WE WILL COVER FOLLOWING

TOPICS

• Basic heart anatomy-OVERVIEW

• The electrical conduction system
• The ECG waveform
• Basic arrhythmia recognition-
• Clinical considerations
• Why measure ECG?
• 3 Leads, 5 leads, 12 leads....???
 Basic Heart Anatomy
The heart is a two-sided pump divided into four chambers. The
top two chambers are the atria, the bottom two are the ventricles.

body to Left side: oxygenated blood goes from lungs to

body.
Right side: de-oxygenated blood goes from lungs.
HEART AS A PUMP

• WORKS AS A PUMP
• PUMPS BLOOD TO
AND FRO IN THE
BODY.
• PUMPS ABOUT ONE
LAC TIMES AND 2100
GALLONS OF BLOOD
PER DAY
 FUNCTION OF HEART

• COLLECTS
BLOOD FROM
BODY AN SENDS
IT TO LUNGS.
• COLLECTS
BLOOD FROM
LUNGS AND PUMP
IT TO VARIOUS
PARTS OF BODY.
 TYPES OF BLOOD.

• OXYGENATED BLOOD: BLOOD RICH

WITH OXYGEN . IT FLOWS FROM THE
LUNGS TO THE HEART.

• DE-OXYGENATED BLOOD: IMPURE

BLOOD. FLOWS FROM THE BODY TO
THE HEART.
 BLOOD VESSELS
• ARTERIES: BLOOD
VESSELS WHICH
CARRIES
OXYGENATED
BLOOD FROM
ARTRIES HEART TO THE
BODY.(RED)

• VEINS: BLOOD
VESSELS WHICH
CARRIES IMPURE
VEINS BLOOD FROM THE
BODY TO
HEART.(BLUE)
FLOW OF BLOOD IN HEART
TO BODY
IMPURE BLOOD
TO LUNGS
RIGHT
ATRIUM LEFT ATRIUM
PURE
BLOOD

LEFT
VENTRICLE
RIGHT
VENTRICLE
 ANATOMY
• HEART COMPOSED OF MUSCLE CALLED
MYOCARDIUM

• EXTERIOR SURFACE OF MYOCARDIUM

IS EPICARDIUM
• INTERIOR-ENDOCARDIUM
 ANATOMY
• HEART IS TWO SIDED PUMP
• RIGHT SIDE SERVES PUMP
FOR PULMONARY CKT.
(it receives un-oxygeneted blood
from veins and pumps to lungs)

• LEFT SIDE PUMP FOR

SYSTEMIC CKT.
(receives oxygenated blood from
pulmonary veins and pumps to
tissues of body.)
 ANATOMY
• EACH SIDE OF HEART -TWO CHAMBERS
• THE ATRIA ARE INFLOW CHAMBERS(receives
blood from veins and deliver to ventricles)

• THE VENTRICLES ARE PUMPING

CHAMBERS(squeeze blood out through arteries by
contracting )
 ANATOMY
•THE WALL BETWEEN ATRIA -ATRIAL SEPTUM

•THE WALL BETWEEN VENTRICLES-VENTRICULAR

SEPTUM

•THUS HEART CONSISTS OF 4 CHAMBERS

 ANATOMY
• 4 CHAMBERS
IN PULMONARY SIDE:(RIGHT)
• THE RIGHT ATRIUM(RA)
• THE RIGHT VENTRICLE (RV)

IN SYSTEMIC SIDE:(LEFT)
• THE LEFT ATRIUM(LA)
• THE LEFT VENTRICLE(LV)
 ANATOMY
• TO PREVENT BACKFLOW OF BLOOD IT
CONTAINS FOUR VALVES,TWO ON EACH SIDE
• BETWEEN EACH ATRIUM AND VENTRICLE
THERE IS AN ATRIO-VENTRICULAR VALVE (AV
VALVE) TO PREVENT BACKFLOW WHEN
VENTRICLES CONTRACT
• ON RIGHT SIDE -TRICUSPID VALVE

• ON LEFT SIDE - MITRAL VALVE

 ANATOMY
• TWO ARTERIES LEADING FROM VENTRICLES
ARE PULMONARY AND AORTA.
• PULMONARY ARTERY: ON RIGHT SIDE
CARRIES BLOOD TO LUNGS FOR
OXYGENATION

• AORTA: ON LEFT SIDE SUPPLIES BLOOD TO

REST OF BODY
 ANATOMY
• BETWEEN RIGHT VENTRICLE AND
PULMONARY ARTERY -PULMONARY
VALVE

• BETWEEN LEFT VENTRICLE AND AORTA -

 The Electrical Conduction System
• AS ATRIAL MYOCARDIUM
DEPOLARIZES,POTENTIAL
GENERATED BY
DEPOLARIZED WAVE IS
RECORDED AS P-WAVE ON
ECG

• DURING DELAY OF
DEPOLARIZATION WAVE IN
AV NODE, ELECTRICAL
ACTIVITY OCCURRING IS
SMALL TO BE MEASURE BY
ELECTRODES HENCE ECG IS
FLAT(PR SEGMENT)
 The Electrical Conduction System
• AS DEPOLARIZATION WAVES
MOVES FROM
ENDOCARDIAL TO
EPICARDIAL SURFACE
OFMYOCARDIUM,POTENTIA
LS OF HIGH VOLTAGE ARE
RECORDED .
QRS REPRESENTS VENT.
DEPOLARIZATION

• IN INTERVAL BETWEEN END

OF VENT. DEPOLARIZATION
AND BEGINNING OF
REPOLARIZATION ,AGAIN
NO MEASURABLE
ELECTRICAL ACTIVITY IN
HEART CALLED
ST SEGMENT
 The Electrical Conduction System
•REPOLARIZATION OF MYOCARDIUM PRODUCES
ELECTRICAL POTENTIAL JUST AS
DEPOLARIZATION DOES.

•AS VENT. MYOCARDIUM REPOLAIZES THESE

POTENTIALS ARE MEASURED AS T-WAVE
 The Electrical Conduction System

• The heart generates it’s own electricity. The

conduction of this electricity is what causes the
contraction of the atria and ventricles.

• The SINOATRIAL (SA) NODE is the pacemaker of

the heart. It is located high up in the right atrium.
The SA node generates each electrical impulse
which initiates a heartbeat. The SA node fires about
60-100 times per minute. Every time it fires, it
starts a wave of electricity which moves down the
atria, pauses, then moves down the ventricles.
• The conduction of the electrical impulse causes it to
contract, and push the blood down to the ventricle.

• Then, the electrical impulse moves through the

ventricles, causing them to contract and push the
blood out to either the body or the lungs.

• After each pumping cycle, the heart pauses briefly.

• The flat part of the tracing is called the baseline.
• The P Wave represents the contraction of the atria.
• The QRS Complex represents the contraction of the
ventricle.
• The T Wave represents the relaxation of the ventricle.
• Together, the PQRST represent the activity of a
normal cardiac cycle.
 CARDIAC CYCLE
• TWO PRIMARY PHASES

• ONE-DIASTOLE:A PERIOD OF
MYOCARDIAL CONTRACTION WHEN
HEART FILLS WITH BLOOD

• TWO-SYSTOLE: A PERIOD OF
MYOCARDIAL CONTRACTION WHEN
BLOOD IS FORCED OUT OF VENTRICLES
 CARDIAC CYCLE
• DURING DIASTOLE: SEMI-LUNAR VALVES(aortic &
pulmonary) ARE CLOSED,PREVENTS BACKFLOW OF
BLOOD FROM ARTERIES INTO VENTRICLES.
• THE AV VALVES(mitral & tricupid) ARE OPEN,BLOOD
FLOWS FROM THEM INTO VENTRICLES

• AS VENTICULAR WALLS BECOME STRECHED FLOW

 CARDIAC CYCLE
• AT END OF DIASTOLE ,ATRIAL SYSTOLE
OCCURS,MYOCARDIUM IS STILL RELAXED.

• FORCES LAST PORTION OF ATRIAL BLOOD

INTO VENTRICLES
 CARDIAC CYCLE
• AFTER BRIEF PAUSE ,TO ALLOW VENTRICLES
FILL COMPLETELY,VENTRICULAR SYSTOLE
BEGINS

• AS PRESSURE IN VENTRICLES BEGIN TO RISE

,AV VALVES ARE FORCED CLOSED
 CARDIAC CYCLE
• AS VENTRICULAR
PRESSURE RISES,
SEMI-LUNAR VALVES
ARE FORCED OPEN
AND EJACTION OF
BLOOD BEGINS

• VENTRICULAR
CONTRACTION
BEGINS AT APEX &
TOWARDS BASE SO
BLOOD IS FORCED
INTO ARTERIES
 CARDIAC CYCLE
• AFTER SYSTOLE
VENT .
MYOCARDIUM
RELAXES & SEMI-
LUNAR VALVES
ARE FORCED TO
CLOSE BY
PRESSURE OF
BLOOD IN
ARTERIES
• ECG means “electrocardiograph”. Electricity
makes the heart beat. The ECG is a recording of
the heart’s electrical activity. ECG is one of the
most widely used monitoring and diagnostic tools
available.

• Interpretation of the ECG waveform can reveal

abnormal cardiac events such as myocardial
infarction (heart attacks), life-threatening
arrhythmias (abnormal ECG waveforms) or
changes in cardiac status.
 The ECG Waveform
• The ECG is simply a recording of the conduction
of the electrical impulse as it moves through the
heart. When electrodes are placed on the
patient’s chest, they detect the electrical activity
generated and conducted through the heart.

• The contraction of the atria, the contraction of the

ventricles and the brief rest as the heart relaxes
are seen as waveforms on the ECG monitor.
Each waveform represents the path of an
electrical impulse as it is conducted through the
heart.
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• The ECG provides an early warning
of abnormally high or low heart rates,
or life-threatening arrhythmias.

• The ECG can also alert practitioners

to the need for more extensive
assessment of the patient, or the need
for intervention.
 Basic Arrhythmia Recognition

The terms “arrhythmia” and “Ectopic” refer to any

disturbances in the rhythm of the heart. Disturbances
can occur in the discharge of impulses from the SA node ,
or in the conduction of the impulses through the heart.

T
P

S
Q

NORMAL SINUS RHYTHM

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 TYPES OF BEATS
• VENTRICULAR • NORMAL
ECTOPIC • BRADYCARDIA
• COUPLET • TACHYCARDIA
• BIGEMINY • PAUSE
• TRIGEMINY • SVE
• QUDRAGEMINY • SVT
• V-TECH • ARTIFECT
 PVC (Premature Ventricular Contraction) - the electrical
impulse is generated somewhere in the ventricle, instead
of at the SA node. There is no P wave, because the atria
have not contracted. The QRS will be wider than normal.

PAC (Premature Atrial Contraction) - the electrical

impulse is generated somewhere in the atria, other
than the SA node. The P wave will be different, the
QRS is normal.
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It is characterized by absence of P-Wave, a QRS that is
wide in Morphology and Typically followed by
compensatory pause these beats can occur singlets, VPB in
pair called couplet, or in Multiples called run.
When VPBs occurs alternating with normal beats so that every
other beat is a VPB from same ventricular focus the rhythm is
called BIGEMINY. When every third beat is a VBP, the
rhythm is called TRIGEMINY; when every fourth beat is a
VBP, the rhythm is called QUADRIGEMINY.
WHEN THREE OR MORE VPB’s OCCUR IN A ROW THEN IT
IS CALLED VENTRICULAR TACHYCARDIA
 RATE DISTURBANCES

NORMAL SINUS

TACHYCARDIA

Normal Heart Rate

BRADYCARDIA
APPROX. 60-70 BPM
PAUSE
 RATE DISTURBANCES

SINUS TRACHYCARDIA

If the Heart Rate is above than that of the limit set

then ECG strip is labeled as Tachycardia. Usually
the limit is set as 120 bpm.
 RATE DISTURBANCES
SINUS BRADYCARDIA

IF THE HEART RATE IS BELOW THE SET

VALUE ,THEN THE ECG STRIP IS LABELED
AS BRADYCARDIA. NORMALLY THE SET
VALUE IS 50 bpm.
BRADYCARDIA: Normal waveform, slower than
normal heart rate, generally < 60 bpm.

TACHYCARDIA: Normal waveform, faster

than normal heart rate, generally >100
bpm.
A BEAT WHICH LOOKS NORMAL IN MORPHOLOGY
AND
OCCURS EARLY COMPARED TO THE NORMAL SINUS
RHYTHEM IS CALLED SVPB.
% OF PREMATURITY IS SET IN THE SCANNING
CRITERIA.
WHEN ONE OR MORE SVB’s OCCURE IN A ROW AND THE
HEART RATE IS ABOVE 100 bpm THEN IT IS CALLED SVT
J-POINT AND DELAY POINT
THE ST SEGMENT

ST-ELEVATION

ST-DEPRESSION
 ARTIFACTS

BEATS WHICH DOES NOT HAVE

MORPHOLOGY OF ECG SUCH AS

NOISE ARE LABELLED AS ARTIFACTS

 CLINICAL CONSIDERATIONS

ARTIFACT is interference which causes disruption

of the ECG signal. It is a fact of life in cardiac
monitoring. The source of artifact can be from the
patient, the monitor or other equipment in the
room.

Electrical interference from an electrosurgical device

– Excessive patient movement
– Muscle tremours, sweating, shivering
– Sneezing, coughing, heavy breathing
– Oily skin, chest hair
– Poorly applied electrodes
 EXAMPLES OF ARTIFACT
Muscle
movement

60 cycle
electrical
interference

Patient
movement or
incorrect lead
placement

In some cases, artifact can bear an alarming

resemblance to a life-threatening arrhythmia.

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 Clinical Considerations
ELECTRODE APPLICATION
The single most important factor in getting a true ECG
tracing is the proper application of the electrodes.
Anything that comes between the skin and electrode can
produce artifact. Here are some tips:
- Shave hair growth.
- Clean skin with soap & water or alcohol, dry.
- Abrade skin until reddened to remove dead skin.
- Don’t put electrodes on scar tissue,burns, rashes or
lesions.
- Press on the edges of the electrodes, not the middle!

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 3-Leads, 5-Leads, 12-Leads... ???
There are three different lead configurations for ECG
monitoring, 3-lead, 5-lead and 12-lead. Each lead gives a
different view of the electrical activity of the heart.
3-LEAD: The most commonly used configuration. Not used
for diagnosis, but for trending gross changes in rate or
rhythm.
5-LEAD: Generally used in more critical care areas. It is
more comprehensive because it allows more views of the
heart to be seen. Atlas can be used as a 5-lead ECG
monitor.
12-LEAD: The most comprehensive way to view the heart.
Can also be equipped
with measurement and interpretation. Atlas cannot be used
as a 12-lead ECG! Most of the ECG machines are 12-lead.
 3-LEAD PLACEMENT

RA - RIGHT ARM
LA - LEFT ARM
LL - LEFT LEG
 ELECTRODE PLACEMENT FOR 3-LEAD ECG

For 3-lead ECG, there are 3 choices of views of the heart:

• LEAD I - best view of the atria

• LEAD II - best view of the ventricles
• LEAD III - “up and under” view of the heart
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VIEWS OF THE HEART - 3 LEAD ECG

“Einhoven’s Triangle”
5-LEAD PLACEMENT
10 LEAD PLACEMENT

RA - Right Arm
RL - Right Leg
LA - Left Arm
LL - Left Leg
V1 - 4th Intercostal, right of Sternum
V2 - 4th Intercostal, Left of Sternum
V3 - Between V2 and V4
V4 - 5th intercostal, left midclavicular line
V5 - Between V4 and V6
V6 - 5th Intercostal, left midaxillary