ISRN UTH-INGUTB-EX-E-2020/004-SE

Examensarbete 15 hp

Juni 2020

Investigation of ECG electrodes for burn wounds

Linus Falk

Populärvetenskaplig sammanfattning

Stora och svåra brännskador påverkar inte enbart huden utan även många system i

kroppen. Brännskadevård är därför en specialistgren inom sjukvården och Akademiska

sjukhuset i Uppsala var det första sjukhuset i Sverige med en avdelning specialiserad på

dessa skador. De har idag tillsammans med Linköping det nationella uppdraget att ta

hand om svåra brännskador.

Eftersom brännskadan påverkar många system i kroppen är det viktigt att kunna

övervaka patientens parametrar under vårdtiden. Med ett EKG kan man ställa diagnos

och övervaka hjärtats funktion och det används därför regelbundet inom intensivvården.

EKGt tas vanligtvis med engångselektroder som sätts på huden på standardiserade

platser och tillsammans med en EKG apparat kan man registrera hjärtats elektriska

aktivitet och ställa diagnoser.

På brännskadecentrum i Uppsala har man under långt tid haft återkommande problem

med mycket störningar vid EKG-mätningar vilket försvårar arbetet att ställa diagnoser

och övervaka patientens tillstånd. Målet med detta arbete var att granska EKG-kurvor

från brännskadecentrum med uppenbara störningar och undersöka brännskadans effekt

på elektroderna för att kunna rekommendera en typ av elektroder för denna typ av

patienter.

Arbetet utfördes med en litteraturöversikt över EKG-instrumentering, vanliga

störningar, elektroder och hur brännskadan kunde efterliknas i ett standardiserat test av

elektrodernas elektriska egenskaper. Tester gjordes sedan på elektroderna med och utan

denna efterliknelse för att se hur mycket elektroderna påverkades och om det var

tillräckligt för att åstadkomma de problem som avdelningen ofta har.

Resultatet blev en rekommendation av elektroder av våt gel typ eftersom de uppvisade

bäst elektriska egenskaper för att minska förvrängning av EKG signalen och att risken

för störningar på grund av obalans i impedans mellan elektroder på brännskada och hel

hud är lägre med den typen av elektroder.

4

Acknowledgments

Many people have been kind to help and guide me through this work and with the fear

of leaving someone out by mistake, I want to give a special thanks to the involved

institutions:

Burn Center – Uppsala University Hospital

The section for medical technique – Uppsala University Hospital

Microwaves in Medical Engineering Group – Uppsala University

Signal and system – Uppsala University

5

Table of contents

Nomenclature _______________________________________________________________ 7

1 Introduction _______________________________________________________________ 8

1.1 Background _________________________________________________________ 8

1.2 Purpose ____________________________________________________________ 9

1.3 Delimitations _________________________________________________________ 9

1.4 Method _____________________________________________________________ 9

1.5 Objective ___________________________________________________________ 9

2 Theory ___________________________________________________________________ 10

2.1 Skin and burn wounds ________________________________________________ 10

2.1.1 Normal skin __________________________________________________ 10

2.1.2 Burns and severity classification __________________________________ 10

2.1.3 Care and treatment ____________________________________________ 11

2.2 Heart and ECG measurements _________________________________________ 11

2.3 ECG electrodes _____________________________________________________ 15

2.3.1 ECG electrode introduction ______________________________________ 15

2.3.2 Equivalent circuit of an ECG electrode _____________________________ 18

2.3.3 Equivalent circuit of an ECG electrode placed on the skin ______________ 21

2.3.4 ECG electrode quality control according to ANSI/AAMI ________________ 22

2.4 ECG measuring technique and common artefacts __________________________ 22

3 Method __________________________________________________________________ 25

3.1 Devices and material _________________________________________________ 25

3.1.1 Data acquisition (DAQ) device ___________________________________ 25

3.1.2 Graphical programming language: ________________________________ 25

3.1.3 Electrodes ___________________________________________________ 25

3.1.4 Ringer’s acetate ______________________________________________ 26

3.2 Investigation of artefacts in ECG signals __________________________________ 26

3.3 Burn wound simulation ________________________________________________ 26

3.4 Electrode selections and measurements __________________________________ 27

3.4.1 DC offset ____________________________________________________ 27

3.4.2 10Hz AC impedance ___________________________________________ 28

3.4.3 Adhesiveness ________________________________________________ 29

4 Result and discussion _____________________________________________________ 30

4.1 Artefacts in ECG signals and their counter ________________________________ 30

6

4.2 Measurements ______________________________________________________ 30

4.3 Adhesive __________________________________________________________ 33

6 Conclusion and further work ________________________________________________ 35

References ________________________________________________________________ 36

7

Nomenclature AAMI Association for the Advancement of Medical Instrumentation

ANSI American National Standards Institute

aVF Augmented vector foot

aVL Augmented vector left

aVR Augmented vector right

CMRR Common Mode Rejection Rate

ECG Electrocardiography

Interstitium Space between the cells

QRS Graphical deflections in ECG waveform

SSCD Skin surface conductance density

8

1 Introduction In this chapter, the project works background, purpose, delimitations and method will

be explained.

1.1 Background

Advanced treatment of burn victims has been carried out at Uppsala University Hospital

for over 60 years and together with Linköping university Hospital they got the total

responsibility for treatment of severe burns in Sweden. Since May 2011 there is a

modern centre: Burn Center, for burn treatments on Uppsala University Hospital.

Large and severe burn injuries cause the human body to lose large amount of liquid

through the damaged areas. This liquid leakage combined with the added liquid from

“fluid treatment” makes this type of patient difficult to use conventional “stick on” ECG

electrodes on. The ECG electrodes are placed on the body in standard places and

together with an ECG device the electrical activity in the heart can be picked up. In Fig.

1.1 a part of a 12-lead ECG is shown taken on one of the patients in the Burn Center.

The ECG waveforms from different leads show different amount of interference that are

frequently encountered on ECG waveforms at from this category of patients, because

burn wounded skin affect the performance of ECG electrodes.

Fig. 1.1 ECG waveform from burn patient

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1.2 Purpose

The purpose of this project work is to investigate ECG-electrodes to determine which

type is most suitable for extracting the ECG signal from burn wounded skin.

1.3 Delimitations

The project work is limited to investigate the properties of ECG electrodes used for

measuring ECG signals from full thickness burn wounded skin. Electrodes that are not

suitable for easy sterilization or not of disposable type will be excluded from the work

due to hygienic reasons. No new methods to replace the conventional placement of the

electrodes will be developed or investigated in this project.

1.4 Method

The project work will begin with a literature review of the basics of an ECG and

theoretical and empirical methods of recreating the surface and electrical properties of

burn wounded skin in an artificial way. To test the electrodes’ electrical quality an

industrial standards test will be done on the selected electrodes, one reference test

without burn wound replication and one with. A test of the adhesive of the electrodes

will also be performed. Selecting suitable electrodes for testing will be done by

consulting personnel of the Uppsala University Hospital Burn Center.

1.5 Objective

The objective of this project work is to deliver a recommendation of what sort of

electrode is suitable to use on burn wounds. Following secondary objectives shall be

fulfilled during the work:

• Collect and validate ECG waveforms at the Burn Center of Uppsala

University Hospital

• Describe the electrical properties of burn wounded skin and how it could be

replicated

• Construct a test for ECG electrodes and test them

• Validate the result.

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2 Theory In this chapter the relevant theory for the project work will be presented.

2.1 Skin and burn wounds

The skin is the largest organ of the human body and serves several important functions

for the human body.

2.1.1 Normal skin

The skin act as a barrier against the surrounding environment and some of its main tasks

are:

- protect against mechanical and chemical impact

- protect against dehydration

- stop microorganism entering the body

Skin consists of two layers, the Epidermis and Dermis. Epidermis is outer layer and is

around 0.1-1mm thick depending on how much wear the skin is subjected to. There are

no blood vessels in the epidermis, all nutrients are transported by diffusion. The

outermost layer of the Epidermis is called the Corneum stratum and consists of

cornified dead cells. Dermis is the layer underneath the Epidermis and is 0.3-3mm

thick. It consists of fibrous connective tissue, sweat glands, hair follicle, sebaceous

glands, and a lot of blood vessels. Dermis merges gradually to the subcutaneous layer of

loose fibrous connective tissue and varying amount of fat. The blood vessels in the

epidermis is supplied with blood from larger vessels in the subcutaneous layer [1].

2.1.2 Burns and severity classification

Burn wounds separate themselves from many other wounds. Even though it is only one

organ involved in the damage it affects almost all systems in the whole body. Burn

wound treatment and care is there for a medical speciality.

Burn wounds can be caused by many things but the categorisation of the burn wounded

skin is the same for all of them [2]. The skin is divided into 3 parts: the utmost part is

called the epidermis followed by the dermis and the subcutaneous layers. Burn wounds

are divided into categories depending on the depth of the wound.

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Superficial, epidermal or first-degree burn has only damaged the outer layer of the

skin, epidermis. Common damages of superficial burns are a typical sunburn with

redness and mild swelling [3].

Superficial dermal or second-degree (2a) burn is damage to the epidermis and the

superficial part of the dermis. Blisters, red and moist wound surface.

Deep dermal or second-degree (2b) burn has damaged deeper into the dermis with

grey white or red often dry wound surface. Often is surgery needed to remove the

damaged epidermis.

Full thickness burn has damaged all of the dermis down to the subcutaneous layers of

fat and possibly also deeper tissue layers. Surgery is mandatory for healing unless the

wound is very small, approximately 1cm2 [3].

In response to a burn wound an inflammatory response is triggered and blood

components is leaked out from the intravascular space into the interstitium causing

oedema in the damaged areas and often also in the whole body [4]. The blood

components consist of blood cells, proteins and plasma. In the blood plasma ions is the

main component of the solved substances with natrium being the one of highest

concentrations [5].

2.1.3 Care and treatment

To replace the intravascular fluid that is leaked out from the damaged areas, fluid

treatment is started with Ringer’s acetate [4]. Ringer’s acetate is an isotonic infusion

liquid that does not change the volumes of the cells when injected. It contains all ions

normally found in the extracellular liquid in similar concentrations [6].

2.2 Heart and ECG measurements

The heart is a muscle that consists of four chambers, left and right ventricles and

atriums. The purpose of the heart is to circulate the blood in the body to deliver

nutrition, oxygen and remove waste products from cells. By contracting in a specific

order, shown in Fig. 2.1, it pumps the blood through the heart and out into the

circulatory systems [7].

12

Fig. 2.1 Contraction of the atrium and chambers [8]

The contraction of a single muscle fibre relates to the change in potential on the surface

of the muscle cells. In rest the muscle cell is polarized so that the inside of the cells has

a negative charge compared to the surrounding membrane. This potential of around -

90mV difference is maintained by active transportation of Na+ through the cell

membrane out of the cell. When a contraction of a muscle fibre occurs an action

potential is triggered which is caused by a sudden change of the cell membranes

permeability of Na+ ions flipping the potential of the membrane. A dipole field

contraction wave is created in the moment when depolarization occurs traveling along

the muscle fibre. It is later followed by a repolarization wave in the opposite direction

[9].

These potentials caused by individual muscle fibres contractions can be picked up by

electrodes connected to an ECG device and are added up to a waveform, the ECG.

These potentials are in the magnitude of 0,5 to 4 mV and in the frequency range: 0.01 to

250 Hz [10]. The waveform is shown in Fig. 2.2 where the P wave is representing the

depolarization of the atria and QRS interval or QRS complex represent the

depolarization of the ventricles and the T wave representing the repolarization of the

ventricles [8].

13

Fig. 2.2 Intervals of the ECG [8]

For diagnosing heart problems, a 12-lead ECG is often used. The 12-leads imply that

there are 12 different waveforms formed by electrodes placed in a standardized

placement on the body [11]. The leads are of three types:

Bipolar extremity leads – standard leads I, II and III: In the standard leads the

potential between the points shown in Fig. 2.3 is measured.

Unipolar extremity leads – aVR, aVL, and aVF: Analysis of the ECG signal from the

extremities can be made easier by registering them in relationship to a point whose

potential does not change during the heart cycle. This is achieved by connecting the two

other extremity leads with two equally large resistors.

Fig. 2.3 The bipolar and unipolar extremity leads [12]

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Unipolar chest leads – V1,V2, … Vn; To get more detailed information of the changes

in potential in the heart, electrodes are placed around the chest in anatomically specified

places as seen in Fig. 2.4. The potentials in these sites are measured in relationship with

a constructed point that connects the left arm, right arm, and left leg with three equal

resistors.

Fig. 2.4 The unipolar chest lead placements [13]

These placements of the electrodes make it possible to observe the electrical activity in

the heart from different angles [11], resulting in different shapes of the ECG waveform

seen in Fig. 2.5.

15

Fig. 2.5 The 12-lead ECG waveforms [14]

2.3 ECG electrodes

In this chapter the ECG electrode is introduced, and its electrical properties explained.

2.3.1 ECG electrode introduction

ECG electrodes exist in three main categories:

• Surface electrodes

• Monopolar electrodes

• Concentric electrodes

The most commonly used ECG electrode is the disposable surface electrodes which are

often covered with a thin layer of electrode-paste containing electrolytes to improve

conductivity. These electrodes are kept in place by either suction, tape, glue or a strap.

It’s the potential difference between two electrodes or between one electrode and a

constructed point with a ground reference electrode that are picked up and conducted to

the ECG device that filters and amplifies the signal and displays it for interpretation.

The sum of the electrical activity in the tissue under the electrode is picked up by

16

surface electrodes and they are therefore not suitable when locating the exact position of

the source of a signal.

ECG surface electrodes job is to convert the current in the body that consists of ion

transport to electrons through the surface of the electrode, often combined with an

electrolyte [15]. Surface ECG electrodes can be further categorised as either polarizable

or non-nonpolarizable [16]. The most widely used non-polarizable disposable electrode

is the silver chloride Ag-AgCl electrode because of its property to easily exchange ions

with its surroundings. The easy exchange of ions makes it not as polarized as other

conductive materials like stainless steel or platinum. Polarization of the electrode

resembles the surfaces of a capacitor with charges distributed on two sides, the electrode

surface as one side and the electrolyte the other. This double layer is called the

Helmholtz double layer and its simplest form is shown in Fig. 2.6. Polarization can in

some cases lead to difficulties to register an ECG signal in the low frequencies or even

build up a voltage so high that it blocks the input of the amplifier in the ECG device

[15].

Fig. 2.6 The Helmholtz layer [17]

The Ag-AgCl electrodes are often made with either a solid or wet gel for the electrolyte.

The solid gel or hydrogel is held together by crosslinked polymers that can by

absorption contain more than 99% water. This solid gel can either just contain the

electrolyte or the adhesive for the electrode also. The wet gel is in a liquid state that

lowers the resistance in combination with the skin by penetrating the outer layer of it

[18]. One of the wet gel electrodes design features is that it reduces the risk of artefacts

in the ECG curve by having a buffer layer of isotonic electrolyte between the surface of

17

the patient and the electrode, shown in Fig. 2.7. This layer absorbs the movement of the

electrode in relationship to the patient. This is to maintain a constant polarization or

half-cell potential [17].

Fig. 2.7 Buffer layer in wet gel ECG electrode [17]

Comparing the low frequency conductivity between solid and wet gel electrodes on

skin, shown in Fig. 2.8 the wet electrode (b) performed up to 8,5 times better when the

patient is resting/passive. When the patient was exercising the conductivity improves

for the solid gel (a) in contrast to the wet gel electrode that performed worse. The reason

for this is probably that the sweat improves the conductivity in the skin solid gel

interface but decreased it in the wet gel case because the wet gel was replaced by sweat

that is less conductive then the gel. Solid gel as contact medium to skin shows in

general more capacitive coupling and performs there for worse in low frequency

applications. When choosing wet or solid gel electrode these characteristics should be

considered [18].

18

Fig 2.8 Conductivity with skin of a solid gel (a) and wet gel (b) electrode [18].

2.3.2 Equivalent circuit of an ECG electrode

The ECG signal is an AC signal and the electrical property of the electrode is therefore

described as an impedance. Impedance Z is complexed valued, consisting of resistance

R as its real part and reactance X as its imaginary part. Mathematically, the impedance

can be expressed as:

𝑍 = 𝑅 + 𝑗𝑋 (2.1)

Where the reactance can be either capacitive or inductive. The capacitive reactance is

described as negative in the imaginary plane and inductance positive. The impedance

can also be described in exponential form where the magnitude is the hypotenuse of the

resistance and reactance together with the angle θ between them. This is denoted in the

form:

𝑍 = |𝑍|𝑒𝑗𝜃 = √𝑅2 + 𝑋2𝑒𝑗𝜃 (2.2)

𝜃 = tan−1𝑋

𝑅 (2.3)

19

If the impedance is purely capacitive its angle is -90 degrees or if purely inductive + 90

degrees. With Ohm’s law the impedance can be calculated from the complexed valued

voltage V and current I, shown in Eq. (2.4) [19].

𝑍 =𝑉

𝐼(2.4)

The impedance of a surface electrode typically has resistance of <10kOhm and

capacitance <0.1µF [15]. The current through a capacitor is described by Eq. (2.5). That

means that the voltage can’t change instantaneously over a capacitor because that would

need a current that is infinitely large. The voltage vc over capacitor in a RC circuit will

therefore lag after the voltage over the resistor vr as shown in Fig. 2.9. This is called the

phase shift and is measured in degrees or radians [19].

𝐼(𝑡) = 𝐶𝑑𝑉(𝑡)

𝑑𝑡(2.5)

Fig. 2.9 Phase shift between VR and VC [19]

The value of an unknown impedance Z often needs to be determined. This can be done

by connecting an AC source and a known resistance Rref with it in series as shown in

fig. 2.10. The value of Z can be calculated in the following manner: [20].

𝑍 = |𝑍|𝑒𝑗𝛼 =𝑉2𝑅𝑟𝑒𝑓

√𝑉12 − 2𝑉1𝑉2 cos 𝜃 + 𝑉2

2 𝑒𝑗𝛼 (2.6)

20

𝛼 = 𝜃 − tan−1−𝑉2 sin 𝜃

𝑉1 − 𝑉2 cos 𝜃 (2.7)

Where V1 and V2 is the amplitude over the known resistance and the unknown

impedance, respectively, and θ is the phase shift.

Fig. 2.10 Circuit for determining value of an unknown impedance Z

The disposable ECG electrode works by the principle of half-cell voltage. This voltage

is created whenever an ionic solution comes in contact with an electrode metal and the

electrode metal tries to exchange ions with the electrolyte [15]. In the case of non-

polarizable electrode, the current between the metal and the electrolyte passes through

the electrolyte – electrode interface. This is possible by the oxidation of the electrode

that forms cations and electrons, the cations travel out in the electrolyte while the

electron is carried through the lead wire. In the electrolyte the anions are traveling

towards the electrode to deliver electrons to the electrode. The uneven distribution of

these cations and anions form the half-cell voltage and act also as a polarized interface.

In contrast the polarized electrode does not allow a current to pass freely through the

electrode – electrolyte interface, instead the interface acts like a capacitor where the

currents are displaced.

21

The equivalent circuit for the non-polarizable electrode can therefore be described in

Fig. 2.11. The resistor Rd in parallel represents the electrical resistance of the current

that passes through the electrolyte with the help of oxidation. Because the non-

polarizable electrode is not perfect, a polarization occurs that is represented by the

capacitance Cd. The resistance Rs represents the resistance in the electrolyte. The half-

cell voltage is represented as a battery, Ehc [21].

Fig. 2.11 Equivalent circuit model of ECG electrode [22]

2.3.3 Equivalent circuit of an ECG electrode placed on the skin

Epidermis is the part of the skin that stands for most of the impedance and it vary a lot

between patients, a Re of around 300kOhm for 10Hz signal is not unusual, shown in the

simplified electrical model in Fig. 2.12 [17]. The capacitive properties are added

because the epidermis/corneum stratum forms a semipermeable layer for ions, so there

can be a difference in concentrations of ions. This difference forms a small potential

difference Ese and acts as a capacitive surface Ce. The electrical properties change in

the case of perspiration, and a parallel RC (Rp and Cp) circuit is added to describe the

wall of the glands and the conducting sweat [22]. The Epidermis impedance can in

normal cases be lowered by carefully abrading the skin to remove the utmost layer, the

stratum corneum. The capacitive The impedance of dermis and subcutaneous layers are

often described with only a resistance Ru of around 100Ohm [18].

22

Fig. 1.12 The electrical properties of skin [22]

2.3.4 ECG electrode quality control according to ANSI/AAMI

Disposable ECG electrodes can be characterized by using a series of tests developed by

the Association for the Advancement of Medical Instrumentation (AAMI) which is an

accredited standards development organization by the American National Standards

Institute (ANSI). This test is to ensure safety and efficiency in the use of the electrodes

in clinical use. A selection of the standard is presented in the list below [23].

1. DC offset voltage: A pair of electrodes that are connected gel to gel after 1

minute of stabilization time shall not exceed 100mV offset voltage.

2. Average value of 10 Hz impedance: The average value of the impedance of 12

pairs of electrodes connected gel to gel, max 2kOhm, individual pair max

3kOhm. The current when testing should not exceed 100µA.

2.4 ECG measuring technique and common artefacts

One of the difficulties in measuring the ECG signal is to limit the interference caused by

the capacitive connection between the patient and the main 230V 50Hz network. This is

often solved by differential amplifiers that have a high Common Mode Rejection Rate

(CMRR) [24]. With high CMRR the interference that is present at both inputs of the

amplifiers is cancelled out. This is only possible if the common mode signal (the

23

interference) stays at the same amplitude and phase at both inputs. Imbalance in

impedance between the electrodes (Zex in Fig. 2.13) can make the common mode signal

become differential by voltage dividing over the electrode impedance, the amplifier can

in these cases not cancel out all the interference [25]. Common mode to differential

mode conversion can also occur because of voltage drop in the body (Ztx in Fig 2.13)

between the measuring electrodes from the coupled 50Hz current [26].

Fig. 2.13 Capacitive coupling to main 230V, 50 Hz network [27]

Artefacts in an ECG makes it difficult to interpret and to set a correct diagnosis. Some

common artefacts in ECGs are described and explained bellow:

Wandering baseline in Fig. 2.14, is a low frequency artefact well below 1Hz. This

wandering baseline makes it very difficult to interpret the S-T interval of the ECG.

Wandering baseline is often caused by perspiration, respiration, patient movement and

poor electrode contact [28].

24

Fig. 2.14 Wandering baseline [28]

Muscle tremor artefact in Fig. 2.15 is the result of muscle activity from other muscles

than the heart. These are best avoided by trying to keep the patient warm to avoid

shivering and tell them to be still and relaxed [29].

Fig. 2.15 Muscle tremor artefact [28]

AC 50-60Hz interference in Fig. 2.16 is an artefact that makes the baseline thick and

fuzzy. It is often related to poor electrode contact, dried electrode gel from incorrect

storage and defective cables [26].

Fig. 2.16 The 50-60Hz interference [28]

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3 Method

In this chapter the method to achieve the objectives in this work is described. To find

what type of disposable electrode is best suitable for burn wounds the following issues

are investigated: the ECG-waveforms from Burn Center and the effect of the electrical

properties and adhesive of the electrode by the burn wound.

3.1 Devices and material

In this section the devices and material used in this project are introduced.

3.1.1 Data acquisition (DAQ) device

A National Instruments USB-6210 data acquisition device was used for the

measurements. USB-6210 is a multifunctional 16-Bit, 250kS/s DAQ that offers 16

analog inputs and 4 digital inputs [30].

3.1.2 Graphical programming language:

Laboratory Virtual Instrument Engineering Workbench (LabVIEW) is a graphical

programming language that was used to collect and calculate the measurements from

the DAQ. A LabVIEW program is called a virtual instruments (VI) and consists of a

block diagram, front panel and a connector pane [31]. Collection and calculations of

data from the DAQ was programmed in the block diagram and the results was displayed

in the front panel.

3.1.3 Electrodes

In table 3.1 the selected electrodes for the test are presented. The notes describe

specification of use for the electrode.

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Table 3.1 Selected electrodes

Manufacturer Model Gel Notes

Ambu Bluesensor L-00-S/25 Wet For long time ECG

3M 2670-5 Solid Repositionable

Ambu Bluesensor R-00-S/25 Wet Exercise test

Milmedtek T-VO01 Wet Dry skin

Medtronic Arbo Solid For X-ray and MRI

Ambu Whitesensor WSP30-00-S/50 Solid Exercise test

3.1.4 Ringer’s acetate

Ringer’s acetate is an isotonic infusion liquid. It contains all ions normally found in the

extracellular liquid in similar concentrations [6].

3.2 Investigation of artefacts in ECG signals

By comparing the artefacts found in the two ECG waveforms received from Burn

Center with common artefacts, possible sources could be identified.

3.3 Burn wound simulation

The main difference of the measurement of an ECG on a burn wounded patient is the

often lack of the outer part of the skin, the epidermis, and the presence of extracellular

liquid leaking from the areas where the electrode is supposed to be attached. To

investigate the effect this wound has on the electrode’s electrical properties 0.5ml

Ringer’s acetate, which is a liquid very similar to extra cellular liquid was placed

between two electrodes gel to gel, shown in Fig. 3.1. The electrodes were then tested

using the two test methods (AAMI) described in theory chapter. This test was repeated

without Ringer’s acetate for comparison. The purpose of these tests was to see if and

how the electrodes electrical properties changed and if there were any differences in the

results between the different types of gel used on the electrodes.

27

Fig. 3.1 Applying Ringer’s acetate to electrode

3.4 Electrode selections and measurements

Selection of ECG electrodes was done consulting an intensive care nurse at Burn

Center. The goal was to test a variety of disposable electrodes with different kinds of

gels that were easily available from their suppliers. One electrode for dry skin was

selected for comparison in the effect on the adhesive.

The two methods to test the electrodes are described here. The results from each test

were collected in an excel form and saved. The results were then collected into graphs

and displayed with the mean value of 12 electrode pair tests and with the standard

deviation.

3.4.1 DC offset

The electrodes were connected to a 3.5mm audio cable with snap-on connectors to one

of the DAQ’s differential ports by a 3.5mm port. The input configuration for the DAQ

was set to Differential mode in LabVIEW and 10kOhm resistors for bias currents were

placed from the differential ports to the AIGND port.

28

Fig. 3.2 DC offset test circuit

3.4.2 10Hz AC impedance

The 10Hz AC impedance was measured using a Velleman PCSU200 oscilloscope with

signal generator. The signal generator was set to sine wave, 10Hz and 8V peak to peak.

The electrodes were connected in series with a 1MOhm resistor to ensure that the

current was lower than the maximum value according to AAMI standard. The voltage

and phase shift over the resistor (VR) and electrodes (VE) were measured in differential

mode with the DAQ. The impedance was calculated in LabVIEW using Eqs. (2.6) and

(2.7). The measurement was done with a sample rate of 1kHz for 1 second and then

repeated 30 times, a mean value was then calculated for each pair of electrodes. This is

to ensure that a single measurement error would not have a big impact on the result.

R_output shown in fig. 3.3 is the output resistance of the signal generator and does not

affect the result in this test.

29

Fig. 3.3 Impedance test circuit

3.4.3 Adhesiveness

During the measurements of the electrode, notes were taken on the effect on the

adhesive of the electrodes. Noted was how the liquid spread over the electrode and if the

adhesive stopped working.

30

4 Result and discussion The results from the measurements and observations are presented and discussed in this

chapter.

4.1 Artefacts in ECG signals and their counter

The unidentified ECG waveforms found in the appendix and a part of it in Fig 3.3

shows a lot of 50Hz interference. Electrode related causes is dried out gel, poor contact

and common mode to differential mode conversion by impedance imbalance between

the electrodes.

Fig. 3.3 Part of unidentified ECG showing (a) 50Hz interference and (b) ventricle

contractions

The most common solutions for this kind of problems are:

Dried out gel is a problem caused by storing the electrode wrong and is easily corrected

by following the manufactures guidelines.

Poor contact is caused by badly performing adhesive and is best solved by choosing an

electrode that is developed for the application in question, for an example sweaty skin

or exercise ECG.

Impedance imbalance is controlled by reducing the differences in skin-electrode

impedances between electrodes.

4.2 Measurements

The results of the measurements are presented here as graphs with the blue bars (test 1)

representing the test without Ringer’s acetate and the red bars (test 2) with Ringer’s

acetate.

31

The measurements of the electrodes showed that the impedance of the electrodes

changed when Ringer’s acetate was introduced between the electrode pairs. This is

expected when introducing a conductive liquid between two electrodes and the result

was in almost all cases a lower impedance, shown in Fig. 4.1. A two-sided T-test with

significance level of 5% showed a convincing difference between the mean value in test

1 and 2 in impedance and phase. Lower impedance can cause more imbalance in

impedance between electrodes placed on burn wound and skin, which increases the risk

of 50Hz interference. The change in impedance because of Ringer’s acetate was often

less than 100Ohm and is very small in comparison with the impedance of dry skin of

around 300kOhm if the electrodes are placed on both skin and burn wound.

Recommending an electrode that showed least change is there for not necessary. Even

though the solid gel electrodes showed lower impedance should wet gel electrodes still

be considered. This is because of the much higher conductivity in combination with

non-sweaty skin to reduce impedance imbalance when electrodes are placed on both

skin and burn wound.

Fig. 4.1 impedance of ECG electrode pairs

Increased phase shift was observed in almost all cases in test 2, shown in Fig. 4.2. This

could be caused by either lower resistance between the electrodes or increased

polarization because of changed concentration of ions in the electrode-gel interface. An

increase in DC-offset (shown in Fig. 4.3) would have also been observed if increase in

0

100

200

300

400

500

600

700

800

900

1000

3M 2670 Medtronic arbo AMBU BLUE L-00-S25

AMBU BLUE R-00-S25

Milmedtek T-VO01

AMBU WhiteWPS30-00-S/50

Impedance |Z| (Ohm)

Test 1 Test 2

32

polarization occurred, but no statistical difference (Two-sided T-test with 5%

significance level) between test 1 and 2 was found. Capacitive coupling impacts the

ECG by increasing high pass filtering of the signal and is not wanted. The wet gel

electrodes with general low capacitive coupling is therefore a better choice.

Fig. 4.2 Phase shift between voltage over resistor and electrode pair

Fig. 4.3 DC offset in electrode pair after 1 min stabilization time

-45

-40

-35

-30

-25

-20

-15

-10

-5

0

3M 2670 Medtronic arbo AMBU BLUE L-00-S25

AMBU BLUE R-00-S25

Milmedtek T-VO01

AMBU WhiteWPS30-00-S/50

Phase (º degrees)

Test 1 Test 2

-0,5

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

3M 2670 Medtronic arbo AMBU BLUE L-00-S25

AMBU BLUE R-00-S25

Milmedtek T-VO01

AMBU WhiteWPS30-00-S/50

DC Offset (mV)

Test 1 Test 2

33

The resistors for bias currents were not tested and could therefore have been better

selected. The manufacturer of the DAQ, National instruments recommendation is to

have resistors in the interval 10kOhm up to 100kOhm and is suitable for the

environment the measurements are done [32]. In this case the resistors were 10kOhm

and could have had the effect of lowering the input impedance making the

measurements incorrect. This measurement problem could explain why no statistical

difference was found between the tests. The result from the DC offset should therefore

be interpreted carefully. Increased phase shift in test 2 that could be caused by increased

polarization of the electrode needs better measurements and other test methods to be

confirmed.

4.3 Adhesive

The notes of how the adhesive reacted in test 2 with Ringer acetate are presented in

table 4.1 and discussed below.

Table 4.1 Notes on how the adhesive reacted to Ringer acetate

Electrode: Notes

3M 2670 Liquid not absorbed, some pushed out from the electrode surface.

Medtronic arbo Liquid not absorbed, some pushed out from the electrode surface.

AMBU BLUE L-00-S25 All liquid stayed inside electrode, absorbed by the sponge with gel, no effect on adhesive

AMBU BLUE R-00-S25 All liquid stayed inside electrode, absorbed by the sponge with gel, no effect on adhesive

Milmedtek T-VO01 Adhesive in the center of electrode stopped working after a couple of minutes

AMBU White WPS30-00-S/50 Liquid not absorbed, some pushed out from the electrode surface.

The volume of Ringer’s Acetate applied to the electrodes was chosen so that the

smallest electrode would not flood over before the electrodes were put together, this

meant that for some of the electrodes it only covered the central part of the electrode

and didn’t affect the adhesive as much as the smaller electrodes. The control electrode

for dry skin in the adhesive test was the only electrode that showed worse performance

in test 2, with increased impedance. It was also the only electrodes that started to loosen

from each other during the same test. Any conclusion except following the

34

manufacturers recommendation for use regarding the adhesive could therefore not be

made in this test.

35

6 Conclusion and further work To conclude from the results of the measurements and known differences between

different types of electrodes presented in this work it would be recommended to use

electrodes of wet type because of the general lower high pass filtering and its negative

effect on the ECG signal. The increase in phase shift with Ringer’s Acetate with

possibly higher polarization support this choice also. The lower impedance on regular

skin from the wet gel decrease the risk of interference because of impedance imbalance

when electrodes are placed on both skin and burn wound. Of the tested electrodes

should the Ambu Bluesensor R-00-S/25 be recommended because of its wet gel and

adhesive that is developed for sweaty/wet skin.

Suggestions for further investigation would be to see if the interference could be solved

by impedance balancing between electrodes on dry skin and burn wound with an

external impedance. Another suggestion would be to investigate if there is a greater

coupling between the wet burn wounds and the main 230V 50Hz network causing

higher currents and voltage drops in the body increasing the risk of common mode to

differential mode conversion.

36

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39

Appendix

40