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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.
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.
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.
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.