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NORMAL ECG
ELECTROCARDIOGRAM
Lead Configurations
– Bipolar Leads
• Two electrodes placed at 2 different sites
• Register the difference in potential between these 2
leads
– Unipolar leads
• Measure the absolute electrical potential at one site
• Requires a reference site
• Reference site formed by the limb leads
12 LEAD ECG
Limb Leads
RA Red Right arm
LA Yellow Left arm
LL Green Left leg
RL Black Right leg
Chest Leads
V1 Red 4th ICS RPSB
V2 Yellow 4th ICS LPSB
V3 Green Midway between V2 and V4
V4 Brown 5th ICS LMCL
ELECTROPHYSIOLOGY OF THE HEART
Epicardium
– Coronary arteries are
found in this layer
Myocardium
– Responsible for
contraction of the heart
Endocardium
– Lines the inside of the
myocardium
– Covers the heart valves
CONDUCTION SYSTEM OF THE HEART
SA Node
Atrial Muscle
AV Node
Bundle of His
Bundle Branches
Purkinje Fibers
Ventricular Muscle
MYOCARDIAL CELL TYPES
Specialized cells
of the electrical Electrical Generation and Automaticity
conduction conduction conduction of Conductivity
system system electrical
impulses
TERMINOLOGY
Chronotropic Effect
– Refers to a change in heart rate
– A positive chronotropic effect refers to an increase in heart rate
– A negative chronotropic effect refers to a decrease in heart rate
Dromotropic Effect
– Refers to a change in the speed of conduction through the AV
junction
– A positive dromotropic effect results in an increase in AV
conduction velocity
– A negative dromotropic effect results in a decrease in AV
conduction velocity
Inotropic Effect
– Refers to a change in myocardial contractility
– A postive inotropic effect results in an increase in myocardial
contractility
– A negative inotropic effect results in a decrease in myocardial
TERMINOLOGY
Waveform
– Movement away from the baseline
in either a positive or negative
direction
Segment
– A line between wave forms
Interval
– A waveform and a segment
Complex
– Consists of several waveforms
ECG PAPER
ELECTROGRAM
Upward deflection
- +
Downward deflection
- +
Diphasic deflection - +
AVL
AVR
AVF
THE NORMAL ELECTROCARDIOGRAM
P wave
– Generated by activation of the atria
PR segment
– Represents the duration of atrioventricular (AV)
conduction
QRS complex
– Produced by activation of both ventricles
ST-T wave
– Reflects ventricular recovery
STANDARD 12 LEAD ECG
The P wave
– Atrial activation
– Height < 0.2 mV (2 mm)
– Duration < 0.12 sec
STANDARD 12 LEAD ECG
P-R Interval
– Intraatrial, internodal, His purkinje conduction
– Duration 0.12 to 0.20 or 0.22 sec
STANDARD 12 LEAD ECG
The ST-segment
– Phase 2 of transmembrane potential
– Isoelectric in normal subjects
STANDARD 12 LEAD ECG
The T wave
– Upright after the age of 16
– Juvenile T wave
STANDARD 12 LEAD ECG
The U wave
– Surface reflection of negative after potential
– Repolarization of Purkinje fibers
– Ventricular relaxation
STANDARD 12 LEAD ECG
The QT Interval
– From beginning of QRS to end of T wave
– Reflects the duration of depolarization and
repolarization
– Bezett: Q-Tc Interval = Q-T/ R-R
ANALYZING A RHYTHM STRIP
Rate
Rhythm
Axis
P wave
PR Interval
QRS Complex
T wave
Q-T Interval
ANALYZING A RHYTHM STRIP
Ventricular Rate
– Small squares (R-R Interval) / 1500
– Big squares (R-R Interval) / 300
What Is The Rate?
Sinus rhythm
Atrial Fibrillation
– QRS complexes in 6-sec strip X 10
ANALYZING A RHYTHM STRIP
Normal
– 0 – (+90)
Left axis AVL
– 0 – (-90) I
Right axis
AVR
– (+90) – (+180)
Extreme axis AVF
– (-90) – (-180)
What Is The Axis?
} 10
AVL
I
Lead I
}
AVR
10
AVF
AVF
ANALYZING A RHYTHM STRIP
Localization
I, AVL
– High lateral
II, III, AVF AVL
– Inferior
I
AVR
AVF
ANALYZING THE RHYTHM STRIP
Localization
V1,V2
– Septal V1-V6 – Extensive anterior
V3,V4 I,AVL,V5,V6 - Lateral
– Anterior
V5,V6
– Apicolateral
V1-V3 or V4
– Anteroseptal
V3 or V4-V6
– Anterolateral
ANALYZING A RHYTHM STRIP
Indications:
• Unstable ventricular tachycardia with a pulse
• Pulseless ventricular tachycardia
• Ventricular fibrillation
• Sustained Torsades de Pointes
Ventricular Rhythms
Asystole
Rate Ventricular usually indiscernible but may see some atrial
activity.
Rhythm Atrial may be discernible.
Ventricular indiscernible.
P waves Usually not discernible
PR interval Not measurable
QRS Absent
Ventricular Rhythms
Causes of Pulseless Electrical Activity (MATCHx4ED)
Myocardial infarction (massive acute)
Acidosis
Tension pneumothorax
Cardiac tamponade
Hypovolemia (most common cause)
Hypoxia
Hyperkalemia
Hypothermia
Embolus (massive pulmonary)
Drug overdoses (cyclic antidepressants, calcium channel blockers, beta-blockers,
digitalis)
Atrioventricular Blocks
Classification of AV Blocks
Degree Partial First-degree AV block
of block (incomplete) Second-degree AV block type I
blocks Second-degree AV block type II
Second-degree AV block 2:1 conduction
Third-degree AV block
Complete block
First-degree AV block
Site of AV node Second-degree AV block type I
block Third-degree AV block
QRS
Atrioventricular Blocks
Second-Degree AV Block, Type II (Mobitz)
Rate Atrial rate is greater than the ventricular rate.
Ventricular rate is often slow.
Rhythm Atrial regular (P’s plot through)
Ventricular irregular.
P waves Normal in size and shape. Some P waves are not followed by
a QRS complex (more P’s than QRS’s).
Within normal limits or prolonged but always constant for the
PR interval conducted beats. There may be some shortening of the PRI
that follows a nonconducted P wave.
Usually 0.10 second or greater, periodically absent after P
waves.
QRS
Atrioventricular Blocks
Second-Degree AV Block, 2:1 Conduction
Rate Atrial rate is greater than the ventricular rate.
Atrial regular (P’s plot through)
Rhythm Ventricular regular.
P waves Normal in size and shape; every other P wave is followed by a
QRS complex (more P’s than QRS’s)
Constant
PR interval Within normal limits if the block occurs above the bundle of
QRS His (probably type I); wide if the block occurs at or below
the bundle of His (probably type II); absent after every other
P wave.
Atrioventricular Blocks
Complete (Third-Degree) AV Block
Rate Atrial rate is greater than the ventricular rate. The ventricular
rate is determined by the origin of the escape rhythm.
Atrial regular (P’s plot through). Ventricular regular. There is
Rhythm no relationship between the atrial and ventricular rhythm.
Normal in size and shape.
None – the atria and ventricles beat independently of each
P waves other, thus there is no true PR interval.
PR interval Narrow or broad depending on the location of the escape
pacemaker and the condition of the intraventricular
QRS conduction system.
Narrow = junctional pacemaker; wide = ventricular
pacemaker.
Atrioventricular Blocks
Classification of AV Blocks
Second-Degree AV Block Second-Degree AV Block
Type I Type II
Ventricular Rhythm
PR Interval Irregular Irregular
QRS Width Lengthening Constant
Usually narrow Usually wide