart at the area (et7een the Ventrical .eptum. !he ?4Ray machine shoots the picture from the anterior heart directly a(ove the film. and the film catures the image. =e 7ould (e loo*ing at the area of the heart at the .eptal region 7hich 7ould (e in +: terminology V3. !he infract area 7ill have no electrical current. !he .! segment 7ill (e depressed !he in"ured area 7ill have .! elevations and 7ill release +ardiac 9uscle enzimes. !hese enzimes are +@$ 9yo:lo(in and !roponin 8

!he ishemic area may have .! elevations and and PB+As.

+: cahnges to include PV+As$ PA+As

!he #2 Lead Photograph .imulatneous a>uisition 2.& seconds per vie7$ #/ seconds for a complete study 8 88 888 #2 lead aVR aVL aVF V# V2 V3 V% V& V'

+:C a real time vedio recording of the hearts electrical function. !his record indicates a 0septal D anterior 8nfarct.0

8f you can comprehend 7hich 7ay the current is e1pected to flo7 in !he 3 ?A?8AL V8 = and !he PR +-R28AL V8 = of the heart$ then you can diagnose 7hich area is effected if it is an a(normal flo7... .ee the information (elo7. #2 lead rapid interpretation +ommon +: Formation 6sceh"ia>6nverted ' $aves Inverted wave is symmetrical waves are usually upright in leads I, II, and &0%&: 6n1ury>Elevated *' seg"ent 'ignifies an acute processE ' returns to !aseline with time If ' elevation is diffuse and unassociated with @ wavesor reciprocal ' depression, consider pericarditis

Location of injury can !e determined in same manner as infarct location

Fsually associated with reciprocal ' depression in other leads 6nfarction>. $ave 'mall @s may !e normal in &9, &:, I and a&L A!normal @ must !e one small s2uare "1.18 sec$ wide

Also a!normal if @%wave depth is greater than one%third of @#' height in lead III

9a*ing the accurate Field 2iagnosis,

!here are elevations ) # mm )in t7o contegous )connecting) leads, Leads ad"acent to eachother... !here is at least one lead 7ith reciprocal changes.. 8f the E 7ave is more than #D3 the size of the R 7ave...

!a(le (elo7 sho7s 7hat the +: 7ould loo* li*e in the Vector 7here the heart is (eing affescted. All other areas 7ould loo* normal$ 7ithout elevation or depression. unless there is an 0old 98.0 8n that case$ the prior damage 7ould sho7 up as a depressed segment.

Anterior 8nfarction ' elevation without a!normal @ wave Fsually associated with occlusion of the left anterior decending !ranch of the left coronary artery "LCA$ Lateral 8nfarction ' elevation withGwithout a!normal @ wave <ay !e a component of a mutiple%site infarction Fsually associated with a!struction of the left circumfle) artery 8nferior 8nfarction ' elevation withGwithout a!normal @ wave Fsally associated with right coronary artery "#CA$ occlusion

Right Ventricular 8nfarction Fsually accompanies inferior <I due to pro)imal acclusion of the #CA .est diagnosed !y / % 0 mm ' elevation in lead &8# An important cause of hypotension in inferior <I recogni4ed !y jugular venous distension with clear lung fields Aggressive therapy is indicated, including; reprofussion, ade2uate I& fluids for right heart filling, and pacingf to maintain A%& synchrony if necessary Poterior 8nfarction all, !road "H1.18 sec$ # wavr and ' depression in &/ and &0 "reciprocal changes$ 3re2uestly associated with inferior <I Fsually associated with o!struction of #CA and or left circumfle) coronary artery

Pathological E 7aves, 8f the E 7ave ) the first do7n7ard 0negative0 deflected 7ave ) is more than #D3 the size of the R 7ave ) the first up7ard deflected 0positive0 7ave ) it is pathological and indicative of an A.9.8. 8f no R 7ave is recorded$ then the infarct is e1treamly acute. !here is no electrical activity of the ventricle durring polarization and contraction. 6undle 6ranch 6loc* In .undle .ranch .lock, the firing of the &entricles does not occur simultaneously as it should "It occurs in series instead of parallel$. Conduction reaches a !lock in one of the !ranches "in the cardiac septum$ and refers it to the opposing !ranch to !e conducted completely. It is then when

conduction jumps the Intra%&entricular 'eptum to ultimately conduct to the remaining !locked .undle .ranch. It is !ecause of this that you see two different distinctly separate @#' comple)es over%lapping one another. (ence, the 0Ra(it ar0 and 0R.R pattern.0 #emem!er, the @#' comple) will always !e at least ./0 in width and posses a!normal morphology. AL=AF. +3 +@ R8:3! A;2 L F! +3 .! L A2. F-R 6<; 2L 6RA;+3 6L-+@ )V4#$ V42$ 5 V4&$ V4') 8nfarction associated 7ith a Left 6undle 6ranch 6loc* A L... may result from an acute myocardial infarction "A<I$, !ut field paramedics cannot dianose A<I in the presence of L.... he presence of L... negates meaning ful interpretation of other EIG criteria A L... pattern prior to the onset of clinical findings of A<I with marked reduction in voltage of the @#' comple) may offer clues to the diagnosis of an infarction. L... o!scures the pattern of A<I since the initial @#' vector is a!noemally directed in a L... pattern. It will o!scure the infarction vector and a!normal @ waves will not appear. he most diagnostic feature of A<I is the a!normal direction of the initial 1.18 sec of the @#' vector "ieE the a!normal @ wave$.

L... is usually associated with an Inferior wall A<I when an A<I is diagnosed. L... is usually associated with hypertensive ishemia or primary myocardial disease.

?iagnosing the Bundle Branch Bloc&9 Right or LeftGGG he last 1.18 seconds of deflection on the @#' comple) is used to determine the direction of the !lock. In &/ or <CL/, if the @#' duration is greater that 1./0 seconds "usually 1./8 % 1.01 seconds$ and the last 1.18 second segment of the comple) is pointing down "negative defle)tion$, the !lock is LE3 . If the last 1.18 seconds of the @#' comple) is pointing up and is positively deflected, the !lock is #IG( . 6nfarct /ecognition .ome Additional !ips... Certain easily identifia!le ECG changes that are o!served in the presence of cardiogenic chest pain, reveal some strong presumptive evidence toward the positive diagnosis of A<I. his pattern of changes is refered to as the 0evolution of 9yocardial 8nfarction.0 It is offen suggested that the first o!serva!le evolutionary change is the ischemia we associate with %wave inversion or ' segmnet depression. hen, onto what is refered as the hyperacute phase. In the hyperacute phase of the <I, "usually the first few minutes$ the %wave may simply increase in height, andGor the ' segment !ecomes elevated. he finale phase is the acute phase. In the acute phase, "usually the first hour or more$ the ' segment elevation is accompanied !y the developement of a pathological E 7ave. !his E47ave comfirms the diagnosis of 98. his evolution is not precise, however. =ften times the %wave may invert in the presence of ' segmnet elevation durring the end of the hyperacute phase. In any event... the mose critical o!servation should !e the recognition of ' elevation in 0 or contiguos leads. his is most

important to paramnedic in the pre%hospital phase !ecause the developement of the @%wave may take hours and could easily !e missed in the field. Eventually, the ' segment will return to its !aseline and the %wave resumes its normal position, leaving only the @%wave as evidence that an infarction has occurred. #ecent research and studies have produced 79J accuracy in field diagnosis !y paramedics. >erhaps some reasons would include other indications for ' changes. hey would include simple angina, drug effects, and electrolyte im!alance.