Changes

==Introduction==

==Introduction==

Electrocardiography is one of the most commonly found piece of monitoring equipment in modern veterinary practices.

'''Electrocardiography''' is one of the most commonly used pieces of monitoring equipment in veterinary practices.

The ECG can determine the rate, rhythm and nature of cardiac depolarisation and repolarisation. It can also indicate changes in myocardial mass, conductivity between the heart and skin and the presence of metabolic abnormalities affect the heart.

The '''ECG''' can determine the '''rate, [[Arrhythmias Overview|rhythm]] and nature of cardiac depolarisation and repolarisation'''. It can also indicate changes in '''myocardial mass''', '''conductivity''' between the heart and skin and the presence of '''metabolic abnormalities''' that affect the heart.

==Recording an ECG==

==Recording an ECG==

The ECG detects the electrical activity of the heart through 3 electrodes. These electrodes are most commonly placed on the 2 forelimbs and the left hindlimb. An additional 'earth' electrode may be placed on the right hindlimb.  

The ECG detects the electrical activity of the heart through '''3 electrodes'''. In small animals these electrodes are most commonly placed on the 2 forelimbs and the left hindlimb. An additional electrode may be placed on the right hindlimb. Resting ECGs in the horse are recorded using a '''base-apex lead''' - with negative (red) electrode placed over the jugular groove, the positive electrode (yellow) placed just behind the left elbow over the apex beat of the heart (B) and the earth electrode attached at a site remote to the heart. This produces an ECG with large complexes that are not significantly affected by movement artifact.  

The electrodes are attached to the patient via ECG pads (most commonly), crocodile clips (more common in horses) and transcutaneous needles (rare). Any hair should be clipped to improve contact between the ECG pad and the skin. Pads should be secured with tape and additional electrode gel or alcohol should be used to improve contact between the patient and electrodes. The electrodes are connected to the ECG machine by colour-coded cables.

The electrodes are attached to the patient via '''ECG pads''', '''crocodile clips''' (more common in horses) and '''transcutaneous needles''' (rare). Hair should be '''clipped''' to improve contact between the ECG pad and the skin. Pads should be secured with tape and additional '''electrode gel or alcohol''' should be used to improve contact between the patient and electrodes. The electrodes are connected to the ECG machine by colour-coded '''cables'''.

'''The colour coding system:'''

'''The colour coding system:'''

 

:<font color = "yellow">'''Yellow </font color>(positive): Left forelimb'''

<font color = "yellow">Yellow: Left forelimb

:<font color = "red">'''Red </font color>(negative): Right forelimb'''

 

:<font color = "green">'''Green</font color>: Left hindlimb'''

<font color = "red">Red: Right forelimb

:'''Black: Right hindlimb'''

 

<font color = "green">Green: Left hindlimb<font color = "black">

 

'''Black: Right hindlimb'''

The ECG should be recorded in a calm and quiet environment. If the animal is stressed it may help to dim the lights. The patient should be kept as still and relaxed as possible as muscle tremors and movement can cause artifacts on the trace. Dogs should be placed in right lateral recumbency but positioning in a cat is less important. The cables should be positioned so that they do not drape over the animals chest as they can cause respiratory movement artifact. Electrical activity can cause interference on the ECG trace (known as 50Hz interference). To prevent this it should be taken on an insulated surface away from computers and fluorescent lighting and other electrical equipment.  

The ECG should be recorded in a '''calm and quiet environment'''. The patient should be kept as '''still and relaxed''' as possible as '''muscle tremors and movement''' can cause '''artifacts''' on the trace. In horses the ECG is recorded '''standing'''. Dogs should be placed in '''right lateral recumbency''' but positioning in a cat is less important. The cables should be positioned so that they do not drape over the animals chest as they can cause '''respiratory movement artifact'''. Electrical activity can cause interference on the ECG trace (known as '''50Hz interference'''). To prevent this it should be taken on an '''insulated surface''' away from fluorescent lighting, computers and other electrical equipment. A '''Holter''' ECG can be used in both small and large animal to record the electrical activity of the heart over 24 hours or during exercise.  

Chemical restraint should be avoided if at all possible as this changes the ECG.  

'''Chemical restraint''' should be '''avoided''' if at all possible as this changes the ECG.

==Reading an ECG Trace==

==Reading an ECG Trace==

An ECG supplies information about the electrical activity of the heart only. It indicates the heart rate and rhythm and can be used to detect any arrhythmias. It does not supply information about cardiac function. It is important to remember to treat the patient not the ECG!

An ECG only supplies information about the '''electrical activity of the heart'''. It indicates the heart rate and rhythm and can be used to detect any arrhythmias but does not supply information about cardiac function. It is important to remember to '''treat the patient not the ECG'''!

To interpret an ECG it is necessary to understand the path of depolarisation through the heart:

To interpret an ECG it is necessary to understand the path of depolarisation through the [[:Category:Heart - Anatomy & Physiology|heart]]:

The sino-atrial node depolarises spontaneously and this wave of depolarisation spreads through the atria. The impulse is then conducted through AV node slowly. Then it rapidly passes through the bundle of His and bundle branches, spreading through the ventricular myocardium. The myocardium then remains depolarised for a period before repolarising. This depolarisation and repolarisation are detected as potential differences on the skin surface - producing the classic shape of the ECG trace.  

The sino-atrial node depolarises spontaneously and this wave of depolarisation spreads through the atria. The impulse is then conducted through AV node slowly. Then it rapidly passes through the bundle of His and bundle branches, spreading through the ventricular myocardium. The myocardium then remains depolarised for a period before repolarising. This '''depolarisation and repolarisation are detected as potential differences on the skin surface - producing the classic shape of the ECG trace'''.  

[[Image:ECG.jpg|left|]]

[[Image:ECG.jpg|left|]]

Six limb leads (ECG traces derived from a pair of electrodes) are produced from the reading of the four electrodes. These are named leads I, II, III, aVR, aLV, aVF.  

 

The trace should always be read from left to right. Ideally it should be read from the start but if this is too difficult then the most recognisable portion should be identified and the trace read from this point. and if it is hard to read then you should identify the

In small animals '''six limb leads''' ('''ECG traces derived from a pair of electrodes''') are produced from the reading of the '''four electrodes'''. These are named leads '''I, II, III, aVR, aLV, aVF'''.  

The trace should always be read from '''left to right'''. Ideally it should be read from the start but if this is too difficult then the most recognisable portion should be identified and the trace read from this point.  

'''(1) Instantaneous heart rate'''

'''(1) Instantaneous heart rate'''

 

:1500/R-R interval (25 mm/sec)

1500/R-R interval (25 mm/sec)

:3000/R-R interval (50 mm/sec)

 

3000/R-R interval (50 mm/sec)

'''(2) Number of R-R intervals in 6 seconds x 10'''

'''(2) Number of R-R intervals in 6 seconds x 10'''

Where multiple rhythms exist, the rate of all rhythms present should be calculated.

Where multiple rhythms exist, the rate of all rhythms present should be calculated.

An high heart rate may be due to sinus tachycardia, supraventricular tachycardia, ventricular tachycardia and atrial fibrillation. A slow heart rate may be caused by sinus bradycardia, sinus arrhythmia, second or third degree AV block, atrial standstill and sinus arrest.  

A high heart rate may be due to [[Sinus Tachycardia|sinus tachycardia]], [[Supraventricular Tachycardia|supraventricular tachycardia]], [[Ventricular Tachycardia|ventricular tachycardia]] and [[Atrial Fibrillation & Atrial Flutter|atrial fibrillation]]. A slow heart rate may be caused by [[Sinus Bradycardias|sinus bradycardia]], [[Sinus Arrhythmias|sinus arrhythmia]], second or third degree [[Atrio-Ventricular Block|AV block]], [[Atrial Standstill|atrial standstill]] and [[Sinus Arrest & Sinus Block|sinus arrest]].  

===='''What is the heart rhythm?'''====

===='''What is the heart rhythm?'''====

Changes in the morphology of the complexes are classed as a change in the shape, size or duration of the P wave, QRS complex or T wave. The magnitude and duration of deflections can be caused by hypertrophy of the myocardium, electrolyte abnormalities or an alterations in autonomic tone within the heart.

Changes in the morphology of the complexes are classed as a change in the shape, size or duration of the P wave, QRS complex or T wave. The magnitude and duration of deflections can be caused by hypertrophy of the myocardium, electrolyte abnormalities or an alterations in autonomic tone within the heart.

You should record whether all the deflections are the same, as some variations may be normal.  

'''Variation in P-wave''' can be caused by a [[Sinus Arrhythmias|wandering pacemaker]] or atrial ectopy. Variation in QRS complexes may be caused by either variable conduction or electrical alternans.

Variation in P-wave can be caused by a wandering pacemaker or atrial ectopy. Variation in QRS complexes may be caused by either variable conduction or electrical alternans.

'''No P to every QRS''' - this occurs when ventricular depolarisation follows an abnormal atrial depolarisation. This can be caused by [[Ventricular Premature Complexes|premature ventricular]] or [[Supraventricular Premature Complexes|junctional complexes]], [[Sinus Arrest & Sinus Block|sinus arrest]] with ventricular or junctional escape complexes, [[Atrial Standstill|atrial standstill]] and [[Atrial Fibrillation|atrial fibrillation]].

No P to every QRS - this occurs when ventricular depolarisation follows an abnormal atrial depolarisation. This can be caused by premature ventricular or junctional complexes, sinus arrest with ventricular or junctional escape complexes, atrial standstill and atrial fibrillation.

'''No QRS to every P''' - this occurs the AV node fails to conduct impulses normally. This can be caused by second and third degree [[Atrio-Ventricular Block|AV block]]. Second degree AV block is normal in the resting horse - however it should disappear following exercise.

The '''shape''' of a complex can be used to identify the location of the origin of a rhythm disturbance. Complexes that originate in the ventricles are produce wide and bizarre QRS complexes, whereas complexes of atrioventricular origin are narrow and upright.  

 

The shape of a complex can be used to identify the location of the origin of a rhythm disturbance. Complexes that originate in the ventricles are produce wide and bizarre QRS complexes, whereas complexes of atrioventricular origin are narrow and upright.  

====Are they consistently and reasonably related?====

====Are they consistently and reasonably related?====

An '''abnormal P-R interval''' is caused by atrioventricular dissociation. This occurs secondary to junctional and [[Altered Ventricular Impulse Formations|ventricular rhythm disturbances]] and third degree [[Atrio-Ventricular Block|AV block]].  

A variable P-R interval is caused by atrioventricular dissociation. This occurs secondary to junctional and ventricular rhythm disturbances and third degree AV block.  

To calculate this the P-P, R-R and P-R intervals should all be measured. If the P-R interval is the only variable factor this is very suggestive of AV dissociation.  

To calculate this the P-P, R-R and P-R intervals should all be measured. If the P-R interval is the only variable factor this is very suggestive of AV dissociation.  

Common problems:

Robinson, SA (1990) '''Practical use of ECG in the horse''' ''In Practice 1990 12: 59-6''

 

Determining the origin of non-sinus depolarisations

 

Sparks, AH & Caney, SMA (2005) '''Self-Assessment Colour Review Feline Medicine''' ''Manson''

[[Category:Monitoring Anaesthesia]]

[[Category:Monitoring Anaesthesia]]

[[Category: To Do - Siobhan Brade]]

[[Category:Clinical Techniques]]

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