Highlights of This Lecture :-
• Describe the physiological basis of the ECG signal
• Identify the key features of ECG monitoring
• Recognize the components, basic designs and functionality of ECG monitoring
• Define the factors that might affect or interfere with the accuracy of ECG monitoring
• Describe the various ECG configurations used intra-operatively
/Sameh-Basiony
ECG is widely used to monitor the electrical activity of the heart, both inside and outside hospital. It is one of the
basic standards of care used during Diagnosis, intensive care and sedation.
In this Lecture, you will explore some of the key components of ECG monitoring and it’s Physics.
you will explore the components and functionality of the skin
electrodes, cables and monitors including the methods used to
reduce any interferences to the signal.
Finally, the common clinical configurations of leads used to
monitor ECG during anaesthesia and intensive care are
described.
What can be determined from the ECG?
Answer :-
1. Heart rate
2. Ischaemia to the myocardium
3. The presence of arrhythmias
4. The presence of conduction defects
5. The presence of chamber hypertrophy
6. The presence of electrolyte disturbances
The sinoatrial (SA) node, situated in the right atrium,
initiates the impulse, which flows over the right and left
atria.
The electrical impulse is picked up by the atrioventricular (AV) node, which is situated in the lower part of the
right atrium.
The electrical impulse then flows down the interventricular septum and into the left and right bundle branches via
the electrical conductive tissue to carry the impulse over each of the ventricles.
It is the passage of this electric conduction from the SA node over the atria through the septum and ventricles that
causes the muscle to contract.
Physiological Basis of ECG
The ECG indirectly records the electrical activity of the heart over time. This activity reflects the
action of the cardiac muscle as it depolarizes and repolarizes during the cardiac cycle.
The electrical potentials measured at the surface of the skin are about 0.5 to 2 mV.
ECG Electrodes
Skin electrodes are used to detect the heart’s small electric potentials. They are
typically made of a silver and silver chloride material that forms a stable electrode
combination when exposed to biological tissue. Both are held in an adhesive cup
mount and are separated from the skin by a foam pad soaked in conducting gel.
Proper attachment of ECG electrodes might involve cleaning the skin, gently
abrading the stratum corneum and ensuring adequate contact using conductive gel.
Skin impedance varies at different sites and it is thought to be higher in females.
The electrodes are best positioned on bony prominences to reduce artifacts from
respiration.
Inadequate detection of the ECG signal can occur when using electrodes with dry
gel or when electrodes are placed on areas with excessive hair.
External conducting skin gel can be used to improve the contact between the ECG electrodes and skin as seen in
the adjacent image.
ECG Cables
The ECG signal is transmitted from the electrodes to the monitor using ECG cables.
These cables are colour coded for correct positioning and connection to each individual electrode. The ECG
cables are available in 3 and 5 lead versions as snap or grabber design and with a variety of lengths, as shown in
the adjacent images. All the cables of a particular set should have the same length to minimize the effect of
electromagnetic interference. Fig 2
The cable design includes a shielding by copper
screens to reduce interference from electrostatic
induction and capacitance coupling. Stray
capacitances can occur between the operating table, Fig 1
lights, monitors, patients and electrical cables.
Electromagnetic induction originating from electrical cables or lights (power line
interference) is reduced by using ECG leads that are sufficiently long and
incorporate a lattice construction. The induced signal is rejected as common mode.
Fig 1 An ECG lead showing lattice construction.
Fig 2 ECG cables with colour coding.
Fig 3 ECG cables of different design
Fig 3
ECG Amplifiers
The ECG signal is boosted using an amplifier. Amplifiers are needed to
convert the very weak electrical signal from the heart into a more
readable signal for the output device The amplifier covers a frequency
range of 0.05 up to 150 Hz. It also filters out some of the frequencies
considered to be ‘noise’.
As the ECG signal is a differential signal, i.e. the difference in potential
between two electrodes, differential amplifiers are usually used in ECG
monitors. Such amplifiers process the signal and measure the difference
between the electrical potential from two different sources.
If there is interference common to the two input terminals (e.g. mains frequency), it can be eliminated as only the
differences between the two terminals is amplified. This is called common mode rejection.
Amplifiers used in ECG monitoring should have a high ‘Common Mode Rejection Ratio’ (CMRR) of 100 000:1
to 1 000 000:1, which is a measurement of capability to reject the noise. They should also have a high input
impedance (about 10 MΩ) to minimize the current taken from the electrodes.
ECG filters
In order to remove the noise/artifacts from ECG and produce a ‘clean’ signal, modern ECG monitors use
multiple filters for signal processing. The filters used should be capable of removing the unwanted frequencies,
leaving the signal intact. Two types of filters are used for this purpose:
1. High Pass filters
- High pass filters attenuate the frequency components of a signal below a certain
frequency. They help to remove lower frequency noise from the signal. For example,
you can remove the respiratory component from ECG by turning on a 1 Hz high pass
filter on the amplifier. The filter will centre the signal around the zero iso-line.
2. Low Pass filters
- Low pass filters attenuate the frequency components of a signal above a certain
frequency. They are useful for removing noise from lower frequency signals. If you have
a noisy ECG signal, you can use an amplifier with a 35 Hz low pass filter to improve the
signal quality. This will remove/attenuate signals above 35 Hz and help to ‘clean’ the
ECG signal.
ECG Filter Modes
1. Monitoring mode
As mentioned earlier, modern ECG monitors offer multiple filters for signal processing. The most common
settings are monitoring mode and diagnostic mode.
The monitoring mode has a limited frequency response of 0.5-50 Hz.
The high-pass filter (also called the low frequency filter because signals above the threshold are allowed to pass)
is usually set at 0.5 Hz. This filter provides a stable baseline by reducing respiratory and body movement artifacts,
as shown in Graph 1. This limits environmental artifacts for routine cardiac rhythm monitoring.
The low-pass filter (also called the high frequency filter because signals below the threshold are allowed to pass)
is set at 40 Hz. This filter helps reduce 50 Hz power mains line noise as seen in Graph 2, distortions from muscle
movement (Graph 1) and electromagnetic interference from other equipment.
ECG Filter Modes
2. Diagnostic Mode
The diagnostic mode has a wider frequency response of 0.05-150 Hz
The high pass (low frequency) filter is set at 0.05 Hz, which allows accurate ST segments to be recorded and
analyzed, and representation of P and T-wave morphology.
The low pass (high frequency) filter is set to 40 100 or 150 Hz. This allows the assessment of the ST segment,
QRS morphology and tachy - arrhythmias.
Consequently, in the monitoring mode the ECG display is more filtered than in the diagnostic mode.
1. Oscilloscope
An oscilloscope incorporating a high-resolution monochrome or color monitor is routinely used to display the
amplified ECG signal.
On an oscilloscope, there is a continuous real - time display of the ECG. This allows uninterrupted monitoring of
the electrical activity of the heart.
When ECG is recorded on paper, the display is a one - off snap recording of the myocardial electrical activity.
2. Paper speed
Usually, the ECG runs at a paper speed of 25 mm/s, although faster paper speeds are occasionally used (e.g. 50
mm/s). Each small square of ECG paper is 1 mm².
At a paper speed of 25 mm/s, one small square of ECG paper translates into 0.04 s (or 40 ms). Five small squares
make up one large square, which translates into 0.20 s (or 200 ms). Hence, five large squares represent one
second.
ECG Filter Modes
3. Calibration
A diagnostic quality 12 lead ECG is calibrated at 10 mm/mV, so 1 mm translates into 0.1 mV as illustrated here.
During Diagnosis, and in ICU, usually only three (sometimes five) leads, instead of 12, are used for practical
purposes. The three limb leads used include two that are 'active' and one that is 'inactive' (earth).
ECG Artifacts
Artifacts developing during ECG monitoring are common, and often of no clinical significance. They can
usually be easily recognized and ignored. However, some can be confusing and deceiving.
The suspicion of artifacts should be raised when new arrhythmia occurs in an asymptomatic patient, with
unchanged clinical signs, and where peripheral pulse rate correlates with apical pulse and QRS complexes on the
monitor. It can be more confusing when an artifact appears in the presence of an established abnormal rhythm.
Correlation with other monitored parameters may provide clues allowing the diagnosis of genuine changes. Other
waveforms providing rate and rhythm may not be consistent with the artifactual rhythm, e.g. plethysmographic.
Such waveforms will indicate true heart rate in case of pseudo-arrhythmia as seen on the adjacent image. On the
other hand, in case of true atrial fibrillation, these monitors may underestimate the heart rate.
Artifacts will not respond to the administration of anti-arrhythmic drugs or other therapeutic measures. The lack of
any response to intervention should at least raise the suspicion of an extrinsic source of pseudo - arrhythmia.
Types of Electrical Interferences
The operating theatres and intensive care units are full of electrical devices used for patient care. Accurate
interpretation of the ECG requires that it be of high quality and free from distortion and artifact. As we have
seen, there are a number of electrical factors that can interfere with the ECG signal recording and its quality. The
main factors can be summarized as follows:
Capacitance coupling and electrostatic induction
These can be caused by stray capacitances between table, lights, monitors, patients
and electrical cables. The energy is transferred via capacitance allowing AC signal
but not DC voltage. To reduce this effect, the ECG cables are surrounded by copper
screens. The induced signal is rejected as common mode.
Electromagnetic induction (inductive coupling)
This can be caused by any electrical cable or lighting. Such interference is reduced
by using long, latticed ECG leads so rejecting the induced signal as common mode
and also by using selective filters in amplifiers.
Radiofrequency interference (>150 Hz)
This is mainly caused by the use of the surgical diathermy. Such a high
frequency current can enter the system via the mains supply, directly applied
by the surgical probe or via radio-transmission via the probe and wire. This
high frequency electrical interference can be reduced by using high
frequency filters to clean up the signal, double screening the electronic
components of the amplifiers and earthing the monitor’s outer screen.
ECG Leads
1. Bipolar
In recording the ECG, two types of leads are used; bipolar and unipolar.
The bipolar leads (I, II, III, AVR, AVL and AVF) measure voltage difference between two electrodes. They detect
the electrical potential change in the frontal plane.
2. Unipolar
The unipolar leads (V1-6) measure voltage at different electrodes relative to a zero point. They record the electric
potential changes in the heart in a cross-sectional plane. Each lead records the electrical potential variations that
occur directly under the electrode.
There are a number of ECG electrode configurations that are commonly used. Conventionally, the electrodes
are placed in a standard position each time so that abnormalities are easier to detect.
In Diagnosis, usually three skin electrodes are applied : one bipolar lead between two of the electrodes and the
third electrode serving as a ground.
Red - right arm (or second intercostal space on the right of the sternum).
Yellow - left arm (or second intercostal space on the left of the sternum).
Black (or green) - left leg (or more often in the region of the apex beat).
The three electrodes provide three lead configurations (Lead I, II and III) as
illustrated here. In practice, Lead II is the most commonly used.
Usually, the ECG monitor has a selector switch which allows the
user to alter the designation of the electrodes. Such a system allows the
three ECG leads to be examined in sequence without changing the
location of electrodes, as shown in Fig 1.
The three-electrode system is simple and practical in the operating theatre
but its use is limited in the detection of myocardial ischaemia. This is
because it provides a narrow picture of the electrical activity of the
myocardium.
Fig 2 Fig 1
However, these modified three-electrode ECG systems
have been shown to be at least as sensitive as the standard
V5 lead system for the intra-operative diagnosis of
ischaemia.
Fig 1 Electrode configuration used in intra-operative ECG.
Fig 2 ECG trace from lead configuration I.
Fig 3 ECG trace from lead configuration II
Fig 4 ECG trace from lead configuration III
Fig 3 Fig 4
Two types of ECG configurations are considered here:
1. CM5 ECG Configuration
Although Lead II is ideal for detecting arrhythmias, the CM5 configuration is ideal for detecting ischaemic
changes. It is able to detect about 90 % of ST segment changes due to left ventricular ischaemia and provides an
excellent means of detecting arrythmias.
In CM5, the right arm electrode is positioned on the manubrium (chest lead from manubrium), the left arm
electrode is on V5 position (fifth interspace in the left anterior axillary line) and the indifferent lead is on the left
shoulder or any convenient position, as seen on the adjacent image.
2. CB5 ECG Configuration
The CB5 configuration is useful during thoracic. The right arm electrode is positioned over the center of the right
scapula and the left arm electrode is over V5 (chest lead from back).
In addition to using skin electrodes to record ECG, other more invasive methods can be used.
The following methods are covered in the subsequent pages:
1. Oesophageal ECG
2. Intracardiac ECG
3. Tracheal ECG
1. Oesophageal ECG
This can be recorded by using oesophageal electrodes that are incorporated into an oesophageal
stethoscope and temperature probe. It has been found to be useful in detecting atrial arrhythmias.
As it is positioned near the posterior aspect of the left ventricle, it can be helpful in detecting
posterior wall ischaemia.
Fig 1 Oesophageal ECG electrodes
Fig 2 Oesophageal ECG (top) shows more sensitivity in detecting ischaemia and atrial
arrhythmias than the surface ECG (bottom)
Fig 1
Fig 2
2. Intracardiac ECG
Electrodes are inserted using the multi-purpose pulmonary artery floatation catheter. There are three atrial and
two ventricular electrodes. In addition to ECG recording, these electrodes can be used in atrial or AV pacing.
Such ECG recording has great diagnostic capabilities and can be part of an implantable defibrillator. It is used for
loci that cannot be assessed by body surface electrodes, such as the bundle of His or ventricular septal activity, as
shown in Fig 2.
Fig 1 Comparison of surface ECG (upper) and intracardiac ECG (lower).
Fig 2 Intracardiac ECG lead. Fig 1
3. Tracheal ECG
Two electrodes are embedded into a standard tracheal tube that can be used to monitor
ECG. It is useful in diagnosing atrial arrhythmias especially in children.
Fig 2
