electrocardiogram basic
TRANSCRIPT
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ECG
CES-1
DR.NILESH KATE.M.D.ASSOCIATE PROFESSOR,DEPARTMENT OF PHYSIOLOGY,ESIC MEDICAL COLLEGE, SEDAM ROAD, GULBARGA.
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OBJECTIVES.
ANATOMIC CONSIDERATION
MECHANISM OF ORIGIN OF RHYTHMIC CARDIAC IMPULSE
SPREAD OF CARDIAC IMPULSE
ELECTROCARDIOGRAPHY
RECORDING OF ECG
NORMAL ECG
VECTORIAL ANALYSIS OF ECG AND VECTOR CARDIOGRAPHY
CONCEPT OF LEADS (UNIPOLAR/BIPOLAR)
WAVES, SEGMENTS – DURATION & VOLTAGE.
CLINICAL APPLICATION OF ECG
CES-2
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Cardiac Anatomy
CES-3
Atrial muscle
Sinoatrial (SA)A node Left atrium
Descending aortaInferior
vena cava
Ventricluar
Pulmonary
veins
Superior
vena cava
Tricuspid valve
Mitral valve
Atrioventricular (AV) node
Purkinje
fibers
muscle
Internodal
conductingtissue
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ORIGIN AND SPREAD
OF CARDIAC
IMPULSE.
CES-4
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Flow of Cardiac Electrical Activity
CES-5
SA node Atrial muscle
AV node (slow)
Purkinje fiber
conducting systemVentricular muscle
Internodal
conducting
fibers
Atrial muscle
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Conduction in the Heart
CES-6
0.12-0.2 s approx. 0.44 s
SA
Atria
Purkinje
Ventricle
node
nodeAV
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INTRINSIC CONDUCTION SYSTEM
CES-7
Function: initiate & distribute impulses so heart depolarizes & contracts in orderly manner from atria to ventricles…….
SA node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
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The ECG/EKG
Def:- Extracellular recording of the summed up
electrical events of all the cardiac muscle fibers
generated with each heart beat.
Can record a reflection of cardiac electrical activity on
the skin- EKG
The magnitude and polarity of the signal depends on
what the heart is doing electrically
○ depolarizing
○ repolarizing
○ whatever
the position and orientation of the recording electrodes
CES-8
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Electrocardiography is based on the principle of BIOELECTROMAGNETISM, a discipline that examines the electric, electromagnetic, and magnetic phenomena which arise in biological tissues.
An ECG is a representation of depolarization & Repolarization waves in the myocardium.
Genesis of the ECG
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HISTORY
WILLIAM EINTHOVEN
-- Dutch physiologist
developed techniques of
ECG
Awarded NOBEL PRIZE
in 1924
Father of modern
electrophysiology.
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ECG trace
taken by
WALLER
IN 1887
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INTRODUCTION
Electrocardiography
(ECG or EKG)
An electrical picture of
the functioning of the
heart.
Etymology:
electro- electricity
cardio[Gr.]- heart
graph[Gr.]- to write
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THE HEART
CES-13
is a pump has
electrical activity
(action potentials)
generates electrical
current that can be
measured
on the skin surface
(the EKG)
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CURRENTS AND VOLTAGES
At rest, Vm is constant
No current flowing
Inside of cell is at
constant potential
Outside of cell is at
constant potential
CES-14
++++++++++++++++++
------------------------------
A piece of cardiac muscle
outside
inside
0 mV
+-
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CURRENTS AND VOLTAGES
During AP upstroke, Vm
is NOT constant
Current IS flowing
Inside the cell is NOT
at constant potential
Outside the cell is NOT
at constant potential
CES-15
++++------------------------------++++++++++++++
A piece of cardiac muscle
outside
inside
Some positive
potential+-
current
AP
An action potential propagating
toward the positive ECG lead
produces a positive signal
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MORE CURRENTS AND
VOLTAGES
CES-16
A piece of cardiac muscle
outside
current
+-
A negative voltage reading
------++++++++++++++
inside
++++------------------------An action potential propagating
Away from the positive ECG lead
produces a negative signal
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More Currents and Voltages
CES-17
current
-------------------------------
A piece of totally depolarized
cardiac muscle
outside
inside
+++++++++++++++++++
Vm not changing
No current
No ECG signal
+++++++-------------------
A piece of cardiac muscle
outside
inside
------------+++++++++++
During Repolarization
+-Some negative potential
Repolarization spreading toward
the positive ECG lead produces
a negative response
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Electrophysiology of a Cardiac Muscle
DEPOLARISATION REPOLARISATION RESTORATION OF
IONIC BALANCE
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• When a DEPOLARISATION Wave moves
towards a positive electrode a positive signal is
generated and when it moves towards a negative
electrode a negative signal is generated.
• The reverse happens in
case of
REPOLARISATION
Waves
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The Normal EKG
CES-21
P
Q
R
S
T
Right Arm
Left Leg
QTPR
0.12-0.2 s approx. 0.44 s
Atrial muscle
depolarization
Ventricular muscle
depolarization
Ventricular
muscle
repolarization
“Lead II”
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Action Potentials in the Heart
CES-22
AV
Purkinje
Ventricle
Aortic artery
Left atrium
Descending aortaInferior
vena cava
Ventricluar
Atrial muscle
Pulmonary
veins
Superior
vena cava
Pulmonary artery
Tricuspid valve
Mitral valve
Interventricular
septum
AV node
SA node
ECG
QTPR
0.12-0.2 s approx. 0.44 s
SA
Atria
Purkinje
fibersmuscle
Specializedconducting
tissue
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ECG Graph Paper
Recording ECG
Speed of paper – 25 mm/sec
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Recording ECG
ISOELECTRIC LINE: Tracing following the T Wave & preceding the next P Wave.
HEART RATE: The frequency of:
• P Wave gives Atrial Rate &
• QRS Complex gives Ventricular Rate
Calculation of HR=
Speed of paper 25
mm/ sec
So in 1 min = 1500
mm
So HR / MIN
= 1500/ RR Interval
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THE INFORMATION CONTENT OF
THE 12-LEAD SYSTEM
Leads
Bipolar
I,II,III
Unipolar
Precordial
( Chest leads )
V1,v2 ,V3,V4,V5,V6
Augmented limb leads
aVR,aVL,aVF
Standard limb leads
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LEADS USED IN ECG
Einthoven's
assumption
body – homogenous
plate
Both shoulders &
pubic region corners
of equilateral triangle.
With heart in centre.
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Einthoven’s Triangle Hypothesis
He was awarded the Nobel
Prize in Medicine for his
work on ECG.
This Hypothesis states that if
the electrical potentials of 2
limb leads are known, the 3rd
can be determined by simply
summing up the two.
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Electrode Electrode Placement
RA On the right arm, avoiding bony
prominences.
LA Same as RA, but on the left arm this
time.
LL On the left leg, avoiding bony
prominences.
NOTE: The right leg is used as earth
to minimize interference.
Positioning of Electrodes
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Standardlimb lead
RA LA
LL
l
ll lll ll lll
l
LL
RA LA
+ +
+-
- -
RECORDING THE CARDIAC ELECTRICAL SIGNAL
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Standard bipolar limb leads
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THE INFORMATION CONTENT OF
THE 12-LEAD SYSTEM
Leads
Bipolar
I,II,III
Unipolar
Precordial
( Chest leads )
V1,v2 ,V3,V4,V5,V6
Augmented limb leads
aVR,aVL,aVF
Standard limb leads
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Position of Precordial Leads
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E.C.G. Recording of Precordial
Leads
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Augmented Unipolar Limb Leads
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Precordial Leads
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Summary of Leads
Limb Leads Precordial Leads
Bipolar I, II, III(standard limb leads)
-
Unipolar aVR, aVL, aVF (augmented limb leads)
V1-V6
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Arrangement of Leads on the EKG
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Anatomic Groups(Septum)
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Anatomic Groups(Anterior Wall)
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Anatomic Groups(Lateral Wall)
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Anatomic Groups(Inferior Wall)
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Anatomic Groups(Summary)
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CES-44
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ECG Deflection Waves
CES-45
(Pacemaker) Atrial repolarization
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ECG
P wave
CONFIGURATION –
○ Positive ( upright deflection)
CAUSE -- Atrial depolarization
DURATION -- < 0.1 sec
AMPLITUDE – 0.1- 0.12 mv
CLINICAL SIGNIFICANCE
. If the Waves are normal in
morphology & the P Wave is regularly
followed by a QRS Complex,
CES-46
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ECGs, Normal & Abnormal
No P waves
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ECGs, Abnormal
CES-48
Arrhythmia: conduction failure at AV node
No pumping action occurs
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QRS complex
QRS complex
Configuration –
○ Q wave small negative wave.
○ R wave tall positive.
○ S wave small negative wave.
Cause -- Ventricular Depolarization.
Duration --Q < 0.08 sec
Amplitude
Q – 0.1- 0.2, R wave – 1mv, S wave – 0.4 mv.
Clinical significance.
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QRS complex
< 0.10 s 0.10-0.12 s > 0.12 s
NormalIncomplete bundle
branch block
Bundle branch block
PVC
Ventricular rhythm
Remember: If you have a BBB determine if it is a right or left BBB.
3rd degree AV block
with ventricular
escape rhythmIncomplete bundle branch block
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ECG Deflection Wave Irregularities
CES-51
Enlarged
QRS =
Hypertrophy
of ventricles
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T wave
Configuration – last positive dome shaped
deflection
Cause – ventricular repolarization.
Duration – approx 0.27 sec
Amplitude – 0.3 mv
Clinical significance.
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ECG Deflection Wave Irregularities
CES-53
Elevated T wave :
Hyperkalemia
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ECG Deflection Wave Irregularities
CES-54
Flat T wave :
Hypokalemia
or ischemia
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U wave
Configuration – small round positive wave
Cause – slow repolarization of papillary muscles.
Duration – approx 0.08 sec
Amplitude – 0.2 mv
Clinical significance. – rarely seen normally
Prominent in hypokalemia.
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Axis of three bipolar and three
unipolar leads
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AXIS.
Axis refers to the mean QRS axis (or vector) during ventricular depolarization. As you recall when the ventricles depolarize (in a normal heart) the direction of current flows leftward and downward because most of the ventricular mass is in the left ventricle.
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Axis
The QRS axis is determined by overlying a circle, in the frontal plane.
By convention, the degrees of the circle are as shown.
The normal QRS axis lies between -30o and +110o.
0o
30o
-30o
60o
-60o-90o
-120o
90o120o
150o
180o
-150o
A QRS axis that falls between -30o
and -90o is abnormal and called left
axis deviation.
A QRS axis that falls between +90o
and +150o is abnormal and called
right axis deviation.
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Axis
Causes of left axis deviation include:
Left ventricular hypertrophy
Inferior wall MI
Left bundle branch block
Left anterior fascicular block
Horizontal heart
0o
-90o
90o
180o
• Causes of right axis deviation include:
– Right ventricular hypertrophy
– Lateral wall MI
– Right bundle branch block
– Pulmonary hypertension
– Vertical heart
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Intervals
It is the duration between two specific ECG
events. For example:
PQ/PR Interval
It is from the beginning of the P wave to the beginning of the QRS complex
Time duration:
0.16 second
QT Interval
It is from the beginning of the QRS complex (ventricular depolarization) to the end of the T wave (ventricular repolarization).
0.35 second
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Intervals
PR interval
< 0.12 s 0.12-0.20 s > 0.20 s
High catecholamine
states
Wolff-Parkinson-White
Normal AV nodal blocks
Wolff-Parkinson-White1st Degree AV Block
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Intervals
QT interval
The duration of the QT interval is
proportionate to the heart rate. The faster
the heart beats, the faster the ventricles
repolarize so the shorter the QT interval.
Therefore what is a “normal” QT varies
with the heart rate. For each heart rate you
need to calculate an adjusted QT interval,
called the “corrected QT” (QTc):
QTc = QT / square root of RR interval
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Intervals
QTc interval
< 0.44 s > 0.44 s
Normal Long QT
A prolonged QT can be very dangerous. It may predispose an individual to a type of
ventricular tachycardia called Torsades de Pointes. Causes include drugs, electrolyte
abnormalities, CNS disease, post-MI, and congenital heart disease.
Torsades de Pointes
Long QT
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Segments
A segment is the length between two specific points on the ECG which are supposed to be at the baseline amplitude .
ST Segment The ST segment connects the QRS complex and the T wave
TP Segment The portion of the ECG from the end of the T wave to the beginning of the P wave.
PR Segment portion of the ECG from the end of the P wave to the beginning of the QRS complex.
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ECG Deflection Waves
CES-66
60 seconds ÷ 0.8 seconds = resting heart rate of 75 beats/minute
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ECG Deflection Waves
CES-67
1st
Degree
Heart
Block =
P-Q
interval
longer
than 0.2
seconds.
60 seconds ÷ 0.8 seconds = resting heart rate of 75 beats/minute
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ECG Deflection Wave Irregularities
CES-68
Prolonged QT
Interval =
Repolarization
abnormalities
increase chances
of ventricular
arrhythmias.
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Rhythm Summary
Rate 90-95 bpm
Regularity regular
P waves normal
PR interval 0.12 s
QRS duration 0.08 s
Interpretation?
Normal Sinus Rhythm
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Normal Sinus Rhythm (NSR)
Etiology: the electrical impulse is formed in
the SA node and conducted normally.
This is the normal rhythm of the heart; other
rhythms that do not conduct via the typical
pathway are called arrhythmias.
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NSR Parameters
Rate 60 - 100 bpm
Regularity regular
P waves normal
PR interval 0.12 - 0.20 s
QRS duration 0.04 - 0.12 s
Any deviation from above is sinus tachycardia,
sinus bradycardia or an arrhythmia
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Arrhythmia Formation
Arrhythmias can arise from problems in the:
• Sinus node
• Atrial cells
• AV junction
• Ventricular cells
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SA Node Problems
The SA Node can:
fire too slow
fire too fast Sinus Bradycardia
Sinus Tachycardia
Sinus Tachycardia may be an appropriate
response to stress.
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Rhythm #1
30 bpm• Rate?
• Regularity? regular
normal
0.10 s
• P waves?
• PR interval? 0.12 s
• QRS duration?
Interpretation? Sinus Bradycardia
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Rhythm #2
130 bpm• Rate?
• Regularity? regular
normal
0.08 s
• P waves?
• PR interval? 0.16 s
• QRS duration?
Interpretation? Sinus Tachycardia
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Rhythm #3
70 bpm• Rate?
• Regularity? occasionally irreg.
2/7 different contour
0.08 s
• P waves?
• PR interval? 0.14 s (except 2/7)
• QRS duration?
Interpretation? NSR with Premature Atrial
Contractions
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Premature Atrial Contractions
Deviation from NSR
These ectopic beats originate in the atria (but not
in the SA node), therefore the contour of the P
wave, the PR interval, and the timing are different
than a normally generated pulse from the SA
node.
Etiology: Excitation of an Atrial cell forms an impulse that is
then conducted normally through the AV node and ventricles.
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AV Junctional Problems
The AV junction can:
fire continuously
due to a looping re-
entrant circuit
block impulses
coming from the SA
Node
Paroxysmal
Supraventricular
Tachycardia
AV Junctional Blocks
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Ventricular Cell Problems
Ventricular cells can:
fire occasionally from 1 or more foci
fire continuously from multiple foci
fire continuously due to a looping re-entrant circuit
Premature Ventricular
Contractions (PVCs)
Ventricular Fibrillation
Ventricular Tachycardia
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Rhythm #4
60 bpm• Rate?
• Regularity? occasionally irreg.
none for 7th QRS
0.08 s (7th wide)
• P waves?
• PR interval? 0.14 s
• QRS duration?
Interpretation? Sinus Rhythm with 1 PVC
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PVCs
Deviation from NSR
Ectopic beats originate in the ventricles resulting in wide and bizarre QRS complexes.
When there are more than 1 premature beats and look alike, they are called “uniform”. When they look different, they are called “multiform”.
Etiology: One or more ventricular cells are depolarizing and the impulses are abnormally conducting through the ventricles.
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Ventricular Conduction
NormalSignal moves rapidly
through the ventricles
AbnormalSignal moves slowly
through the ventricles
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Rhythm #5
100 bpm• Rate?
• Regularity? irregularly irregular
none
0.06 s
• P waves?
• PR interval? none
• QRS duration?
Interpretation? Atrial Fibrillation
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Atrial Fibrillation
Deviation from NSR
No organized atrial depolarization, so no normal P waves (impulses are not originating from the sinus node).
Atrial activity is chaotic (resulting in an irregularly irregular rate).
Common, affects 2-4%, up to 5-10% if > 80 years old
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Rhythm #6
70 bpm• Rate?
• Regularity? regular
flutter waves
0.06 s
• P waves?
• PR interval? none
• QRS duration?
Interpretation? Atrial Flutter
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Atrial Flutter
Deviation from NSR
No P waves. Instead flutter waves (note “sawtooth” pattern) are formed at a rate of 250 -350 bpm.
Only some impulses conduct through the AV node (usually every other impulse).
Etiology: Reentrant pathway in the right atrium with every 2nd, 3rd or 4th impulse generating a QRS (others are blocked in the AV node as the node repolarizes).
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Ventricular Arrhythmias
Ventricular Tachycardia
Ventricular Fibrillation
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Rhythm #8
160 bpm• Rate?
• Regularity? regular
none
wide (> 0.12 sec)
• P waves?
• PR interval? none
• QRS duration?
Interpretation? Ventricular Tachycardia
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Ventricular Tachycardia
Deviation from NSR
Impulse is originating in the ventricles (no P waves, wide QRS).
Etiology: There is a re-entrant pathway looping in a ventricle (most common cause).
Ventricular tachycardia can sometimes generate enough cardiac output to produce a pulse; at other times no pulse can be felt.
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Rhythm #9
none• Rate?
• Regularity? irregularly irreg.
none
wide, if recognizable
• P waves?
• PR interval? none
• QRS duration?
Interpretation? Ventricular Fibrillation
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Ventricular Fibrillation
Deviation from NSR
Completely abnormal.
Etiology: The ventricular cells are excitable and
depolarizing randomly.
Rapid drop in cardiac output and death occurs if not
quickly reversed
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AV Nodal Blocks
1st Degree AV Block
2nd Degree AV Block, Type I
2nd Degree AV Block, Type II
3rd Degree AV Block
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Rhythm #10
60 bpm• Rate?
• Regularity? regular
normal
0.08 s
• P waves?
• PR interval? 0.36 s
• QRS duration?
Interpretation? 1st Degree AV Block
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1st Degree AV Block
Deviation from NSR
PR Interval > 0.20 s
Etiology: Prolonged conduction delay in
the AV node or Bundle of His.
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Rhythm #11
50 bpm• Rate?
• Regularity? regularly irregular
nl, but 4th no QRS
0.08 s
• P waves?
• PR interval? lengthens
• QRS duration?
Interpretation? 2nd Degree AV Block, Type I
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2nd Degree AV Block, Type I
Deviation from NSR
PR interval progressively lengthens,
then the impulse is completely blocked
(P wave not followed by QRS).
Etiology: Each successive atrial impulse
encounters a longer and longer delay in the AV
node until one impulse (usually the 3rd or 4th)
fails to make it through the AV node.
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Rhythm #12
40 bpm• Rate?
• Regularity? regular
nl, 2 of 3 no QRS
0.08 s
• P waves?
• PR interval? 0.14 s
• QRS duration?
Interpretation? 2nd Degree AV Block, Type II
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2nd Degree AV Block, Type II
Deviation from NSR
Occasional P waves are completely blocked (P
wave not followed by QRS).
Etiology: Conduction is all or nothing (no prolongation of
PR interval); typically block occurs in the Bundle of His.
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Rhythm #13
40 bpm• Rate?
• Regularity? regular
no relation to QRS
wide (> 0.12 s)
• P waves?
• PR interval? none
• QRS duration?
Interpretation? 3rd Degree AV Block
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3rd Degree AV Block
Deviation from NSR
The P waves are completely blocked in the AV
junction; QRS complexes originate
independently from below the junction.
Etiology: There is complete block of conduction in the AV
junction, so the atria and ventricles form impulses
independently of each other. Without impulses from the
atria, the ventricles own intrinsic pacemaker kicks in at
around 30 - 45 beats/minute.
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Views of the Heart
Some leads get a
good view of the:
Anterior portion
of the heart
Lateral portion
of the heart
Inferior portion
of the heart
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MI -- ST Elevation
One way to
diagnose an
acute MI is to
look for
elevation of the
ST segment.
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ST Elevation (cont)
Elevation of the ST
segment (greater
than 1 small box) in
2 leads is consistent
with a myocardial
infarction.
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Other MI Locations
Now, using these 3 diagrams let’s figure where to look for a lateral wall and inferior wall MI.
Limb Leads Augmented Leads Precordial Leads
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Anterior MI
Remember the anterior portion of the heart is best
viewed using leads V1- V4.
Limb Leads Augmented Leads Precordial Leads
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Lateral MI
So what leads do you think the lateral portion of the heart is best viewed?
Limb Leads Augmented Leads Precordial Leads
Leads I, aVL, and V5- V6
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Inferior MI
Now how about the inferior portion of the heart?
Limb Leads Augmented Leads Precordial Leads
Leads II, III and aVF
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Left Ventricular Hypertrophy
Compare these two 12-lead ECGs. What stands out as
different with the second one?
Normal Left Ventricular Hypertrophy
Answer: The QRS complexes are very tall
(increased voltage)
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Left Ventricular Hypertrophy
Why is left ventricular hypertrophy characterized by tall QRS
complexes?
LVH ECHOcardiogramIncreased QRS voltage
As the heart muscle wall thickens there is an increase in
electrical forces moving through the myocardium resulting
in increased QRS voltage.
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Left Ventricular Hypertrophy
Criteria exists to diagnose LVH using a 12-lead ECG.
For example:
○ The R wave in V5 or V6 plus the S wave in V1 or V2 exceeds 35
mm.
• However, for now, all
you need to know is
that the QRS voltage
increases with LVH.
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Bundle Branch Blocks
Turning our attention to bundle branch blocks…
Remember normal
impulse conduction is
SA node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
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Normal Impulse ConductionSinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
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Bundle Branch Blocks
So, depolarization of the
Bundle Branches and
Purkinje fibers are seen
as the QRS complex on
the ECG.
Therefore, a conduction
block of the Bundle
Branches would be
reflected as a change in
the QRS complex.
Right
BBB
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Bundle Branch Blocks
With Bundle Branch Blocks you will see two changes on the
ECG.
1. QRS complex widens (> 0.12 sec).
2. QRS morphology changes (varies depending on ECG lead, and if
it is a right vs. left bundle branch block).
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Bundle Branch Blocks
Why does the QRS complex widen?
When the conduction
pathway is blocked it
will take longer for
the electrical signal
to pass throughout
the ventricles.
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Right Bundle Branch Blocks
What QRS morphology is characteristic?
V1
For RBBB the wide QRS complex assumes a
unique, virtually diagnostic shape in those
leads overlying the right ventricle (V1 and V2).
“Rabbit Ears”
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Left Bundle Branch Blocks
What QRS morphology is characteristic?
For LBBB the wide QRS complex assumes a
characteristic change in shape in those leads
opposite the left ventricle (right ventricular
leads - V1 and V2).
Broad,
deep S
wavesNormal
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CHANGES IN IONIC
COMPOSITION OF BLOOD
SODIUM –
Associated with low voltage ECG.
POTASSIUM –
Normal plasma levels 4-5.5 meq/L
HYPERKALEMIA -- > 7 meq/L TALL T WAVE
HYPOKALEMIA -- < 4.5 meq/L LOW VOLTAGE
CALCIUM –
HYPERCALCEMIA – heart stops in systole
(calcium rigor)
HYPOCALCEMIA – prolonged ST segment.
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THANK YOU
CES-119