A GOOD 12 LEAD ECG

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A GOOD 12 LEAD ECG

• K.PADMANABHAN
• MADRAS MEDICAL MISSION

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
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WHAT IS ECG?

• The heart conduction system of electrical impulse
  produces currents that radiates through the
  surrounding tissue to the skin. When electrodes
  are attached to the skin, they sense those
  electrical currents and transmit them to an
  electrocardiograph monitor.
• The currents are then transformed into waveforms
  that represent the hearts depolarization -
  repolarization cycle.

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WHY 12 LEAD ECG ?

• A 12 Lead ECG records information from 12
  different views of the heart and provides a
  complete picture of electrical activity. DIFFERE
  NT LEADS PROVIDE DIFFERENT INFORMATION

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THE COMPONENTS OF ECG
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WHAT ARE THE CLINICAL USE OF ECG

• To assess the cardiac functions
• eg, rate, rhythm, and conduction.
• To diagnose cardiac rhythm disorders
• eg, heart block
• To diagnose cardiac diseases
• eg, myocardial infarction
• To detect electrolyte imbalance
• eg, hyperkalaemia
• To evaluate effects of treatments
• eg, administration of cardiac drugs.

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ECG MACHINE
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KNOWLEDGE OF ECG MACHINE

• OPERATING TECHINQUE
• GAINING ADJUSTMENTS
• TEMPARATURE SETTINGS (STYLUS)
• STYLUS RECORDING SHOULD BE CRISP AND FINE
  (CENTRAL PLACEMENT)
• NICE RECORD

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BASIC SETTINGS FOR GOOD ECG MACHINE

• (1) TO KEEP ALWAYS PAPER SPEED (25MM/SEC)
  FAST RATE DOUBLE SPEED ( 50MM/SEC)
• (2) TO KEEP ALWAYS STANDARDIZATION(10mm/mv)
• TO AVOID OVER STANDADIZATION
  UNDER STANDADIZATION
• PURPOSE OF 5MM 20MM STANDARDIZATION
• (3) TO KEEP ALWAYS BATTERY CHARGING POSITION
• TO AVOID AC INTERFERENCE
• (4) TO KEEP ALWAYS BULB ELECTRODES CLEANLY

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• KNOWLEDGE OF ECG LEADS
• PLACEMENT

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LIMB LEAD PLACEMENT

• LEAD-1
• LEAD-11
• LEAD-111
• AVR
• AVL
• AVF

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CHEST LEADS AND EXTRA LEADS PLACEMENTS

• V1
• V2
• V3
• V4
• V5
• V6
• V3R V4R
• V7 V8

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RIGHT SIDE LEADS

• The usual 12-lead ECG evaluates only the left
  ventricle.
• If the RV needs to be assessed for damage or
  dysfunction. Eg.Inferior wall MI - RV lead
  to rule out the RV involvement

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POSTERIOR LEAD ECG

• These ECGs used to assess the posterior side of
  the heart, standared 12 lead ECGs cant
  assess(posterior surface of myocardium).
• V7, V8, V9, These leads are placed opposite of
  the anterior leads V4,V5, AND V6 on the left side
  of the patient back following the same horizontal
  line.

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WHERE THE ECG LEADS WIRES SHOULD GO

• Where to place the electrodes on the patient
  is easy because each lead wire is labeled or
  colour coded, according to which wire
  corresponds to which lead.
• If they are placed too low, the ECG tracing
  will be inaccurate.

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PREPARING FOR THE RECORDING

• First gather all the necessary supplies
  including the
• 1. ECG Machine
• 2. Recording paper
• 3. Electrodes
• 4. ECG Jelly
• 5. Gauze pads.
• Take them to the patient bedside.

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EXPLAIN THE PROCEDURE

• Tell the patient (If stable) 1.The doctor
  advised to take ECG 2.Explain about
  test,duration and purpose 3. First prepare the
  mentally physically

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PATIENT COMFORTABLE COT

• 4. Ask the patient to lie supine position
  
• 5.Arms and his legs are relax position
• 6.If he cant tolerate to lying flat, raise
  the head of the bed to semi flowers
  position.
• 7. Ensure privacy and expose the patients
  arms, legs and chest, draping him
• comfort.

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ELECTRODES

• Explain The Electrode Placement Procedure
• The Electrodes Must Be Applied Correctly.
• Expose The Patients Chest And Select Electrode
  Sites .
• Choose Sites Over Soft Tissues Or Close To Bone
  Not Over Thick Muscles Or Skin Folds, Those Areas
  Can Produce ECG Artifacts.

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ELECTRODES
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PREPARE THE PATIENT
-APPLY ECG JELLY -CONNECT THE ECG CABLE GENTLEY
-ONCE AGAIN CHECK THE LEADS PROPERLY
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BEFORE START OF ECG RECORDING

• TELL TO BREATHE CALMLY ( IF STABLE)
• TELL THE PATIENT NOT TO MOVE
• TELL TO AVOID TALKING DURING ECG
• TELL TO RELAX (To avoid muscle tremor)

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BEFORE START OF ECG RECORING

• IF SHIVERING (PROVIDE COVERING SHEET)
• TREAT AND TAKE AFTER SETTLING
• FEMALES PATIENT- FEMALE ATTANDANT AND PRIVACY
  MUST.
• (NO ONE SHOULD NOT BE ALLOWED WHEN FEMALE
  PATIENT ECG UNLESS PATIENT SERIOUS).

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DURING ECG RECORDING

• DO NOT BE MISERLY
• ATLEAST TAKE 2-3 BEATS IN EACH LEAD
• LONG LEAD II AND V1 SHOULD BE
• AT LEAST FOR 20 COMPLEXES IN TACHYCARDIAS

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DURING ECG RECORDING

• ALWAYS TAKE ECG PROMPTLY WHEN PATIENT HAS
  CHEST PAIN
• SHOULD CHECK FOR ST ELEVATION OR DEPRESSION
• INFORM PYHSICIAN IMMEDIATELY
• DONOT LEAVE ALONE UNSTABLE PATIENTS WITHOUT
  ATTENDED

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AFTER ECG TRACING

• - OBSERVE THE QUALITY OF TRACING
• REMOVE THE ELECTRODES CLEAN
• TELL HIM ONCE TEST IS OVER
• ALWAYS WIPE THE JELLY YOURSELF
• DESPATCH THE REPORT
• ASK HIM TAKE PHOTOCOPY FOR FUTURE REFERENCE

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HOW TO DESPATCH ECG REPORT

• PATIENT NAME
• AGE
• SEX
• DATE
• TIME
• REFERED DOCTOR NAME
• TECHNICIAN NAME
• PASTE THE ECG GENTLEY

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GOOD NORMAL ECG
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TROUBLESHOOTING PROBLEMS
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TROUBLESHOOTING PROBLEMS

• ARTIFACT (WAVEFORM INTERFERENCE)
• INTERFERENCE
• WANDERING BASELINE
• FAULTY EQUIPMENT

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PATIENT MOVEMENT
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PATIENT MOVEMENT

• CAUSE PATIENT TURNING IN BED OR EXTREMITY
  MOVEMENT.
• SOLUTION PROBLEM IS USUALLY INTERMITTENT
  AND NO CORRECTIONIS NECESSARY. MOVEMENT ARTIFACT
  CAN BE REDUCED BY AVOIDING PLACEMENT OF
  ELECTRODE IN AREAS WHERE EXTREMITY MOVEMENT IS
  GREATEST. (BONY AREAS SUCH AS THE CLAVICLES).

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CONTINUOUS MUSCLE TREMOR
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INTERMITTENT MUSCLE TREMOR
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CONTINUOUS MUSCLE TREMOR

• CAUSES MUSCLE TREMORS ARE USUALLY RELATED
  T0 TENSE NERVOUS PATIENTS THOSE
  SHIVERING FROM COLD OR A CHIL TIGHT ELECTRODE
  STRAPS LOOSE ELECTRODES OR FALULTY CABLES
• SOLUTION TREAT CAUSE

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TIGHTNING OF STYLUS
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WANDERING BASELINE ECG
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WANDERING BASELINE

• CAUSES EXAGGERATED RESPIRATORY MOVEMENTS
  USUALLY SEEN IN PATIENTS IN RESPIRATORY DISTRESS
  .
• SOLUTION AVOID PLACING ELECTRODE IN AREAS
  WHERE MOVEMENTS OF THE ACCESSORY MUSCLES ARE MOST
  EXAGGERATED . PLACE THE ELECTRODES ON THE TOP OF
  THE SHOULDERS.

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ELECTRICAL INTERFERENCE
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ELECTRICAL INTERFERENCE

• CAUSES PATIENT USING ELECTRICAL EQUIPMENT
  
• IMPROPERLY GROUNDED EQUIPMENT LOOSE
  ELECTRICAL CONNECTIONS OR EXPOSED WIRING.
• SOLUTIONS
• (A) IF PATIENT IS USING ELECTRICAL EQUIPMENT,
  TO PUT OFF THE EQUIPMENT. PROBLEM IS TRANSIENT
  AND WILL CORRECT ITSELF.
• (B) IF PATIENT IS NOT USING ELECTRICAL
  EQUIPMENT (1) UNPLUG ALL EQUIPMENT
  NOT IN CONTINOUS USE (2) REMOVE
  FROM SERVICE AND USE BATTERY
  CONNECTION (3) ASK THE
  ELECTRICAL ENGINEER TO CHECK THE
  WIRING.

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HIGH TEMPRATURE
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REMEMBER

• ELECTRONIC MACHINES
• NOT TO RELY FULLY ON THE MACHINE DIAGNOISIS
• BETTER TO INTERPRET IT PERSONALLY

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REMEMBER

• ALWAYS READ SOME TEXTBOOK ON ECG
• TRY TO INTERPRET THE ECG YOURSELF
• START WITH SOME EASY TEXTBOOKS
• YOU SHOULD KNOW WHAT YOU ARE DOING

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REMEMBER

• INTERPRET THE RECORDING
• TAKE ACTIVE INTEREST IN ARRHYTHMIA DIAGNOSIS AND
  CLINICAL CORRELATION
• KNOWLEDGE CAN BE A GREAT ASSET

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REMEMBER

• YOU MAY BE THE FIRST PERSON TO DETECT A
  DANGEROUS ARRHYTHMIA OR ACUTE MI!

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