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Normal Electrical Conduction of the Heart: The electrical impulse that stimulates and paces the cardiac muscle normally originates in the sinus (SA) Node .The electrical impulse quickly travels from the sinus node through the atria to the atrio-ventricular (AV) node. The electrical stimulation of the muscle cells of the atria causes them to contract. The structure of the AV node slows the electrical impulse, which allows time for the atria to contract and fill the ventricles with blood. This is called AV delay. The electrical impulse then travels very quickly through the bundle of His to the right and left bundle branches and the Purkinjie fibers, located in the ventricular muscle. The electrical stimulation of the muscle cells of the ventricles, in turn causes the mechanical contraction of the ventricles (systole).the cell repolarize and the ventricles then relax (Diastole). The electrical stimulation causes contraction is called depolarization (Systole) The electrical relaxation is called repolarization (Diastole). ELECTROCARDIOGRAM (ECG) The electrical impulse that travels through the heart can be viewed by means of electrocardiography; each phase of the cardiac cycle is reflected by specific waveforms on a strip of ECG graph. Recording of the ECG: Standard ECG's utilize 12 leads which are composed of 6 limb leads and 6 precordial leads (chest leads). 6 Standard Limb leads: I, II, III, aVR, aVL, and aVF. 6 Standard Precordial / Chest leads: V1, V2, V3, V4, V5, and V6.


Limb Leads are located on the extremities: right arm (RA), left arm (LA), and left leg (LL). The right leg electrodes serve as aground to prevent display of background interference on ECG tracing. Leads I, II, III are bipolar leads, using both positive and negative electrodes. Leads aVR, aVL, and aVF are augmented unipolar leads that use the center of the heart as their negative electrode.


5 intercostal space in midclavicular line V5 .4 intercostal space at Rt sternal boarder V2 .4 intercostal space at Lt sternal boarder V3 .5 intercostal space in midaxillary line th th th th The positive electrode on the skin acts as a camera.The six standard precordial/chest leads are distributed in an arch around the left side of the chest. Precordial or chest (Unipolar) leads: V1 .midway between V2 and V4 V4 . 3 . If the wave of depolarization travels towards the camera.5 intercostal space in anterior axillary line th V6 .

depending on location of positive electrode.positive deflection is written on the ECG paper. If the wave of depolarization travels away from the camera negative deflection is recorded. When depolarization travel perpendiculars to camera biphasic complex occur (isoelectric line). 4 . The wave of ventricular depolarization in healthy heart travels from right to left and from head to toe. The appearance of the wave form in different ECG leads will vary.

Septal depolarization vector 3. Ventricular repolarization vector 5 . Late ventricular depolarization vector 5. Cardiac vectors of each cardiac cycle include: 1.Cardiac Vectors vs ECG The wave of depolarization that spreads through the heart during each cardiac cycle has vector properties defined by its direction and magnitude. Apical and early ventricular depolarization vector 4. At any instant depolarization occurs in multiple directions as the activation wave is propagated. Thus the instantaneous direction of the wave recorded at the skin surface is the resultant of multiple ‘minivectors’ through the heart. Atrial depolarization vector 2.

Interpretation of Electrocardiogram The ECG wave form represents the function of the heart's conduction system. 3. 1. Time and rate are measured on the horizontal axis of the graph. 6 . ECG waveforms are printed on graph paper that is divided by light and dark vertical and horizontal lines at standard intervals. in relation to the lead. which normally initiates and conducts the electrical activity. 2. Amplitude or voltage is measured on the vertical axis.

Normal voltage: Amplitude of the QRS has a wide range of normal limits.• P wave: represents the electrical impulse starting in the sinus node and spreading through the atria. flat or biphasic in III.5 mm below to 1 mm above baseline in limb leads. aVF. R.8 mm • ST segment: Interval between the end of ventricular depolarization (QRS complex) and the beginning of repolarization (T wave) . upright or biphasic in III.Amplitude is 5-25% the height of the T wave (usually < 1. aVL. V2. inverted in aVR. .Normal duration: not exceeds 0. II.Morphology is upright in all leads except aVR . . V1. V1. depending on the lead. • T wave: represents ventricular muscle repolarization . may be upright. • PR interval: From the beginning of the P wave to the first deflection of the QRS complex. and up to 3 mm concave upward elevation may be seen in the precordial leads in early repolarization 7 .Elevation is usually < 0. V3 .Normal amplitude: Usually < 6 mm in limb leads and ≤ 10 mm in precordial leads • U wave: Controversial: Afterpotentials of ventricular muscle vs.75 of one small square) . aVF. V2. aVL. . capital letters (Q.Normal Duration: < 0.Morphology: Upright in I. s) are used.5 mm. V1. .Amplitude/height: up to 2.Normal U wave: Not always present. age of the individual.U waves are typically most prominent in leads V2. except aVR. V3-V6. . small letters (q.5 mm= 1. and other factors • Q wave: The first negative deflection after the P wave .It is identified as the segment between the end of the QRS complex and the beginning of the T wave .2 sec .PR interval represents conduction time from the onset of atrial depolarization to the onset of ventricular repolarization . II. Therefore. repolarization of Purkinje fibers . May be displaced in a direction opposite to the P wave . but may vary from 0.5 small square) • QRS complex: Represents ventricular muscle depolarization . V1-V3 • R wave: the first positive deflection after the P wave • S wave: is the first negative deflection after the R wave .It sometimes is seen in patients with hypokalemia (low potassium levels).Normal: less than 25% of the R wave amplitude .Normal P wave morphology: Upright in I. depression is usually < 0.Normal PR segment: Usually isoelectric.When a wave is less than 5 mm in height. r. when a wave is taller than 5 mm. S) are used.Common in most leads.Normal ST segment: Usually isoelectric. hypertension. the P wave represents atrial muscle depolarization.5 small square) .03 seconds (0.5mm (2. or heart disease.

If the P-P (R-R) intervals are not consistently the same. the atrial (ventricular) rhythm is irregular.• The PP interval: measured from the beginning of one P wave to the beginning of the next P wave. Count the number of R waves in a 6 second strip and multiply by 10 2. 2. the atrial (ventricular) rhythm is regular. Are all the P waves similar in size and shape? 4. Does the duration of PR interval fall within normal limits? 8 . Divide that number of large squares into 300 Irregular rhythms 1. Count the number of R waves in a 3 second strip and multiply by 20 STEP 3: Evaluate the P wave 1. 2. 4. Compare the P-P and R-R intervals in several cycles. Are P waves present? 2. Do you see a one-to-one relationship between the P waves and the QRS complexes? STEP 4: Calculate the duration of the PR interval 1. STEP 2: Calculate the rate (atrial and ventricular) There are several ways to calculate heart rate. Count the number of large squares (one large square = 0. Count the number of small squares between two R waves. Used to determine atrial rhythm and atrial rate • The RR interval: measured from one QRS complex to the next QRS complex. Some are given to use with regular rhythms and one to use with irregular rhythms. the atrial (ventricular) rhythm is considered to be regularly irregular. The RR interval is used to determine ventricular rate and rhythm Analysis of the ECG . Do the P waves have a normal shape? (Small and rounded) 3. If the P-P (R-R) intervals are consistently the same. Regular rhythms 1. 3. If there is a pattern to the irregularity. Divide the number of small squares into 1500 or 1.5 step Method STEP 1: Evaluate the rhythm (atrial and ventricular) 1.20 second) between two R waves. 2.

The following are the ECG criteria for normal sinus rhythm: • Ventricular and atrial rate: 60 to 100 in the adult • Ventricular and atrial rhythm: Regular/equal RR intervals Regular/equal PP intervals • QRS: All QRS complex must look like (similar) QRS duration: between 0.R = P waves: Upright.08 .12 -0 .5 to 2. and always in front of the QRS Duration: 0.11 seconds (3 small squares) • PR interval: Consistent interval Duration: Between 0.04 – 0.0..12 and 0. Are all the QRS complexes the same size and shape? 3. Are any QRS complexes present that appear different from the other QRS complexes on the strip? 4. round in shape. Does the duration of the QRS complex fall within normal limits? 2. Is there a QRS complex for each P wave? Normal Sinus Rhythm Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the sinus node and travels through the normal conduction pathway.10 second P:qRs: 1P:1qRs 9 . similar P-R: 0.10 second (1.20 second & consistent qRs: 0.20 seconds (3 to 5 small squares) • ST segment: isoelectric line • P: QRS ratio: 1:1 • • • • • • Rate: 60-100 per minute Rhythm: R. Is the PR interval constant? STEP 5: Calculate the duration of the QRS complex 1.2.5 small squares) • P wave: Present.06 . identifiable and are of the same morphology.

2. 3. 4. Junctional. Sinus node. 10 . Atrial.CARDIAC DYSRHYTHMIAS Cardiac Dysrhythmias: are disturbances in regular heart rate and/or rhythm due to change in electrical conduction or refers to abnormal cardiac rhythms. Types of Dysrhythmias: 1. Ventricular.

athletic training. always in front of the QRS • PR interval: Consistent interval..20 second & consistent qRs: 0.Sinus bradycardia occurs when the sinus node creates an impulse at a slower-than-normal rate. similar P-R: 0.1. especially of the inferior wall . but may be regularly abnormal -P wave: Normal and consistent shape.20 seconds • • • • • • Rate: < 60 Rhythm: R. extreme emotions). Vagal stimulation (from vomiting.R = P waves: Upright. 3. Sinus Bradycardia: .12 and 0. hypothermia. calcium channel blockers. Amiderone..12 -0 . severe pain. Sinus Node Dysrhythmias A. Increased intracranial pressure and myocardial infarction (MI). .Characteristics of Sinus Bradycardia: • Ventricular and atrial rate: Less than 60 in the adult • Ventricular and atrial rhythm: Regular.g.10 second P:qRs: 1P:1qRs 11 . between 0. beta-blockers) 4.04 – 0. 2.. • QRS shape and duration: Usually normal. suctioning.g. Medications (e. Lower metabolic needs (e.Causes may include: 1. sleep. Hypothyroidism.

pain. shock.12 and 0. Rate: > 100 Rhythm: R. hypovolemia. If the rapid rate persists and the heart cannot compensate for the decreased ventricular filling. fever. As the heart rate increases. exercise. Characteristics of Sinus Tachycardia: Ventricular and atrial rate: Greater. possibly resulting in reduced cardiac output and subsequent symptoms of syncope and low blood pressure. or sympathomimetic medications.Sinus Tachycardia: Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate.20 second P: QRS ratio is 1:1.R = P waves: Upright. the diastolic filling time decreases.04 – 0. but may be buried in the preceding T wave PR interval: Consistent interval between 0. except for the rate. but may be regularly abnormal P wave: Normal and consistent shape. Hyper metabolic states.B. All aspects of sinus tachycardia are the same as those of normal sinus rhythm. anxiety. than 100 in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal.10 second P:qRs: 1P:1qRs • • • • • • • • • • • • 12 .20 second & consistent qRs: 0. anemia. congestive heart failure.12 -0 . similar P-R: 0. It may be caused by acute blood loss. the patient may develop acute pulmonary edema. always in front of the QRS.

20 seconds • P: QRS ratio: 1:1 . 13 . but may be regularly abnormal • P wave: Normal and consistent shape. but these are rarely seen.12 and 0.Non respiratory causes include heart disease and valvular disease.Sinus arrhythmia occurs when the sinus node creates an impulse at an irregular rhythm.Sinus arrhythmia does not cause any significant hemodynamic effect and usually is not treated. Sinus Arrhythmia: . the rate usually increases with inspiration and decreases with expiration. .C.Characteristics of Sinus Arrhythmia: • Ventricular and atrial rate: 60 to 100 in the adult • Ventricular and atrial rhythm: Irregular • QRS shape and duration: Usually normal. always in front of the QRS • PR interval: Consistent interval between 0. .

creating a PP interval that is shorter than the others. ATRIAL DYSRHYTHMIAS A. alcohol. dependent on underlying rhythm Rhythm: irregular P waves: Early & upright. hypokalemia (Low potassium level).04 – 0. Premature Atrial Complex: .2. different from Sinus qRs: 0. injury. but still between 0..The PAC may be caused by caffeine. different from Sinus PR: 0.12 – 0. • QRS shape and duration: The QRS that follows the early P wave is usually normal. or atrial ischemia. stretched atrial myocardium (as in hypervolemia).10 second P:qRs = 1:1 14 . but one that is less than twice the normal PP interval.Characteristics of PACs: • Ventricular and atrial rate: Depends on the underlying rhythm (e. • P: QRS ratio is usually 1:1.A premature atrial complex (PAC) is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node. or infarction. other P waves in the Strip are consistent. • P wave: An early and different P wave may be seen or may be hidden in the T wave. . . . or it may even be absent (blocked PAC). • PR interval: The early P wave has a shorter-than-normal PR interval.20 seconds. nicotine.20 second.PACs are often seen with sinus tachycardia.g. This type of interval is called a non-compensatory pause.12 and 0. • • • • • • Rate: usually < 100. This is sometimes followed by a longer-than-normal PP interval. anxiety. hyper metabolic states. sinus tachycardia) • Ventricular and atrial rhythm: Irregular due to early P waves. but it may be abnormal (aberrantly conducted PAC).

Because the atrial rate is faster than the AV node can conduct. This is an important feature of this dysrhythmia. the ventricular rhythm is usually regular but may be irregular because of a change in the AV conduction. but may be abnormal or may be absent.Characteristics of Atrial Flutter: • Ventricular and atrial rate: Atrial rate ranges between 250 and 400. PR interval: Multiple F waves may make it difficult to determine the PR interval. the ventricular rate would also be 250 to 400. causing a therapeutic block at the AV node. or 4:1 Rate: Atrial rate 250-350 Vent 150 common Rhythm: Atrial = Regular Vent = Reg. shortness of breath. such as chest pain. . . or irreg P waves: Not identifiable F waves: Uniform (sawtooth or picket fence ) PRI: not measurable qRs: 0. a life-threatening dysrhythmia. 3:1. and low blood pressure.10 second 15 . not all atrial impulses are conducted into the ventricle. ventricular rate usually ranges between 75 and 150. If all atrial impulses were conducted to the ventricle. Atrial Flutter: .04 – 0. • • • • • • • • • • • - QRS shape and duration: Usually normal. which would result in ventricular fibrillation. • Ventricular and atrial rhythm: The atrial rhythm is regular. P wave: Saw-toothed shape.Atrial flutter can cause serious signs and symptoms. P: QRS ratio: 2:1. .Atrial flutter occurs in the atrium and creates impulses at an atrial rate between 250 and 400 times per minute.B. These waves are referred to as F waves.

disorganized.Atrial fibrillation is usually associated with advanced age.Atrial fibrillation causes a rapid.Characteristics of Atrial Fibrillation: • Ventricular and atrial rate: Atrial rate is 300 to 600. pulmonary disease. coronary artery disease.A rapid ventricular response reduces the time for ventricular filling. but may be abnormal • P wave: No discernible P waves. . Vent. PRI: unable to measure (No identifiable P) qRs: usually normal 16 . or the aftermath of open heart surgery. This leads to symptoms of irregular palpitations. Ventricular rate is usually 120 to 200 in untreated atrial fibrillation • Ventricular and atrial rhythm: Highly irregular QRS shape and duration: Usually normal.Atrial fibrillation may occur for a very short time (paroxysmal). and malaise. resulting in a smaller stroke volume.C. valvular heart disease.: irregular P waves: No identifiable Ps f waves: may be seen. hyperthyroidism. Atrial Fibrillation: . irregular undulating waves are seen and are referred to as fibrillatory or f waves • PR interval: Cannot be measured • P: QRS ratio: many: l • • • • • • Rate: Atrial: 400-700 Vent. . which accounts for 25% to 30% of the cardiac output) is also lost. fatigue. cardiomyopathy. . and uncoordinated twitching of atrial musculature. or it may be chronic. . Because this rhythm causes the atria and ventricles to contract at different times. hypertension. acute moderate to heavy ingestion of alcohol ("holiday heart" syndrome). the atrial kick (the last part of diastole and ventricular filling.It may start and stop suddenly. 160-180/minute Rhythm: Atrial: irregular. .

which means that circulation is inefficient. if present. . Ventricular Dysrhythmias A. the ventricles contract first. the ventricles contract after the atria have helped to fill them by contracting. . not associated with PVC • qRs: 0. Certain medicines such as digoxin. .12 second or greater (wide). it is more dangerous than uniformal • Pattern:  When PVC follows each normal beat it is called ventricular bigemeny (every other). However. and therefore it may take unlimited number of shapes and patterns. in this way the ventricles can pump a maximized amount of blood both to the lungs and to the rest of the body. which increases heart contraction.It is a relatively common happened when the impulse is in initiated by the ventricles rather than by the SA node.In a PVC. Smoking. single beat PVC arrhythmias do not usually pose a danger and can be asymptomatic in healthy individuals.  If PVC follows every two normal beat it is called ventricular trigeminy (every third). it happened more frequent in the elderly .In a normal heartbeat. if PVC originates from various foci it will take different shapes. .Characteristics of PVC: • Rate: Dependent upon underlying rhythm • Rhythm: R – R ≠ • P waves: Usually absent. • Morphology:  Similar shape = Uniformed.A PVCs may be perceived as a "skipped beat" or felt as palpitations in the chest. couplet  Three in a row = V Tachycardia 17 .Possible causes: Ischemia. bizarre and notched • ST & T: Often opposite in direction to the qRs. Premature ventricular contraction (PVC): . Myocarditis. and electrolyte imbalance.Its a single ectopic impulse originates from any ectopic focus in the ventricles. • Location: R – on – T = PVC falls on the T wave of the complex before the PVC • Timing:  One on a strip = Rare  One in a row = Isolated  Two in a row = Pair.3. . if PVC originates from the same irritable focus it will take the same shape  Different shape = Multiformed. Hypoxia.

bizarre. if P waves seen. • QRS shape and duration: Duration > 0.VT is usually associate d with coronary artery disease and may precede ventricular fibrillation. . Ventricular Tachycardia (VT): . • P wave: Very difficult to detect. 18 . so atrial rate and rhythm may be indeterminable • PR interval: Very irregular. .12 sec (wide).Ventricular tachycardia (VT) is defined as three or more PVC in row.ECG characteristics of VT: • Ventricular and atrial rate: Ventricular rate is 100 to 200 beats per minute. VT is an emergency because the patient is usually. • Ventricular and atrial rhythm: Usually regular.The patient's tolerance or lack of tolerance for this rapid rhythm depends on the ventricular rate and underlying disease. atrial rate depends on the underlying rhythm. atrial rhythm may also be regular. there are usually more QRS complexes than P waves. occurring at a rate exceeding 100 beats per minute.B. The causes are similar to those for PVC. (although not always) unresponsive and pulseless. but if P waves are apparent. • P: QRS ratio: Difficult to determine. .

Ventricular Fibrillation (VF): .• • • • • Rate: > 100 per minute and usually not > 220 Rhythm: Usually regular P Waves: No P waves or if present.This dysrhythmia is always characterized by the absence of an audible heartbeat. .Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles. .12 sec). undulating waves without recognizable QRS complexes 19 .Because there is no coordinated cardiac activity. not associated with qRs qRs: Wide (≥ 0.Causes of ventricular fibrillation are the same as for VT. cardiac arrest and death are imminent if ventricular fibrillation is not corrected. a palpable pulse. Other causes include electrical shock . without specific pattern • QRS shape and duration: Irregular. There is no atrial activity seen on the ECG. it may also result from untreated or unsuccessfully treated VT. . and respirations. bizarre ST/T wave: Opposite direction of qRs C.ECG characteristics of Ventricular Fibrillation: • Ventricular rate: Greater than 300 per minute • Ventricular rhythm: Extremely irregular.

ECG characteristics of 1st degree AV Block: • Ventricular and atrial rhythm: Depends on the underlying rhythm -QRS shape and duration: Usually normal. .PR intervals meaures is constant • P: QRS ratio: 1:1 • • 1P : 1 qRs Prolonged PRI (> 0.vulvular disease myocarditis.drug toxicity or electrolyte imbalance .20 sec not > 0. but may be abnormal • P wave: In front of the QRS complex.40 sec) 20 . regular shape • PR interval:greater than 0. shows sinus rhythm.All the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal.20 seconds.Causes: may be according to coronary artery disease.CONDUCTION ABNORMALITIES 1. First-Degree Atrioventricular Block: .

2. so that the next atrial impulse can be conducted within the shortest amount of time. . until one impulse is fully blocked. Starting from the RR that is the longest. Type I: • Ventricular and atrial rate: Depends on the underlying rhythm • Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm. Second-Degree Atrioventricular Block. Type I: . but may be abnormal P wave: In front of the QRS complex. Cyclic pattern reoccurs R–R≠ 21 . 5:4.Each atrial impulse takes a longer time for conduction than the one before. creating a pattern in the irregular PR interval measurements. • P: QRS ratio: 3:2. shape depends on underlying rhythm • PR interval: PR interval becomes longer with each succeeding ECG complex until there is a P wave not followed by QRS. 4:3. the RR interval characteristically reflects a pattern of change. the RR interval gradually shortens until there is another long RR interval.Because the AV node is not depolarized by the blocked atrial impulse. and so forth • • • • More P waves than qRs PRI progressively increases in a cycle until P appears w/o qRs.ECG Characteristics of 2nd degree AV Block. . . • QRS shape and duration: Usually normal. The changes in the PR interval are repeated between each "dropped" QRS. the AV node has time to fully repolarize.Occurs when all but one of the atrial impulses are conducted through the AV node into the ventricles.

Type II: • Ventricular and atrial rate: Depends on the underlying rhythm • Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm. of the atrial. type II heart block occurs when only some. 4:1. • PR interval: PR interval is constant for those P waves just before QRS complexes. Second-Degree Atrioventricular Block. shape depends on underlying rhythm.Second-degree. • QRS shape and duration: Usually abnormal.R≠ or R – R = 22 . • P: QRS ratio: 2:1. 3:1. Type II: . depending on the P:QRS ratio. impulses are conducted through the AV node into the ventricles . 5:1. and so forth • • • • More P waves than qRs PRI consistent (regular) qRs normal or wide (bundle branch block) R .PR PR 3.ECG characteristics of 2nd degree AV Block. • The RR interval is usually regular but may be irregular. but may be normal • P wave: In front of the QRS complex.

This is called AV dissociation. sinus rhythm. and one stimulates the atria (eg. represented by the QRS complex. but the atrial electrical activity is not conducted down into the ventricles to cause the QRS complex. however. QRS shape and duration are usually abnormal.ECG characteristics of 3rd degree AV Block: • Ventricular and atrial rate: Depends on the escape and underlying atrial rhythm • Ventricular and atrial rhythm: The PP interval is regular and the RR interval is regular. the ventricular electrical activity. Junctional or ventricular escape rhythm). atrial fibrillation). Third-Degree Atrioventricular Block: . two impulses stimulate the heart: one stimulates the ventricles (eg.Third-degree heart block occurs when no atrial impulse is conducted through the AV node into the ventricles. represented by the P wave. P waves may be seen.4. P too far) PRI varies greatly qRs normal or wide R–R= 23 . • P wave: Depends on underlying rhythm • PR interval: Very irregular • P: QRS ratio: More P waves than QRS complexes • • • • • More P waves than qRs P not r/t qRs (P too close. . the PP interval is not equal to the RR interval. QRS shape and duration are usually normal. • QRS shape and duration: Depends on the escape rhythm. . and in ventricular escape. in junctional escape.In third-degree heart block.

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