Electrocardiography (ECG)

Definition of ECG: Electrocardiography is the study of the electrical activity of the heart. An electrocardiogram is a graph that depicts the electrical recordings of the heart

How to use an EKG to record the heart's electricity :

Preparation

A. Alat

  • ECG machine, equipped with:
  • cable for power source
  • wire for earth  (ground)
  • Extremity and chest electrode wires
  • Extremity electrode plate with rubber band
  • Chest electrode suction balloon
  • Jelly
  • tissue paper
  • An alcohol swab
  • ECG paper
  • Hospital

B. Patient

Explanation  (informed consent)

- Purpose of inspection

- Things to pay attention to when recording

The chest wall should be exposed and no metal jewelry attached.

The patient is asked to remain calm or not to move during the ECG recording

How to install an EKG

1. Install all components/cables on the EKG machine

2. Turn on the ECG machine

3. Lay the patient quietly on a wide bed. Hands and feet don't touch each other

4. Clean the chest, both ankles and hands with alcohol cotton (if necessary, shave the chest and ankles)

5. The four extremity electrodes are given jelly.

6. Place the four extremity electrodes on both wrists and feet. The right hand is usually red, the left hand is yellow, the left foot is green and the right foot is black.

7. The chest is given jelly according to the location of the electrodes V1 to V6.

- V1 on the right parasternal line parallel to ICS 4 is red

- V2 on the left parasternal line parallel to ICS 4 is yellow

-V3 between V2 and V4, green

- V4 in the left mid clavicle line parallel to ICS 5, brown

- V5 in the left anterior axillary line parallel to ICS 5, black

- V6 in the left mid axillary line aligned with ICS 5, purple in color

1. Attach the chest electrode by pressing the suction rubber.

2. Make calibration

3. Record each lead 3-4 beats (waves), if necessary long lead II (minimum 6 beats)

4. If necessary, calibrate after recording is complete

5. All electrodes removed

6. Jelly is cleaned from the patient's body

7. Notify the patient that the recording is complete

8. Turn off the ECG machine

9. Write on the recording results: name, age, gender, hour, date, month and year of manufacture, the name of each lead and the name of the person who recorded

10.Clean and tidy up the tools

Attention :

Before work check engine speed 25mm/sec and voltage 10mm. If the paper is not enough calibrate the voltage is reduced to times or 5 mm. If the ECG is small, the voltage calibration is increased to 2 times or 20 mm.

Avoid electrical and mechanical interference while recording

When recording, the operator must face the patient

Lead EKG

There are 2 types of leads:

A. Bipolar leads: record the potential difference of the 2 electrodes

Lead I: recording the potential difference between the right hand (RA) and the left hand (LA) where the right hand is charged (-) and the left hand is charged (+)

Lead II: recording the potential difference between the right hand (RA) and the left foot (LF) where the right hand is charged (-) and the left foot is charged (+)

Lead III: recording the potential difference between the left hand (LA) and the left foot (LF) where the left hand is charged (-) and the left foot is charged (+)

B. Unipolar lead: recording a potential difference of more than 2 electrodes

Divided into extremity unipolar leads and precordial unipolar leads

limb unipolar leads

Lead aVR: recording the potential difference in the right hand (RA) with the left hand and left foot where the right hand is charged (+)

Lead aVL: record the potential difference in the left hand (LA) with the right hand and left foot where the left hand is charged (+)

Lead aVF: record the potential difference in the left leg (LF) with the right hand and left hand where the left leg is charged (+)

Precordial unipolar leads: records the potential difference between the chest leads and the three limb leads. Namely V1 to V6


ECG paper

ECG paper is a graph paper consisting of horizontal and vertical lines in the form of a square with a distance of 1 mm. Thicker lines (large squares) occur every 5 mm. The horizontal line represents the time (seconds) where 1 mm (1 small square) = 0.04 seconds, 5 mm (1 large square) = 0.20 seconds. The vertical line represents the voltage where 1 mm (1 small square) = 0.1 mV.

Curve ECG

The ECG curve depicts the electrical processes that occur in the atria and ventricles. The electrical process consists of:

💥Atrial depolarization (shown in the P wave)

💥Atrial repolarization (not visible on the ECG because it coincides with ventricular depolarization)

💥Ventricular depolarization (visible from the QRS complex)

💥Ventricular repolarization (viewed from the ST segment)

💥The normal ECG curve consists of P, Q, R, S and T waves, sometimes a U wave is seen.

EKG 12 Lead

✨Leads I, aVL, V5, V6 show the lateral side of the heart

✨Leads II, III, aVFV5, V6 show the lateral side of the heart

✨Leads II, III, aVF show the inferior part of the heart

✨Leads V1 to V4 show the anterior part of the heart

✨The aVR lead is only a guide to see if the ECG is properly inserted

heart axis

The electrical axis of the heart or the cardiac axis can be identified from the frontal and horizontal planes. The frontal plane is identified by looking at leads I and aVF, while the horizontal plane by looking at the precordial leads, especially V3 and V4. Normal frontal heart axis ranges from -30 to +110 degrees. Left axis deviation is between -30 to -90 degrees, right deviation is between +110 to -180 degrees.

Overview of Normal ECG

P Gelombang wave

Normal value:

Width 0.12 seconds

Height 0.3 mV

Always (+) in lead II

Always (-) in lead aVR

Interval PR

Measured from the beginning of the P wave to the beginning of the QRS wave. Normal values ​​range from 0.12 to 0.20 seconds.

QRS wave (QRS complex)

Normal values: width 0.04 - 0.12 seconds, height depending on the lead.

Q wave: the first negative deflection of the QRS wave

Normal value: width < 0.04 seconds, in < 1/3 of the R wave. If the depth is > 1/3 the height of the R wave, it means that the  Q is pathological.

The R wave is the first positive deflection of the QRS wave. Generally in Leads aVR, V1 and V2, the S wave is seen to be deeper, in leads V4, V5 and V6 it disappears or decreases in depth.

T Gelombang wave

This is an illustration of the process of ventricular repolarization. Generally positive T wave, in almost all leads except in aVR

U wave

It is a positive deflection after the T wave and before the next P wave. The cause of the emergence of U waves is still unknown, but it is thought to arise due to slow repolarization of the interventricular conduction system.

Interval PR

The PR interval is measured from the beginning of the P wave to the beginning of the QRS wave. Normal values ​​range from 0.12 to 0.20 seconds, this is the time required for atrial depolarization and the passage of the impulse through the bundle of His until the onset of ventricular depolarization.

ST segment

The ST segment is measured from the end of the QRS wave to the beginning of the T wave. This segment is normally isoelectric, but in the precordial leads it can vary from –0.5 to +2mm. The ST segment that rises above the isoelectric line is called ST elevation and one that falls below the isoelectric line is called  ST depression .

How to assess the ECG

  • Determine whether the ECG image is worth reading or not
  • Determine heart
  • rhythm (“ Rhythm ”)
  • Determine the frequency (“ Heart rate ”)
  • Determine the axis of the heart (“ Axis ”)
  • Determine the presence or absence of signs of hypertrophy (atrial / ventricular)
  • Determine the presence or absence of signs of myocardial abnormalities (ischemia/injury/infarction)
  • Determine the presence or absence of signs of other disorders (drug effects, electrolyte balance disorders, impaired pacemaker function in patients with pacemakers)

    • 1. DETERMINING THE HEART FREQUENCY

    How to determine the frequency through the ECG picture can be done in 3 ways, namely:

    1. 300 divided by the number of large squares between R – R'
    2. 1500 divided by the number of small squares between R – R'
    3. Take an ECG strip for 6 seconds, count the number of QRS waves in 6 seconds and then multiply by 10 or take it in 12 seconds, multiply by 5

    2. DETERMINING THE HEART Rhythm

    In determining the heart rhythm, the sequence that must be determined is as follows:

    • Determine whether the rhythmic heart rate is regular or not
    • Determine what heart rate (HR)
    • Determine the P wave is present / not and normal / not
    • Determine the normal PR interval or not
    • Determine the QRS wave is normal or not

    The normal impulse ECG rhythm (source of electricity) comes from the SA Node, so the rhythm is called the  Sinus Rhythm ("Sinus Rhytem")

    The criteria for sinus rhythm are:

    • The rhythm is regular
    • heart rate (HR) 60 – 100 x/minute
    • Normal P waves, each P wave is always followed by a QRS gel, T
    • Normal QRS wave (0.06 – < 0.12 sec)
    • Normal PR interval (0.12-0.20 seconds)

    A rhythm that does not have the above criteria is  likely to be abnormal

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