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Fundamentals of Electrocardiography Part I Mary Patricia English Slides are not to be reproduced without the permission of the author The Beginning Slides are not to be reproduced without the permission of the author Basic Electrophysiology Objectives • Describe the characteristics of cardiac cells • Describe the normal sequences of electrical conduction through the heart • Explain why the SA node is the dominate pacemaker in the normal heart • State the intrinsic rate of the SA node AV junction and the Purkinje fibers Slides are not to be reproduced without the permission of the author Types of Cardiac Cells •Myocardial cells – Working or mechanical cells – Contain contractile filaments •Pacemaker cells – Specialized cells of the electrical conduction system – Responsible for the spontaneous generation and conduction of electrical impulses Slides are not to be reproduced without the permission of the author Properties of Cardiac Cells •Conductivity – Ability of a cardiac cell to receive an electrical stimulus and conduct that impulse to an adjacent cardiac cell •Contractility – Ability of cardiac cells to shorten, causing cardiac muscle contraction in response to an electrical stimulus Slides are not to be reproduced without the permission of the author The Conduction System •Conduction system – Specialized electrical (pacemaker) cells in the heart arranged in a system of pathways •Normally, the pacemaker site with the fastest firing rate controls the heart Slides are not to be reproduced without the permission of the author Sinoatrial (SA) Node • Located at the junction of the superior vena cava and the right atrium • Initiates electrical impulses at a rate of 60 to 100 beats/min • Normally the primary pacemaker of the heart Slides are not to be reproduced without the permission of the author Atria • Fibers of SA node connect directly with fibers of atria • Impulse leaves SA node and is spread from cell to cell across the atrial muscle Slides are not to be reproduced without the permission of the author Internodal Pathways • Conduction through the AV node begins before atrial depolarization is completed • Impulse is spread to AV node via internodal pathways – Pathways merge gradually with cells of AV node Slides are not to be reproduced without the permission of the author AV Junction • Area of specialized conduction tissue Slides are not to be reproduced without the permission of the author AV Node •Located in the posterior septal wall of the right atrium – Supplied by right coronary artery in most individuals •As the impulse from the atria enters the AV node, there is a delay in conduction of the impulse to the ventricles – Allows time for atria to empty contents into ventricles – Provides electrical links between atrium and ventricle Slides are not to be reproduced without the permission of the author AV Node •Divided into three functional regions according to their action potentials and responses to electrical and chemical stimulation – Atrionodal (AN) or upper junctional region Nodal (N) region Nodal-His (NH) Slides are not to be reproduced without the permission of the author AV Node • The primary delay in the passage of the electrical impulse from the atria to the ventricles occurs in the AN and N areas of the AV node Slides are not to be reproduced without the permission of the author Bundle of His •Also called the “common bundle” or the “AV bundle” •Normally the only electrical connection between the atria and the ventricles – Connects AV node with bundle branches – Has pacemaker cells capable of discharging at an intrinsic rate of 40 to 60 beats/min – Conducts impulse to right and left bundle branches Slides are not to be reproduced without the permission of the author Right & Left Bundle Branches • Right bundle branch – Innervates the right ventricle • Left bundle branch – Spreads the electrical impulse to the interventricular septum and left ventricle – Divides into three divisions (fascicles) • Anterior fascicle • Posterior fascicle • Septal fascicle Slides are not to be reproduced without the permission of the author Purkinje Fibers •Elaborate web of fibers that penetrate about 1/3 of the way into the ventricular muscle mass – Become continuous with cardiac muscle fibers •Receive impulse from bundle branches and relay it to ventricular myocardium •Intrinsic pacemaker ability of 20 to 40 beats/min Slides are not to be reproduced without the permission of the author Conduction System Activation •Sequence of Activation through the Conduction System Slides are not to be reproduced without the permission of the author Conduction Disturbances •May occur because of: – Trauma – Drug toxicity – Electrolyte disturbances – Myocardial ischemia or infarction •Conduction may be too rapid or too slow Slides are not to be reproduced without the permission of the author The ECG •The ECG is a voltmeter – Records electrical voltages (potentials) generated by depolarization of heart muscle •Electrical activity within the heart can be observed by means of electrodes connected by cables to an ECG machine Slides are not to be reproduced without the permission of the author The ECG •Can provide information about: – The orientation of the heart in the chest – Conduction disturbances – The electrical effects of medications and electrolytes – The mass of cardiac muscle – The presence of ischemic damage Slides are not to be reproduced without the permission of the author The ECG •Does not provide information about the mechanical (contractile) condition of the myocardium – Evaluated by assessment of pulse and blood pressure Slides are not to be reproduced without the permission of the author Electrodes • Disposable disk electrodes contain conductive media – Conductive media conducts the skin surface voltage change through color-coded wires to a cardiac monitor • Applied at specific locations on the patient's chest wall and extremities Slides are not to be reproduced without the permission of the author Leads •A lead is a record of electrical activity between two electrodes – Allow viewing of the heart’s electrical activity in two different planes: frontal (coronal) or horizontal (transverse) •Each lead records the average current flow at a specific time in a portion of the heart Slides are not to be reproduced without the permission of the author ECG Paper •ECG paper is graph paper made up of small and larger, heavylined squares – Smallest squares are 1 mm wide and 1 mm high – 5 small squares between the heavier black lines – 25 small squares within each large square Slides are not to be reproduced without the permission of the author Horizontal Axis = Time • Width of each small box = 0.04 second • Width of each large box (5 small boxes) = 0.20 second – 5 large boxes (each consisting of 5 small boxes) = 1 second • 15 large boxes = 3 seconds • 30 large boxes = 6 seconds Slides are not to be reproduced without the permission of the author Vertical Axis = Voltage/Amplitude •Size or amplitude of a waveform is measured in millivolts (voltage) or millimeters (amplitude) Slides are not to be reproduced without the permission of the author Waveforms •A waveform or deflection is movement away from the baseline in either a positive (upward) or negative (downward) direction – A waveform that is partly positive and partly negative is “biphasic” – A waveform or deflection that rests on the baseline is “isoelectric” Slides are not to be reproduced without the permission of the author P Wave • The first wave in the cardiac cycle • Represents atrial depolarization and spread of the electrical impulse throughout the right and left atria Slides are not to be reproduced without the permission of the author The Normal P Wave • Smooth and rounded • Usually no more than 2.5 mm in height and 0.11 second in duration • Positive in leads I, II, aVF, and V2 through V6 • May be positive, negative, or biphasic in leads III, aVL, and V1 Slides are not to be reproduced without the permission of the author Abnormal P waves • May be notched, tall and pointed (peaked), or inverted (negative) • May be seen in conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), or valvular disease Slides are not to be reproduced without the permission of the author Terminology •Waveform – Movement away from the baseline in either a positive or negative direction •Segment – A line between waveforms – Named by the waveform that precedes or follows it •Interval – A waveform and a segment •Complex – Several waveforms Slides are not to be reproduced without the permission of the author PR Segment •Part of the PR interval – Horizontal line between the end of the P wave and the beginning of the QRS complex •Normally isoelectric (flat) – Used as a baseline from which to evaluate ST segment elevation or depression Slides are not to be reproduced without the permission of the author PR Interval • The P wave plus the PR segment equals the PR interval • Begins with the onset of the P wave and ends with the onset of the QRS complex • Normally measures 0.12 to 0.20 second Slides are not to be reproduced without the permission of the author PR Interval • Reflects: – Depolarization of the right and left atria (P wave) – Spread of the impulse through the AV node, bundle of His, right and left bundle branches, and Purkinje fibers (PR segment) Slides are not to be reproduced without the permission of the author Abnormal PR Interval •Long PR interval (greater than 0.20 sec) – Indicates the impulse was delayed as it passed through the atria or AV junction •Short PR interval (less than 0.12 sec) – May be seen when the impulse originates in the atria close to the AV node or in the AV junction Slides are not to be reproduced without the permission of the author QRS Complex • A QRS complex normally follows each P wave • Consists of Q wave, R wave, and S wave • Represents the spread of electrical impulse through the ventricles (ventricular depolarization) Slides are not to be reproduced without the permission of the author Q Wave •The first negative, or downward, deflection following the P wave •Always a negative waveform •Represents depolarization of the interventricular septum Slides are not to be reproduced without the permission of the author Q Wave • Physiological Q waves – A normal Q wave is less than 25% of the amplitude of the R wave – Normal Q wave duration does not exceed 0.04 second • Pathological Q waves – More than 0.04 second in duration – More than 25% of the amplitude of the following R wave in that lead Slides are not to be reproduced without the permission of the author R Wave •The first positive, or upward, deflection following the P wave • Always positive Slides are not to be reproduced without the permission of the author S Wave • A negative waveform following the R wave • Always negative • R and S waves represent simultaneous depolarization of the right and left ventricles Slides are not to be reproduced without the permission of the author QRS Measurement •The width of a QRS complex is most accurately determined when it is viewed and measured in more than one lead – Measure the QRS complex with the longest duration and clearest onset and end •Normal QRS duration in an adult varies between 0.06 and 0.10 second Slides are not to be reproduced without the permission of the author ST Segment • The portion of the ECG tracing between the QRS complex and the T wave Represents the early part of repolarization of the right and left ventricles Slides are not to be reproduced without the permission of the author ST Segment •The point at which the QRS complex and the ST segment meet = “J point” or junction •Normally isoelectric (flat) in the limb leads Slides are not to be reproduced without the permission of the author Normal ST Segment • Begins with the end of the QRS complex and ends with the onset of the T wave • Limb leads – Normal ST segment is isoelectric (flat) – May normally be slightly elevated or depressed (usually less than 1 mm) • Precordial leads – In some precordial leads, ST segment may be normally elevated by as much as 2 to 3 mm – In the left precordial leads, ST segment elevation is not normally greater than 1 mm Slides are not to be reproduced without the permission of the author ST Segment •The PR segment used as the baseline from which to evaluate the degree of displacement of the ST segment from the isoelectric line (elevation or depression) – Measure at a point 0.04 second (one small box) after the end of the QRS complex (J point) Slides are not to be reproduced without the permission of the author ST Segment •The ST segment is considered: – “Elevated” if the segment deviates above the baseline of the segment – “Depressed” if the segment deviates below it Slides are not to be reproduced without the permission of the author PR Abnormal ST Segment •ST segment depression of more than 1 mm is suggestive of myocardial ischemia •ST segment elevation of more than 1 mm is suggestive of myocardial injury – Pericarditis causes ST-segment elevation in virtually all leads Slides are not to be reproduced without the permission of the author Abnormal ST Segment •A horizontal ST segment (forms a sharp angle with the T wave) is suggestive of ischemia •Digitalis causes a depression (scoop) of the ST segment – “Dig dip” Slides are not to be reproduced without the permission of the author T Wave •Represents ventricular repolarization – The beginning of the T wave is identified as the point where the slope of the ST segment appears to become abruptly or gradually steeper – The T wave ends when it returns to the baseline Slides are not to be reproduced without the permission of the author Abnormal T Waves •The T wave following an abnormal QRS complex is usually opposite in the direction of the QRS •Negative T waves suggest myocardial ischemia Slides are not to be reproduced without the permission of the author Abnormal T Waves •Tall, pointed (peaked) T waves are commonly seen in hyperkalemia •Significant cerebral disease (e.g., subarachnoid hemorrhage) may be associated with deeply inverted T waves – “Cerebral T waves” Slides are not to be reproduced without the permission of the author QT Interval •Measured from the beginning of the QRS complex to end of the T wave – In the absence of a Q wave, measure the QT interval from the beginning of the R wave to the end of the T wave Slides are not to be reproduced without the permission of the author U Wave •Significance is not definitely known – Thought to represent repolarization of Purkinje fibers •Not easily identified due to its low amplitude Slides are not to be reproduced without the permission of the author U Wave - Normal Characteristics • Usually less than 2 mm in amplitude • In general, a U wave of more than 1.5 mm in height in any lead is considered abnormal • Rounded and symmetrical Slides are not to be reproduced without the permission of the author Review Slides are not to be reproduced without the permission of the author Causes of Artifact • Loose electrodes • Broken ECG cables or broken wires • Muscle tremor • Patient movement • External chest compressions • 60-cycle interference Slides are not to be reproduced without the permission of the author Artifact – Loose Electrodes Slides are not to be reproduced without the permission of the author Artifact – Muscle Tremor Slides are not to be reproduced without the permission of the author Artifact – 60-cycle Interference Slides are not to be reproduced without the permission of the author Rate Measurement Slides are not to be reproduced without the permission of the author Six-Second Method • Ventricular rate – Count the number of complete QRS complexes within a period of 6 seconds – Multiply that number by 10 to determine the number of QRS complexes in 1 minute • May be used for regular and irregular rhythms Slides are not to be reproduced without the permission of the author Large Box Method •Count the number of large boxes between the consecutive R waves and divide into 300 Slides are not to be reproduced without the permission of the author Sequence Method •Select an R wave that falls on a dark vertical line – Number the next 6 consecutive dark vertical lines as follows: • 300, 150, 100, 75, 60, and 50 – Note where the next R wave falls in relation to the 6 dark vertical lines already marked—this is the heart rate Slides are not to be reproduced without the permission of the author Analyzing a Rhythm Strip •Assess the Rate •Assess Rhythm/Regularity •Identify & Examine P Waves •PR Interval (PRI) Slides are not to be reproduced without the permission of the author PR Interval (PRI) • Measured from the point where the P wave leaves the baseline to the beginning of the QRS complex • Normal PR interval is 0.12 to 0.20 second • If the PR intervals are the same, they are said to be constant • If the PR intervals are different, is there a pattern? – Lengthening – Variable (no pattern) Slides are not to be reproduced without the permission of the author Assess the Rate •What is the rate? – Determine ventricular rate (R-R intervals) – Determine atrial rate (P-P intervals) •A “tachycardia” exists if the rate is greater than 100 bpm •A “bradycardia” exists if the rate is less than 60 bpm Slides are not to be reproduced without the permission of the author Assess Rhythm/Regularity •Ventricular rhythm – Measure the distance between two consecutive R-R intervals – Compare with other R-R intervals •Atrial rhythm – Measure the distance between two consecutive P-P intervals – Compare with other P-P intervals • When analyzing a rhythm strip, determine: – Atrial (P-P intervals) rhythm – Ventricular (R-R intervals) rhythm Slides are not to be reproduced without the permission of the author Identify & Examine P Waves •Look to the left of each QRS complex •Normally: – One P wave precedes each QRS complex – P waves occur regularly and appear similar in size, shape, position Slides are not to be reproduced without the permission of the author and PR Interval (PRI) • Measured from the point where the P wave leaves the baseline to the beginning of the QRS complex • Normal PR interval is 0.12 to 0.20 second • If the PR intervals are the same, they are said to be constant • If the PR intervals are different, is there a pattern? – Lengthening – Variable (no pattern) Slides are not to be reproduced without the permission of the author QRS Complex •Identify the QRS complexes and measure their duration – Narrow (normal) if it measures 0.10 second or less – Wide if it measures more than 0.10 second Slides are not to be reproduced without the permission of the author QT Interval •Measure in the leads that show the largest amplitude T waves – Measured from the beginning of the QRS complex to end of the T wave – If the measured QT interval is less than half the R-R interval, it is probably normal Slides are not to be reproduced without the permission of the author ST Segment •Usually isoelectric in the limb leads •To determine ST segment elevation or depression, measure at a point 0.04 second (one small box) after the end of the QRS complex – Use the PR segment as the baseline Slides are not to be reproduced without the permission of the author T Waves • Are the T waves upright and of normal height • The T wave following an abnormal QRS complex is usually opposite in direction of the QRS • Negative T waves suggest myocardial ischemia • Tall, pointed (peaked) T waves are commonly seen in hyperkalemia Slides are not to be reproduced without the permission of the author Questions? Slides are not to be reproduced without the permission of the author