Action Potentials = Change in membrane potential occurring in nerve, muscle, heart and other cells

The ECG is not an action potential but reflects their cumulative effect at the level of the skin where the recording electrodes are located.

 Electrocardiograph: instrument used to record the

electrical activity of the heart

Electrocardiogram (ECG): graphic representation of

the electrical activity of the heart

Electrocardiogram (ECG/EKG)
Is a recording of electrical activity of heart conducted thru ions in body to surface

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Normal conduction pathway:

SA node -> atrial muscle -> AV node -> bundle of His -> Left and Right Bundle Branches > Ventricular muscle

ECG
3 distinct waves are produced during cardiac cycle P wave caused by atrial depolarization QRS complex caused by ventricular depolarization T wave results from ventricular repolarization

Elements of the ECG:

P wave: Depolarization of both atria; Relationship between P and QRS helps distinguish various cardiac arrhythmias Shape and duration of P may indicate atrial enlargement PR interval: from onset of P wave to onset of QRS Normal duration = 0.12-2.0 sec (120-200 ms) (3-4 horizontal boxes) Represents atria to ventricular conduction time (through His bundle) Prolonged PR interval may indicate a 1st degree heart block QRS complex: Ventricular depolarization Larger than P wave because of greater muscle mass of ventricles Normal duration = 0.08-0.12 seconds Its duration, amplitude, and morphology are useful in diagnosing cardiac arrhythmias, ventricular hypertrophy, MI, electrolyte derangement, etc. Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec are abnormal and may represent MI

ST segment: Connects the QRS complex and T wave Duration of 0.08-0.12 sec (80-120 msec T wave: Represents repolarization or recovery of ventricles Interval from beginning of QRS to apex of T is referred to as the absolute refractory period QT Interval Measured from beginning of QRS to the end of the T wave Normal QT is usually about 0.40 sec QT interval varies based on heart rate

Elements of the ECG:

P wave
Depolarization of both atria; Relationship between P and QRS helps distinguish various arrhythmias Shape and duration of P may indicate atrial enlargement cardiac

PQRST wave

Deflection waves

P wave Lasts 0.08 s Results due to depolarization from SA node throughout atria Atrial systole Normal duration is not longer than 0.11 seconds (less than 3 small squares) Amplitude (height) is no more than 3 mm

QRS complex:
Represents ventricular depolarization Larger than P wave because of greater muscle mass of ventricles Normal duration = 0.08-0.12 seconds Its duration, amplitude, and morphology are useful in diagnosing cardiac arrhythmias, ventricular hypertrophy, MI, electrolyte derangement, etc. Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec are abnormal and may represent MI

PR interval:
From onset of P wave to onset of QRS Normal duration = 0.12-2.0 sec (120-200 ms) (3-4 horizontal boxes) Represents atria to ventricular conduction time (through His bundle) Prolonged PR interval may indicate a 1st degree heart block

Deflection waves
QRS complex Lasts 0.08 s (Normally not longer than 0.10 s in duration) Results due to depolarization of ventricles Ventricular systole & atrial diastole R waves are deflected positively and the Q and S waves are negative

T wave Results due to repolarization of ventricles Lasts 0.16 s Ventricular diastole

ST segment:
Connects the QRS complex and T wave Duration of 0.08-0.12 sec (80-120 msec

QT Interval
Measured from beginning of QRS to the end of the T wave Normal QT is usually about 0.40 sec QT interval varies based on heart rate

Types of ECG Recordings

Bipolar leads record voltage between electrodes placed on wrists & legs (right leg is ground) Lead I records between right arm & left arm Lead II: right arm & left leg Lead III: left arm & left leg

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Producing the ECG Waveform

The 12-lead ECG produces a complete picture of the heart s electrical activity

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12-Lead ECG
Utilizes 10 lead wires Wires are color coded Six chest leads Four limb leads Each lead is attached to an electrode

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30

Types of Leads
10 lead wires produce 12 different lead circuits
Three standard leads (bipolar) Three augmented leads (unipolar) Six chest leads (unipolar)

Lead wires produce 12 different views of the heart

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Einthoven Triangle

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Waveform Types
Isoelectric flat, no current flowing Positive upright, current flows to positive electrode Negative downward, current flows away from positive electrode

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Standard Limb Leads

Lead I records tracing from right arm (-) to left arm (+) and produces positive deflection Lead II records tracing from right arm (-) to left leg (+) and produces positive deflection Lead III records electrical activity from left arm (-) to left leg (+)

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Standard Limb Leads

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Augmented Leads
aVR aVL aVF Known as augmented leads because their tracings are increased in size by the ECG machine

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Augmented Leads
aVR
Measures in the direction of the right arm Records activity from midway between left arm and left leg to right arm

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Augmented Leads
aVL
Measures in the direction of the left arm Records activity from the midpoint between right arm and left leg to left arm

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Augmented Leads
aVF
Measures in the direction of the left foot Records activity from the midpoint between right arm and left arm to left leg

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Augmented Leads

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Chest Leads
Also known as the precordial leads Measure in one direction only (unipolar) Placed on specific sites on the chest Numbered V1 V6

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Chest Leads
V1: Fourth intercostal space at the right sternal border. (First palpable intercostals space, below the clavicle is the 2nd intercostal space. V2: Fourth intercostal space at the left sternal border V3: Midway between V2 and V4 V4: Fifth intercostal space in the midclavicular line V5: Anterior axillary line at the same horizontal level as V4 V6: Mid-axillary line at the same horizontal plane as V4 and V5
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Electrocardiogram Paper
A grid system where time is measured along the horizontal axis. Each small square is 1 mm in length & represents 0.04 seconds. Each larger square is 5 mm in length & represents 0.2 seconds.

ECG Graph Paper

Dot matrix
Requires less ink Easier to read Makes sharper photocopies

Standard grid


Less expensive

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ECG Graph Paper

Graph paper may be heat/pressure sensitive and may be erased by:
Alcohol Plastic Sunlight X-ray film

Some graph paper requires no special handling/storage and is guaranteed for 50 years

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Graph Paper Measurements

Horizontal readings
Represent time Measured in millimeters

Vertical readings
Represent voltage 1 cm = 1 millivolt

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Graph Paper Measurements

Each large box is 5mm x 5mm Each large box or vertical heavy line is 0.2 second in time Each horizontal heavy line is 5mV in voltage Each small box is 0.04 second in time and 1mV in voltage

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Graph Paper Measurements

48

Heart rate can be calculated from the EKG strip

When the rhythm is regular, the heart rate is 300 divided by the number of large squares between the QRS complexes. For example, if there are 4 large squares between regular QRS complexes, the heart rate is 75 (300/4=75).

 Can be used with an irregular rhythm to estimate the rate. Count the number of R waves in a 6 second strip and multiply by 10.

Heart rate can be calculated from the EKG strip

For example, if there are 7 R waves in a 6 second strip, the heart rate is 70 (7x10=70).

Generalized Instrumentation System

Control And feedback Power source Variable Conversion element Signal processing Output display Perceptible output

Sensor Measurand Primary Sensing element

Calibration signal Radiation, electric current, or other applied energy

Data storage

Data transmission

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Types of ECG Machines

Single-channel recorders Multi-channel recorders

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Single Channel Recorder

Monitors leads individually Produces strips six feet long Tracing strip must be cut and mounted or placed on a card for interpretation

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Multi-channel Recorder
Monitors leads three to six leads at a time Recording time is approximately 10 seconds

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ECG Machine Functions

Input
Impulse from electrodes

Signal processing
Amplifies electrical impulse inside the machine

Output display
Either a printed report or an oscilloscope

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ECG Machine Functions (Cont d)

Computerized measurements and analysis Storage Communication Interpretation

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ECG Machine Controls

Speed
Regulates speed of paper Normally 25 mm/sec unless directed by physician Changes must be noted on ECG report Troubleshooting Very fast heart rates may require faster paper speed.

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ECG Machine Controls

Gain
Controls height of waveform Normal setting is 10mm/mV Changes must be noted on ECG report

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ECG Machine Controls

Artifact filter
Normal setting between 40 and 150 Hz Can be used to reduce artifact or abnormal marks on tracing Computer interpretation will be non-filtered.

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ECG Machine Controls

LCD display
Liquid crystal diode Area where patient info can be viewed

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ECG Machine Controls

Heart rate limits
Machines may allow user to set heart rate limits which activate an audio alarm and marking on the tracing.

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ECG Machine Controls

Stylus and standardization control
Stylus control found on older machines sets the intensity of print and must be standardized before use. Standardization is required on some machines

Thermal technology is used on digital machines

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ECG Machine Controls

Lead selector
Can be used if one or more leads needs to be repeated

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ECG Electrodes
Sensors that pick up electrical activity, conducting to the ECG machine Ten electrodes are used for the 12-lead ECG Most electrodes are of the disposable type

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Chapter Summary (Cont d)

Input, signal processing, and output display are functions of the ECG ECG machines contain lead wires, LCD display, and paper for output Various types of ECG electrodes are used for ECG machines

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Ischemic Heart Disease

Is most commonly due to atherosclerosis in coronary arteries Ischemia occurs when blood supply to tissue is deficient
Causes increased lactic acid from anaerobic metabolism

Often accompanied by angina pectoris (chest pain)

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Ischemic Heart Disease

Detectable by changes in S-T segment of ECG Myocardial infarction (MI) is a heart attack
Diagnosed by high levels of creatine phosphate (CPK) & lactate dehydrogenase (LDH)

Fig 13.34

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Arrhythmias Detected on ECG

Arrhythmias are abnormal heart rhythms Heart rate <60/min is bradycardia; >100/min is tachycardia

Fig 13.35

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AV Transmission Blocks
Impulse transmission through conduction tissue blocked. His Bundle Electrogram may be used to localize block.

His Bundle Electrogram

Prolongation of either the A-H or H-V interval indicates block above or below the Bundle of His

Atrial Wave

His Bundle Wave

V Ventricular wave

Arrhythmias Detected on ECG continued

In flutter contraction rates can be 200-300/min In fibrillation contraction of myocardial cells is uncoordinated & pumping ineffective
Ventricular fibrillation is life-threatening
Electrical defibrillation resynchronizes heart by depolarizing all cells at same time

Fig 13.35

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Arrhythmias Detected on ECG continued

AV node block occur when node is damaged First degree AV node block is when conduction through AV node > 0.2 sec
Causes long P-R interval

Second-degree AV node block is when only 1 out of 2-4 atrial APs can pass to ventricles
Causes P waves with no QRS

In third-degree or complete AV node block no atrial activity passes to ventricles

Ventricles driven slowly by bundle of His or Purkinjes

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Arrhythmias Detected on ECG continued

AV node block occurs when node is damaged First degree AV node block is when conduction thru AV node > 0.2 sec
Causes long P-R interval
Fig 13.36

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Arrhythmias Detected on ECG continued

Second-degree AV node block is when only 1 out of 2-4 atrial APs can pass to ventricles
Causes P waves with no QRS
Fig 13.36

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Arrhythmias Detected on ECG continued

In third-degree or complete AV node block, no atrial activity passes to ventricles
Ventricles are driven slowly by bundle of His or Purkinjes
Fig 13.36

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Fibrillation
Arrhythmia that is ineffectual in pumping blood. Atria or Ventricles may be involved. Is due to fragmentation of reentry loop into multiple irregular circuits.

Atrial Fibrillation

Atria do not contract and relax sequentially. No contribution to ventricular filling. No P waves. Irregular fluctuations or f waves. Normal QRS complexes but irregular rhythm. Compatible with life and full physical activity. 20-30% reduction in ventricular pumping.

Ventricular Fibrillation

Irregular continuous twitching of the ventricular muscle. No pumping of blood possible. Loss of consciousness occurs rapidly Irregular fluctuations in the EKG Often initiated by a premature impulse arriving in the vulnerable phase.

Atrial Flutter
F wave

Normal EKG

Wolf Parkinson-White Syndrome

Normal

Wolf Parkinson White

Alternate Conduction Pathway Bundle of Kent

Left Atrial Enlargement

Left atrial enlargement is best observed in the P waves of Leads II and V1. In V1 P is biphasic due to the position of the lead over the heart. Remember that the right side of the P wave represents the right atrial component and the left side the left atrial component. In figure B you can see that in both P waves the left atrial component has increased. In Lead I a notch has appeared in the left atrial component and in Lead V1 the left atrial component which is negative in more prominent.

Right Atrial Enlargement

In figure A the normal P waves of Leads II and V1 are shown. Figure B shows that the right atrial component of the P waves are more prominent in both leads. This is an indication of right atrial enlargement also called P pulmonale due to its relation to pulmonary disease.