Electrocardiograph (ECG) is an instrument used to record electrical activity of

the heart over a period of time, as detected by electrodes attached to the surface of
the skin and recorded by a device external to the body. The recording produced by
this noninvasive procedure is termed an electrocardiogram.

A normal ECG wave is shown above. The amplitude and time period of various
waves are given below:
Amplitude:

Time period:

P wave 0.25 mV

PR interval 0.12 0.22 sec

Q wave 0.4 mV

QT interval 0.35 0.44 sec

R wave 1.6 mV

ST segment 0.05 0.15 sec

T wave 0.1 0.5 mV

U wave - <0.1 mV

P wave interval 0.11 sec

QRS duration 0.06 0.1 sec

An ECG is used to measure the rate and regularity of heartbeats, as well as

the size and position of the chambers, the presence of any damage to the heart,
and the effects of drugs or devices used to regulate the heart, such as a pacemaker.

The conducting system of the electrical pulses in heart is shown above. ECG
provides a wide range of cardiac disorders such as the presence of an inactive part
(infarct) or an enlargement (hypertrophy) of heart muscle. The ECG device detects
and amplifies the tiny electrical changes on the skin that are caused when
the heart muscle depolarizes during each heartbeat.
The diagnostically useful frequency range is usually 0.05 too 150Hz. The
interference of non-biological noises can be handled by using modern differential
amplifiers, which are capable of providing excellent rejection capabilities. Common
Mode Rejection Ratio of the order of 100-120db with 5K unbalance in the leads is
a desirable feature of ECG machines. It is necessary to use a notch filter tuned to
50Hz to reject hum due to power mains.
LEADS:
The term "lead" in electrocardiography refers to the electrical cable attaching
the electrodes to the ECG recorder. These leads are placed according to a practical
system of electrocardiography used in medical diagnostics known as Einthovens
Triangle.
Einthovens Triangle is an equilateral triangle whose vertices lie at the left
and right shoulders and the pubic region and whose center corresponds to the
vector sum of all electric activity occurring in the heart at any given moment,
allowing for the determination of the electrical axis. Einthoven's triangle is
approximated by the triangle formed by the axes of the bipolar electrocardiographic
(ECG) limb leads I, II, and III.

There are three different configurations of leads that are used to record ECG
signals. They are:
1. Limb leads
2. Precordial leads
3. Augmented limb leads
LIMB LEADS:
Leads I, II and III are called limb leads. The electrodes that form these signals
are located on the limbsone on each arm and one on the left leg. The limb leads
form the points of what is known as Einthoven's triangle.
Lead I is the voltage between the (positive) left arm (LA) electrode and right arm
(RA) electrode:
Lead II is the voltage between the (positive) left leg (LL) electrode and the right arm
(RA) electrode:

Lead III is the voltage between the (positive) left leg (LL) electrode and the left arm
(LA) electrode:

AUGMENTED LIMB LEADS:

Leads aVR, aVL, and aVF are augmented limb leads. They are derived from the
same three electrodes as leads I, II, and III. However, they view the heart from
different angles (or vectors) because the negative electrode for these leads is a
modification of Einthoven's central terminal. Wilson Einthoven's central terminal
paved the way for the development of the augmented limb leads aVR, aVL, aVF and
the precordial leads V1, V2, V3, V4, V5 and V6.

Lead augmented vector right (aVR) has the positive electrode (white) on the
right arm. The negative electrode is a combination of the left arm (black)
electrode and the left leg (red) electrode, which "augments" the signal strength
of the positive electrode on the right arm.

Lead augmented vector left (aVL) has the positive (black) electrode on the left
arm. The negative electrode is a combination of the right arm (white) electrode
and the left leg (red) electrode, which "augments" the signal strength of the
positive electrode on the left arm.

Lead augmented vector foot (aVF) has the positive (red) electrode on the left leg.
The negative electrode is a combination of the right arm (white) electrode and
the left arm (black) electrode, which "augments" the signal of the positive
electrode on the left leg.

PRECORDIAL LEADS:
The electrodes for the precordial leads (V1, V2, V3, V4, V5 and V6) are placed
directly on the chest. Because of their close proximity to the heart, they do not
require augmentation. Wilson's central terminal is used for the negative electrode,
and these leads are considered to be unipolar. The precordial leads view the heart's
electrical activity in the so-called horizontal plane. The heart's electrical axis in the
horizontal plane is referred to as the Z axis.

PLACEMENT OF ELECTRODES:

Electrode
label

RA

Electrode placement

On the right arm, avoiding thick muscle.

LA

In the same location where RA was placed, but on the left arm.

RL

On the right leg, lateral calf muscle.

LL

In the same location where RL was placed, but on the left leg.

V1

In the fourth intercostal space (between ribs 4 and 5) just to the

right of the sternum (breastbone).

V2

In the fourth intercostal space (between ribs 4 and 5) just to the left
of the sternum.

V3

Between leads V2 and V4.

V4

In the fifth intercostal space (between ribs 5 and 6) in the midclavicular line.

V5

Horizontally even with V4, in the left anterior axillary line.

V6

Horizontally even with V4 and V5 in the mid axillary line.

EFFECT OF ARTIFACTS ON ECG RECORDING:

Abnormal patterns of ECG recording may be due to pathological states or on
occasion they may be due to artifacts.
(i)

INTERFERENCE FROM POWRERLINE:

Power line interference is easily recognizable since the interfering voltage in

ECG would have a frequency of 50Hz. This interference may be due to the stray
interference of the alternating current on the patient or because of alternating
current fields due to loops in the patient cable. Other causes of interference are
loose contacts on the patient cable as well as dirty electrodes. When the machines
or the patient is not properly grounded, power line may even completely obscure the
ECG waveform.

The most common cause of 50Hz interference is the disconnected electrode

resulting in a very strong disturbing signal. It is often strong enough to damage the
stylus of an unprotected direct writing recorder, and therefore needs a quick action.
(ii)

SHIFTING OF BASELINE:

A wandering baseline but otherwise normal ECG trace is usually due to the
movement of the patient or electrode, the baseline shift is eliminated by ensuring
that the patient lies relaxed and the electrodes are properly attached. Baseline
wander is usually observed immediately after the application of electrodes.
(iii)

MUSCLE TREMOR:

Irregular trembling of ECG trace, without wandering of the baseline occurs

when the patient is not relaxed or is cold. It is generally formed in the case of older
patients. Muscle tremor signals are especially bothersome on limb leads. When a
patient moves or the muscles are stretched. For normal ECG recording, the patient
must be advised to get warm and to relax so that muscle tremor from shivering or
tension is dominated. The most critical component of the ECG recorder is the
patient cable. They should be made of silicon-rubber, which provides better
elasticity over long period.

TYPICAL ECG RECORD

HEART RATE CALCULATION:

ECG paper is a grid where time is measured along the horizontal axis.

Each small square is 1 mm in length and represents 0.04 seconds.

Each larger square is 5 mm in length and represents 0.2 seconds.

Voltage is measured along the vertical axis.

10 mm is equal to 1mV in voltage.

The diagram below illustrates the configuration of ECG graph paper and
where to measure the components of the ECG wave form

Heart rate can be easily calculated from the ECG strip:

METHOD 1: When the rhythm is regular, the heart rate is 300 divided by the
number of large squares between the QRS complexes.
o

For example, if there are 4 large squares between regular QRS

complexes, the heart rate is 75bpm (300/4=75).
300*0.2(time of 1 large box)=60sec.

METHOD 2: The second method can be used with an irregular rhythm to estimate
the rate. Count the number of R waves in a 6 second strip and multiply by 10.
o

For example, if there are 7 R waves in a 6 second strip, the heart rate
is 70bpm (7x10=70).

METHOD 3: When the rhythm is regular, the heart rate is 1500 divided by the
number of small squares between the QRS complexes.
o

For example, if there are 22 small squares between regular QRS

complexes, the heart rate is 68bpm (1500/22=68).
1 small square 0.04sec. For 60 sec the numbers of small boxes are
1500. (1500*0.04=60sec.)

METHOD 4:
60 divided by [(number of small squares between the QRS complexes) *(0.04 sec)]

METHOD 5:
R R interval = t
Heart Rate = 60/t (Beats /min)

Differentiate external pacemaker and internal pacemakers.

What is the type of Electrode used for recording ECG signal?

Differentiate atrial fibrillation and ventricular fibrillation.

Differentiate synchronized and unsynchronized defibrillators

1. What is Electrocardiograph and Electrocardiogram?

Electrocardiograph is the equipment used to measure the electrical activity
of the heart. Electrocardiogram is the output from Electrocardiograph.
2. What is Leads?
The connecting wires between two electrodes and the resulting tracing of voltage
difference at any two sites due to electrical activity of the heart is called leads.

3. Define cardiac fibrillation.

The cardiac fibrillation is a condition wherein the individual
myocardial cells
contract asynchronously (continuously stimulated by the adjacent cells)
with only very local pattern relating the contraction of one cell and that of
the other. During defibrillation the normal rhythmic contraction of either
the atria or the ventricles are replaced by rapid irregular twitching of the
muscular wall. Fibrillation of atrial muscles is called atrial fibrillation.
Fibrillation of ventricles is known as ventricular fibrillation.
What is defibrillation?
Electric shock to the heart can be used to re-establish a more
normal cardiac rhythm.Ventricular fibrillation can be converted into a
more efficient rhythm by applying high energy shock to the heart.By
applying sudden surge across the heart which causes all the heart muscle
fibres to contract simultaneously there by cardiac fibrillation can be
converted to normal rhythm.
What is a cardiac Defibrillator? Mention the difference between
external and internal defibrillators. (Nov/Dec 2014)
A cardiac defibrillator is a device that delivers high energy shock to
the heart muscle undergoing a fatal arrhythmia, so as to convert them
into normal rhythm. This high energy shock depolarizes a critical mass of
the heart muscle, terminates the dysrhythmia and allows normal sinus
rhythm to be reestablished by the body's natural
pacemaker, in the sinoatrial node of the heart. IN external defrillation
the shock is delivered to the heart by means of electrodes placed on the
chest of the patient. In internal defibrillation, the electrodes may be
held directly against the heart when the
chest is open. Higher voltages are required for external defrillation than
the internal defibrillation.
What are the drawbacks of AC defibrillator? (May/June 2012)
A defibrillator is a device that delivers high energy shock to the
heart muscle

undergoing a fatal arrhythmia, so as to convert them into normal rhythm.

The success rate for a.c.defibrillators is rather low, as it was useful for
correcting atrial
fibrillation. In attempting to correct atrial fibrillation using a.c defibrillator
often
resulted in producing ventricular fibrillation, a much more serious
arrthythmia.

Classify the types of pacemakers.

What is a cardioverter?
The conversion of atrial fibrillation to a normal rhythm by
defibrillation is usually called as Cardioversion and defibrillator with a
synchronizer is called a cardioverter which delivers a shock only after
detecting a R wave threshold.
Mention the energy requirements of pacemaker?
Heart can be stimulated with electric shock
Min Energy required 10J
Typically a pulse of 5V, 10mA, 2ms is used
More than 400J causes ventricular fibrillation

What are the different types of lead system found in ECG?

Limb leads (bipolar)-Lead I,Lead II,Lead III

Precordial leads (unipolar)-V1,V2,V3,V4,V5,V6

Augmented limb leads (unipolar)-avR,avL,avF

Write the Physiological conditions of ECG wave?

P wave- Atrial Depolarization
QRS wave-Ventricular Depolarization
T wave-Ventricular Repolarization
Write the electrode placement for ECG?
RA-Right Arm
LA- left arm
RL- right leg
LL- left leg
V1- fourth intercostal space (between ribs 4 and 5) just to the right of the
sternum (breastbone).
V2- fourth intercostal space (between ribs 4 and 5) just to the left of the
sternum
V3- Between leads V2 and V4
V4- fifth intercostal space (between ribs 5 and 6) in the mid-clavicular line
V5- Horizontally even with V4, in the left anterior axillary line.
V6- Horizontally even with V4 and V5 in the mid axillary line
Which electrode is used as the reference electrode in ECG?
Right Leg electrode is used as the reference electrode for measurement of
ECG signal.
What is the difference between heart rate and pulse rate?

Heart rate is the number of times per minute that the heart contracts
- the number of heart beats per minute (bpm). Heart rate is most accurately
measured from the thorax with the transmitter of heart rate monitor or the
electrodes of the electrocardiograph (EKG).
Pulse is the mechanical pulse of blood flow through the capillaries
caused by the contractions of the heart per minute. Pulse can be measured
from an earlobe with a pulse meter (also called photoreflectance or infrared
sensor monitor) containing a photocell sensor