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ALFREDO P.

YAMBAO I, RN, MAN (C)


ASSISTANT PROFESSOR 2
OLIVAREZ COLLEGE

NORNAL ECG

Physiology of the Heart


TWO ACTIVITIES
MECHANICAL
ELECTICAL

ACTION
POTENTIAL

HOW DOES AN
ELECTRICAL
IMPULSE MAKE
OUR HEART
BEAT?

ONCE A MUSCLE CELL HAS


RECEIVED AN IMPULSE LARGE
ENOUGH TO STIMULATE CELLULAR
DEPOLARIZATION, THE CELL
MEMBRANE BECOMES PERMEABLY
TO SODIUM AND CALCIUM.THIS IS
KNOWN AS PHASE O.
AS Na AND Ca DIFFUSE IN THE CELL,
THE INTERNAL ENVIRONMENT
BECOMES MORE POSITIVE.

THIS STIMULATE THE SARCOPLASMIC


RETICULUM TO RELEASE MORE Ca.
THIS STIMULATE THE MITOCHONDRIA
TO RELEASE ATP.
ATP AND Ca THEN JOIN THE BONDS
IN THE MYOFIBRILS, BETWEEN
MYOSIN AND ACTIN CAUSING
CONTRACTION OF THE MUSCLE.
IN THE HEART, WE CALL THIS GROSS
MUSCLE CONTRACTION, SYSTOLE

DURING STAGE 3 OF THE ACTI


SARCOPLASMIC RETICULUMON
POTENTIAL ASLSO KNOWN RAPID
DEPOLARIZATION, THE Ca CHANNELS
CLOSE BLOCKING Ca FROM ENTERING
THE CELL AND Na IS REMOVE FROM
THE CELL. THE CELL NOW BECOME
NEGATIVE AGAIN. THIS CAUSE
SARCOPLASMIC RETICULUM TO STOP
RELEASING CALCIUM AND
MITOCHONDRIA SLOW DOWN THE
RELEASE OF ATP.

WITHOUT Ca AND ATP THERE IS A


HUGE REDUCTION IN THE AMOUNT OF
BONDS BETWEEN MYOSIN AND ACTIN.
THIS HAS END RESULT OF RELAXING
THE MYOFIBRILS BACK TO THE
MISSING STATE, THEREFORE
RELAXING THE CELL AND MUSCLE
TISSUE. IN THE HEART, WE CALL THIS
MECHANISM DIASTOLE.

THE ACTION POTENTIAL IN SUMMARY

CELL

CELL
MEMBRANE

PHASE O RAPID DEPOLARIZATION

Na
Ca

PHASE 1 EARLY REPOLARIZATION

Na

Na CHANNEL CLOSE

PHASE 2 PLATEU PHASE


Ca CONTINUES TO FLOW; K GOES OUT

PHASE 3 RAPID REPOLARIZATION


Ca CHANNEL CLOSE
K FLOWS OUT RAPIDLY
ACTIVE TRANSPORT VIA Na K PUMP
BEGINS RESTORING K TO THE INSIDE OF THE CELL AND Na TO THE
OUTSIDE

Ca
K
Ca
K
Na K Pump
Na

PHASE 4 RESTING PHASE


CELL MEMBRANE IS IMPERMEABLE TO Na
K MOVES OUT OF THE CELL

Na
K

Physiologic Characteristics of
the cardiac muscle
AUTOMATICITY- ABILITY TO
INITIATE AN ELECTRICAL IMPULSE

Physiologic Characteristics of
the cardiac muscle
AUTOMATICITY- ABILITY TO
INITIATE AN ELECTRICAL IMPULSE

EXCITABILITY- ABILITY TO
RESPOND TO AN ELECTRICAL
IMPULSE

Physiologic Characteristics of
the cardiac muscle
AUTOMATICITY- ABILITY TO
INITIATE AN ELECTRICAL IMPULSE
EXCITABILITY- ABILITY TO RESPOND
TO AN ELECTRICAL IMPULSE

CONDUCTIVITY- ABILITY TO
TRANSMIT AN ELECTRICAL IMPULSE
FROM ONE CELL TO ANOTHER

Physiologic Characteristics of
the cardiac muscle
AUTOMATICITY- ABILITY TO INITIATE AN
ELECTRICAL IMPULSE
EXCITABILITY- ABILITY TO RESPOND TO
AN ELECTRICAL IMPULSE

CONDUCTIVITY- ABILITY TO TRANSMIT


AN ELECTRICAL IMPULSE
FROM ONE CELL TO ANOTHER

REFRACTORINESS ABILITY OF THE


HEART TO RESIST ANOTHER IMPULSE

SA

AV

SA

AV

SA

AV

BUNDLE OF HIS

SA

AV

BUNDLE OF HIS

RBB

LBB

SA

AV

BUNDLE OF HIS
RBB

LBB

PURKINJE FIBERS

TYPES OF ECG MACHINE


SINGLE CHANNEL

MULTI CHANNEL

TYPES OF ECG MACHINE


SINGLE CHANNEL

MULTI CHANNEL

12 lead ECG
6 chest leads ( V1-V6 )
3 limb leads unipolar ( AVF,AVL, AVF )
3 limb leads bipolar ( I, II, III )

V1 4th intercoastal space, rightsternal boarder

V2 4th intercoastal space , left sternal boarder

V3 inbetween V2 and V4

V4 5th intercoastal space left mid-clavicular line

V5 mid-axillary line

V6 mid-axillary line

P WAVE

P WAVE
Is the first component of a
normal ECG

P WAVE
Is the first component of a
normal ECG
Denotes electrical activity in atria

P WAVE
Is the first component of a normal
ECG
Denotes electrical activity in atria
represents atrial depolarization
which initiates atrial contraction

P WAVE
Is the first component of a
normal ECG
Denotes electrical activity in atria
represents atrial depolarization
which initiates atrial contraction
Is small rounded

P WAVE AMPLITUDE

Normal is 1.5 3mm. If P


waves are higher than
5mm, it is an indication of
right atrial hyperthrophy,
also known as ppulmonale.

P WAVE DURATION

Normal is 0.06+ / - 0.02


seconds. A p wave which is
prolonged, and frequently
notched may indicate atrial
hyperthrophy or pmitrale.

PR
INTERVAL

PR INTERVAL

PR INTERVAL
This represents activity from the
beginning of atrial depolarization to
the beginning of venticular
depolarization which initiates
ventricular contraction.

PR INTERVAL
This represents activity from the
beginning of atrial depolarization to
the beginning of venticular
depolarization which initiates
ventricular contraction.
Located from the beginning of P
wave to the beginning of QRS

PR INTERVAL
Varies with age and heart rate. As the
persons ages, their heart rate decreases
and the PR interval subsequently
lengthens. The limit that you look for is:

< 3 years
3-16 years
>16 years

0.08 seconds
0.10 seconds
0.12 seconds

QRS
COMPLEX

QRS
COMPLEX

QRS COMPLEX
represents ventricular depolarization
follows the PR interval
consists of 3 waves
1. q wave 1st negative deflection
2. r wave the positive deflection
3. s wave negative deflection after r wave
NB: do NOT always see all 3 waves
Can deflect either way depending on lead

The average durations are


as follows:
Premature infants
Full term infants
1 to 3 years
> 3 years
Adults

0.04 seconds
0.05 seconds
0.06 seconds
0.07 seconds
< 0.08 seconds

When the QRS duration is greater than the higher limit


for a particular hypertrophy.

QRS AMPLITUDE
Amplitude is the most important criteria
for the diagnosis for ventricular
hypertrophy.
Q WAVE
The average Q wave duration is
0.02 seconds and does not
normally exceed 0.03 seconds.

Measurements of QRS duration

ST SEGMENT

ST SEGMENT

ST SEGMENT
REPRESENTS THE END OF
VENTRICULAR DEPOLARIZATION
AND THE BEGINNING OF
VENTRICULAR REPOLAZATION

ST SEGMENT
REPRESENTS THE END OF
VENTRICULAR DEPOLARIZATION
AND THE BEGINNING OF
VENTRICULAR REPOLAZATION
EXTENDS FROM THE S WAVE TO
THE BEGINNING OF THE T WAVE

ST SEGMENT
REPRESENTS THE END OF
VENTRICULAR DEPOLARIZATION
AND THE BEGINNING OF
VENTRICULAR REPOLARIZATION
EXTENDS FROM THE S WAVE TO THE
BEGINNING OF THE T WAVE
ISOELECTRIC- DEFLECTION ONLY
SLIGTHLY 0.1 mV

T WAVE

T WAVE

T WAVE
REPRESENTS VENTRICULAR
REPOLARIZATION

T WAVE
REPRESENTS VENTRICULAR
REPOLARIZATION
FOLLOWS THE S WAVE

T WAVE
REPRESENTS VENTRICULAR
REPOLARIZATION
FOLLOWS THE S WAVE
TYPICALLY ROUNDED AND SMOOTH

T WAVE
REPRESENTS VENTRICULAR
REPOLARIZATION
FOLLOWS THE S WAVE
TYPICALLY ROUNDED AND SMOOTH
NB: CELLS MOST VULMERABLE TO
STIMULI AT THIS TIME

QT
INTERVAL

QT INTERVAL
VARIES WITH HEART RATE, BUT NOT AGE,
EXECPT IN THE INFANCY.QT MUST BE
THEREFOREMEASURED IN RELATION TO
THE HEART RATE. TO MEASURE THIS YOU
MAY USE; A COMMERCIALLY PRODUCED
RULER, TABLES OF AVERAGES OR
BAZETTS RULE.

BAZETTS RULE : QT MEASUREMENT


THE SQUARE ROOT OR THE PR I

ECG
PAPER

ECG PAPER
TO MEASURE THE DURATION

ECG PAPER
TO MEASURE THE DURATION
1 SMALL BOX = 0.04 SEC.

ECG PAPER
TO MEASURE THE DURATION
1 SMALL BOX = 0.04 SEC.
1 LARGE BOX= 0.20 SEC.

ECG PAPER
MEASURE THE DURATION
MEASURE THE AMPLITUDE

ECG
AMPLITUDE
1 SMALL BOX=1MM
1 LARGE BOX= 5MM

CARDIAC RATE
6 SECONDS STRIP

CARDIAC RATE
6 SECONDS STRIP
WHEN THE RHYTHM IS IRREGULAR,
CARDIAC RATE CAN BE DETERMINED BY
COUNTING THE R WAVES IN A 6 SECONDS
STRIP AND MULTIFLY IT BY 10 FRO THE
VENTRICULAR RATE.
FOR THE ATRIAL RATE COUNT THE

P WAVE.

6 SECONDS STRIP
6 X 10 = 60 BEATS PER MINUTE

TRIPLICATE

300,

TRIPLICATE

300, 150

TRIPLICATE

300,150, 100

TRIPLICATE

300,150, 100
75,

TRIPLICATE

300,150, 100
75, 60

TRIPLICATE

300,150, 100
75, 60,50

TRIPLICATE

___,150, 100
75, 60, 50

TRIPLICATE

___,___, 100
75, 60, 50

TRIPLICATE

___,___, ___
75, 60, 50

TRIPLICATE

___,___, ___
___, 60, 50

TRIPLICATE

___,___, ___
___, __, 50

TRIPLICATE

___,___, ___
___, ___, ___

COMPUTING THE CR
LOOK FOR THE R WAVE THAT
FALLS ON A HEAVY DARK
LINE AND LOK FOR THE
FOLLOWING R WAVE AND
APPLY THE TRIPLICATE
VALUE ON THE LINE IN
BETWEEN THE TWO R WAVE.

COMPUTATION USING
LARGE BOX

LOOK FOR TWO R


WAVE OR P WAVE
AND COUNT THE
NUMBER OF LARGE
BOX AND DIVIDE IT BY
300

COMPUTATION USING
SMALL BOX

LOOK FOR TWO R


WAVE OR P WAVE
AND COUNT THE
NUMBER OF SMALL
BOX AND DIVIDE IT BY
1500

LEVEL

INHERENT RATE

ATRIA
60-80/ Min.
AV JUNCTION 40-60/ Min>

LEVEL

INHERENT RATE

ATRIA
60-80/ Min.
AV JUNCTION 40-60/ Min>

LEVEL

INHERENT RATE

ATRIA
60-80/ Min.
AV JUNCTION 40-60/ Min>

LEVEL

INHERENT RATE

ATRIA

60-80/ Min.

LEVEL

INHERENT RATE

ATRIA
60-80/ Min.
AV JUNCTION 40-60/ Min>

LEVEL

INHERENT RATE

ATRIA
60-80/ Min.
AV JUNCTION 40-60/ Min.
VENTRICLES 20-40/ Min.
Pacing Rate
Of Ectopic Foci
20
40
60
80
I Ventricular I Junctional I Atrial I

INHERENT RATE

NEW BOR

2 YRS

4 YRS

6 YRS

>6 YRS

SA

11O-150

85-125

75-115

65-100

60-100

Atria

110-120

85-100

75-92

65-80

80-80

A V Junction

73-90

56-75

50-69

43-60

40-60

Ventricles

37-60

29-50

25-38

22-40

20-40