Comprehensive Guide to Patient Identification and Normal ECG Interpretation

[Music] [Music] hello everyone i am dr vino assistant

professor from the department of medicine in this session we'll be dealing with

patient identification preparation and interpretation of a normal ecg before going into the session i would like you

to know why do we request or why do we do an ecg for a patient ecg is usually used in the evaluation of

symptoms like chest pain palpitations breathlessness and syncope because these symptoms might be an

indication of an acute cardiac event like myocardial infarction acute heart failure and arrhythmias

ecg is also used in the evaluation of electrolyte imbalances like imbalances in sodium potassium magnesium calcium

etc ecg is used during the process of cardiopulmonary

resuscitation and also after the process of cpr ecg is also used in evaluation of side

effects of drugs and toxins certain drugs like digitalis tricyclic antidepressants are pro arithmogenic and

they can lead to certain cardiac events which can be identified in an ecg coming to the first step in an ecg

recording first is patient identification

identifying a correct patient is very very important you should either identify the patient by using the risk

brands which the patient wear or if the patient is not able to communicate at least through the bystanders

the printed recording that is the ecg paper should always bear the correct identification details of the patient

coming to the next step of ecg recording is informed consent this is one of the most important step in the process of

ecg recording first thing the patient should be given a clear and precise information about

the process of this ecg recording and also the the person who is performing the procedure should

introduce themselves and they should explain about the process in a very short

and also the person who is recording should also inform the patient that the procedure is

going to be very brief not more than five minutes and it is going to be painless

also information about the level of unrest and the use of adhesive electrodes should also be mentioned to

the patient coming to the third important step is positioning the patient the patient

should ideally be positioned in a semi recommend position with 45 degree inclination

if not possible a supine position is also enough and you should make sure that the limbs

are well supported on the couch and also you should make sure that the patient is completely relaxed uncomfortable

you should make sure that the limbs do not touch the railings of the cart because either

the limbs moving moving around or the limbs which are touching the railings can alter your ecg recording

in patients whom the ecg recording is altered or because the patient is not able to position properly because of the

pain then you should mention or you should annotate in the ecg the reason for

suboptimal ecg quality before recording an ecg make sure the patient is still

and relaxed this picture shows you the normal positioning of a patient where the

patient is completely relaxed sitting in a semi-recommend position with 45 degree inclination with the recorder standing

to the right side of the patient and an ecg recording is made coming to the next step the equipment

and clinical room specification you should make sure that the room and the equipment are clean

next the equipment should be safe and it is ready to use with correct date and time which is entered

also you should make a visual inspection of the equipment such as the cables the wires the plugs and rule out any faults

in the machinery for battery operated mission you should ensure that it is fully charged before

the procedure coming to the next step the environmental conditions this is also

very critical step in an ecg recording process the you should make sure that the room

is safe it is private either walled or screened or curtained and also it should be quiet

uncomfortable the room should be made or designed in such a way that it is accessible for

even the disabled patients and also the couch should have a height adjustable option

for and also that should be accessible from both the sides and you should make sure that it is

stocked appropriately with adequate batteries electrodes ecg papers etc and you should also have options for

cleaning and disposable of the waste materials properly now coming to the process of documenting

either the digital documentation or manual documentation is mandatory for all ecgs

the documentation should have the following parameters

one thing first important thing is the patient's name next is the patient's date of birth or

the age next is the patient's identification number or the hospital number

the ecg should also have the data about the recorder and also the person who has requested for the ecg

also it should bear the date and time along with name of the institution

and it should also have a mention about any alterations in the standard lead positions

coming to the next step of placing an electrode you all know that we have four limb electrodes and

six chest electrodes so first coming to the limb electrodes you should remember in such a way that

each arm electrode has a separate color code so remember in the order of right arm

left arm left leg and the right leg the colors are

red yellow green and black respectively these electrodes will have a specific

color and the electrodes will also be named but remembering each arm electrode with

that particular color is very very important this right arm limb lead is placed in

the right forearm proximal to the wrist in the similar way the left arm limb lead is placed in the left forearm

proximal to the wrist coming to the left leg limb lead it is placed in the left lower leg proximal to the ankle

similarly the right leg lead is placed in the right lower leg proximal to the ankle

so i think this picture will explain you the color code so this is the this is the limb electrode and this is

the chest electrode the limb electrodes are marked as red green yellow and black

this is placed in the corresponding arms to the corresponding with the corresponding colors

this picture the second picture is about the chest leads it is also coated with colors

red yellow green brown black and purple it is named from

c1 to c6 so v1

v1 to v6 has separate colors v1 is red v2 is low v3 is green v4 is brown v5 is black and v6 is purple

these six leads are placed in the chest in certain anatomical landmarks which is very very important

so for placing the chest leads you should first identify the angle of fluid that

is your manibrium's turning this corresponds to your second intercostal space

so for placing v1 it is placed in the fourth intercostal space at the right sternal border

v2 is placed similarly on the fourth intercostal space on the left sternal border

after placing v2 v4 should be placed v4 is placed in the fifth intercostal space in the mid clavicular line

so this is the mid clavicular line v3 is placed between v2 and v4 so this picture will clearly tell you

how v4 to v6 is placed v4 as you all know it is placed in the fifth intercostal space in the mid clavicular

line and v5 is placed in the same horizontal plane that is in the same fifth intercostal space but in the

anterior axillary line and b6 is placed in the same horizontal plane as v4 but in the mid axillary line

okay so now you have been given a clear idea about placing the limb leads on the

chest leads now we will go to some special situations where the positioning of the leads is not possible as we have

seen previously one such condition is dextrocardia dextrocardia is a condition which is the heart is placed on the

right side instead of the usual left side so the recording cannot be done in the

usual way so what we do is we change the leads and place them on the right side how do we place

this picture will give a clear understanding we are not going to change the position

of v1 and v2 it is in the same position as before but we change this v3 to v6 exactly opposite

as the left side we are not going to change any of the intercostal spaces any of the anatomical landmarks but exactly

on the right side like how we saw v3 v4 v5 and v6 earlier but on the opposite side but we name the

leads as v 1 r to v 6 r now coming to one another special situation is posterior wall myocardial

infarction where your leads has to be placed at the back of your chest so this picture will

tell you how do we record a posterior wall recording so we have leads v7 v8 and v9 these v7 v8 and v9 are placed in

the same fifth intercostal space that is corresponding to v4 but v7 is placed in the posterior axillary line and v8 is

placed in the tip of the scapula and b9 in the left para spinal region so now you know how do we record a

posterior wall ecg

okay so you have placed the leads properly but in certain conditions you may have

certain abnormalities in the ecg not because of the cardiac activity but because of some altered electrical

activity so for a good quality ecg you should make sure that it is devoid of these abnormal electrical activities

one such thing is the loose lead artifact when you look at this ecg when you look at these

waves you might think there is something which is very much abnormal with the heart but it is not so

the scenario here is these leads that is two and lead one are not attached properly in their

corresponding positions this could be either because of excessive sweat or it could be because

the leads are not properly attached because of less amount of adhesive material

so these are all the possibilities to to avoid this you should make sure the skin is clear less hair and it is attached

properly so this is not some abnormal cardiac activity this is an abnormal activity because of the electrodes not

being attached properly coming to this ecg if you see this point this is the isoelectric line

but this isoelectric line is somewhere above this similarly in this lead also you have an isoelectric line but

isoelectric line instead of being here it is somewhere here this is called as wandering baseline

effect this could be because of movement of the patient or abnormal respiratory moments all those things so

this is also an artifact which can be avoided and now coming to this ecg when you look

at the first instant you may think it as atrial fibrillation but when you have a closer look at these leads you can see a

p wave which is prior to a qrs so it is not atrial fibrillation this kind of abnormal moments is because of the

muscle tremors which could be either because of anxiety or it could be because of the

hypothyroidism related tremors or a parkinsonian tremor shivering etc so this is also a kind of artifact

and can you look at this point in the ecg where you have very much abnormal activity this is also not a abnormal

cardiac activity this is also an artifact because of electromagnetic interference that is either because of

having a mobile phone or a television or a radio nearby so this should also be avoided

okay so now what is a normal ecg a normal ecg should be as in this picture it should have a normal

isoelectric line without any artifacts the waveform should be very much clearly visible so this ecg has a regular rhythm

that is the rr interval or regular of 84 beats per minute and the p wave morphology that is the p way morphology

is an upright p wave in leads one two ok so it is also normal it has a normal qrs complex so the qrs

complex duration is less than 100 milliseconds that is not more than four small boxes and the p wave each p wave

is followed by qrs wave you have a p wave here you are a you have a qrs wave here and the pr interval is also

constant not more than three to five small boxes so a normal ecg will have this is called a sinus rhythm a regular

rhythm with a normal q p p wave ah normal qrs wave that is a p wave which is followed by qrs with a normal p r

interval with isoelectric line remaining the same and

without any artifacts so before providing a final ecg printout you should make sure that the ecg is of

good quality without any artifacts the waveforms should be very much clearly visible and also you should make sure

that at the end of the procedure the electrodes are completely removed and disposed off to the clinical waste

thank you i hope this session was really useful to you