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2)
3)
4)
5)
6)
6)
7)
Evaluate calibration
Calculate rate
Determine rhythm
Determine QRS axis
Measure intervals
Analyze the morphology and interrelation of ECG
elements (P, P-Q, Q, QRS, ST, T, QT) in frontal
and in precordial leads
OR
Asses for Hypertrophy
Look for evidence of Infarction
NSR Parameters
Rate
Regularity
P waves
PR interval
QRS duration
60 - 100 bpm
regular
normal
0.12 - 0.20 s
0.04 - 0.12 s
Arrhythmia Formation
Arrhythmias can arise from electrophysiological
abnormalities in the:
Sinus node
Atrial cells
AV junction
Ventricular cells
His Purkinje network
SA Node Problems
The SA Node can:
fire too slow (< 60 bpm)
fire too fast (>100 bpm)
Sinus Bradycardia
Sinus Tachycardia
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
30 bpm
regular
normal
0.12 s
0.10 s
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
130 bpm
regular
normal
0.16 s
0.08 s
Sinoatrial Block
Rare
The impulse from the sinus node is blocked before it
focus
fire continuously due to
a looping re-entrant
circuit
Premature Atrial
Contractions (PACs)
Atrial Flutter
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
70 bpm
occasionally irreg.
2/7 different contour
0.14 s (except 2/7)
0.08 s
Enhanced Automaticity
Enhancement of normal automacity
Development of automaticity in plain atrial or ventricular cells
Can arise when
the maximum diastolic potential becomes reduced to -50 mV
Triggered Activity
Requires the presence of an action potential
Initiated by afterdepolarizations = depolarizing oscillations
EAD
During a prolonged AP (bradicardia, hypokalemia, drugs that
DAD
Spontaneous release of Ca++ from SR during Ca++ overload
DAD
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
Interpretation?
70 bpm
regular
flutter waves
none
0.06 s
Atrial Flutter
Atrial Flutter
Re-entry
A re-entrant pathway
(re-entrant excitation
or circus movement)
Is a wave of
depolarization that
travels in an
endless circle
Occurs when an
action potential
loops and results in
self-perpetuating
impulse formation
Re entrant Excitation
Re-entry has three requirements:
Unidirectional block
Partial conduction block in which impulses travel in one
When the pathway isnt long enough, the head of the re-
SHORT PATHWAY
multiple foci
or
fire continuously due to
Atrial Fibrillation
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
Interpretation?
100 bpm
irregularly irregular
none
none
0.06 s
Atrial Fibrillation
Atrial Fibrillation
irregular rate)
Atrial Fibrillation
Mechanism:
Multiple re-entrant wavelets conducted between the right
Atrial tissue
AV Junctional Problems
The AV junction can:
fire continuously due to a
focus
block impulses coming from
the SA node
Paroxysmal Supraventricular
Tachycardia (PSVT)
Premature Junctional
Contractions
AV Junctional Blocks
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
Interpretation?
74 148 bpm
Regular regular
Normal none
0.16 s none
0.08 s
A-V Nodal Paroxysmal
Tachycardia
PSVT
Deviation from NSR
The heart rate suddenly speeds up ventricular rate 150
AV Premature Contractions
Premature contractions fired from the A-V node or the A-V
bundle
The P wave is superimposed onto the QRS-T complex (no P
AV Nodal Blocks
1st Degree AV Block
2nd Degree AV Block, Type I
2nd Degree AV Block, Type II
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
Interpretation?
60 bpm
regular
normal
0.36 s
0.08 s
1st Degree AV Block
> 0.20 s
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
Interpretation?
50 bpm
regularly irregular
nl, but 4th no QRS
lengthens
0.08 s
longer delay in the AV node until one impulse (usually the 3rd
or 4th) fails to be conducted through the AV node
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
75 bpm
regularly irregular
nl, 1 of 5 no QRS
0.14 s
0.08 s
constant)
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
Interpretation?
40 bpm
regular
no relation to QRS
none
wide (> 0.12 s)
3rd Degree AV Block
more foci
fire continuously due to a
Premature Ventricular
Contractions (PVCs)
Ventricular Tachycardia
multiple foci
Ventricular Fibrillation
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
60 bpm
occasionally irreg.
none for 7th QRS
0.14 s
0.08 s (7th wide)
PVCs
Ventricular Conduction
Normal
Signal moves rapidly through
the ventricles
Abnormal
Signal moves slowly through
the ventricles
A
When an impulse originates in a
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
160 bpm
regular
none
none
wide (> 0.12 sec)
Ventricular Tachycardia
QRS)
> 3 consecutive ventricular beats at a rate > 120 bpm
Can be regular, monomorphic or irregular, polymorphic
Results from a re-entrant pathway looping in a ventricle
Rate?
Regularity?
P waves?
PR interval?
QRS duration?
Interpretation?
none
irregularly irreg.
none
none
wide, if recognizable
Ventricular Fibrillation
Ventricular Fibrillation
quickly reversed
Electroshock Debrillation
2)
3)
4)
5)
6)
6)
7)
Evaluate calibration
Calculate rate
Determine rhythm
Determine QRS axis
Measure intervals
Analyze the ECG elements (P, P-Q, Q, QRS, ST, T,
QT) and their interrelation in frontal and in
precordial leads
OR
Asses for Hypertrophy
Look for evidence of Infarction
-90o
-120o
-60o
-30o
180o
0o
30o
120o
90
60o
High-voltage electrocardiogram in
congenital pulmonary valve stenosis with
right ventricular hypertrophy. Superior
right axis deviation and a slightly
prolonged QRS complex also are seen.
5) Calculate Intervals
Intervals refers to the length of the PR and QT intervals
0.12-0.20 s
> 0.20 s
High catecholamine
states
Wolff-Parkinson-White
Normal
AV nodal blocks
Wolff-Parkinson-White
QTc interval
< 0.44 s
> 0.44 s
Long QT
Normal
Long QT
Torsades de Pointes
QT = 0.40 s
RR = 0.68 s
Square root of
RR = 0.82
QTc = 0.40/0.82
= 0.49 s
PR interval?
0.16 seconds
Interpretation of
intervals?
QRS width?
0.08 seconds
QTc interval?
0.49 seconds
RR
23 boxes
17 boxes
10 boxes
13 boxes
QT
Normal QT
Long QT
QTc = QT/RR
Tip: Instead of calculating the QTc, a quick way to estimate if
the QT interval is long is to use the following rule:
A QT > half of the RR interval is probably long
QRS complex
< 0.10 s
Normal
0.10-0.12 s
> 0.12 s
Incomplete bundle
branch block
depolarization
3. QRS morphology changes (varies depending on ECG lead,
and if it is a right vs. left bundle branch block)
4. Intrinsecoid deflection > 0.06 for RBBB and > 0.08 for LBBB
5. T wave inversion appears
widest complex
Intrinsecoid deflection:
measures the duration of transmural activation under the
recording electrode of a precordial lead (V1, V2, V5, V6)
measured from the peak of the last R of the complex until
the onset of the QRS complex
Normal values: < 0.035 s in V1, V2 and < 0.045 s in V5, V6
QRS
ID
ID
V1
Rabbit Ears
qRS
QS
6) Hypertrophy
The ECG can reveal enlargement or hypertrophy of the four
chambers of the heart:
Right atrial enlargement (RAE)
Atrial Enlargement
P wave changes (morphology, axis, amplitude)
Due to
Inlet ventricular valve stenosis (mitral - often, tricuspid -
rare) or insufficiency
Pulmonary hypertension
Congenital heart diseases
Heart failure
Normal
Notched
Negative deflection
Ventricular Hypertrophy
Due to a pressure or volume load
ECG abnormalities
High voltage R, S waves
QRS axis deviation
Increased intrinsecoid deflection
T-wave inversions
LVH
ECHOcardiogram
There is left axis deviation and there are tall R waves in V5,
V6 and deep S waves in V1, V2
lead
The amplitude of R and S waves it is used for the
leads (I, aVL, V5, V6) and S waves in the right leads (V1, V2)
are oversized (and sometimes notched)
Sokolow-Lyon index: SV1 + (RV5 or RV6) > 3.5 mV,
RaVL > 1.1 mV
Cornell voltage criteria: SV3 + SaVL > 2.8 mV and > 2.0 mV
QRS duration > 0.11 s, ID > 0.05 s in V5, V6
QRS axis horizontal or with a left deviation
ST depression and T inversion in leads with a tall R
S = 13 mm
R = 25 mm
S in I, aVL, V5 (V6):
R in V1 > 0.7 mV, S in V5, V6 > 0.7 mV
RV1 + SV5 > 1,05 mV
ID > 0.03 s in V1,2
Right QRS axis deviation
T-wave inversions
Normal
RVH
R waves in V1, V2 from a normal ECG and from a person with RVH
The extent:
Transmural
Subendocardial
ST Elevation
Elevation of the ST
segment in at least 2
leads is consistent with a
myocardial infarction
Because blood flow is
regional, the area of
infarction are also
regional specific ECG
leads can provide the
best view of the infarcted
area
Lateral portion
of the heart
Anterior portion
of the heart
Leads I, aVL,
V5, V6
Leads V1 V4
Inferior portion
of the heart
Anterior Wall MI
Can be recognized if there are changes in leads V1 - V4
that are consistent with a myocardial infarction
Inferior Wall MI
ST segment is elevated in leads II, III and aVF
Anterolateral MI
This persons MI involves both the anterior wall (V2-V4)
and the lateral wall (V5-V6, I, and aVL)!
shortens APD
affected areas are repolarized before the rest of the
myocardium
changes of repolarization vector leading to T wave
abnormalities
ECG Changes
Ways the ECG can change include:
ST elevation &
depression
T-waves
peaked
Appearance
of pathologic
Q-waves
flattened
inverted
Non-ST Elevation
ST Elevation
ST Elevation Infarction
Diagram depicting an evolving infarction:
A. Normal ECG prior to MI
B. Ischemia from coronary artery occlusion
results in ST elevation and peaked T-waves
C. Infarction from ongoing ischemia results in
marked ST elevation
normal
hours
hours
days
weeks
months
ST Elevation Infarction
ECG of an inferior MI:
Look at the
inferior leads
(II, III, aVF)
What ECG
changes do
you see?
ST elevation
and Q-waves
Extra credit:
What is the
rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!
Ischemia
Infarction
Fibrosis
Question:
What area of
the heart is
infarcting?
Anterolateral