Figure 18.15
Cell Depolarization
Flow of sodium ions into cell during activation
Depol
Repol.
Restoration of
ionic balance
Figure 18.13
Figure 18.14a
Cardiac Cycle
Cardiac cycle refers to all events
associated with blood flow through the
heart
Systole contraction of heart muscle
Diastole relaxation of heart muscle
Figure 18.20
What is an ECG?
The electrocardiogram (ECG) is a
representation of the electrical events of the
cardiac cycle.
Each event has a distinctive waveform, the
study of which can lead to greater insight
into a patients cardiac pathophysiology.
BASIC TERMINOLOGY
Arrhythmia:
Abnormal rhythm
Segment:
Combination of several
baseline,
12 ECG LEADS
Vertically
One large box - 0.5 mV
3 sec
Electrocardiography
Electrical activity is recorded by
electrocardiogram (ECG)
P wave corresponds to depolarization of SA node
QRS complex corresponds to ventricular
depolarization
T wave corresponds to ventricular repolarization
Atrial repolarization record is masked by the
larger QRS complex
Electrophysiology
ECG Signal
Heart behaves as a syncytium:
a propagating wave that once
initiated continues to propagate
uniformly into the region that is
still at rest.
The depolarization wavefront
defines a dividing line between
activated and resting cells.
Elsewhere, the signal is zero
Will propagate along conduction
paths sinus node AV node
bundle branches Purkinjie
fibers
Electrocardiography
Figure 18.16
Electrocardiogram
Normal P wave has
amplitude of 0.25 mV
Q wave is first
downward deflection
after P wave; signals
start of ventricular
depolarization
R wave is positive
deflection after Q wave
S wave is negative
deflection preceded by
Q or R waves
T wave follows QRS
ECG Signal
The excitation begins at the
sinus (SA) node and spreads
along the atrial walls
The resultant electric vector
is shown in yellow
Cannot propagate across the
boundary between atria and
ventricle
The projections on Leads I, II
and III are all positive
ECG Signal
Atrioventricular (AV) node
located on atria/ventricle
boundary and provides
conducting path
Pathway provides a delay to
allow ventricles to fill
Excitation begins with the
septum
ECG Signal
Depolarization continues to
propagate toward the apex of
the heart as the signal moves
down the bundle branches
Overall electric vector points
toward apex as both left and
right ventricles depolarize
and begin to contract
ECG Signal
Depolarization of the right
ventricle reaches the
epicardial surface
Left ventricle wall is thicker
and continues to depolarize
As there is no compensating
electric forces on the right,
the electric vector reaches
maximum size and points left
Note the atria have
repolarized, but signal is not
seen
ECG Signal
Depolarization front
continues to propagate to the
back of the left ventricular
wall
Electric vector decreases in
size as there is less tissue
depolarizing
ECG Signal
Depolarization of the
ventricles is complete and
the electric vector has
returned to zero
ECG Signal
Ventricular repolarization
begins from the outer side of
the ventricles with the left
being slightly dominant
Note that this produces an
electric vector that is in the
same direction as the
depolarization traveling in the
opposite direction
Repolarization is diffuse and
generates a smaller and longer
signal than depolarization
ECG Signal
Upon complete
repolarization, the heart is
ready to go again and we
have recorded an ECG trace
Figure 18.17
Electrophysiology
When myocardial muscle is completely
polarized or depolarized, the ECG will not
record any electrical potential but rather a
flat line, isoelectric line.
After depolarization, myocardial cells
undergo repolarization to return to
electrical state at rest.
Electrophysiology
P wave represents depolarization of atria which
causes atrial contraction
Repolarization of atria not normally detectable on
an ECG
Excitation of bundle of His and bundle branches
occur in middle of PR interval
QRS complex reflects depolarization of ventricles
T wave reflects repolarization of muscle fibers in
ventricles
Aksis QRS
The P Wave
The P Wave Is The Signal That Electrical
Potential Has Left The SA Node, Swept
Across The Atria, & Has Initiated Atrial
Contraction.
Amplitude
A Normal Amplitude For A
P Wave Is 2-3 mm.
BiPhasic P Wave In V1
The PR Interval
After The P Wave There Is A Silent
Period Where Nothing Is Happening In
The EKG Tracing. This Quiescent Period
Is Called The PR Interval.
The Q Wave
Definition : The Q wave is the first downward
deflection after the P wave & before the R
wave.
Sometimes Q waves are present &
sometimes they are absent depending on
the lead.
The R Wave
Definition : The R wave is the first upward
deflection after the P wave.
In the precordial chest leads, there should
be an R wave progression - i.e. - an ever
increasing amplitude of the R wave from
V1 through V6
The S Wave
Definition : The s wave is defined as the
first downward deflection after the R wave.
There is a normal progressive decrease in
the size of the S wave in the precordial
leads
V1 through V2 should have large S waves
with a decreasing appearance of S through
V5 and V6.
The ST Segment
The ST segment is the pause after the
QRS Complex - the interval between the
end of the QRS complex & the beginning
of the T wave.
The ST Segment
ST Segment Elevation
When the ST segment is elevated in A
patient with known disease, it is usually
A sign of an evolving transmural
infarction - an MI in progress.
ST segment elevations will be seen in
the lateral chest leads - Leads I, aVL
and V5 and V6.
ST Segment Elevation
ST Segment Elevation
ST Segment Depression
When The ST Segment Is Depressed,
Then It Is Usually A Sign Of Cardiac
Ischemia.
Types Of
ST Segment Depression
The T Wave
The T Wave Represents Repolarization
Of The Ventricles.
Repolarization Proceeds From The Apex
Of The Heart To The Base Of The Heart.
In Normal Hearts, The T Wave Is Usually
Upright In Leads I, II, III, aVF, aVL, & V2V6.
The QT Interval
The QT Interval Encompasses The Time
From The Beginning Of The Q Or R Wave
Through The End Of The T Wave.
The QT Interval Represents 40% Of The
Normal Cardiac Cycle Whether At Rest Or
During Exercise.
The QT Interval Becomes Shorter As The
Heart Rate Increases.
PR Intervals
Normal
Duration : 3-5 mm
Q Waves
Normal
Duration : < .5 mm
Normal Amplitude : <25% of R
amplitude or ~ 1.0 mm
QRS Complex
Normal
ST Segment
Normal
Amplitude : 1-2 mm
Normal Duration : 2-3 mm
T Wave
Normal
Duration : 2 mm
Normal Amplitude : < 5 mm in Limb
Leads & < 10 mm in Precordial
Leads
Irama
Rate QRS
Aksis QRS
Morfologi Gelombang P
Interval PR
Durasi QRS
Morfologi QRS
Deviasi Segmen ST
Morfologi Gelombang T
Morfologi Gelombang U
Lain-lain (LVH,LV Strain,BBB,
QT interval)
Kesimpulan EKG
Nilai Normal :
Interval PR
Durasi QRS
Aksis Normal
- 300
s/d + 1100
EKG Abnormal
Rhythm Analysis
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Calculate rate.
Determine regularity.
Assess the P waves.
Determine PR interval.
Determine QRS duration.
3 sec
Option 1
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.
Reminder: all rhythm strips in the Modules are
6 seconds in length.
Interpretation?
9 x 10 = 90 bpm
Option 2
Find a R wave that lands on a bold line.
Count the # of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes 100, 4 boxes - 75, etc. (cont)
Option 2 (cont)
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50
Interpretation?
Regular
Interpretation?
0.12 seconds
Interpretation?
0.08 seconds
Rhythm Summary
Rate
Regularity
P waves
PR interval
QRS duration
Interpretation?
90-95 bpm
regular
normal
0.12 s
0.08 s
NSR Parameters
Rate
60 - 100 bpm
Regularity regular
P waves
normal
PR interval 0.12 - 0.20 s
QRS duration
0.04 - 0.12 s
Any deviation from above is sinus tachycardia,
sinus bradycardia or an arrhythmia
Arrhythmia Formation
Arrhythmias can arise from problems in
the:
Sinus node
Atrial cells
AV junction
Ventricular cells