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Electrocardiogram Introduction

The electrocardiogram (ECG or EKG) is a diagnostic tool that measures and records the electrical activity of the heart in exquisite detail. Interpretation of these details allows diagnosis of a wide range of heart conditions. These conditions can vary from minor to life threatening. The term electrocardiogram was introduced by Willem Einthoven in 1893 at a meeting of the Dutch Medical Society. In 1924, Einthoven received the Nobel Prize for his life's work in developing the ECG. The ECG has evolved over the years. The standard 12-lead ECG that is used throughout the world was introduced in 1942. It is called a 12-lead ECG because it examines the electrical activity of the heart from 12 points of view. This is necessary because no single point (or even 2 or 3 points of view) provides a complete picture of what is going on. To fully understand how an ECG reveals useful information about the condition of your heart requires a basic understanding of the anatomy (that is, the structure) and physiology (that is, the function) of the heart.

Heart Function and the ECG


The heart normally beats between 60 and 100 times per minute, with many normal variations. For example, athletes at rest have slower heart rates than most people. This rate is set by a small collection of specialized heart cells called the sinoatrial (SA) or sinus node. Located in the right atrium, the sinus node is the heart's "natural pacemaker." It has "automaticity," meaning it discharges all by itself without control from the brain. Two events occur with each discharge: (1) both atria contract, and (2) an electrical impulse travels through the atria to reach another area of the heart called the atrioventricular (AV) node, which lies in the wall between the 2 ventricles. The AV node serves as a relay point to further propagate the electrical impulse. From the AV node, an electrical wave travels to both ventricles, causing them to contract and pump blood. The normal delay between the contraction of the atria and of the ventricles is 0.12 to 0.20 seconds. This delay is perfectly timed to account for the physical passage of the blood from the atrium to the ventricle. Intervals shorter or longer than this range indicate possible problems. The ECG records the electrical activity that results when the heart muscle cells in the atria and ventricles contract. Atrial contractions (both right and left) show up as the P wave. Ventricular contractions (both right and left) show as a series of 3 waves, Q-R-S, known as the QRS complex. The third and last common wave in an ECG is the T wave. This reflects the electrical activity produced when the ventricles are recharging for the next contraction (repolarizing). Interestingly, the letters P, Q, R, S, and T are not abbreviations for any actual words but were chosen many years ago for their position in the middle of the alphabet. The electrical activity results in P, QRS, and T waves that have a myriad of sizes and shapes. When viewed from multiple anatomic-electric perspectives (that is, leads), these

waves can show a wide range of abnormalities of both the electrical conduction system and the muscle tissue of the heart's 4 pumping chambers.

What You Can Expect During an ECG


Few procedures in medicine are easier than an ECG. You will lie down quietly on a bed or stretcher. A technician (or sometimes a nurse, doctor, or other medical professional) will place 6 small adhesive electrode pads across your chest from your lower breast bone (sternum) to an area below your left armpit. Other pads will be placed on each of your arms and legs. Insulated wires will connect each of these 10 pads to the ECG machine. Once these wires, called "leads," are attached, the ECG records a few heartbeats on a single sheet of graph paper. Each heartbeat produces a set of P-QRS-T waves. This set of waves, in turn, is recorded and analyzed from each of 12 points of view. Six of these points of view are the locations of the 6 pads placed across your chest. These are called V1, V2, V3, V4, V5, and V6 (pronounced Vee One, Vee Two, and so on). The other points of view represent combinations of the pads placed on the arms and legs. These are called I, II, III , aVR, aVL, and aVF. The interpretation of the waves produced by each of these 12 views provides valuable information about the functioning of your heart. In some circumstances, medical illnesses elsewhere in the body or various drugs (especially in overdose situations) affect an otherwise healthy heart in ways revealed by diagnostic or suggestive changes in to the ECG changes. In addition to the 12-lead ECG, an additional "rhythm strip" may be taken. This represents only one point of view but is a good way to see important changes that may be occurring over longer periods of time. These may be changes that are hard to interpret or are not even detected in the handful of heartbeats recorded in the standard 12-lead ECG. This is especially useful when the heart is beating slower or faster than normal. Some people with heart rhythm disorders (arrhythmias) or coronary heart disease have symptoms that come and go. These symptoms may include brief chest pain or angina, palpitations, dizziness, or weakness. If you are not having symptoms when you see your health care provider, your ECG result may be perfectly normal. This is a common occurrence, and it is frustrating because your health care provider cannot properly diagnose or treat your problem until it has been documented on ECG. If this happens to you, your health care provider will probably recommend ambulatory ECG. This is a good way to "catch" and document any temporary or intermittent abnormalities such as irregular heartbeats. For this test, you are attached to an ECG recording device (sometimes called a Holter monitor) that records every heartbeat for periods of 24 hours (or longer, if necessary). An alternative method is to record the heartbeats only intermittently but for a longer period of time, days or weeks. Long-term monitoring significantly increases your chances of "catching" any abnormalities on the ECG, even if they last only a few minutes or seconds.

Reasons to Have an ECG


Heart problems can produce a wide array of symptoms. Without the benefit of an ECG, it may be impossible to tell whether these symptoms are being caused by a heart problem or just mimicking one. Therefore, unless your symptoms are explained by an illness, injury, or condition known to not affect the heart, an ECG will generally be done. Common symptoms that frequently require an ECG include the following: Chest pain or discomfort Shortness of breath Nausea Weakness Palpitations (rapid or pounding heartbeats or increased awareness of heart beating) Anxiety Abdominal pain Fainting (syncope) ECG often reveals a problem that is not primarily cardiac in nature. Examples are overdoses of certain drugs (such as certain antidepressants, cocaine, or amphetamines) or electrolyte abnormalities (especially potassium). If you are about to have surgery with general anesthesia, you will have an ECG to detect any latent (silent) cardiac conditions that might worsen with the stresses of surgery and anesthesia. People of any age who are in occupations that stress the heart (professional athletes or firefighters, for example) or involve public safety (commercial airline pilots, train conductors, and bus drivers) require ECGs as well. Anyone aged 40 years or older should have an ECG done. This first ECG serves as a screening tool to detect any cardiac problems and as a baseline for comparison of future ECGs.

1. ECG Waves and Intervals:


What do they mean? P wave: the sequential activation (depolarization) of the right and left atria QRS complex: right and left ventricular depolarization (normally the ventricles are activated simultaneously) ST-T wave: ventricular repolarization U wave: origin for this wave is not clear - but probably represents "afterdepolarizations" in the ventricles PR interval: time interval from onset of atrial depolarization (P wave) to onset of ventricular depolarization (QRS complex) QRS duration: duration of ventricular muscle depolarization QT interval: duration of ventricular depolarization and repolarization RR interval: duration of ventricular cardiac cycle (an indicator of ventricular rate)

PP interval: duration of atrial cycle (an indicator of atrial rate)

Common Causes of ECG Tracings


If you are having symptoms, the ECG is just one test your health care provider will use in making an overall evaluation. Your ECG may be completely normal despite the presence of significant heart disease. Here's an example: An overweight man who smokes, never exercises, and eats a fatty diet has his coronary arteries 70% blocked by cholesterol deposits. Despite this, during the quiet resting conditions under which most ECGs are performed, coronary blood flow will be sufficient to give the heart muscle the oxygen it needs. The ECG, therefore, may be perfectly normal. In these circumstances, a normal ECG would give a false sense of security that all is well with the heart. If this person exercises on a treadmill (or shovels snow, chops wood, digs a hole for a fence, or performs similar activity), his heart will need to pump twice as much blood to deliver twice as much oxygen to the muscles of the arms and legs. With 70% blockage of the coronary arteries, the heart muscle likely will not get the blood flow it needs. This may manifest as fatigue, shortness of breath, or discomfort in the chest or arms. An unsuspecting person may attribute these symptoms to overexertion and will slow down or stop the exercise and never realize that is heart is producing warning signs. On a treadmill under continuous ECG monitoring, however, the ECG usually identifies the problem before a full-blown heart attack has occurred, it is hoped. In cases of angina, when the blockage is temporary, the telltale ECG changes will be temporary as well. When a heart attack has occurred, on the other hand, a part of the actual heart muscle has died, and the ECG changes will be permanent. In a heart attack, affected portion(s) of the heart will be electrically silent, and, like a burned-out light bulb, no longer radiate energy. This shows up as changes in the voltages of the ECG, especially of the QRS complex. For these reasons, it is especially important to go to a hospital emergency department in the early stages of a heart attack. Some people are eligible to receive a medication that rapidly dissolves the coronary artery blockage. This medication works only if it is given within 6 hours after the onset of symptoms. Other people are not eligible to receive this medication because of potential complications, such as bleeding. Electrical problems within the heart may disrupt the heart's natural pacemaker. The extensive electrical network of nerves and nerve centers that coordinate the firing of the 4 chambers is made of living cells that require oxygen every bit as much as the heart muscle. These cells are subject to malfunction when starved of oxygen by blockage of a coronary artery. When this occurs, the heart may beat too fast, too slowly, or too irregularly to sustain its normal pumping function. For example, if the coronary artery supplying the sinus node is blocked, the sinus node may fail. If the failure is partial, the heart rate will slow down. If the failure is complete, then there will be no activation of the atria, no atrial contraction, and no signal to trigger

the AV node. The heart will stop pumping. This is called cardiac arrest and usually causes death. Fortunately, the AV node has automaticity of its own. This means that in the absence of a normal incoming signal from the sinus node, the AV node will fire on its own, but at the slower rate of 35-60 times per minute. Depending on the condition of the rest of the heart (the coronary arteries and the valves, for example), this slower rate may or may not result in symptoms. Because a heart so affected loses its ability to speed up when needed, it is generally only a matter of time before the condition results in noticeable symptoms. This condition, known as sick sinus syndrome, is one of the more common reasons that people need an artificial pacemaker. Sometimes a body's natural pacemaker malfunctions despite an otherwise perfectly healthy heart. (This is the equivalent to a car engine that doesn't run well because of a spark plug problem.) This was the situation for Arne Larsson, a Swedish engineer who received the first artificial pacemaker in 1958. He died in December 2001, aged 86 years, of causes unrelated to his heart. Sometimes the heart's 2 ventricles beat so rapidly that very little or no blood at all is pumped because there is not enough time between contractions for the ventricles to fill. This dangerous condition is known as ventricular tachycardia if the heartbeat is regular and ventricular fibrillation if the heartbeat is irregular. When this occurs, a well-placed electrical shock across the chest may be life saving. The shock, known as defibrillation, neutralizes all the abnormal electric circuits, thus giving the heart's pacemaker a chance to kick in at a normal rate. Because the brain and heart cannot survive total loss of blood flow lasting much more than about 10 minutes, it is crucial that the shock be delivered within this time frame. A device called an AED (automatic external defibrillator) is increasingly being made available in public locations such as large office buildings, shopping malls, golf courses, and airplanes. For further information, see the American Heart Association's Questions and Answers about AEDs.

Eye opening Assessment of eye opening involves the evaluation of arousal (being aware of the environment):

Score 4: eyes open spontaneously; Score 3: eyes open to speech; Score 2: eyes open in response to pain only, for example trapezium squeeze (caution if applying a painful stimulus); Score 1: eyes do not open to verbal or painful stimuli. Record 'C' if the patient is unable to open her or his eyes because of swelling, ptosis (drooping of the upper eye lid) or a dressing.

Verbal response Assessment involves evaluating awareness:

Score 5: orientated; Score 4: confused; Score 3: inappropriate words; Score 2: incomprehensible sounds; Score 1: no response. This is despite both verbal and physical stimuli. Record 'D' if the patient is dysphasic and 'T' if the patient has a tracheal or tracheostomy tube in situ.

Motor response Assessment of motor response is designed to determine the patient's ability to obey a command and to localise, and to withdraw or assume abnormal body positions, in response to a painful stimulus (Adam and Osborne, 2005):

Score 6: obeys commands. The patient can perform two different movements; Score 5: localises to central pain. The patient does not respond to a verbal stimulus but purposely moves an arm to remove the cause of a central painful stimulus; Score 4: withdraws from pain. The patient flexes or bends the arm towards the source of the pain but fails to locate the source of the pain (no wrist rotation); Score 3: flexion to pain. The patient flexes or bends the arm; characterised by internal rotation and adduction of the shoulder and flexion of the elbow, much slower than normal flexion; Score 2: extension to pain. The patient extends the arm by straightening the elbow and may be associated with internal shoulder and wrist rotation; Score 1: no response to painful stimuli.

Painful stimulus A true localising response to pain involves the patient bringing an arm up to chin level. Painful stimuli that can elicit this response include trapezium squeeze (Fig 4), suborbital ridge pressure (Fig 5) (not recommended if there is a suspected/confirmed facial fracture) and sternal rub (caution, not recommended in some organisations) (Fig 6) (Jevon, 2007). The procedure

Explain the procedure to the patient. Ascertain the patient's acuity of hearing. Ideally, use an interpreter if the patient does not speak English. Check the patient's notes for any medical condition that may affect the accuracy of the GCS, for example previous stroke, affecting the movement of the patient's arms (Fig 1). Check the neurological observation chart for the GCS scale (Fig 2). Check if the patient opens their eyes without the need to speak or to touch them; if the patient does, then the score is 4E. If the patient does not open their eyes, talk to them (Fig 3). Start off with a normal volume and speak louder if necessary. If they now open their eyes, the score is 3E.

If the patient does not open their eyes to speech, administer a painful stimuli, for example trapezium squeeze (using the thumb and two fingers grasp the trapezius muscle where the neck meets the shoulder and twist ) (Fig 4). Or apply suborbital pressure (locate the notch on the suborbital margin and apply pressure to it) (Fig 5). An alternative is the sternal rub (using the knuckles of a clenched fist to apply grinding pressure to the sternum; not recommended for repeated assessment) (Fig 6). If the patient opens their eyes to a painful stimulus record the score as 2E (Dougherty and Lister, 2005). If the patient does not respond, then the score is 1E.

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