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ELECTROCARDIOGRAPHY

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Lecture outline

Part one

Information provided by ECG

Cardiac conduction system: anatomyand physiology

(Normal) ECG interpretation

Part two

Abnormal ECG

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ECG is?

Printout as a result of a particular electrical

function of the heart

The standard 12-lead electrocardiogram is a

representation of the heart's electricalactivity recorded from electrodes on thebody surface

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Information provided by ECG:what do you think?

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SA node AV node

Bundle His

Cardiac conduction

system

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Impulse Transmission

SA Node

Internodal branch AV Node Hiss Bundle Purkinje Fiber

Contraction

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the sequentialactivation

(depolarization) of the right andleft atria

right and left ventricular depolarization (normally theventricles are activated simultaneously)

ventricular repolarization

One complex of ECG waveform

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Leads position

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Limb leads

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Chest lead

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Chest lead

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Chest lead

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ECG interpretation?

1. Calibration2. Rhythm3. Rate4. QRS axis

5. P morphology6. PR interval7. QRS duration8. QRS morphology9. Abnormal Q wave10. R wave progression

11. ST segment morphology12. QT interval13. T morphology14. U morphology15. Others: LVH, LV strain, BBB,16. Conclusion: normal/abnormal

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Paper speed and normal

value

One small box: 0.04 sOne large box: 0.2 s

PR Interval: 0,12- 0,20QRS duration: 0,04- 0,12

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Rate calculation

Method:

300 divided by number of large boxes

between R-R

1500 divided by number of small boxes

between R-R,

Number of QRS complexes in 6 seconds

times 10.

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Rate calculationpaper 25 mm/s

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Sinus Rhythm

Sinus Rhythm

Rhythm: Regular

Rate: 60 100P wave: Normal in configuration; precede eachQRS

PR: Normal (0. 12 0.20 s)

QRS: Normal (

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QRS Axis (N: - 30 s/d + 110)

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P wave

Wave of atrial depolarization

Normal characteristic:

1. Smooth and rounded

2. 3 mm tall

3. Upright in leads I, II avF

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PR interval

Including P wave until the beginning

of QRS complex

Normal duration is 0.12-0.2 seconds

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QRS complex

Wave of ventricular depolarization

5-20 mm tall

Duration 0.06-0.10 seconds

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QRS morphology

qRs RsR

rS

QR Q/QS RsR rSr

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ST segment

Begins at J point

Between ventricular depolarization andventricular repolarization

Generally isoelectric

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T wave

Ventricular repolarization, followed by

ventricular relaxation

Positive in lead : I, II, V3-V6

Negative in lead avR

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Interpret this ECG..

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And this..

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Abnormal ECG

Myocardial ischemia/infarct

Hyperthrophy

Hyperkalemia

Arrhythmia

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ACUTE CORONARY SYNDROME

No ST Elevation ST Elevation

Unstable Angina

NSTEMI

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Acute myocardial

infarction

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STEMI Non STEMI

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Mid LAD occlusion

after the first septal

perforator (arrow)ECG : large anterior MI

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Occlusion of diagonal

branch ( arrow)

ST elevation in I and aVL

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ECG demonstrates large anterior infarction

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Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression

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Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

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Peaking T

Shortening QT interval

Widening P wave,

QRS complex

Prolongation PR interval

HIPERKALEMIA

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PPM

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How to identify arrhythmias ?

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QRS complex

Regular / irregular ?

QRS complex

Normal-looking QRS complex?

Wide / narrow ?

P wave ?

Relationship between P and QRS ?

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NORMAL SINUS RHYTHM

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PSVT :

-due to re-entry mechanism

-narrow QRS complex-regular-retrograde atrial depolarization-P wave ?

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PSVT

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Atrial Fibrillation :-from multiple area of re-entry within atria

-or from multiple ectopic foci-irregular, narrow QRS complex-very rapid atrial electrical activity(400-700 x/min).-no uniform atrial depolarization

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Atrial Flutter :-The result of a re-entry circuit within

the atria-Irregular / regular QRS rate-Narrow QRS complex-Rapid P waves (300x/min), sawtooth

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Junctional rhythm:-AV junction can function as a pace maker

(40-60 x/min).-due to the failure of sinus node to initiatetime impulse or conduction problem.-normal-looking QRS.-retrograde P wave.-P wave may preceede, coincide with, or

follow the QRS

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VES

SR

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SR SR SR SRSR SR

VES VES

Sinus rhythmwithMultifocal VES

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Sinus rhythm with VES couplet

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Sinus Rhythm with VES, R on T

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Ventricular Tachycardia

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Torsade de Pointes

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Ventricular Fibrillation

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Prolonged PR interval

1st degree AV block

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Missing QRSMissing QRS

2nd degree AV block, type 1

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2nd degree AV block, type 2

Missing QRS

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P PP P P P P

QRS QRS QRS

Total AV Block /3rd degree AV block

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