ELECTRO CARDIOGRAM & DYSRYTHMIAS

ELECTRO CARDIOGRAM
ECG, or EKG [from the German Elektrokardiogramm]) is a transthoracic interpretation of the electrical activity of the heart over time captured and externally recorded by skin electrodes. It is a noninvasive recording produced by an electrocardiographic device.

ECG Grid
ECG Grid Left to Right = Time/duration Vertical measure of voltage (amplitude) Expressed in mm

Waveforms and Intervals

P-Wave
Depolarization of atrial muscle Low voltage - 2-3mm in amplitude Duration < 0.11 seconds ( 2 to 2.5 small squares)

PR interval
Duration is 0.12 to 0.20 s (3 - 5 small squares) . Time taken for the excitation to spread from the SA node through the atrium and AV node down the bundle of HIS to the ventricular muscle.

QRS Complex
Depolarization of ventricles which has larger muscle mass. Amplitude as high as 25mm. Duration with Normal Conduction < 0.12 ( 3 small squares). J point is where the S wave (or whatever the last wave in the QRS is) ends and the ST segment begins.

QRS Complex

ST Segment
Time between completion of depolarization and onset of repolarization Normally isoelectric & gently blends into upslope of T wave Point where ST takes off from QRS= J point Plays important role in diagnosis of ischemic heart disease

T - Wave
Repolarization of the ventricles. Tall tented T waves could represent hyperkalaemia. T wave inversion can represent coronary ischaemia, previous infarction or electrolyte abnormality such as hypokalaemia.

QT Interval
Beginning of QRS to end of T Wave. Normal variations with HR and gender Abnormalities. Prolonged commonly from drugs like Procaine or Quinidine or electrolyte imbalance. Increased opportunity for R on T, ventricular re-entry rhythms and sudden death,

Einthoven triangle
Pioneered by Willam Einthoven Machine that was sensitive enough to reliably measure electrical differences between two different parts of the body

Standard limb lead

3 Bipolar limb leadsI, II, III Positive electrode is towards the heart Left foot always positive Right arm is always negative

Augmented limb leads

3 augmented unipolar limb leads- aVR, aVL, aVF

Chest Lead Placement

V1 Right sternal border in 4th ICS. V2 Left sternal border in 4th ICS. V3 Midway Between V2 and V4. V4 Midclavicular line in 5th ICS. V5 Anterior Axillary line in 5th ICS. V6 Mid axillary line in 5th ICS.

Chest Leads (Unipolar)

Leads V1-V2 V3-V4 V5-V6 Ventricular Region Anteroseptal Anteroapical Anterolateral

Region of left ventricle represented in ECG

ECG leads Region of left ventricle

V1, V2
V3, V4

Septal
Anterior

V5, V6
V1 to V4 V3 to V6 LI , aVL LII , L III , aVF

Lateral
antero-septal Antero-lateral High lateral Inferior

Determining the Heart Rate

The more accurate method (only works for regular rhythms) 1500 Rate = No of small squares in R-R interval (1500 as there are 1500 small squares in a minute.)

What is the Heart Rate?

(1500 / 30) = 50 bpm

What is the Heart Rate?

(1500 / 20) = 75 bpm

Dysrhythmias
Dysrhythmias are disorders of the formation or conduction (or both) of the electrical impulse within the heart. These disorders can cause disturbances of the heart rate, the heart rhythm, or both.

Normal Sinus Rhythm

Characteristics of Normal Sinus Rhythm

Characteristics of Normal Sinus Rhythm

Heart rate between 60 and 100 Initiated by SA node (upright P wave before QRS complex) Impulse travels to the Atrioventricular (AV) node in 0.12 to 0.2 seconds (the PR interval) Ventricles depolarize in 0.12 sec. or less Each impulse occurs regularly and evenly spaced

CLASSIFICATION OF DYSRYTHMIAS
Atrial Dysrythmias

Junctional dysrhythmias
Atrio-ventricular dysrhythmias Ventricular dysrhythmias

Heart blocks
SADS

I. Atrial dysrhythmias
Premature Atrial Contractions (PACs) Wandering Atrial Pacemaker Multifocal atrial tachycardia Atrial flutter Atrial fibrillation (Afib)

II. Junctional arrhythmias

Supraventricular tachycardia (SVT) AV nodal reentrant tachycardia is the
most common cause of Paroxysmal Supraventricular Tachycardia (PSVT)

Junctional rhythm Junctional tachycardia Premature junctional complex

III. Atrio-ventricular arrhythmias

AV reentrant tachycardia occurs when a re-

entry circuit crosses between the atria and ventricles somewhere other than the AV node. Wolff-Parkinson-White syndrome

Lown-Ganong-Levine syndrome

 Premature Ventricular Contractions (PVC)

sometimes called Ventricular Extra Beats (VEBs)
Premature Ventricular beats occurring after every normal beat are termed ventricular bigeminy PVCs that occur at intervals of 2 normal beats to 1 PVC are termed PVCs in trigeminy Three premature ventricular grouped together is termed "A Run of PVCs", runs lasting longer than 3 beats are generally referred to as ventricular tachycardia

IV. Ventricular arrhythmias

Cont. Accelerated idioventricular rhythm Monomorphic Ventricular tachycardia Polymorphic ventricular tachycardia Ventricular fibrillation

V.
Heart blocks :-

Heart blocks

These are also known as AV blocks, because the vast majority of them arise from pathology at the atrioventricular node. They are the most common causes of bradycardia

Types of heart blocks

First degree heart block, which manifests as PR prolongation Second degree heart block Type 1 Second degree heart block, also known as Mobitz I. Type 2 Second degree heart block, also known as Mobitz II Third degree heart block, also known as complete heart block.

VI .SADS (sudden arrhythmic death

syndrome)

SADS is a term used to describe sudden death due to cardiac arrest brought on by an arrhythmia in the absence of any structural heart disease.

Sinus node dysrythmias

Sinus bradycardia Sinus tachycardia

Sinus bradycardia
Appears like normal sinus rhythm except that the rate is slower than 60 per minute Athletes

Sinus Tachycardia
normal sinus rhythm except that the rate is faster than 100 per minute.

Sinus arrhythmia
Similar to normal sinus rhythm except that it the rate is irregular Relatively common in young and is often asymptomatic

Atrial dysrythmias

Premature atrial complex

A premature atrial complex (PAC) describes a wave or set of waves caused by an atrial pacemaker that interrupts the underlying rhythm The PACs shown consist of an atrial P wave along with a normal QRS complex and a normal T wave.