12 lead ecg recording and basic interpretation delegate …
TRANSCRIPT
12 Lead ECG Recording
and Basic Interpretation
Delegate Notes
To download online visit www.ecgtraining.co.uk
> delegate resources > 12 lead > password 12LeadR&I
Reviewed November 2019
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
2
Anatomy and Physiology of the Heart
The Cardiac Cycle
o Veins bring blood into the heart which collects in the atria.
o The atria contract and blood moves to the ventricles through valves which prevent the
backflow of blood (step 1 below).
o Once the ventricles are full of blood, they contract to pump blood out through valves
into arteries which take blood away from the heart (step 2 below).
o Blood circulates around this system, taking up oxygen in the lungs and giving it up to
the tissues and organs of the body.
o The heart has four chambers – the right atrium, the
left atrium, the right ventricle and the left ventricle.
o The right side of the heart pumps deoxygenated
blood to the lungs.
o The left side of the heart pumps oxygenated blood
to the body.
o Veins bring blood towards the heart, while arteries
take blood away from the heart.
A tip to remember this:
VeIN – IN to the heart
Arteries – take blood Away
Right
Atrium
Left
Atrium
Right
Ventricle
Left
Ventricle
Step 1 Step 2
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
3
The Structure of the Heart
The Electrical Conduction System of the Heart
Contraction of the heart muscle is associated with electrical activity. The electrical conduction
system of the heart is made up of specialised cells. These specialist cells can initiate a heartbeat
and transmit the impulses through the heart in an organised manner. The change in electrical
charge of a cell is known as depolarization.
1) The impulse is initiated from the
Sino-Atrial (SA) node, which is the
hearts natural pacemaker and
beats between approximately
60-100 times per minute at
rest.
2) The wave of depolarisation travels
across the atria to the
Atrioventricular (AV) node.
3) The depolarisation continues down
through the Bundle of His which
branches off into the left and right
bundle branches.
4) Purkinje fibres emerge from these
branches and innervate the
myocardial cells.
5) After depolarisation the cells return
to their original electrical state
known as repolarisation (which
causes relaxation of the muscle).
The heart consists of three layers:
o Pericardium – a thin outer lining that
protects and surrounds your heart.
o Myocardium – a thick muscular middle
layer that contracts and to squeeze blood
out of your heart.
o Endocardium – The innermost layer of the
heart.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
4
How an ECG complex is formed
The depolarisation of cardiac cells is detected by electrodes on the skin when we perform an
ECG. A standard ECG complex consists of three main components.
A wave is a deflection from the baseline that represents a cardiac event.
P wave – this deflection shows the depolarisation of the atria, which causes atrial contraction.
QRS complex – this deflection shows the depolarisation of the ventricles, which causes the
ventricles to contract.
T wave – this deflection shows the repolarisation of the ventricles, which causes the ventricles
to relax.
A specific portion of a complex is described as a segment, for example the segment between
the end of the P wave and the beginning of the QRS complex is known as the PR segment.
The distance occurring between two cardiac events measured as time is known as the interval.
The time interval between the beginning of the P wave and the beginning of the QRS complex
is known as the PR interval (note there is a PR interval as well as a PR segment).
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
5
The ECG Paper
The standard calibration settings should be set to:
Paper speed: 25mm/s Voltage: 10mm/mV
The ECG paper runs at a rate of 25mm per second. Each 1mm square is therefore is 1/25th of
a second or 0.04 seconds. Each large box is made up of 5 smaller boxes, it represents 5 X
0.04 seconds = 0.2 seconds. Therefore 5 large boxes make 1 second.
The ECG should print 10mm of height per 1mV of electrical activity detected. When talking
about the height of a wave we use millimetres.
The paper is also broken down into four strips, the top 3 strips are made up of the 12 leads
which are appropriately labelled for easy identification. The 4th, a continual strip found at the
bottom of the page is a rhythm strip (lead II). The complete ECG is 10 seconds long.
See the example ECG below.
1 second = 5 large
squares
5mm
=
0.5m
V
0.2 sec.
0.04
sec
1mm
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
6
How does the ECG ‘look’ at the heart?
This is helpful to understand the term ’12 lead ECG’. This is more advanced information for
your reference.
To make sense of an ECG we need to understand the concept of the ‘lead’, this term does not
refer to the wires that connect the patient to the machine, but the different viewpoints of the
heart’s electrical activity.
An ECG machine uses the information it collects via its four limb electrodes and six chest
electrodes to compile a comprehensive picture of the electrical activity in the heart as
observed from 12 different viewpoints (hence the name ’12 Lead ECG’).
Each lead is given a name. I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5 & V6.
Leads I, II and III are bipolar (measure electrical potentials between a negative and a positive
electrode). All other leads are unipolar using a nominal centre point of the heart (use a single
positive electrode and use a combination of all other electrodes to act as a negative
electrode).
The measured electrical potentials from the four limb electrodes are used by the ECG
machine to create the six limb viewpoints (Leads I, II, III, aVR, aVL & aVF – see below).
V1, V2, V3, V4, V5, V6 correspond to each of the six chest electrodes. This is useful to
know when dealing with artefact on the ECG.
The different sections on the ECG represent the different regions of the heart -
lateral being the left side of the heart, anterior being the front of the heart and the inferior
being the lower area of the heart.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
7
Preparing the Patient
Prior to undertaking the procedure, the following should be checked:
• That the ECG machine is safe and ready to use (date & time settings are correct)
• The patient area is clean and tidy
• There is enough paper, electrodes, razors and skin preparation equipment
• The identity of the patient should be confirmed and cross-checked with the request
• Room to be warm and private to maintain dignity.
Once the electrodes are positioned and the connecting wires are appropriately attached, the
patient should be covered with a gown to preserve his/her dignity during the procedure.
Patients may feel uncomfortable about being touched on their upper torso. The ECG
procedure requires sensitivity. Operators must take every effort to respect the sensitivities of
patients and minimise any discomfort. Operators must adhere to the organisation’s chaperone
policy and ensure that patients are made aware of the policy.
Skin preparation:
Skin preparation is required to help produce an artefact-free and accurate ECG. Various
methods are available, all of which are designed to minimise the skin-to-electrode problems.
Considerations include:
The removal of chest hair may be required to ensure adequate contact with the skin. Verbal
consent should be obtained from the patient and a clean razor used which should be disposed
of in a sharps bin immediately afterwards.
Exfoliation may be required and should be undertaken with very light abrasion using either a
paper towel, gauze swab or proprietary abrasive tape designed specifically for this purpose.
On occasions the skin may require cleansing. A variety of methods exist ranging from
washing with mild soap to cleaning with an alcohol wipe. However, care must be taken in
patients with sensitive or broken skin.
Check the wires and connection areas as occasionally gel can accumulate on the clips which
can affect contact. Clean with alcohol wipes.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
8
Chest Electrode Placement
Chest electrodes should be accurately placed as according to the SCST Guidelines (2017).
Step one:
Find the Angle of Louis by feeling for the ‘bump’ on the
sternum. Direct your finger down and leftwards until you feel
the space between two ribs. This is an accurate way to locate
the second intercostal (rib) space. From this position, count
down two more rib spaces and place an electrode in the fourth
intercostal space at the right sternal edge (V1).
Repeat on the patients left side (moving your finger to the
right from the Angle of Louis) and place an electrode on in the
fourth intercostal space at the left sternal edge (V2).
Step two:
Look at the patient’s clavicle (collar bone) and estimate the
midway distance across this bone. Follow a straight line down
from this point by eye. Place the electrode in the fifth
intercostal space by counting one space lower and following
across to the level of the mid-clavicle (V4). Where there is
breast tissue, the electrode should be placed at the level of the
mid-clavicle underneath the breast.
Step three:
Place an electrode at the mid-point between the second and
fourth electrodes (V3) (as shown).
Step four:
Place an electrode at the same horizontal level as V4, on the
anatomical ‘mid-axillary line’ – this is usually where you would
find the line of the seam of a tshirt. From here you can place
an electrode between V4 and V6 – known as the enterior
axillary line.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
9
Recording an ECG
It is vital to get the electrode placement, wire connections and overall recording procedure
correct as an inaccurate ECG could result in inappropriate diagnosis and treatment.
Electrode Position
V1
V2
V3
V4
V5
V6
Fourth intercostal space at the right sternal edge
Fourth intercostal space at the left sternal edge
Midway between V2 and V4
Fifth intercostal space in the mid-clavicular line
Left anterior axillary line at same horizontal level as V4
Left mid-axillary line at same horizontal level as V4 & V5
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
10
Recording an ECG
Colours on the wires are useful, but if you are new to recording ECGs or do so infrequently,
we recommend you read the numbers labelled 1-6 on the wires which should be placed from
left to right in order across the chest electrodes.
Limb electrodes:
• Right arm limb lead (RA, red) - right forearm, proximal to wrist
• Left arm limb (LA, yellow) - left forearm, proximal to wrist
• Left leg limb lead (LL, green) - left lower leg, proximal to ankle
• Right leg limb lead (N, black) - right lower leg, proximal to ankle
This may help you remember
the order of limb positions:
Red, Yellow, Green, Black
‘Ride Your Green Bike’
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
11
Recording an ECG
• Begin by asking the patient to lie down (at an angle of 45 degrees – halfway between flat and upright) and relax, this reduces artefact and ensures consistency between ECGs.
• Attach the chest and limb electrodes as described and connect wires.
• Check that paper is loaded and ensure the date and time is correct.
• Enter patient’s details – name, DOB, gender.
• Press start and allow the machine to follow its process until printing is complete. • Inform the necessary clinician that the ECG has been done. Any changes on the ECG that
might require urgent medical attention should be identified and advice sought from a senior member of staff if necessary.
• If the patient has any cardiac symptoms at the time of recording, such as chest pain or
palpitations then this should be noted on the tracing and brought to the immediate attention of a senior member of staff.
• It is imperative that any changes from the standard procedure of recording are noted on
the ECG to prevent misinterpretation (e.g. patient sat upright in wheelchair).
Once the ECG has been printed you should check the following:
• Calibration – calibration markers are printed on the ECG alongside a rectangular box
that measures 10 small squares (10mm) in height. The paper speed is usually printed
on the bottom left corner of the ECG. Standard setting is 25mm/second. Any alterations
to this will alter the analysis. The vertical axis of the ECG measures the amplitude (size)
of the waveforms. The standard calibration is 10mm/mv. Alterations to the amplitude
settings can alter the size of the waveforms and lead to incorrect analysis of the ECG.
• Quality of the trace – the ECG should be clear with no artefact, wandering baseline,
electrical or muscle interference or missing leads.
• aVR should always be negative –if aVR is positive, it is usually because the right and
left arm wires have accidently been switched.
• The relevant patient details including name, date and time of the ECG need to be on
the printout. It is also useful to make a note of any symptoms that the patient was
experiencing e.g. chest pain when the ECG was being recorded.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
12
Examples of poor-quality ECGs
Wandering baseline
Caused by poor skin to electrode contact.
Muscle interference
Caused by patient movement/muscle tension.
Electrical interference
Caused by electrical devices/sources of AC artefact. Internal neurostimulators (e.g. DBS).
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
13
Other Types of ECG Recording
There are other ways that an ECG may be recorded. Although you might not be involved in
these, your patient may be asked to have further testing because of the initial ECG. The 12
lead ECG may not pick up on abnormalities occurring less frequently.
Other tests include:
Exercise stress test – this is usually performed to see if there are any changes to the
heart that occur during exercise. The test may be performed with the individual on an
exercise bike or walking on a treadmill. They are also connected to an ECG and this is
monitored as the intensity increases to look for heart rhythm abnormalities or signs of
ischaemia.
Holter monitor (also known as ambulatory monitoring) – a small device is connected to
the individual via 3 or 6 electrodes which are worn for 24-72 hours. The patient is advised
not to shower or bath while wearing the device. They would usually be asked to keep a
diary of activities during this time so that this can be compared to the recording.
7-day Holter monitor – this is the same device as above however the device can be
removed when the patient wishes to bath or shower.
Cardiac event recorder – this is useful if the patient’s symptoms are infrequent. There
are no wires or electrodes. The patient would hold this to the chest when they are having
symptoms.
Implantable loop recorder – this is a small device (approximately the size of a
computer memory stick). It is implanted under the skin in the upper left chest area. The
battery can last up to three years. When the patient experiences symptoms they hold a
hand-held activator over the loop recorder and press a button to record the activity.
For further information regarding any of these investigations, please see the British Heart
Foundation website: www.bhf.org.uk/heart-health/tests
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
14
Basic ECG interpretation
The next section of the course will be concentrating on rhythm analysis using the six-stage
approach.
We break the analysis of the ECG into two parts:
1) Analysis of the rhythm strip (bottom line of ECG)
2) Looking at the main body of the ECG (top three lines of ECG)
Rhythm Analysis
Accurate analysis requires experience, but six basic principles can help with the interpretation
of most rhythms encountered and lead to a diagnosis on which to base appropriate treatment.
It is important to always look at the ECG in the context of the patient’s clinical condition. It is
a useful diagnostic tool, however it is important to act on any symptoms they may be
experiencing.
The Six Steps Approach
This 6-step systematic approach can be applied to all rhythm
strips:
1. Is there any electrical activity?
2. What is the ventricular rate? (QRS)
3. Is the QRS rhythm regular or irregular?
4. Is the QRS complex width normal or prolonged?
5. Is atrial activity present?
6. How is atrial activity related to ventricular activity?
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
15
1 Is there any electrical activity?
If there is no electrical activity, check the patient first, then the gain, leads and electrical
connection.
If electrical activity is present and there are recognisable complexes, then follow the remaining
steps.
2 What is the ventricular rate?
The normal rate is between 60 – 100 beats per minute.
• A rate below 60bpm = bradycardia
• A rate above 100 bpm = tachycardia
• Easy way to calculate the rate:
• Starting with an ‘R’ wave, count 30 large boxes (6 seconds) and then count the number
of QRS complexes within that distance.
• Multiply that number by 10 which will give you the rate
30 large boxes shown
5 complexes visible between lines
5 x 10 = 50bpm
This method is useful for both regular and irregular rhythms.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
16
Activity 7: Work out the rate of the following rhythms
DO NOT WRITE IN THIS BOOKLET
Please write your answers in your workbooks
7A) Rate = ? write the answer in your workbook
7B) Rate = ? write the answer in your workbook
3 Is the QRS rhythm regular or irregular?
This is often easy to decide, however, problems arise as the rate becomes faster, as the beat
to beat variation become less pronounced.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
17
• An easy way to work this out is to place another piece of paper over the rhythm strip,
ensuring the R waves are still visible
• Mark on the top sheet the position of 3 to 4 R waves
• Move that paper along the rhythm strip to see if the distance remains the same
throughout
If the QRS rhythm is irregular you must decide whether it is:
• Totally irregular (irregularly irregular) OR
• A repeated pattern to the irregular rhythm (regularly irregular)
Activity 8: Is this rhythm regular or irregular?
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
18
4 Is the QRS complex width normal or prolonged?
The normal QRS interval is up to 0.12 secs (3 small squares). This tells us that the rhythm
originates from above the bundle of his. (This is often helpful when naming the rhythm e.g.:
atrial fibrillation)
If the QRS width is longer than 0.12 secs the rhythm originates in the ventricles (again giving
clues with its name e.g.: ventricular tachycardia)
Activity 9: Are these QRS complexes normal or prolonged?
Write the answer in your workbooks!
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
19
5 Is atrial activity present?
Having looked at the rhythm in terms of rate, regularity and QRS with, the rhythm strip should
then be looked at carefully for atrial activity (seen as the P wave). This is often difficult to identify
(if not impossible) especially in fast rates.
The rate and regularity of a P wave can be determined in the same way as we did for the QRS
complex.
6 How is atrial activity related to ventricular activity?
Is there a consistent time interval between each P wave and the nearest QRS complex? This is
useful for the more experienced practitioner who is diagnosing heart blocks.
Rhythm recognition – basic interpretation This section gives examples of some of the rhythm abnormalities that they may see. It is important to remind them though that this should be done in conjunction with the patient’s clinical symptoms and these need to be addressed first. Then you can go onto looking at the rhythm strip, initially we can put the patient’s rhythm into
4 categories:
• Normal sinus rhythm (all 6 questions present with ‘normal’ answers)
• Broad Complex Tachycardia
• Narrow complex Tachycardia
• Bradycardia
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
20
ECG 1
The rhythm is Ventricular Tachycardia.
In ventricular tachycardia (VT) the ECG shows wide QRS complexes with no identifiable P wave.
Most importantly – how is your patient!
The heart rate is fast (over 100bpm) and the rhythm is usually regular. The rhythm is originating
in the ventricles hence the bizarre looking complexes. When the rate is too fast for the heart to
effectively pump blood, this is known as pulseless VT which and is one of the shockable cardiac
arrest rhythms.
This is normally a shockable cardiac arrest rhythm and therefore should be treated
accordingly.
ECG 2
We can refer to this rhythm as a Narrow Complex Tachycardia (because the width of the QRS
is narrow). Most importantly – how is your patient!
Different types of rhythm will present as narrow complex tachycardia such as atrial fibrillation,
atrial flutter and junctional tachycardia. This example of narrow complex tachycardia is atrial
fibrillation (AF). This is the most common type of rhythm abnormality that you are likely to see.
The patient’s heart rate can be >100bpm unless the rhythm is being controlled with medication.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
21
The rhythm is irregular. There are no discernible P waves however the ECG will show wavy
deflections (from the chaotic contractions of the atria) between the QRS complexes.
A patient in fast AF may experience palpitations, breathlessness, fatigue and dizziness. The most
serious consequence is a thromboembolic stroke, so it is important that it is diagnosed and
treated quickly.
This is one of the most common arrhythmias you are likely to encounter. The patient may feel
very unwell, particularly if the rhythm is fast and may not be able to lie flat for the ECG to be
recorded. They may have a low blood pressure too.
ECG 3
Again, answer the 6 questions with this rhythm
1) Is there electrical activity?
2) What is the ventricular rate?
3) Is the QRS rhythm regular or irregular?
4) Is the QRS complex width normal or prolonged?
5) Is atrial activity present?
6) How is the atrial activity related to ventricular activity?
This is a Bradycardia because the rate is less than 60 beats per minute. Most importantly – how
is your patient!
Heart Blocks.
Other types of bradycardia that you may encounter include heart blocks. There are different
types of heart blocks however the one we are looking at is complete (3rd degree) heart block.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
22
4. Complete (3rd degree heart block)
In complete heart block there is no relationship between the conduction system in the atria and
ventricles. The atria will be stimulated by the SA node and a P wave will be shown on the ECG.
These impulses will be blocked from going through to the ventricles. The ventricles will be
stimulated by automatic foci in or below the AV node. The QRS complex may be narrow or broad
depending where the impulse originates from. The rate is slow but the rhythm is usually regular.
The rhythm strip will show P waves at a consistent rate and QRS complexes at a consistent rate,
however there is no relationship between the two sets of waves.
The pulse rate of the patient will be slow and they may have symptoms such as shortness of
breath, dizziness and chest pain. Complete heart block will always require immediate treatment
as there is a risk of deterioration.
ECG Analysis
This course will only look at the analysis of the ST segment so that delegates can start to
recognise ischaemia or acute infarction on an ECG. The 10 rules given are just for information
purposes. There are other tools that they may come across, but this is one of the most
common ones. Using a tool such as this can ensure that a practitioner is systematic in their
analysis of the ECG and does not miss anything. It is useful to highlight though that some
abnormalities on an ECG may be normal for an individual and may not have clinical
significance. Where possible it is useful to compare the ECG to a baseline one if available.
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
23
In this course we will just be focusing on how to identify ischaemia and / or a myocardial
infarction. It is essential that you get expert help to diagnose the ECG and review your patient
if you are worried about their condition!
ECGs provide the evidence in diagnosing many cardiac abnormalities such as heart blocks but
for this package, we will be focusing on MIs and Ischaemia.
Both can be diagnosed by examining the QRS complexes within each region.
Ischaemia can be diagnosed by the presence of the ST segment lying below the baseline or
an inverted T wave.
Baseline
An example of where the ST segment is lying below the baseline.
ST elevation, with or without T wave changes, is a sign of myocardial injury.
An Acute Myocardial Infarction (AMI) is characterised by ST segment elevation above
the baseline. The ECG patterns in an AMI are not static, they change with the progression of a
normal state to that of a full infarct. The first thing that happens is T wave inversion in ischaemia,
then you will see ST elevation as the condition deteriorates. The amount of tissue infarcted
depends on the size and location of the artery blocked, and the amount of area that it perfuses.
Examples of ST elevation
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
24
A Normal ECG:
Remember to always seek expert help if you are worried about your patient’s
condition, even if their ECG appears normal!
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
25
INFERIOR AMI
Remind yourself which leads represent the inferior wall
Inferior wall AMIs will produces changes in II, III, and aVF. These are often combined with
other areas of the heart i.e.: inferolateral AMIs (affecting the Inferior wall & Lateral wall)
© 2019 ECG – All rights reserved LessonPlans/ECG12Lead/Pack&Kit/R&I/Handout December 2019
26
References
12-Lead ECG. The Art of Interpretation. Garcia & Holtz.2001.
Making Sense of the ECG. A Hands-On Guide. Houghton & Gray 2003.
Cardiology. Lowe et al 1997.
Advanced Life Support manual. (Fifth Edition) Resuscitation Council UK 2006.
Some pictures have been reproduced thanks to Nigel Barraclough. First on Scene Training Ltd
Campbell B, Richley D, Ross C, Eggett CJ. Clinical Guidelines by Consensus: Recording a
standard 12-lead electrocardiogram. An approved method by the Society for Cardiological
Science and Technology (SCST) 2017. Available at:
http://www.scst.org.uk/resources/SCST_ECG_Recording_Guidelines_2017
Emergency Care Gateway
The Gatehouse Bradwell Abbey
Alston Drive
Milton Keynes
MK13 9AP
Tel: 0845 423 8993
www.ecgtraining.co.uk