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Basic Electrocardiography
A diagnostic exam to help in the diagnosis and management
primarily of cardiac conditions (others: renal, brain abn)
Cardiac cells:
o electrically polarized at resting state
o mainly negatively charged inside, positively charged outside
o charge: -90 millivolts
Depolarization:
o Fundamental electrical event of the heart
o Lose their internal negativity
o What happens is positive ions go inside the cell, and then it will
depolarize the rest of the cardiac cells, cardiac cells lose their
internal negativity, it will proceed to transfer to another cell until
everything is depolarized
Repolarization
o Restoration of polarity (opposite the direction of depolarization)
o Return of negative charge inside the cell
o Last one to be depolarized is the first one to repolarized
Sinus node
o Main pacemaker of the heart
o 60-100bpm (fastest pacemaker)
o Influenced by the ANS (Sympa=HR;
Vagal=HR)
o Main blood supply: left coronary system
and right coronary system
Atrioventricular node
o 40-60 bpm
o Influenced by ANS
o Main blood supply: right coronary artery and left circumflex
artery
Myocardial cells
o Contains abundant contractile proteins actin and myosin
o Contractile unit of the heart
o Current is spread slowly across the entire myocardium causing
the heart to beat at 30-45bpm
o Ventricular pacemaker
ECG leads
Limb leads
o Bipolar leads
Page 1 of 10
Red (R): R UE
Yellow (L): L UE
Green (F): L foot
Black (N): just a ground
Placement:
o
o
o
Precordial leads
ECG READING
Standardization
Regularity
Rhythm
Rate
Axis
Intervals
STANDARDIZATION:
ECG paper:
o 1 big square = 5 small square
o Big square: 0.2 sec and
0.5mV
o Small square: 0.04 sec and
0.1mV
o Should cover 10mm
o Duration express in seconds
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ECG tracing
o P wave: atrial depolarization
o QRS wave: ventricular depolarization, atrial repolarization
REGULARITY
Normal: 60-100bpm
1
2
3
4
5
large
large
large
large
large
AXIS
INTERVALS
V6 (-) deflection
o Depolarization of the rest of ventricle, dominated by left ventricle
Movement from V1 to V6
LV depolarization
o S wave
smaller
o V3 and V4: transition zone (equal + and equal deflections)
ST segment
o End of S and beginning of T wave
o Measures the time of the end of the ventricular depolarization to
the start of ventricular repolarization
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J point
o Junction of S wave and beginning of ST segment
o Should be at the level of the PR segment
o Basis of ST elevation or depression
T wave
o ventricular repolarization
Sinus arrhythmia
o Normal in all respects except
that it is slightly irregular
Inspiration: accelerates HR
Expiration: slows HR
Sinus bradycardia
o Heart rate: <60
o May be normal in athlete, seen in inferior wall MI, drug induced
(B-blockers, Ca channels)
Sinus tachycardia
o Heart rate >100
o Causes: infection, anemia, HF, hyperthyroidism
Sinus arrest/pause
o Failure of the sinus node to fire
o PP interval during the pause
>2secs
o Sinus rhythm resumes at a PP
interval that is not a multiple of the basic sinus PP interval
Intermittent absence of P
wave
Type II (Mobitz)
QTc interval
o Tachycardial: falsely short QT interval
o Bradycardia: falsely long QT interval
o Bazetts formula:
Cardiac cycle
ATRIAL RHYTHMS
Narrow QRS; usually supraventricular
Sinus rhythm
o Normal P
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Premature atrial
depolarization
o Atrial premature beat originated at an atrial site distant from the
sinus node
o Occurs before the
next anticipated sinus
wave
o Normal looking QRS
wave
o May be followed by a pause
Atrial tachycardia
o P wave is different from sinus node
o 3 or more beats in succession at an
atrial rate of 100-180bpm
o QRS complex resembles normal QRS
during sinus rhythm
o PR interval may be normal or
prolonged
o May see in V1
o Form of atrial flutter
Multifocal atrial tachycardia
o Atrial rate > 100bpm
o P wave with >/= 3 morphologies with distinct isoelectric baseline
o Varying PR, RR, RP interval
Supraventricular tachyardia
o No identifiable P waves, often buried in
the QRS
o Narrow QRS
o Regular rhythm
o 150-250bpm
o May be paroxysmal (PSVT)
o Seen:
Normal hearts
Atrial fibrillation
o Different circuits are occurring in the atria, some can produce
ventricular response
o No Identifiable P waves (fibrillation waves)
o Irregularly irregular ventricular rhythm
o Heart rate: HR = # of R waves in 6 secs x 10
Hyperthyroidism
o Treatment: rate control or rhythm control digoxin, B blockers,
amiodarone
Atrial flutter
o Circuit in : Sinus node, tricuspid area, IVC (clockwise or
counterclockwise)
o P waves rate: 250-350 bpm
o Rapid regular atrial undulations (flutter waves)
Saw-toothed appearance
AV JUNCTIONAL RHYTHMS
Area of AV node
QRS in between supraventricular and ventricular
0.10-0.12 sec
AV junctional premature
complex
o Premature QRS complex
may be narrow
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o
o
Inverted P waves leads II, III, aVF and upright P waves in leads I
and aVL commonly seen
P wave may precede the QRS by less than 0.12 seconds or may
be buried in QRS
AV junctional Rhythm
o Depolarization
originates from the
AV node
o No P wave or
presence of inverted
P wave
o HR: <60bpm
o QRS usually narrow
Wide QRS
1 PVD : 1
sinus beat Bigeminy
0: none
1b:= >1/min
2: > 30/hr
VENTRICULAR RHYTHMS
Ventricular tachycardia
o Run of three or more consecutive PVDs
o HR: 120-200bpm
o Regular
o Monomorphic or polymorphic
o Seen in MI, electrolyte abnormalities, myocarditis
o Management:
AV dissociation
Fusion beats
Capture beats
QRS concordance
Monomorphic ventricular VT
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Polymorphic VT
VT preceded by prolonged
QT interval
o Prolonged QT caused by:
congenital, electrolyte
abnormalites
(hypoK,Ca,Mg)
Idioventricular Rhythm
o Regular ventricular
rhythm
o QRS morphology
similar to PVD
o Rate: < 60bpm
o slow VT
o Accelerated idioventricular rhythm
Rate 60 -100
Ventricular fibrillation
o No true QRS complexes,
ECG tracing appears
coarse or fine
o Chaotic and irregular
deflections of varying
amplitude and contour
o Preterminal event
o Tx: defibrillation
o
o
Asystole
Flat line
Check first if leads are properly placed
AV CONDUCTION ABNORMALITIES
ARREST RHYTHMS
Pulseless electrical activity (PEA) or electromechanical dissociation
(EMD)
See QRS but no pulse
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o
o
Example of AV dissociation
Causes: Degenerative, complication of MI
ACCESSORY PATHWAY
Wolff-Parkinson-White pattern
(WPW)
o Normal P wave
o PR interval <0.12 sec
o Initial slurring of the QRS (delta
wave) resulting in wide QRS
(>0.10 sec)
o Secondary ST- T wave changes
o Accessory pathway: Bundle of
Kent
o When stimulus comes from sinus
AV node accessory pathway
o
o
Lown-Ganong-Levine
o Normal P wave
o PR interval <0.12 sec
o No delta wave
o Accessory pathway: James bundle
o
o
Conduction blocks
o Bundle Branch Block (BBB)
Present in
2% healthy adults
R ventricular hypertrophy
Post wall MI
Complete
T wave inversion
LBBB
Obstruction in the conduction through the L bundle
QRS changes in Lead I, aVL, V5 and V6: marked prolongation in
the rise of the R waves which will be either broad or notched
(RSR pattern)
Bifascicular block
o RSR in V1 (RBBB)
o LAD (LAHB)
o RBBB cannot explain LAD
Trifascicular block
o RSR in V1 (RBBB)
o LAD (LAHB)
o 1st degree AV block
>24 mm in male
>20 mm in female
Non-voltage criteria for LVH
LAD
Causes:
HPN
CAD
LA enlargement
o Amplitude of the terminal component of the P wave may be
increase in V1
o Increase duration of P wave in inferior leads (>/= 0.12 secs)
o May produce P mitrale (often caused by mitral valve disease)
o parang M shape sya
RV hypertrophy
o RAD
o R/S ration in V1 > 1
o R/S ration in V5 or V6 </=1
o R wave in V1 is >/= 7mm
o Normal: R biggest in V5 & V6, S biggest in V1
o Seen in
Pulmonary disease
Dextroposition
LV hypertrophy
o LAD
o Sokolows criteria: S wave in V1 + R wave In V6 >/=35mm
REPOLARIZATION ABNORMALITY
Pericardial effusion
Obesity
Pleural effusion
LAD
o
LAHB
o LBBB
o LVH
RAD
o RVH
o COPD
o Pulmonary embolism
o Dextrocardia
Electrical alternans
o Alternation in amplitude and/or direction of the P, QRS & PQ
o Seen in:
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Pericardial effusion
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