Zabrina Bellina

University of Central Florida

Teaching With Technology Project
At the conclusion of this presentation,
students will able to:

1. Describe coronary circulation and gain

working knowledge of blood supply to
heart structures.

2. Define the term electrocardiography and

describe the electrical conduction system
of the heart.
3. Correlate electrical events in the heart with
the waveform represented in a normal EKG.

3. Gain understanding of EKG interpretation

through waveform measurement, analysis,
and correct rate computation of rhythm
strips.

4. Understand and identify lethal cardiac

arrhythmia waveforms.
Figure 1
Superior & Inferior Vena Cava

Right Atrium

Tricuspid Valve

Right Ventricle

Pulmonary Semi-lunar Valve

 Pulmonary Trunk

Right & Left Pulmonary Arteries

Lungs

Pulmonary Veins

Left Atrium
 Mitral Valve

Left Ventricle

Aortic Semi-lunar Valve

Aorta

Body
supplies blood to:
Right Atrium

Right Ventricle

the SA Node in 55% of population the LV

inferior wall
the LV posterior wall and of the
posterior interventricular septum in 90%
of the population
supplies blood to:
the Left Atrium
the LV lateral wall

the SA Node in 45% of the population and to

the LV posterior wall

of the interventricular septum

AV Node and Bundle of His in 10% of the

population
 supplies blood to:
the LV anterior and lateral walls

the Left and Right Bundle Branches

the anterior of the interventricular

septum
 Remember:

The Right Coronary Artery supplies both

the Right and Left heart.

The Left Coronary Artery and its

branches only supply the Left heart.
An electrocardiogram (ECG) , also known as
an EKG, is a graphic recording of the electrical
activity of the heart. It is used as a diagnostic
tool to assess cardiac function.
An EKG is a painless procedure that can be
performed by placing disposable electrodes on
the skin of a persons chest wall, upper and lower
extremities.

Figure 2 Figure 3
An EKG can be recorded with 12, 15, and
sometimes even 18 leads. However, the
12 lead EKG is the most commonly used
tool to diagnose cardiac conduction
abnormalities, arrhythmias, myocardial
infarction and ischemia.
 Remember,
an EKG represents the electrical
impulses that the heart transmits
and are recorded as tracings on
specialized graph paper.
The Conduction System of the Heart

Figure 4
The SA Node is the primary pacemaker for
the heart at
60-100 beats/minute

The AV Node is the back-up pacemaker of

the heart at
40-60 beats/ minute
The Ventricles (bundle branches &
Purkinje fibers)
are the last resort and maintain an
intrinsic rate of only
20-40 beats/minute
 Lets look at a normal conduction pathway:

SA Node AV Node Bundle of His

Myocardial Right and Left

Purkinje Fibers Bundle
Contraction Branches
Myocardial Cells = the mechanical cells of the
heart. They contract when they receive an
electrical impulse from the pacemaker cells.

Myocardial = Muscle (Brawn)

Pacemaker Cells are very small cells
within the conduction system which
spontaneously generate electrical
impulses.

Pacemaker = Power Source (Brain)

Electrical Conducting Cells rapidly carry
current to all areas of the heart.

Conducting Cells = Hard Wiring of Heart

(Fuel)
Now, lets correlate the mechanical activity with the
electrical activity.
Ventricular Systole

Atrial
Systole

Atria Ventricles
depolarize repolarize

Ventricles
depolarize
Figure 5
Depolarization occurs when sodium
channels open fast and the inside of the
membrane becomes less negative
(electrical stimulation).

This is manifested as the P wave on an EKG,

which signifies atrial muscle
depolarization.
The plateau that immediately follows the
P wave represents atrial systole, when
calcium channels open slowly and
potassium channels close (at this time
mechanical contraction of the atria takes
place).
The PR interval on an EKG reflects conduction
of an electrical impulse from the SA node
through the AV node.
PR = 0.12 0.20 seconds

Figure 6
The QRS complex of an EKG reflects
ventricular muscle depolarization (the
electrical impulse moves through the
Bundle of His, the left and right bundle
branches and Purkinje fibers).

QRS = 0.08 0.10 seconds

The QT interval measures the time
from the start of ventricular
depolarization to the end of
ventricular repolarization.

QT interval = < 0.43 seconds or

of the R-to-R interval
The ST segment reflects the early
ventricular repolarization and lasts
from the end of the QRS complex to
the beginning of the T wave.
The T-wave on an EKG reflects
ventricular muscle repolarization
(when the cells regain a negative
charge - the resting state) and
mechanical relaxation, which is also
known as diastole.
 Keep in mind how electricity flows

When an electrical current moves toward a

positive electrode, the deflection on the EKG
strip will be positive (up).

When an electrical current moves toward a

negative electrode, the deflection on the
EKG strip will be negative(down).
 ST Segment Changes

Any elevation in the ST segment that

is greater than two small boxes is
indicative of myocardial injury.

Any ST segment depression greater

than two small boxes indicates
myocardial ischemia.
EKG paper comes in a roll of graph paper
consisting of horizontal and vertical light and
dark lines.

The horizontal axis measures time

Figure 7

The vertical axis measures voltage

One small square = 0.04 seconds

One large square = 0.2 seconds

or
One small square(0.04) x 5
The light lines circumscribe
small squares of 1 x 1 mm
One small square = 0.1 mV

The dark lines delineate

large squares of 5 x 5 mm
One large square = 0.5 mV
Rhythm
Rate
P - waves
PR Interval
QRS Complex
 Rate
Whats the normal heart rate for an
adult human being?
60 100 beats/ minute

Is the rate in your strip too fast or too

slow?
In terms of rate computation, heart rate
generally refers to the number of ventricular
contractions that occur in 60 seconds or one
minute.

When calculating rates, if there is a P-wave in

front of every R-wave, the atrial and ventricular
rates will be the same.
.
Atrial rate can be calculated by measuring the
interval of time between P-waves (the P-to-P
intervals).

Ventricular rate can be calculated by measuring

the time intervals between QRS complexes (the
R-to-R intervals).
There are instances, such as 2nd and 3rd degree
AV block, in which the atrial rate and
ventricular rates are different.

This is why it is important to know how to

determine both atrial and ventricular rates.
 Rules
1. Count the number of QRSs in a 6 - second
strip, then multiply that number by 10.

2. Determine the time between R-R

intervals, then divide that number by 60.
For example:
40 (20 small boxes x 0.04 seconds each)
= 50 beats per minute
 Rules
Memorize these numbers:
300, 150, 100, 75, 50

Normal Heart rate for an adult = 60 -100 bpm

This means that 3 to 5 large blocks should exist
between R R intervals.
Bradycardia = more than 5 large blocks
Tachycardia = less than 3 large blocks
Figure 8
 Lets Practice with an Example:

Figure 9

What is the rate based on Rule #1?

If you said 50 bpm.
You are Correct!!!
 Are the P waves regular or irregular?

Are the R-to-R intervals regular or

irregular?
Are there P-waves in your rhythm strip?
Is there a P-wave for each QRS complex?
Do all of the P-waves look the same?
Is the PR Interval measurement normal?
PR = 0.12 0.20 seconds
Is the PR Interval measurement constant?
 Is the QRS wide? > 0.10
Is it normal?
QRS = 0.08 0.10 seconds
Or is it narrow? < 0.08
Is the T-wave peaked, inverted or flat?
Is the ST segment elevated, depressed
or normal?
Is the QT Interval < 0.43 seconds?
Is there any ectopy present?
 Lets try an example..

Figure 10

1. Is the rhythm regular or irregular? Regular

2. Are the P-waves identical? Is there a P-wave for
each QRS complex? Yes for both!
3. Is the PR Interval 0.12 0.20? Yes, PR = 0.16
4. Is the QRS wide, normal or narrow?
Normal QRS = 0.08
5. Is the T-wave peaked, inverted or flat? No, its
normal
6. Is the ST segment elevated or depressed? No
7. Is the QT Interval < 0.43? Yes, QT Interval= 0.36
And last but not least, is there any
ectopy present in this rhythm?
NO!
 And the rhythm is.

Normal Sinus Rhythm

Listed below are the cardiac arrhythmias that
are almost always associated with death:

Atrial Fibrillation
Atrial Flutter
Ventricular Fibrillation
Ventricular Tachycardia
3rd degree AV Block
Asystole
 Atrial Fibrillation

Figure 11
Rhythm: Atrial fibrillation is irregular and chaotic;
Ventricular rhythm is very irregular
Rate: Atrial is > 350 bpm; Ventricular is 120-200 bpm
P-waves: not consistent (they are fine and fibrillating)
PR Interval: not measurable
 Atrial Flutter

Figure 12
Rhythm: Atrial flutter is usually regular
Rate: Atrial is 250-350 bpm
Ventricular rate depends on AV conduction
P-waves: characterized by saw tooth pattern
PR Interval: can not be determined; more flutter
waves than QRS complexes
 Ventricular Fibrillation

Figure 13
Rhythm: Totally erratic
VF Rate: 350-450 bpm
P-waves: none
QRS: none
 Ventricular Tachycardia

Figure 14
aka The Widow-Maker
Rhythm: Typically regular, but can be irregular
Rate: 100 220 bpm
P-waves: can be present but have no correlation to QRS
complex
QRS: > 0.12 seconds with an odd, tomb stone shape
 3rd Degree AV Block = Complete Heart Block

Figure 15
Rate: 40-60 bpm (narrow QRS and junctional);
20-40 bpm (wide QRS and ventricular)
P-waves: normal, but usually more P-waves than
QRSs
 Asystole

Figure 16

In Asystole, there is no rate because the

person that belongs to this rhythm is
DEAD!
Figure 1. (2009). Image retrieved on February 17, 2009 from
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om/images/anatomy-of-the-human-
heart.jpg&imgrefurl=http://www.micardia.com/CHF-Congestive-
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prolapses.php&usg=__vAFkAZBOMi2yoKCxSP0R39jzRQE=&h=324
&w=250&sz=48&hl=en&start=288&um=1&tbnid=zVIu6UfvBI-
h2M:&tbnh=118&tbnw=91&prev=/images%3Fq%3Dblood%2Bflo
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%26start%3D270%26um%3D1
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The End !!!