Lecture Note on Electro Cardiogram Monitoring

1 September 10, 2025

 Key Objectives
By the end of the session students are expected to:
• Describe the anatomy and physiology of the heart
 Highlight the History of ECG
 recognize the normal rhythm of the heart - “Normal
Sinus Rhythm.”
 To recognize the most common rhythm disturbances.

 To recognize an acute myocardial infarction on a 12-

lead ECG.
 Highlight ECG changes on drug and electrolyte
disturbance
 Know ECG art facts
 Interpret ECG findings

2 September 10, 2025

 The heart
Location
Layers
Blood supply
Chambers
Valves
Characteristics

3 September 10, 2025

 ECG monitoring
Definition: is a representation of the electrical
events of the cardiac cycle.

Each event has a distinctive waveform, the study of

which can lead to greater insight into a patient’s
cardiac path physiology

4 September 10, 2025

THE HISTORY OF EKG
Koliker and Muller first demonstrated the
presence of electrical activity in the heart in
1885.
In 1903, William Einthoven introduced the string
galvanometer, a predecessor of current ECG
recorder.
 Enthoven marks three pints on right arm, left
arm and left leg which are at equidistance from
the center, Heart; this forms the hypothetical
equilateral triangle.

5 September 10, 2025

History cont’d…
The imaginary line connecting these points is
called leads and the points are called electrodes.
If one electrode acts as a positive pole, the other
becomes the negative pole that is why the leads
are called bipolar leads.
 Passage of current in the direction of the
positive pole will result in upward deflection the
recording, while flow in the opposite direction will
produce down ward deflection.

6 September 10, 2025

 ECG Monitoring
As the angle between the current and the
lead increases, the recording deflection
becomes smaller.
 The greatest deflection will be made if
current passes parallel to the lead.
If the current is perpendicular to the lead
no deflection is obtained and this line is
called the isoeloctric line.

7 September 10, 2025

 Einthoven's triangle

8 September 10, 2025

FRONTAL PLANE
I BIPOLAR LEADES
The three standard leads are the most useful
leads, with many arrhythmias, heart block,
ischemia but they are limited to the frontal
plane of the heart.
Placement of the three
standard leads
Lead I - measures the potential difference
between the right arm electrode and the left
arm electrode. The third electrode (left leg)
acts as neutral.

9 September 10, 2025

 Lead II - measures the potential difference
between the right arm and left leg electrode.
 Lead III - measures the potential difference
between the left arm and left leg electrode.
Colour code of standard lead
electrodes
Red – right arm electrode
Yellow- left arm electrode
Green/black- left leg electrode

10 September 10, 2025

 UNIPOLAR LIMB LIDES

The standard leads three bipolar leads

record the potential difference between two
points.
Additional information can be obtained by
placing electrodes closer to the heart and
around the thorax

11 September 10, 2025

 Augmented voltage
aVR = Rt arm electrode.
aVL = Lt arm electrode
aVF = left foot

12 September 10, 2025

13 September 10, 2025
14 September 10, 2025
 THE HORIZONTAL PLANE
As we see from above the all limb leads can
only measure the frontal plane action potential,
hence we need to measure the other plane of
the hear like the anteroposterior( the Z- axis)
and this leads to the discovery of pericardial
leads designated V1 –V6

15 September 10, 2025

16 September 10, 2025
 Pericardial leads
V1 Just to the right of sternum on the fourth
inter costal space
V2 Just to the left of sternum on the fourt
intercostals space
V3 mid way between v2 and v4
V4 Mid clavicle line in the fifth inter costal
space
V5 in the anterior auxiliary line lateral to v4
V6 in the mid axillary line lateral to v5

17 September 10, 2025

18 September 10, 2025
 EKG distribution
Septal: V1, V2
Anteroseptal: V1, V2, V3, V4
Anterior: V3–V4
Anterolateral: V4–V6, I, aVL
Lateral: I and aVL, V5 and V6
Inferior: II, III, and aVF
Inferolateral: II, III, aVF, and V5 and V6

19 September 10, 2025

 Normal Impulse Conduction
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

20 September 10, 2025

 Impulse Conduction & the ECG
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

21 September 10, 2025

 The “PQRST”

P wave - Atrial
depolarization

• QRS - Ventricular
depolarization
• T wave - Ventricular
repolarization
22 September 10, 2025
 The PR Interval
Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)

(delay allows time for

the atria to contract
before the ventricles
contract)

23 September 10, 2025

 ECG tracing: waves and
intervals
P- wave
Marks the beginning of the cardiac cycle
and measures the electrical impulse
that causes atrial depolarization and
mechanical contraction
QRS- Complex
Measures the impulse that causes
ventricular depolarization
 Q-wave- may or may not be evident on the
ECG
 R-wave- first upward deflection following P
wave
 S-wave- the first downward deflection
following the R-wave
T- wave
Marks ventricular repolarization that
ends the cardiac cycle

24 September 10, 2025

 ECG tracing: waves, intervals
and segments
P-R interval-
Time interval for impulse to go from
the SA to the AV node
normal 0.12-0.20 secs
QRS Interval
Time interval for impulse to go from
AV node to stimulate Purkinjie fibers
Less than 0.12 secs
QT Interval
Time interval from beginning of
depolarization to the end of
repolarization
Should not exceed ½ the length of
the R-R
ST segment
end of the S to the beginning of the T
25 September 10, 2025
26 September 10, 2025
 Pacemakers of the Heart
SA Node - Dominant pacemaker with an
intrinsic rate of 60 - 100 beats/ minute.
AV Node - Back-up pacemaker with an
intrinsic rate of 40 - 60 beats/minute.
Ventricular cells - Back-up pacemaker with an
intrinsic rate of 20 - 45 bpm.

27 September 10, 2025

 QRS AXIS
The QRS axis represents the net overall
direction of the heart’s electrical activity.

Abnormalities of axis can hint at:

Ventricular enlargement
Conduction blocks (i.e. hemiblocks)

28 September 10, 2025

 QRS AXIS
By near-consensus, the
normal QRS axis is defined
as ranging from -30° to
+90°.

-30° to -90° is referred to

as a left axis deviation
(LAD)

+90° to +180° is referred

to as a right axis deviation
(RAD)
29 September 10, 2025
 DETRMINING THE QRS AXIS
Examine the QRS complex in leads I and
aVF to determine if they are
predominantly positive or predominantly
negative. The combination should place
the axis into one of the 4 quadrants
below.

30 September 10, 2025

 Right axis deviation
Normal axis

31 September 10, 2025

 Summary of anatomical lead
recording

32 September 10, 2025

 ECG Graph Paper
• Runs at a paper speed of 25
mm/sec
• Each small block of ECG
paper is 1 mm2
• At a paper speed of 25
mm/s, one small block equals
0.04 s
• Five small blocks make up 1
large block which translates
into 0.20 s (200 msec)
• Hence, there are 5 large
blocks per second
• Voltage: 1 mm = 0.1 mV
between each individual
block vertically
33 September 10, 2025
ECG Rhythm Interpretation

1. How to Analyze a
Rhythm
 Rhythm Analysis

Step 1: Calculate rate.

Step 2: Determine regularity.
Step 3: Assess the P waves.
Step 4: Determine PR interval.
Step 5: Determine QRS duration.

35 September 10, 2025

 Step 1: Calculate Rate
3 sec 3 sec

Option 1
Method I
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.
This method is employed if the rhythm is
irregular
Interpretation?

9 x 10 = 90 bpm
36 September 10, 2025
 Step 1: Calculate Rate

R wave

Method 2
Find a R wave that lands on a bold line.
Count the number of large boxes to the next R
wave. If the second R wave is 1 large box away the
rate is 300, 2 boxes - 150, 3 boxes - 100, 4 boxes -
75, etc. (cont)
This method is employed for regular ryhtm
37 September 10, 2025
 Determining rate
Method 3

38 September 10, 2025

 Step 2: Determine regularity
R R

Look at the R-R distances (using a caliper

or markings on a pen or paper).
Regular (are they equidistant apart)?
Occasionally irregular? Regularly
irregular? Irregularly irregular?

Interpretation? Regular

39 September 10, 2025

 Step 3: Assess the P waves

Are there P waves?

Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation?
Normal P waves with 1 P
wave for every QRS
40 September 10, 2025
 Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)

Interpretation?

0.12 seconds

41 September 10, 2025

 Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)

Interpretation?

0.08 seconds

42 September 10, 2025

 Rhythm Summary

Rate 90-95 bpm

Regularity regular
P waves normal
PR interval 0.12 s
QRS duration 0.08 s
Interpretation?
Normal Sinus Rhythm

43 September 10, 2025

 NSR Parameters

Rate 60 - 100 bpm

Regularity regular
P waves normal
PR interval 0.12 - 0.20 s
QRS duration 0.04 - 0.12 s
Any deviation from above is sinus
tachycardia, sinus bradycardia or an
arrhythmia

44 September 10, 2025

 Arrhythmia
Definition of Arrhythmia:
It is an abnormal activity of the
heart in at least one of the
following
Origin
Rate
Rhythm
Conduct velocity and sequence
45 September 10, 2025
 Pathogenesis and
Inducement
of Arrhythmia
1. Some physical condition
2. Pathological heart disease
3. Other system disease
4. Electrolyte disturbance and acid-
base imbalance
5. Physical and chemical factors or
toxicosis

46 September 10, 2025

 Arrhythmias
CLASSIFICATION OF ARRHYTHMIAS
Arrhythmias may be divided into narrow
complex and
broad complex for the purpose of rapid
recognition and
management.

47 September 10, 2025

 ARRYTHMIA
Narrow complex arrhythmias - arise above the
bifurcation of the bundle of His. The QRS duration is
less
than 0.1s (2.5 small squares) duration
Broad complex arrhythmias - usually arise either
from
the ventricles or less commonly are conducted
abnormally
from a site above the ventricles so that delay occurs
(this
is called aberrant conduction).
The QRS duration is greater than 0.1s (2.5 small
squares).

48 September 10, 2025

 NARROW COMPLEX
RHYTHMS:

Sinus arrhythmia
 Sinus tachycardia
 Sinus bradycardia
Sinus arrest

Atria arrhythmias
 Atrial tachycardia,
atrial flutter
 Atrial fibrillation
 premature atrial contraction (PAC)

49 September 10, 2025

 BROAD COMPLEX
RHYTHMS

Ventricular ectopic(PVC)
 Ventricular tachycardia
 Supraventricular
tachycardia
Ventricular fibrillation
Asystole
50 September 10, 2025
 Arrhythmia Formation
Arrhythmias can arise from problems in
the:
• Sinus node
• Atrial cells
• AV junction
• Ventricular cells

51 September 10, 2025

 SA Node Problems

The SA Node can:

fire too slow Sinus Bradycardia
fire too fast Sinus Tachycardia*

*Sinus Tachycardia may be an appropriate response to stress.

52 September 10, 2025

 What to check in Arrhythmias
of perioperative period
Assess the vital signs - A.B.C.
Check the airway is patent
Check the patient is breathing adequately
or is being ventilated correctly
Listen for equal air entry into both lungs
Circulation - check pulse, blood pressure,
oxygen saturation.
Is there haemodynamic compromise?
Does the abnormal rhythm on the monitor
match the pulse that you can feel?
53 September 10, 2025
 Consider the following:
Increase the inspired oxygen
concentration
Reduce the inspired volatile
agent concentration
If the arrhythmia is causing
hemodynamic instability,
rapid recognition and
treatment is required.
54 September 10, 2025
 Ensure that ventilation is
adequate to prevent CO2 build up.
Check end tidal CO2 where this
measurement is available
Consider what the surgeon is
doing - is this the cause of the
problem? Eg: traction on the
peritoneum or eye causing a vagal
response. If so ask them to stop
55
while you treat the arrhythmia.
September 10, 2025
 Rhythm #1

• Rate? 30 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.12 s
• QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
56 September 10, 2025
 Sinus Bradycardia

Deviation from NSR

- Rate < 60 bpm

57 September 10, 2025

 Sinus Bradycardia

Etiology: SA node is depolarizing slower

than normal, impulse is conducted
normally (i.e. normal PR and QRS
interval).

58 September 10, 2025

 Rhythm #2

• Rate? 130 bpm

• Regularity? regular
• P waves? normal
• PR interval? 0.16 s
• QRS duration? 0.08 s
Interpretation? Sinus Tachycardia
59 September 10, 2025
 Sinus Tachycardia

Deviation from NSR

- Rate > 100
bpm

60 September 10, 2025

 Sinus Tachycardia

Etiology: SA node is depolarizing faster

than normal, impulse is conducted
normally.
Remember: sinus tachycardia is a
response to physical or psychological
stress, not a primary arrhythmia.

61 September 10, 2025

 Premature Beats
Premature Atrial Contractions
(PACs)
Premature Ventricular
Contractions (PVCs)

62 September 10, 2025

 Rhythm #3

• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2/7 different contour
• PR interval? 0.14 s (except 2/7)
• QRS duration? 0.08 s
Interpretation? NSR with Premature Atrial Contractions
63 September 10, 2025
 Premature Atrial Contractions

Deviation from NSR

These ectopic beats originate in the
atria (but not in the SA node),
therefore the contour of the P wave,
the PR interval, and the timing are
different than a normally generated
pulse from the SA node.
64 September 10, 2025
 Premature Atrial Contractions

Etiology: Excitation of an atrial cell forms

an impulse that is then conducted
normally through the AV node and
ventricles.

65 September 10, 2025

 Teaching Moment
When an impulse originates anywhere in the
atria (SA node, atrial cells, AV node, Bundle
of His) and then is conducted normally
through the ventricles, the QRS will be
narrow (0.04 - 0.12 s).

66 September 10, 2025

 Supraventricular Arrhythmias
Atrial Fibrillation

Atrial Flutter

Paroxysmal Supra Ventricular

Tachycardia (PSVT)

67 September 10, 2025

 Rhythm #5

• Rate? 100 bpm

• Regularity? irregularly irregular
• P waves? none
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Fibrillation
68 September 10, 2025
 Atrial Fibrillation

Deviation from NSR

No organized atrial depolarization, so
no normal P waves (impulses are not
originating from the sinus node).
Atrial activity is chaotic (resulting in an
irregularly irregular rate).
Common, affects 2-4%, up to 5-10% if
> 80 years old

69 September 10, 2025

 Atrial Fibrillation

Etiology: due to multiple re-entrant

wavelets conducted between the R & L
atria and the impulses are formed in a
totally unpredictable fashion.
The AV node allows some of the impulses
to pass through at variable intervals (so
rhythm is irregularly irregular).

70 September 10, 2025

 Rhythm #6

• Rate? 70 bpm
• Regularity? regular
• P waves? flutter waves
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Flutter
71 September 10, 2025
 Atrial Flutter

Deviation from NSR

No P waves. Instead flutter waves
(note “sawtooth” pattern) are formed
at a rate of 250 - 350 bpm.
Only some impulses conduct through
the AV node (usually every other
impulse).
72 September 10, 2025
 Atrial Flutter

Etiology: Reentrant pathway in the right

atrium with every 2nd, 3rd or 4th
impulse generating a QRS (others are
blocked in the AV node as the node
repolarizes).

73 September 10, 2025

 Rhythm #7

• Rate? 74 148 bpm

• Regularity? Regular  regular
• P waves? Normal  none
• PR interval? 0.16 s  none
• QRS duration? 0.08 s
Paroxysmal Supraventricular Tachycardia
Interpretation? (PSVT)
74 September 10, 2025
 PSVT:
Paroxysmal Supra Ventricular
Tachycardia

Deviation from NSR

The heart rate suddenly speeds up,
often triggered by a PAC and the P
waves are lost.

75 September 10, 2025

 Rhythm #4

• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
76 September 10, 2025
 PVCs

Deviation from NSR

Ectopic beats originate in the ventricles
resulting in wide and bizarre QRS complexes.
When there are more than 1 premature beats
and look alike, they are called “uniform”.
When they look different, they are called
“multiform”.

77 September 10, 2025

 Teaching Moment
When an impulse originates in a ventricle,
conduction through the ventricles will be
inefficient and the QRS will be wide and
bizarre.

78 September 10, 2025

 PVCs

Etiology: One or more ventricular cells

are depolarizing and the impulses are
abnormally conducting through the
ventricles.

79 September 10, 2025

A systole- no electrical activity of
the heart

Rate: None

Rhythm: None

P Waves: None

PR Interval: None

80 QRS: None September 10, 2025

 Ventricular Conduction

Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles
81
through theSeptember
ventricles
10, 2025
 AV Nodal Blocks
1st Degree AV Block

2nd Degree AV Block, Type I

2nd Degree AV Block, Type II

3rd Degree AV Block

82 September 10, 2025

 Rhythm #10

• Rate? 60 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.36 s
• QRS duration? 0.08 s
Interpretation? 1st Degree AV Block
83 September 10, 2025
 1st Degree AV Block

Etiology: Prolonged conduction delay in

the AV node or Bundle of His.

84 September 10, 2025

 Rhythm #11

• Rate? 50 bpm
• Regularity? regularly irregular
• P waves? nl, but 4th no QRS
• PR interval? lengthens
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type I
85 September 10, 2025
 2nd Degree AV Block, Type I

Deviation from NSR

PR interval progressively lengthens,
then the impulse is completely blocked
(P wave not followed by QRS).

86 September 10, 2025

 2nd Degree AV Block, Type I

Etiology: Each successive atrial impulse

encounters a longer and longer delay in
the AV node until one impulse (usually
the 3rd or 4th) fails to make it through
the AV node.

87 September 10, 2025

 Rhythm #12

• Rate? 40 bpm
• Regularity? regular
• P waves? nl, 2 of 3 no QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type II
88 September 10, 2025
 2nd Degree AV Block, Type II

Deviation from NSR

Occasional P waves are completely
blocked (P wave not followed by QRS).

89 September 10, 2025

 Rhythm #13

• Rate? 40 bpm
• Regularity? regular
• P waves? no relation to QRS
• PR interval? none
• QRS duration? wide (> 0.12 s)
Interpretation? 3rd Degree AV Block
90 September 10, 2025
 3rd Degree AV Block

Deviation from NSR

The P waves are completely blocked in
the AV junction; QRS complexes
originate independently from below the
junction.

91 September 10, 2025

 3rd Degree AV Block

Etiology: There is complete block of

conduction in the AV junction, so the atria
and ventricles form impulses
independently of each other.
Without impulses from the atria, the
ventricles own intrinsic pacemaker kicks in
at around 30 - 45 beats/minute.

92 September 10, 2025

 Remember
When an impulse originates in a ventricle,
conduction through the ventricles will be
inefficient and the QRS will be wide and
bizarre.

93 September 10, 2025

 .Bundle branch block
 The ventricular conduction system is composed
of two major divisions.
①the right bundle branch
②the left bundle branch

94 September 10, 2025

 BANDLE BRANCH BLOCK
1. Right Bundle Branch Block(RBBB)
ECG:
1).QRS 0.12 sec or wider
2).(M)pattern R in V1 and V2 and
deep ,wide S wave in Ⅰ,V5-6.
3).The ST segment is slight depressed
with negative T waves
When incomplete RBBB is present ,the
pattern is similar, but the QRS width is
less than 0.12sec
95 September 10, 2025
 BBB

96 September 10, 2025

 BANDLE BRANCH BLOCK
 .2. Left Bundle Branch Broch,(LBBB)
ECG:
1). QRS 0.12sec or more .
2)absent q waves in I,V5 and V6
3).wide ,notched,or slurred R waves in V5-6 with
depressed ST segments,downward T waves.
4).wide QS or rS patters with elevated ST
segments and upward T waves in V1-2.
When incomplete LBBB in present ,the pattern is
similar ,but the QRS width is less than 0.12
second.

97 September 10, 2025

 Diagnosing a MI
To diagnose a myocardial infarction you need
to go beyond looking at a rhythm strip and
obtain a 12-Lead ECG.

12-Lead
ECG

Rhythm
Strip
98 September 10, 2025
 The 12-Lead ECG

The 12-Lead ECG sees the heart

from 12 different views.
Therefore, the 12-Lead ECG helps
you see what is happening in
different portions of the heart.
The rhythm strip is only 1 of these
12 views.
99 September 10, 2025
 The 12-Leads

The 12-leads include:

–3 Limb leads
(I, II, III)
–3 Augmented leads
(aVR, aVL,
aVF)
–6 Precordial leads
(V1- V6)
100 September 10, 2025
 Views of the Heart
Lateral portion
Some leads get a
of the heart
good view of the:

Anterior portion
of the heart

Inferior portion
101 of the heart September 10, 2025
 ST Elevation
One way to
diagnose an
acute MI is to
look for
elevation of
the ST
segment.

102 September 10, 2025

 ST Elevation (cont)

Elevation of the ST
segment (greater
than 1 small box)
in 2 leads is
consistent with a
myocardial
infarction.

103 September 10, 2025

 Anterior View of the Heart

The anterior portion of the heart is best

viewed using leads V1- V4.

104 September 10, 2025

 Anterior Myocardial Infarction
If you see changes in leads V1 - V4
that are consistent with a
myocardial infarction, you can
conclude that it is an anterior wall
myocardial infarction.

105 September 10, 2025

 Putting it all Together
Do you think this person is having a
myocardial infarction. If so, where?

106 September 10, 2025

 Interpretation
Yes, this person is having an acute anterior
wall myocardial infarction.

107 September 10, 2025

 Other MI Locations
Now that you know where to look for an
anterior wall myocardial infarction let’s look
at how you would determine if the MI
involves the lateral wall or the inferior wall of
the heart.

108 September 10, 2025

 Views of the Heart
Lateral portion
Some leads get a
of the heart
good view of the:

Anterior portion
of the heart

Inferior portion
109 of the heart September 10, 2025
 Other MI Locations
Second, remember that the 12-leads of the ECG look at
different portions of the heart. The limb and augmented
leads “see” electrical activity moving inferiorly (II, III and
aVF), to the left (I, aVL) and to the right (aVR). Whereas,
the precordial leads “see” electrical activity in the
posterior to anterior direction.

Limb Leads Augmented Leads Precordial Leads

110 September 10, 2025

 Other MI Locations

Now, using these 3 diagrams let’s figure where to

look for a lateral wall and inferior wall MI.

Limb Leads Augmented Leads Precordial Leads

111 September 10, 2025

 Anterior MI

Remember the anterior portion of the heart

is best viewed using leads V1- V4.

Limb Leads Augmented Leads Precordial Leads

112 September 10, 2025

 Lateral MI
So what leads do you think
the lateral portion of the
heart is best viewed?
Leads I, aVL, and V5- V6

Limb Leads Augmented Leads Precordial Leads

113 September 10, 2025

 Inferior MI
Now how about the
inferior portion of the Leads II, III and aVF
heart?

Limb Leads Augmented Leads Precordial Leads

114 September 10, 2025

 Putting it all Together
Now, where do you think this person is having
a myocardial infarction?

115 September 10, 2025

 Inferior Wall MI
This is an inferior MI. Note the ST elevation in
leads II, III and aVF.

116 September 10, 2025

 Putting it all Together
How about now?

117 September 10, 2025

 Anterolateral MI
This person’s MI involves both the anterior wall
(V2-V4) and the lateral wall (V5-V6, I, and aVL)!

118 September 10, 2025

 Reading 12-Lead ECGs

The best way to read 12-lead ECGs is to develop a step-

by-step approach (just as we did for analyzing a rhythm
strip). In these approach:
1. Calculate RATE
2. Determine RHYTHM
3. Determine QRS AXIS
4. Calculate INTERVALS
5. Assess for HYPERTROPHY
6. Look for evidence of INFARCTION

119 September 10, 2025

 Electrolyte imbalance and ECG
changes
Hyper kalmia:
Cause
Administration of potassium
K+ sparing diuretics
Old blood transfusion
Massive haemolysis
Renal Failure
DKA
Suxamethonium administration in a pt with burn,
trauma, certain neurologic and muscular disorder

120 September 10, 2025

 Hyper kalmia cont’d….
CEG changes
Tall peaked T waves
Reduced P waves with widened QRS
complexes
Ultimately a sine wave pattern - pre-cardiac
arrest
Cardiac arrest in diastole

121 September 10, 2025

 Hyper kalmia cont’d….

122 September 10, 2025

 Hypo kalmia
Cause
GIT potassium loss- N&V, diarrhoea
Malabsorbtion
Loop diuretics
Renal dialysis
Hyperaldostronism
Hyperinsulinism
Malignant disease


123 September 10, 2025

 Hypo kalmia cont’d…
ECG changes
Increased myocardial excitability - any
arrhythmiamay occur
Prolonged PR interval
Prominent U waves
Enhancement of digitalis toxicity

124 September 10, 2025

 Hypocalcaemia
Cause
Vitamin D deficiency
Hypoparathriodism
Infusion of citrate
Alkalosis
Hepatic and renal disease
ECG changes: prolonged QT interval

125 September 10, 2025

 Hypocalcaemia
Cause
Increased absorption
decreased mobilization
Decreased excretion
ECG CHANGES: shortened QT interval

126 September 10, 2025

 ART FACTS AFFECTING ECG IN
OPERATION THEATRE
ARTFACTS RELATED TO THE PATIENT
muscle tremor produce a characteristics of
fibrillation
movement of the patient may cause sudden
changes in potential difference between
electrodes
hiccup and movement of diaphragm
respiratory induced vibration in electrical
axis
lateral and trenderlenburg position may
produce abnormal axis deviations
127 September 10, 2025
ARTFACTS RELATED TO LEAD SYSTEM AND ECG
MONITORING
loose electrode may give systolic
pattern tracing
incorrect placement of leads
ARTFACTS PRODUCED BY EXTERNAL
SOURCE INTERFACE
direct contact with the patient by other
personnel
from infusion pumps, roller pump of
CPB( cardiopulmonary bypass)
ELECTRICAL INTERFACE
 electro cautery
128 September 10, 2025