Vectors and EKGs

Chapters 11, 12, and 13

Electrocardiogram (ECG)
Depolarization wave passes through the heart and the electrical currents pass into surrounding tissues. Small part of the extracellular current reaches the surface of the body. The electric potential generated can be recorded from electrodes placed on the skin An EKG is a comparison of two vectors It compares the heart vector showing current flow on the heart with the reference, recording lead vector on the body.

(Non-invasive) Heart Rate Signal conduction Heart tissue (enlarged) Conditions (MI) electrolyte and hormone imbalances

Vector diagrams
Vectors are used to describe depolarization and repolarization events Vectors are arrows which show two things:
Direction or pathway (of charge spread) Magnitude or size (amt of charge)

Vector analysis explains the waves on an EKG

Q S

EKG is Extracellular Recording

Only looks at the charge on the outside of fibers!
Resting cell: outside positive Depolarizing cell: outside negative Repolarizing cell: outside positive +++++++++++ -----------------+++++++++++ -----------------+++++++++++ ------------------

Depolarization: spread of surface neg charge Repolarization: spread of surface positive charge Vectors will always be positioned so that head of vector is in area of positive charge; tail is in area of negative charge.
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+++++++++++ ------------------

Rest
No current flow, no vector.

The following vectors represent the spread of negative charge during depolarization; Then the spread of positive charge during repolarization

= depol SA nodal fibers, spread of neg charge over atria

- +
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+
8

+
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The atria would start to repolarize down and to the left, as the current continues downward to the ventricles We dont detect this on the EKG, but what would the repolarizing vector look like? (review your specialized cells/contractile cells lecture!)

+
10

+
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Atria now have repolarized and now have positive surface charge again.

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Meanwhile, as the atria are repolarizing...... We turn to the Depolarizing AV node

These are small diameter fibers with few gap junctions; little or no detectable current flow

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IV Septal Depolarization
Moving down bundle of His; Current moves down R and L bundle branches from L toward Rwhy?

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Apex then Lateral walls

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Through the thickness of the heart, from endo- , to myo-, to epicardium

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Ventricles completely depolarized, negative surface charge No current No vector

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Begin Ventricular Repolarization

Spread of positive charge

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Rest
End of cycle;
No current flow, no vector.

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Recording from Lead II

Standard limb lead

II

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The Rules of Vectors Analysis

An EKG is a comparison of two vectors It compares the heart vector with the reference recording lead vector on the body. If the vectors run parallel (same direction) the pen moves upward from baseline If the vectors run antiparallel (opposite direction) then the pen moves downward from baseline. If the vectors are perpendicular, the pen remains on baseline. If there is no current flow, the pen remains on baseline. Each lead consists of two electrodes placed on the skin, with a voltmeter between them. The voltmeter is attached to a pen, which travels over paper running at 25 mm/sec. This produces waves called an electrocardiogram.
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+
-

II

III

Einthovens Triangle Bipolar Limb Leads 33

Atrial depolarization

Pen here

II

V
T

The heart vector is parallel to the lead, but how can you confirm?34

II
1.

Atrial depolarization

2.

Draw a perpendicular line to the lead vector Draw a line toward from the perpendicular vector toward your cardiac vector
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Atrial depolarization

II

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AV nodal depolarization

II

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IV septal depol, from L to R

II

Anti-parallel! Pen deflects down

Draw it!

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IV septal depol, from base to apex

II

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Lateral walls depol

II

Draw it!

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Depolarization complete; no current flow; pen returns to baseline

II

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Waiting to begin repolarization; no current flow

II

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Ventricular Repolarization begins

II

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Ventricular Repolarization

II

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Ventricular Repolarization complete; no current flow; pen on baseline

II

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Ventricular Repolarization complete; waiting to start all over again

II

End of one cardiac cycle 46

What does that tell you about the recording you obtain from each lead?
Each lead describes the events on the heart from its own point of view
Reading from several leads gives you different points of view about the same set of repeating events (depol, repol) What if the recording lead was oriented this way? Use the words down or up to note the deflection compared to the five cardiac vectors above
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Body Cross-section at Heart Level Heart

12 Lead EKGs
Read from each lead independently; one at a time over several heartbeats. See what each lead shows. 12 leads 3 bipolar limb leads (I, II, III) 3 augmented unipolar limb leads (aVR, aVL, aVF) 6 precordial leads (chest leads, V1V6)

V6 V4

V5

V1

V2

V3

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6 Leads- bipolar and augmented; all of these are in flat plane

Augmented- Obtained by using the average voltage of any two points on skin as ground (neg pole) and reading from the third electrode (pos pole.)

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Bipolar Leads and Einthovens Law

Lead I - The negative terminal of the electrocardiograph is connected to the right arm, and the positive terminal is connected to the left arm. Lead II - The negative terminal of the electrocardiograph is connected to the right arm, and the positive terminal is connected to the left leg. Lead III - The negative terminal of the electrocardiograph is connected to the left arm, and the positive terminal is connected to the left leg. Einthovens Law states that the electrical potential of any limb equals the sum of the other two (+ and - signs of leads must be observed).
Lead I Lead III Lead II LA RA LL- LA LL- RA

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Summary of Events
P wave atrial depolarization- SA node to the AV node (mechanical event that will result: atrial systole) QRS complex- depolarization of ventricles Q wave- due to left to right depolarization at bundle branch (right has detour) atrial repolarization and diastole (signal obscured) AV node fires, ventricular depolarization (mechanical event that will result: ventricular systole) T wave ventricular repolarization (mechanical event that will result: ventricular diastole. ventricles remain somewhat contracted until a few milliseconds after the end of the T repolarization wave.)
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Intervals & Segments

Segments are flat lines, do not include waves: PR segment, ST segment. Intervals include at least one wave P-R interval- from beginning of P to the Q wave. Is time for atrial depolarization plus delay from AV node. Also, time of atrial contraction (more than .2 sec could be 1st degree block) P-R segment- delay in impulse through AV node. 53

Phases of EKG
Q-T interval- includes Q and T waves, total time for ventricular depolarization and repolarization; this approximates the time of total ventricular contraction. T-P segment - end of one cycle to beginning of next P-P interval - time for one complete cycle (could also use R-R or T-T, etc.) S-T segment: time between ventricular depolarization and repolarization; time of peak ventricular contraction (maximum 54 tension)

Cardiac Arrhythmias
Tachycardia: abnormally fast heart rate Bradycardia: Abnormally slow heart rate Incomplete Atrioventricular Block: Prolonged P-R interval (1st degree) Complete Atrioventricular Block: P waves and QRS complexes become dissociated (3rd degree) Fibrillation: Complete lack of coordination
Arrhythmia: conduction failure at AV node

No pumping action occurs

No P waves
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Electrolyte imbalance
Hypernatremia:
Inhibits calcium entry into the cell Depresses overall heart activity and becomes flaccid; (negative inotropy)

Hypercalcemia:
(-, +) Increased heart irritability More calcium into cytoplasm What reflex could augment the decreased chronotropy?

Hyperkalemia:
Peaked T waves.

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Electrolyte imbalance
Hyponatremia:
Depolarization delay Decreased heart rate

Hypocalcemia:
(+,-) Less heart contractility What reflex could augment the increased chronotropy?

Hypokalemia:
Lowers RMP (makes it more negative) Decreases heart rate U waves
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Determining the MEA Vector

This presentation aims to teach you the trick to visually determine the position of the MEA from the EKG

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Know the Orientation of All Leads

Use any two leads on an EKG Given: limb leads I 210o and avF 180o Goal: to find the MEA vector
+ 120 o

- 90 o

aVR

aVL I

- 30 o

0o

III

II

aVF

+60 o

-90 o
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Step 1: Visually, Lead I examine the profiles of leads I and aVF

aVF

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Lead I: Make note of the SIGN of the net deflection

+ 10 mm

Lead I
- 2mm

Lead I Net deflection (+ 8) is POSITIVE.

Where would this fall in the graph?

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-90o 180o

0
+90o

Lead I

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Lead aVF: Make note of the SIGN of the net deflection

+ 1mm

- 8 mm

aVF

Lead aVF Net deflection (- 7) is NEGATIVE.

Where would this fall in the graph?

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-90o 180o

0
+90o

+
Lead aVF
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Step 2:
Superimpose the two diagrams of the heart, and see where the hatched areas overlap. This will be the area which must contain the MEA vector

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-90o 180o

+ -

0
+90o

+
MEA vector must lie in the zone of overlap
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-90o 180o

+ -

0
+90o

+
MEA vector must lie in the zone of overlap
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-90o 180o

+ -

0
+90o

+
Conclusion: LAD
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Heres Step 1: Visually, Lead I examine the profiles of leads I and aVF
aVF

another example:

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Lead I: Make note of the SIGN of the net deflection

Lead I

Lead I Net deflection is VERY NEGATIVE.

Where would this fall in the graph?

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-90o 180o

0
+90o

Lead I

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Lead aVF: Make note of the SIGN of the net deflection

aVF

Lead aVF Net deflection is a SOMEWHAT POSITIVE.

Where would this fall in the graph?

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-90o 180o

0
+90o

+
Lead aVF
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Step 2:
Superimpose the two diagrams of the heart, and see where the hatched areas overlap. This will be the area which must contain the MEA vector

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-90o 180o

+ -

0
+90o

+
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-90o 180o

+ -

0
+90o

+
MEA vector must lie in the zone of overlap
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-90o 180o

+ -

0
+90o

+
Conclusion: RAD
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Mean Axial Shift

Left axis deviations
endomorph- short stature Pregnancy Left ventricle hypertrophy LBBB

Right axis deviations

Ectomorph- tall /thin Hypertrophy of right ventricle RBBB

How does the current normally flow down the IV septum? Left to right? OR Right to Left? How would this change if there was a LBBB? RBBB? Why does a LBBB cause a LAD? (think about the vector!)

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