You are on page 1of 41

1

Rapid Interpretation of ECGs Rapid Interpretation of ECGs


The Dale Dubin Method The Dale Dubin Method
David Myers, MS,RN,ANP David Myers, MS,RN,ANP- -BC BC
Richard J. Nadan, MBA,MS,RN,ACNP Richard J. Nadan, MBA,MS,RN,ACNP- -BC BC
With Sections from: With Sections from: Introduction Introduction
Why the Dale Dubin method? Why the Dale Dubin method?
Classic, most popular, & most referenced Classic, most popular, & most referenced
ECG text book ECG text book
First published in April, 1970 First published in April, 1970
Printed in 46 languages Printed in 46 languages
Uses a systematic & logical approach Uses a systematic & logical approach
Quick & easy learning Quick & easy learning
Used by all healthcare professionals Used by all healthcare professionals
around the world around the world
Myth or Fact? Myth or Fact?
Who is Dale Dubin, MD? Who is Dale Dubin, MD?
Born in 1940 Born in 1940
A famous, millionaire, plastic surgeon & A famous, millionaire, plastic surgeon &
medical school professor medical school professor
Arrested in Florida in 1986 & charged with Arrested in Florida in 1986 & charged with
sending & receiving child pornography by sending & receiving child pornography by
US mail US mail
Sentenced to 5 years in jail on 22 counts of Sentenced to 5 years in jail on 22 counts of
child pornography & cocaine use child pornography & cocaine use
He was released in 1989 He was released in 1989
Myth or Fact? Myth or Fact?
Although Dr. Dubin lost his medical Although Dr. Dubin lost his medical
license he continues to publish high license he continues to publish high
quality texts on topics in cardiology & quality texts on topics in cardiology &
electrophysiology electrophysiology
2
And now, to the really And now, to the really
important stuff important stuff
Cardiovascular Anatomy Cardiovascular Anatomy
Tissue Layers Tissue Layers
Endocardium Endocardium
Myocardium Myocardium
Pericardium Pericardium
Cardiovascular Anatomy Cardiovascular Anatomy
Coronary Circulation Coronary Circulation
Cardiovascular Anatomy Cardiovascular Anatomy
Cardiovascular Anatomy Cardiovascular Anatomy Cardiovascular Anatomy Cardiovascular Anatomy
RCA RCA: : SA Node 50% of population, AV Node 90%, Rt SA Node 50% of population, AV Node 90%, Rt
atrium, Rt ventricle atrium, Rt ventricle
Inferior wall of LV, Posterior wall 90% Inferior wall of LV, Posterior wall 90%
LCA LCA: : Left anterior descending Left anterior descending
Anterior wall, septum, His bundle, rt bundle, Anterior wall, septum, His bundle, rt bundle,
Anterior fascicle of left bundle Anterior fascicle of left bundle
Circumflex Circumflex
SA node 50%, AV node 10%, Left atrium, Lateral SA node 50%, AV node 10%, Left atrium, Lateral
wall of left ventricle, Posterior wall 10%, wall of left ventricle, Posterior wall 10%,
Posterior fascicle of left branch Posterior fascicle of left branch
3
Cardiac Physiology Cardiac Physiology
The Cardiac Cycle The Cardiac Cycle
Diastole Diastole
Systole Systole
Ejection Fraction Ejection Fraction
Stroke Volume Stroke Volume
Preload Preload
Cardiac Contractility Cardiac Contractility
Afterload Afterload
Cardiac Physiology Cardiac Physiology
Nervous Control of Nervous Control of
the Heart the Heart
Sympathetic Sympathetic
Parasympathetic Parasympathetic
Autonomic Autonomic
Control of the Control of the
Heart Heart
Role of Role of
Electrolytes Electrolytes
Cardiac Physiology Cardiac Physiology
Electrophysiology Electrophysiology
Cardiac Muscle Cardiac Muscle
Atrial Atrial
Ventricular Ventricular
Excitatory & Excitatory &
Conductive Fibers Conductive Fibers
Atrioventricular Atrioventricular
Bundle Bundle
Cardiac Physiology Cardiac Physiology
Cardiac Conduction System: Properties Cardiac Conduction System: Properties
Excitability Excitability
Conductivity Conductivity
Automaticity Automaticity
Contractility Contractility
Cardiac Physiology Cardiac Physiology
Components Components
Sinoatrial Node Sinoatrial Node
Internodal Internodal
Atrial Pathways Atrial Pathways
Atrioventricular Atrioventricular
Node Node
Atrioventricular Atrioventricular
Junction Junction
Bundle of His Bundle of His
Left & Right Left & Right
Bundle Branches Bundle Branches
Purkinje Fibers Purkinje Fibers
A Brief History of EKGs A Brief History of EKGs
In 1790, Luigi In 1790, Luigi
Galvani made a Galvani made a
dead frog dead frog s legs s legs
dance by electrical dance by electrical
stimulation stimulation
4
A Brief History of EKGs A Brief History of EKGs
In 1855, Kollicker & In 1855, Kollicker &
Mueller found that Mueller found that
when a motor nerve when a motor nerve
to a frog to a frog s leg was s leg was
laid over its isolated laid over its isolated
beating heart, the beating heart, the
leg kicked with each leg kicked with each
heartbeat heartbeat
A Brief History of EKGs A Brief History of EKGs
This made an association between the This made an association between the
rhythmic pumping of the heart & an rhythmic pumping of the heart & an
electrical phenomena electrical phenomena
Very basic & very important Very basic & very important
A Brief History of EKGs A Brief History of EKGs
In the mid 1880s In the mid 1880s
Ludwig & Waller Ludwig & Waller
used a used a capillary capillary
electrometer electrometer to to
monitor the hearts monitor the hearts
electric stimuli from electric stimuli from
a person a person s skin s skin
A Brief History of EKGs A Brief History of EKGs
Dr. Willem Dr. Willem
Einthoven placed Einthoven placed
skin sensors on a skin sensors on a
person & suspended person & suspended
a silver wire a silver wire
between the poles of between the poles of
a magnet. The wire a magnet. The wire
twitched with each twitched with each
heart beat. heart beat.
A Brief History of EKGs A Brief History of EKGs
This was a great idea, but Dr. Einthoven This was a great idea, but Dr. Einthoven
wanted a timed tracing wanted a timed tracing
He drilled two holes in the poles of the He drilled two holes in the poles of the
magnet & projected a light beam magnet & projected a light beam
though the holes onto photographic though the holes onto photographic
paper paper
He named the waves P, QRS, & T He named the waves P, QRS, & T
He named his 1901 invention the He named his 1901 invention the
E Electro lectroK Kardio ardioG Gram ram
A Brief History of EKGs A Brief History of EKGs
5
A Brief History of EKGs A Brief History of EKGs
Since 1901 the medical profession has Since 1901 the medical profession has
used used EKG EKG to represent the to represent the
electrocardiogram. Some say that electrocardiogram. Some say that
ECG ECG is more correct. Medicine tends is more correct. Medicine tends
to honor tradition & has used EKG for to honor tradition & has used EKG for
over a century. over a century.
Basic Principles Basic Principles
The EKG records the electrical activity The EKG records the electrical activity
of contraction of the myocardium of contraction of the myocardium
The EKG provides a record of cardiac The EKG provides a record of cardiac
electrical activity electrical activity
The EKG provides information about The EKG provides information about
the heart the heart s function & structure s function & structure
Basic Principles Basic Principles Basic Principles Basic Principles
Myocytes (myocardial cells) are Myocytes (myocardial cells) are
polarized (negative) at rest polarized (negative) at rest
When depolarized (positive) they When depolarized (positive) they
contract contract
Technically, however, in the strictest Technically, however, in the strictest
sense, a resting polarized cell has a sense, a resting polarized cell has a
negatively charged interior & a negatively charged interior & a
positively charged outside surface. But positively charged outside surface. But
we will keep this simple & only we will keep this simple & only
consider the interior. consider the interior.
Basic Principles Basic Principles
Depolarization can be considered a Depolarization can be considered a
wave traveling through the heart wave traveling through the heart
The cell The cell- -to to- -cell conduction of cell conduction of
depolarization through the depolarization through the
myocardium is carried by fast myocardium is carried by fast- -moving moving
Na Na
+ +
ions ions
Basic Principles Basic Principles
6
Basic Principles Basic Principles
Cardiac Depolarization Cardiac Depolarization
Basic Principles Basic Principles
Repolarization is an electrical phenomenon Repolarization is an electrical phenomenon
that begins immediately after depolarization. that begins immediately after depolarization.
The broad hump that we see on an EKG wave The broad hump that we see on an EKG wave
is the most active phase of repolarization is the most active phase of repolarization
Basic Principles Basic Principles
Sensors called Sensors called
electrodes are put on electrodes are put on
the skin the skin
As the positive wave of As the positive wave of
depolarization within depolarization within
the myocytes flows the myocytes flows
towards a positive towards a positive
electrode, there is an electrode, there is an
upward deflection on upward deflection on
the EKG the EKG
Basic Principles Basic Principles
The heart The heart s dominant pacemaker is the s dominant pacemaker is the
SA Node (sinoatrial node) SA Node (sinoatrial node)
Its pacing activity is known as Sinus Its pacing activity is known as Sinus
Rhythm Rhythm
Generation of pacemaking stimuli is Generation of pacemaking stimuli is
automaticity automaticity
Other focal areas of the heart that have Other focal areas of the heart that have
automaticity are called automaticity are called automaticity automaticity
foci foci
Basic Principles Basic Principles
The SA Node is located in the upper The SA Node is located in the upper- -
posterior wall of the right atrium posterior wall of the right atrium
The depolarization wave flows away The depolarization wave flows away
from the SA Node in all directions from the SA Node in all directions
Imagine the atria as a pool of water, a Imagine the atria as a pool of water, a
pebble dropped in at the SA Node pebble dropped in at the SA Node
produces an enlarging, circular wave produces an enlarging, circular wave
(depolarization) that spreads outward. (depolarization) that spreads outward.
Basic Principles Basic Principles
7
Basic Principles Basic Principles
Each depolarization wave emitted by the SA Node Each depolarization wave emitted by the SA Node
spreads through both atria producing a spreads through both atria producing a P wave P wave on on
the EKG the EKG
Note the positive wave of atrial depolarization Note the positive wave of atrial depolarization
advancing toward a positive electrode producing an advancing toward a positive electrode producing an
upward P wave upward P wave
Basic Principles Basic Principles
The P wave The P wave
represents the represents the
depolarization of depolarization of
both atria & the both atria & the
virtually virtually
simultaneous simultaneous
contraction of the contraction of the
atria. atria.
Basic Principles Basic Principles
Atrio Atrio- -Ventricular (AV) valves prevent Ventricular (AV) valves prevent
ventricle ventricle- -to to- -atrium blood backflow atrium blood backflow
AV valves electrically insulate the AV valves electrically insulate the
ventricles from the atria ventricles from the atria EXCEPT for EXCEPT for
the the AV Node AV Node, the only conducting path , the only conducting path
between the atria & ventricles between the atria & ventricles
Basic Principles Basic Principles
The AV Node is just above, but The AV Node is just above, but
continuous with, a specialized continuous with, a specialized
conduction system that distributes conduction system that distributes
depolarization to the ventricles very depolarization to the ventricles very
efficiently. efficiently.
Basic Principles Basic Principles Basic Principles Basic Principles
Blood flow Blood flow
O O
2 2
depleted blood enters the RA via the depleted blood enters the RA via the
IVC, SVC, & coronary sinus IVC, SVC, & coronary sinus
Atrial contraction forces blood through the Atrial contraction forces blood through the
tricuspid valve into the RV tricuspid valve into the RV
Ventricular contraction will force blood Ventricular contraction will force blood
through the pulmonic valve into the through the pulmonic valve into the
pulmonary artery pulmonary artery
8
Basic Principles Basic Principles
Remember Remember
T Tri ricuspid valve is on the cuspid valve is on the ri right ght
Both atria contract simultaneously, both Both atria contract simultaneously, both
ventricles contract simultaneously ventricles contract simultaneously
Right & left sides of the heart have very Right & left sides of the heart have very
different responsibilities different responsibilities
Basic Principles Basic Principles
Basic Principles Basic Principles
Blood flow Blood flow
Blood enters the LA through the Blood enters the LA through the
pulmonary veins pulmonary veins
The LA contracts & forces blood through The LA contracts & forces blood through
the mitral valve into the LV the mitral valve into the LV
The LV contracts & forces blood through The LV contracts & forces blood through
the aortic valve in to the Ao (aorta) into the aortic valve in to the Ao (aorta) into
systemic circulation systemic circulation
Remember Remember
Mitra Mitral l valve in on the valve in on the l left eft
Basic Principles Basic Principles
Basic Principles Basic Principles
Back to the AV Node Back to the AV Node
When the wave of atrial depolarization When the wave of atrial depolarization
enters the AV Node, depolarization slows enters the AV Node, depolarization slows
down, producing a brief pause down, producing a brief pause
This allows time for blood in the atria to This allows time for blood in the atria to
enter the ventricles enter the ventricles
Slow conduction through the AV Node is Slow conduction through the AV Node is
carried by Ca carried by Ca
++ ++
ions ions
Basic Principles Basic Principles
Remember Remember
The AV Node is the only electrical The AV Node is the only electrical
conduction pathway between the atria & conduction pathway between the atria &
ventricles ventricles
We are correlating electrical activity with We are correlating electrical activity with
mechanical physiology mechanical physiology
Atria contract forcing blood through the Atria contract forcing blood through the
AV valves AV valves
It takes time for blood to flow though the It takes time for blood to flow though the
valves into the ventricles valves into the ventricles
9
Basic Principles Basic Principles
Time for blood flow means a necessary pause Time for blood flow means a necessary pause
It takes time for blood to flow though the It takes time for blood to flow though the
valves into the ventricles valves into the ventricles
A necessary pause that produces a short flat A necessary pause that produces a short flat
baseline after each P wave on the EKG baseline after each P wave on the EKG
Remember this pause!!! You will need it later Remember this pause!!! You will need it later
Basic Principles Basic Principles
Note the pause Note the pause
Basic Principles Basic Principles
Just a thought Just a thought
So far we have talked about Na So far we have talked about Na
+ +
& Ca & Ca
++ ++
What medications do you know about that What medications do you know about that
might affect these channels? might affect these channels?
Basic Principles Basic Principles
Depolarization conducts slowly Depolarization conducts slowly
through the AV Node through the AV Node
Upon reaching the ventricular Upon reaching the ventricular
conduction system, depolarization conduction system, depolarization
rapidly shoots through the rapidly shoots through the His Bundle His Bundle
& the & the Left Left & & Right Bundle Branches Right Bundle Branches
Basic Principles Basic Principles
The ventricular conduction system originates The ventricular conduction system originates
at the His Bundle, which penetrates the AV at the His Bundle, which penetrates the AV
valves, then immediately bifurcates in the valves, then immediately bifurcates in the
interventricular septum into the Right & Left interventricular septum into the Right & Left
Bundle Branches Bundle Branches
The His bundle & both Bundle Branches are The His bundle & both Bundle Branches are
bundles bundles of rapidly conducting of rapidly conducting Purkinje Purkinje
Fibers Fibers
Basic Principles Basic Principles
Like the Like the
myocardium, myocardium,
Purkinje Fibers use Purkinje Fibers use
fast fast- -moving Na moving Na
+ +
ions for the ions for the
conduction of conduction of
depolarization depolarization
10
Basic Principles Basic Principles
The ventricular conduction system is The ventricular conduction system is
composed of bundles of rapidly composed of bundles of rapidly- -
conducting Purkinje Fibers that carry conducting Purkinje Fibers that carry
depolarization away from the AV Node depolarization away from the AV Node
at high speed at high speed
Basic Principles Basic Principles
The Purkinje Fibers terminate in tiny The Purkinje Fibers terminate in tiny
filaments that directly depolarize the filaments that directly depolarize the
ventricular myocytes ventricular myocytes
The rapid passage of depolarization The rapid passage of depolarization
down the ventricular conduction down the ventricular conduction
system is too weak to record on the system is too weak to record on the
EKG EKG
Basic Principles Basic Principles
Depolarization of the ventricular Depolarization of the ventricular
myocardium records as a QRS complex myocardium records as a QRS complex
Basic Principles Basic Principles
The terminal The terminal
filaments of the filaments of the
Purkinje Fibers Purkinje Fibers
Producing a QRS Producing a QRS
complex complex
Basic Principles Basic Principles
The terminal filaments of the Purkinje The terminal filaments of the Purkinje
Fibers spread out just beneath the Fibers spread out just beneath the
endocardium that lines both ventricular endocardium that lines both ventricular
cavities cavities
Ventricular depolarization begins at he Ventricular depolarization begins at he
lining & proceeds outward to the lining & proceeds outward to the
outside surface (epicardium) of the outside surface (epicardium) of the
ventricles ventricles
Basic Principles Basic Principles
Purkinje Fibers branch & subdivide just Purkinje Fibers branch & subdivide just
beneath the endocardial lining, but do beneath the endocardial lining, but do
not penetrate the myocardium. not penetrate the myocardium.
11
Basic Principles Basic Principles
The QRS complex actually represents the The QRS complex actually represents the
beginning of ventricular contraction beginning of ventricular contraction
The physical event of ventricular contraction The physical event of ventricular contraction
actually last longer than the QRS complex actually last longer than the QRS complex
Basic Principles Basic Principles
The Q wave is the first downward wave The Q wave is the first downward wave
of the QRS complex. It is followed by an of the QRS complex. It is followed by an
upward R wave. The Q wave is often upward R wave. The Q wave is often
absent on the EKG absent on the EKG
Basic Principles Basic Principles
The Q wave, when The Q wave, when
present ALWAYS present ALWAYS
occurs at the occurs at the
beginning of the beginning of the
QRS complex & is QRS complex & is
the first downward the first downward
deflection of the deflection of the
complex complex
Basic Principles Basic Principles
If there is an If there is an up upward deflection in a QRS ward deflection in a QRS
complex that appears before a Q wave, it is complex that appears before a Q wave, it is
NOT a Q wave. NOT a Q wave.
When present, the Q wave is ALWAYS the When present, the Q wave is ALWAYS the
first wave in the complex first wave in the complex
It is now popular to use small letter to It is now popular to use small letter to
designate small waves in the QRS complex; a designate small waves in the QRS complex; a
q q wave is a small wave, a wave is a small wave, a Q Q wave is a big wave is a big
wave wave
Basic Principles Basic Principles
The first upward wave of the QRS is the The first upward wave of the QRS is the
R wave R wave
Any downward wave PRECEDED by Any downward wave PRECEDED by
an upward wave is an S wave an upward wave is an S wave
Basic Principles Basic Principles
12
Basic Principles Basic Principles
An upward wave is always called an R An upward wave is always called an R
wave wave
Distinguishing between the downward Distinguishing between the downward
Q & downward S waves really depends Q & downward S waves really depends
on whether the downward wave occurs on whether the downward wave occurs
before or after the R wave before or after the R wave
The Q is before the R, & the S is after The Q is before the R, & the S is after
the R the R
Just remember the alphabet! Just remember the alphabet!
Lets Play Name That Wave Lets Play Name That Wave
1: 1: Q wave Q wave
2: 2: R wave R wave
3: 3: S wave S wave
4: 4: QS wave QS wave
Name That Wave Name That Wave
Yes, # 4 is a little unfair. There is no upward wave, Yes, # 4 is a little unfair. There is no upward wave,
hence we cannot determine whether it is a Q wave or hence we cannot determine whether it is a Q wave or
an S wave. Therefore it is called a QS wave, & is an S wave. Therefore it is called a QS wave, & is
considered to be a Q wave when we look for Qs considered to be a Q wave when we look for Qs
Basic Principles Basic Principles
Following the QRS complex, there is a Following the QRS complex, there is a
segment of horizontal baseline known as the segment of horizontal baseline known as the
ST segment, & then a broad T wave appears ST segment, & then a broad T wave appears
Basic Principles Basic Principles
The St segment is a The St segment is a
horizontal, flat, & most horizontal, flat, & most
importantly, it is importantly, it is
normally level with normally level with
other areas of the other areas of the
baseline baseline
If it is elevated or If it is elevated or
depressed beyond the depressed beyond the
normal baseline level, it normal baseline level, it
is usually a serious is usually a serious
pathology pathology
Basic Principles Basic Principles
The ST segment represents the plateau The ST segment represents the plateau
(initial) phase of ventricular (initial) phase of ventricular
repolarization. repolarization.
Ventricular repolarization is rather Ventricular repolarization is rather
minimal during the ST segment minimal during the ST segment
13
Basic Principles Basic Principles
The T wave The T wave
represents the final, represents the final,
rapid rapid phase of phase of
ventricular ventricular
repolarization repolarization
Basic Principles Basic Principles
Both phases of Both phases of
repolarization is repolarization is
accomplished by K accomplished by K
+ +
ions leaving the ions leaving the
myocytes myocytes
Ventricular systole Ventricular systole
begins with the QRS begins with the QRS
& persists until the & persists until the
end of the T wave end of the T wave
Basic Principles Basic Principles
Ventricular contraction (systole) spans Ventricular contraction (systole) spans
depolarization & repolarization of the depolarization & repolarization of the
ventricles ventricles
This a major & convenient physiological This a major & convenient physiological
marker marker
Basic Principles Basic Principles
Since ventricular systole lasts from the Since ventricular systole lasts from the
beginning of the QRS until the end of beginning of the QRS until the end of
the T wave, the the T wave, the QT interval QT interval has clinical has clinical
significance significance
Basic Principles Basic Principles Basic Principles Basic Principles
The QT interval is a good indicator of The QT interval is a good indicator of
repolarization, since repolarization repolarization, since repolarization
comprises most of the QT interval comprises most of the QT interval
Patients with Long QT interval (LQT) Patients with Long QT interval (LQT)
syndromes are vulnerable to deadly syndromes are vulnerable to deadly
rapid ventricular rhythms rapid ventricular rhythms
14
Basic Principles Basic Principles
With rapid heart rates both depolarization & With rapid heart rates both depolarization &
repolarization occur faster for greater repolarization occur faster for greater
efficiency, therefore the QT interval varies efficiency, therefore the QT interval varies
with heart rate with heart rate
Precise QT interval measurements are Precise QT interval measurements are
corrected for rate, we call this the QTc corrected for rate, we call this the QTc
In general, the QT interval is normal if it is In general, the QT interval is normal if it is
less than half the R less than half the R- -to to- -R interval at normal R interval at normal
rates rates
Basic Principles Basic Principles
Physiologically, a cardiac cycle Physiologically, a cardiac cycle
represents atrial systole followed by represents atrial systole followed by
ventricular systole, & the resting stage ventricular systole, & the resting stage
that follows until another cardiac cycle that follows until another cardiac cycle
begins begins
Basic Principles Basic Principles Basic Principles Basic Principles
So far you have seen the P, QRS, & T So far you have seen the P, QRS, & T
waves waves
There is one other wave that you may There is one other wave that you may
see on occasion see on occasion
The U wave The U wave
Basic Principles Basic Principles
The U wave The U wave
A small deflection that may occasionally follow A small deflection that may occasionally follow
the T wave the T wave
Neither presence nor absence is abnormal Neither presence nor absence is abnormal
Part of ventricular repolarization Part of ventricular repolarization
Generally small, rounded ( < 2 mm), same Generally small, rounded ( < 2 mm), same
direction as T wave direction as T wave
Larger with at slow heart rate, smaller at fast heart Larger with at slow heart rate, smaller at fast heart
rate rate
Basic Principles Basic Principles
U wave U wave
15
Basic Principles Basic Principles Basic Principles Basic Principles
The movement of three types of ions determines The movement of three types of ions determines
all aspects of cardiac conduction, contractions, & all aspects of cardiac conduction, contractions, &
repolarization repolarization
Basic Principles Basic Principles - - Review Review
Relationship of the Relationship of the
ECG to electrical events ECG to electrical events
in the heart in the heart
ECG components ECG components
P wave P wave
QRS complex QRS complex
T wave T wave
Basic Principles Basic Principles - - Review Review
Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review
16
Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review
Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review
Recording the EKG Recording the EKG
EKG paper is graph paper EKG paper is graph paper
The smallest divisions are 1 mm The smallest divisions are 1 mm
squares squares
1 mm high x 1 mm long 1 mm high x 1 mm long
Time axis (x) is horizontal & moves left Time axis (x) is horizontal & moves left
to right, like we read to right, like we read
Amplitude axis (y) is vertical Amplitude axis (y) is vertical
Recording the EKG Recording the EKG
Between heavy black lines there are 5 small squares Between heavy black lines there are 5 small squares
Each large square is formed by heavy black lines on Each large square is formed by heavy black lines on
each side & is 5 mm long x 5 mm high each side & is 5 mm long x 5 mm high
17
Recording the EKG Recording the EKG
Deflection is the direction of a wave Deflection is the direction of a wave
Upward or downward Upward or downward
Amplitude is the magnitude of voltage of electrical activity Amplitude is the magnitude of voltage of electrical activity
Amplitude is measured from the baseline (isoelectric line) Amplitude is measured from the baseline (isoelectric line)
Recording the EKG Recording the EKG
When a wave of depolarization When a wave of depolarization
advances toward a positive skin advances toward a positive skin
electrode it produces a positive electrode it produces a positive
deflection deflection
Be positive. This will make more sense in a Be positive. This will make more sense in a
little while. little while.
Recording the EKG Recording the EKG
Upward deflections Upward deflections
are called positive are called positive
deflections deflections
Downward Downward
deflections are deflections are
called negative called negative
deflections deflections
Recording the EKG Recording the EKG
As we said earlier, the horizontal axis is time As we said earlier, the horizontal axis is time
Each small box is 0.04 of a second Each small box is 0.04 of a second
Each big box (or 5 small boxes) is 0.2 of a Each big box (or 5 small boxes) is 0.2 of a
second second
Recording the EKG Recording the EKG
With this information it is now possible to With this information it is now possible to
determine the time of any part of the cardiac determine the time of any part of the cardiac
cycle cycle
Recording the EKG Recording the EKG
EKG paper passes out of the EKG machine at EKG paper passes out of the EKG machine at
a set & constant speed a set & constant speed
In 0.12 second, 3 small squares In 0.12 second, 3 small squares
In general, the paper travels at 25 mm / second In general, the paper travels at 25 mm / second
18
Recording the EKG Recording the EKG
A standard EKG is composed of 12 A standard EKG is composed of 12
separate leads separate leads
6 limb leads 6 limb leads
6 chest leads (also called precordial leads 6 chest leads (also called precordial leads
or vector leads) or vector leads)
Recording the EKG Recording the EKG
Recording the EKG Recording the EKG
Limb leads are placed on the right & Limb leads are placed on the right &
left arms & left leg left arms & left leg
Two electrodes are used to record a Two electrodes are used to record a
lead lead
A different pair for each lead A different pair for each lead
Recording the EKG Recording the EKG
Recording the EKG Recording the EKG
Remember the positive & negative Remember the positive & negative
deflections that an EKG tracing can deflections that an EKG tracing can
make? This is where it all comes make? This is where it all comes
together together
Recording the EKG Recording the EKG
Bipolar limb leads Bipolar limb leads
are recorded using 2 are recorded using 2
electrodes electrodes
Selecting different Selecting different
electrodes will yield electrodes will yield
different leads different leads
One electrode is One electrode is
positive & one is positive & one is
negative negative
19
Recording the EKG Recording the EKG
Bipolar simply means one pole is Bipolar simply means one pole is
positive & one pole is negative positive & one pole is negative
The poles are the electrodes The poles are the electrodes
Recording the EKG Recording the EKG
Lead I is horizontal Lead I is horizontal
Left arm positive, right arm negative Left arm positive, right arm negative
Lead II is diagonal Lead II is diagonal
Left foot is positive, right arm is negative Left foot is positive, right arm is negative
Lead III is vertical Lead III is vertical
Left foot is positive, but now the left arm is Left foot is positive, but now the left arm is
negative negative
Recording the EKG Recording the EKG
The EKG machine will switch the The EKG machine will switch the
polarity of the electrodes automatically polarity of the electrodes automatically
i.e.: the left arm switched from positive to i.e.: the left arm switched from positive to
negative depending which lead we were negative depending which lead we were
looking at looking at
This bipolar limb configuration is call This bipolar limb configuration is call
Einthoven Einthoven s Triangle (remember him?) s Triangle (remember him?)
Recording the EKG Recording the EKG
With your pen draw With your pen draw
Negative sign ( Negative sign (- -) on ) on
your right hand your right hand
Positive sign (+) on Positive sign (+) on
your left leg your left leg
Both signs (+/ Both signs (+/- -) on ) on
your left hand your left hand
Lets play Twister!!! Lets play Twister!!!
Recording the EKG Recording the EKG
Creating three intersecting lines produces a Creating three intersecting lines produces a
point of reference point of reference
Recording the EKG Recording the EKG
So far we have discussed 3 of the 6 limb So far we have discussed 3 of the 6 limb
leads leads
Lead I Lead I
Lead II Lead II
Lead II Lead II
Now for the other 3 Now for the other 3
AVR AVR
AVL AVL
AVF AVF
20
Recording the EKG Recording the EKG
Another standard lead is the AVF lead Another standard lead is the AVF lead
AVF uses the left foot as positive & both AVF uses the left foot as positive & both
arms as a common negative ground arms as a common negative ground
The The A A in AVF means in AVF means augmented augmented
Recording the EKG Recording the EKG
Dr. Emanuel Goldberg designed the Dr. Emanuel Goldberg designed the
augmented limb leads augmented limb leads
He discovered that he had to amplify He discovered that he had to amplify
(augment) the voltage in the EKG (augment) the voltage in the EKG
machine to match the magnitude of machine to match the magnitude of
Leads I, II, & III Leads I, II, & III
He named it A (augmented) V (voltage) He named it A (augmented) V (voltage)
F (Foot) F (Foot)
Recording the EKG Recording the EKG
AVF is a combination of Leads II & III AVF is a combination of Leads II & III
Recording the EKG Recording the EKG
AVR & AVL are obtained in the same manner AVR & AVL are obtained in the same manner
Augmented limb leads are unipolar because Augmented limb leads are unipolar because
they stress the importance of the positive they stress the importance of the positive
electrode electrode
Recording the EKG Recording the EKG
Remember Remember
AV AVR R R Right arm positive ight arm positive
AV AVL L L Left arm positive eft arm positive
AV AVF F Left Left f foot positive oot positive
Recording the EKG Recording the EKG
The augmented (unipolar) limb leads, The augmented (unipolar) limb leads,
AVR, AVL, & AVF intersect at different AVR, AVL, & AVF intersect at different
angles than the bipolar limb leads, I, II, angles than the bipolar limb leads, I, II,
& III & III
They produce three other intersecting They produce three other intersecting
lines of reference lines of reference
21
Recording the EKG Recording the EKG Recording the EKG Recording the EKG
The 6 limb leads combined The 6 limb leads combined
Recording the EKG Recording the EKG
Deep breath Deep breath Don Don t panic by the t panic by the
kaleidoscope of limb leads. It will make kaleidoscope of limb leads. It will make
more sense in a little while. more sense in a little while.
Recording the EKG Recording the EKG
Think of each lead Think of each lead
as a camera looking as a camera looking
at the heart from a at the heart from a
different angle different angle
In the ICU or In the ICU or
telemetry floor, telemetry floor,
think of the camera think of the camera
as a video camera as a video camera
Recording the EKG Recording the EKG
Points to remember Points to remember
The heart The heart s electrical activity remain s electrical activity remain
constant constant
The positive electrode position changes The positive electrode position changes
from lead to lead from lead to lead
The tracing will look slightly different in The tracing will look slightly different in
each lead each lead
Recording the EKG Recording the EKG
Points to remember Points to remember
The angle from which we record the The angle from which we record the
electrical activity changes with each lead electrical activity changes with each lead
A wave of depolarization is a progressive A wave of depolarization is a progressive
wave of POSITIVE charges passing wave of POSITIVE charges passing
through myocardial cells through myocardial cells
22
Recording the EKG Recording the EKG
Points to remember Points to remember
When a depolarization wave moves When a depolarization wave moves
toward a POSITIVE electrode, a POSITIVE toward a POSITIVE electrode, a POSITIVE
deflection is produced deflection is produced
When a POSITIVE current moves toward a When a POSITIVE current moves toward a
POSTIVE electrode it produces a POSITVE POSTIVE electrode it produces a POSITVE
deflection deflection
Repetitious, but vitally important!!! Repetitious, but vitally important!!!
Recording the EKG Recording the EKG
Lets go car shopping Lets go car shopping
Based only on the photo below, would you buy Based only on the photo below, would you buy
this car? this car?
Recording the EKG Recording the EKG
Now would you buy this car? Now would you buy this car?
Recording the EKG Recording the EKG
A bit of trivia A bit of trivia In 2001, Jeffrey Seiden, a third In 2001, Jeffrey Seiden, a third- -year year
medical student at Yale University, was studying medical student at Yale University, was studying
his electrocardiography textbook when he his electrocardiography textbook when he
happened upon the following message tucked away happened upon the following message tucked away
in the book's copyright notice: in the book's copyright notice: Congratulations for Congratulations for
your perseverance. You may win the car on page 46 by your perseverance. You may win the car on page 46 by
writing down your name & address & submitting it to writing down your name & address & submitting it to
the publisher. the publisher.
Trivia Continued Trivia Continued
Dr. Dale Dubin had inserted the note into his 50th Dr. Dale Dubin had inserted the note into his 50th
printing of his "Rapid Interpretation of EKGs," printing of his "Rapid Interpretation of EKGs,"
putting his classic Thunderbird up for grabs. Of the putting his classic Thunderbird up for grabs. Of the
60,000 who bought the book containing the offer, 60,000 who bought the book containing the offer,
only five spotted the hidden message & contacted the only five spotted the hidden message & contacted the
publisher with news of their find. The five names publisher with news of their find. The five names
were placed in a hat, & Jeffrey Seiden's was chosen at were placed in a hat, & Jeffrey Seiden's was chosen at
random. The 1965 Thunderbird convertible was random. The 1965 Thunderbird convertible was
delivered to him on 4 December 2001 by Dubin's delivered to him on 4 December 2001 by Dubin's
daughter, who drove it to Seiden's school. daughter, who drove it to Seiden's school.
Recording the EKG Recording the EKG
The point of the car is that observation The point of the car is that observation
from six angles is clearly better than one from six angles is clearly better than one
23
Recording the EKG Recording the EKG
A positive left arm electrode is used to record A positive left arm electrode is used to record
LATERAL leads (I & AVL) LATERAL leads (I & AVL)
A positive left foot electrode is used to record A positive left foot electrode is used to record
INFERIOR leads (II, III, & AVF) INFERIOR leads (II, III, & AVF)
Recording the EKG Recording the EKG
Lateral & inferior will play a role later Lateral & inferior will play a role later
when referring to myocardial ischemia, when referring to myocardial ischemia,
injury, or infarction injury, or infarction
Recording the EKG Recording the EKG
Now for the six chest leads (also called Now for the six chest leads (also called
precordial leads or vector leads) precordial leads or vector leads)
Recording the EKG Recording the EKG
The chest leads are V The chest leads are V
1 1
, V , V
2 2
, V , V
3 3
, V , V
4 4
, V , V
5 5
, & , &
V V
6 6
The chest lead is always positive The chest lead is always positive
The leads are positioned on the chest The leads are positioned on the chest
from right to left covering the heart in from right to left covering the heart in
its normal anatomical position its normal anatomical position
Again, the lead is positive, the patient Again, the lead is positive, the patient s s
back is negative back is negative
Recording the EKG Recording the EKG Recording the EKG Recording the EKG
Each of the vector Each of the vector
leads is oriented leads is oriented
through the AV through the AV
Node & projects Node & projects
through the through the
patient patient s back which s back which
is negative is negative
Dr. Frank Wilson Dr. Frank Wilson
introduced the V introduced the V
leads leads
24
Recording the EKG Recording the EKG
One more time One more time
A positive depolarization wave moving A positive depolarization wave moving
towards a positive electrode produces a towards a positive electrode produces a
positive deflection positive deflection
Get it? Get it?
Got it. Got it.
Good! Good!
Recording the EKG Recording the EKG
When observing the chest leads from V When observing the chest leads from V
1 1
to V to V
6 6
you should note gradual changes you should note gradual changes
in all the waves as the position of the in all the waves as the position of the
positive electrode changes for each positive electrode changes for each
successive lead successive lead
Recording the EKG Recording the EKG Recording the EKG Recording the EKG
Leads V Leads V
1 1
& V & V
2 2
are oriented over the are oriented over the
right side of the heart while V right side of the heart while V
5 5
& V & V
6 6
are are
oriented over the left side of the heart. oriented over the left side of the heart.
Therefore they are often called the right Therefore they are often called the right
& left chest leads & left chest leads
Recording the EKG Recording the EKG Recording the EKG Recording the EKG
Leads V Leads V
3 3
& V & V
4 4
are oriented over the are oriented over the
interventricular septum with V interventricular septum with V
3 3
being being
closer to the right ventricle & V closer to the right ventricle & V
4 4
closer closer
to the left ventricle to the left ventricle
The right & left bundle branches course The right & left bundle branches course
through the interventricular septum through the interventricular septum
25
Recording the EKG Recording the EKG
Quick review Quick review
The six limb leads all lie in the frontal The six limb leads all lie in the frontal
plane plane
The six precordial leads lie in the The six precordial leads lie in the
horizontal plane horizontal plane
6 + 6 = 12, therefore a 12 6 + 6 = 12, therefore a 12- -Lead EKG Lead EKG
Recording the EKG Recording the EKG
Recording the EKG Recording the EKG
We rarely place the We rarely place the
electrodes on a electrodes on a
patient patient s wrists or s wrists or
ankles, so we have ankles, so we have
modified the modified the
locations locations
Recording the EKG Recording the EKG - - Review Review
ECG Leads ECG Leads
Bipolar (Limb) Bipolar (Limb)
Einthoven Einthoven s s
Triangle Triangle
Leads I, II, III Leads I, II, III
Precordial (unipolar) Precordial (unipolar)
V V
1 1
V V
6 6
Recording the EKG Recording the EKG - - Review Review
Lead I Lead I
Left arm + Left arm +
Right arm Right arm
Shoulder to Shoulder to
shoulder shoulder
Always upright Always upright
Recording the EKG Recording the EKG - - Review Review
Lead II Lead II
Left leg + Left leg +
Right arm Right arm
Right shoulder to Right shoulder to
apex apex
Always upright Always upright
26
Recording the EKG Recording the EKG - - Review Review
Lead III Lead III
Left leg + Left leg +
Left arm Left arm
Left Shoulder to Left Shoulder to
apex apex
Upright Upright
Recording the EKG Recording the EKG - - Review Review
Leads I, II, III Leads I, II, III
Recording the EKG Recording the EKG - - Review Review
Enlargement of Enlargement of
waveform waveform
aVR, aVL, aVF aVR, aVL, aVF
Recording the EKG Recording the EKG - - Review Review
aVR aVR
Unipolar Unipolar
Right arm + Right arm +
Neutral reference Neutral reference
Orphan lead Orphan lead
Negative deflection Negative deflection
If positive, 98% of If positive, 98% of
the time it the time it s VT s VT
Recording the EKG Recording the EKG - - Review Review
aVL aVL
Unipolar Unipolar
Left arm + Left arm +
Neutral reference Neutral reference
Upright deflection Upright deflection
Recording the EKG Recording the EKG - - Review Review
aVF aVF
Unipolar Unipolar
Foot + Foot +
Neutral reference Neutral reference
Positive Positive
27
Recording the EKG Recording the EKG - - Review Review
Vector leads Vector leads
Unipolar Unipolar
Encircle the Encircle the
pericardium pericardium
V1: Right ventricle V1: Right ventricle
V V
2 2
& V & V
3 3
: :
intraventricular intraventricular
septum septum
V V
4: 4:
cardiac apex cardiac apex
V V
5 5
& V & V
6 6
: Left lateral : Left lateral
wall wall
Recording the EKG Recording the EKG - - Review Review
V V
1 1
: 4 : 4
th th
ICS @ right ICS @ right
sternal border sternal border
V V
2 2
: 4 : 4
th th
ICS @ left ICS @ left
sternal border sternal border
V V
4 4
: 5 : 5
th th
ICS @ MCL ICS @ MCL
V V
3 3
: 5 : 5
th th
ICS between V ICS between V
2 2
& V & V
4 4
V V
6 6
: 5 : 5
th th
ICS @ MAL ICS @ MAL
V V
5 5
: 5 : 5
th th
ICS between V ICS between V
4 4
& V & V
6 6
Recording the EKG Recording the EKG - - Review Review
Autonomic Nervous System Autonomic Nervous System
Autonomic Nervous System Autonomic Nervous System
Regulates all vital Regulates all vital
functions by reflex functions by reflex
& CNS control & CNS control
Not conscious Not conscious
control control
Parasympathetic Parasympathetic
Inhibits Inhibits
Sympathetic Sympathetic
Stimulates Stimulates
Autonomic Nervous System Autonomic Nervous System
Both the sympathetic Both the sympathetic
& parasympathetic & parasympathetic
systems secrete their systems secrete their
own neurotransmitter own neurotransmitter
Parasympathetic Parasympathetic
Acetyl Acetylcholine choline (Ach) (Ach)
( (choline cholinergic) rgic)
Sympathetic Sympathetic
Norepinephrine (N Norepinephrine (N- -
epi or NE) epi or NE)
( (adren adrenaline aline- -like = like =
adren adrenergic) ergic)
28
Autonomic Nervous System Autonomic Nervous System
Sympathetic Sympathetic
Norepinephrine Norepinephrine
Activates cardiac Activates cardiac
1 1
adrenergic receptors adrenergic receptors
Rate of SA Node pacing Rate of SA Node pacing
Rate of conduction Rate of conduction
Force of contraction Force of contraction
Irritability of foci Irritability of foci
Autonomic Nervous System Autonomic Nervous System
Norepinephrine is a close relative of Norepinephrine is a close relative of
epinephrine ( epinephrine ( adrenaline adrenaline ) )
Epinephrine is more potent Epinephrine is more potent
Both are emergency drugs as well as Both are emergency drugs as well as
naturally occurring chemicals naturally occurring chemicals
Norepinephrine is also called Levophed Norepinephrine is also called Levophed
Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System
Quick review Quick review
We We ve discussed norepinephrine, ve discussed norepinephrine,
epinephrine, & epinephrine, & receptors receptors
We We ve discussed Na ve discussed Na
+ +
, K , K
+ +
, Ca , Ca
++ ++
Continue to think about all the different Continue to think about all the different
cardiac & emergency medications we can cardiac & emergency medications we can
give our patients. Which ones might affect give our patients. Which ones might affect
all the receptors & electrolytes we all the receptors & electrolytes we ve ve
discussed discussed
Autonomic Nervous System Autonomic Nervous System
Parasympathetic Parasympathetic
Inhibitory Inhibitory
Rate of SA Node pacing Rate of SA Node pacing
Rate of conduction Rate of conduction
Force of contraction Force of contraction
Irritability of atrial & junctional foci Irritability of atrial & junctional foci
Autonomic Nervous System Autonomic Nervous System
The vagus nerves are the body The vagus nerves are the body s main s main
parasympathetic pathway parasympathetic pathway
Vagal stimulation = inhibits Vagal stimulation = inhibits
Vagal stimulation also greatly affects Vagal stimulation also greatly affects
the gastrointestinal system the gastrointestinal system
Recalling the agony of a sever episode of Recalling the agony of a sever episode of
vomiting or painful, crampy diarrhea will vomiting or painful, crampy diarrhea will
help you to remember the parasympathetic help you to remember the parasympathetic
system system
29
Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System
Controls blood flow & pressure Controls blood flow & pressure
Constriction Constriction
Dilation Dilation
Alpha adrenergic = constricts Alpha adrenergic = constricts
Remember Remember constricts ( see the next constricts ( see the next
photo) photo)
Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System
Blood flow is very dependent on heart Blood flow is very dependent on heart
rate rate
Sympathetic stimulation increases the SA Sympathetic stimulation increases the SA
Node pacing rate Node pacing rate
Parasympathetic decreases it Parasympathetic decreases it
Autonomic Nervous System Autonomic Nervous System
Sever pain, seeing one Sever pain, seeing one s own blood, s own blood,
severe loss of blood may induce a severe loss of blood may induce a
parasympathetic reflex causing syncope parasympathetic reflex causing syncope
This is known as This is known as merciful syncope merciful syncope but but
better known in health care as better known in health care as vaso vaso- -vagal vagal
syncope syncope
Be compassionate to the patient that Be compassionate to the patient that
passes passes- -out when you draw their blood. out when you draw their blood.
They cannot help it! They cannot help it!
Autonomic Nervous System Autonomic Nervous System
30
Autonomic Nervous System Autonomic Nervous System
Vagal maneuvers Vagal maneuvers
Can be induced Can be induced
Gagging Gagging
Coughing Coughing
Carotid sinus Carotid sinus
massage (DON massage (DON T DO T DO
THIS UNLESS YOU THIS UNLESS YOU
REALLY KNOW REALLY KNOW
WHAT YOU ARE WHAT YOU ARE
DOING!!!) DOING!!!)
Autonomic Nervous System Autonomic Nervous System
Pressure receptors Pressure receptors
Baroreceptors Baroreceptors
Especially sensitive when standing Especially sensitive when standing
Normally sympathetic reflexes constrict Normally sympathetic reflexes constrict
peripheral arteries & increase heart rate peripheral arteries & increase heart rate
slightly slightly
Orthostatic hypotension (postural hypotension) Orthostatic hypotension (postural hypotension)
Near syncopal or syncopal when standing Near syncopal or syncopal when standing
Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System
Neuro Neuro- -cardiogenic syncope cardiogenic syncope
Pooling of blood in lower extremities from Pooling of blood in lower extremities from
prolonged standing prolonged standing
Sinus pacing accelerates, but peripheral Sinus pacing accelerates, but peripheral
vasoconstriction is inadequate vasoconstriction is inadequate
Partially filled ventricles contract rigorously Partially filled ventricles contract rigorously
which stimulates parasympathetic which stimulates parasympathetic
mechanoreseptors in the LV mechanoreseptors in the LV
Parasympathetic reflex slows the SA Node Parasympathetic reflex slows the SA Node
BP falls BP falls
Patient becomes syncopal Patient becomes syncopal
Autonomic Nervous System Autonomic Nervous System Rate Rate
31
Rate Rate
Remember Remember
Rate Rate
When examining an EKG you should When examining an EKG you should
determine the regularity first determine the regularity first
Regular Regular
Irregular Irregular
Regularly irregular (has a pattern) Regularly irregular (has a pattern)
Irregularly irregular (no pattern) Irregularly irregular (no pattern)
Then examine the rate Then examine the rate
Rate is read as cycles (beats) per minute Rate is read as cycles (beats) per minute
(bpm) (bpm)
Rate Rate
The SA Node (Sinus Node) is The SA Node (Sinus Node) is
the heart the heart s dominant center s dominant center
of automaticity of automaticity
It is the heart It is the heart s pacemaker s pacemaker
under normal circumstances under normal circumstances
It paces the heart in the It paces the heart in the
normal normal range of 60 range of 60 99 99
(100) bpm (100) bpm
The regular rhythm it The regular rhythm it
generates is called sinus generates is called sinus
rhythm (SR) rhythm (SR)
Rate Rate
If the SA nodes If the SA nodes
paces at a rate less paces at a rate less
than 60 bpm it is than 60 bpm it is
called sinus called sinus
bradycardia (SB) bradycardia (SB)
Brady = slow; cardia Brady = slow; cardia
= heart = heart
Rate Rate
SB most often results from SB most often results from
parasympathetic excess, as in a parasympathetic excess, as in a
conditioned athletes at rest conditioned athletes at rest
SB can be a side SB can be a side- -effect of medication effect of medication
Rate Rate
If the SA Node paces faster than 100 (99) it is called If the SA Node paces faster than 100 (99) it is called
sinus tachycardia (ST) sinus tachycardia (ST)
Tachy = fast Tachy = fast
Exercise produces sympathetic stimulation, a Exercise produces sympathetic stimulation, a
common cause of ST common cause of ST
32
Rate Rate
There are focal areas of automaticity in the heart There are focal areas of automaticity in the heart
known as automaticity foci (ectopic foci) known as automaticity foci (ectopic foci)
They are potential pacemakers They are potential pacemakers
Under normal circumstances they are electrically Under normal circumstances they are electrically
silent, hence potential silent, hence potential
Rate Rate
The proximal end of the AV Node has The proximal end of the AV Node has
no automaticity foci no automaticity foci
The middle & distil regions do, this is The middle & distil regions do, this is
called the AV junction called the AV junction
Junctional automaticity foci Junctional automaticity foci
The the AV junction paces at a rate of 40 The the AV junction paces at a rate of 40
- - 60 60
Rate Rate
Not the SA Node
Rate Rate
SA Node overdrive suppresses all other foci SA Node overdrive suppresses all other foci
All automaticity centers will overdrive All automaticity centers will overdrive
suppress all others that have a slower suppress all others that have a slower
pacemaker rate pacemaker rate
Rate Rate
Overdrive suppression also provides an emergency Overdrive suppression also provides an emergency
backup backup
Rate Rate
Don Don t let the 80 vs. 100 confuse you t let the 80 vs. 100 confuse you
SA node is inherently 60 SA node is inherently 60 99 (100) 99 (100)
Atrial automaticity foci is 60 Atrial automaticity foci is 60 80 !!! 80 !!!
Rate Rate
So, without SA Node pacing & atrial So, without SA Node pacing & atrial
automaticity foci can take over, if that automaticity foci can take over, if that
fails, the AV junction can take over, if fails, the AV junction can take over, if
that fails, the ventricular automaticity that fails, the ventricular automaticity
center takes over center takes over
33
Rate Rate
The AV junction has automaticity foci The AV junction has automaticity foci
Its inherent rate is 40 Its inherent rate is 40 60 bpm 60 bpm
The proximal end of the AV Node has no foci The proximal end of the AV Node has no foci
The middle & distil end of the AV Node does The middle & distil end of the AV Node does
have foci have foci
If the junctional foci is the active pacemaker it If the junctional foci is the active pacemaker it
produces a junctional rhythm produces a junctional rhythm
Rate Rate
Rate Rate
Remember that the AV Node is the only Remember that the AV Node is the only
conduction link between the atria & conduction link between the atria &
ventricular conduction system ventricular conduction system
If there is a complete conduction block If there is a complete conduction block
in the AV Node then the AV junction in the AV Node then the AV junction
will not receive stimulus from above & will not receive stimulus from above &
will take over pacing will take over pacing
Rate Rate
Rate Rate
Ventricular automaticity Ventricular automaticity
Inherent rate 20 Inherent rate 20 - -40 bpm 40 bpm
Specialized Purkinje fibers Specialized Purkinje fibers
Produces an idioventricular rhythm Produces an idioventricular rhythm
Idio = Greek, meaning Idio = Greek, meaning one one s own s own
Rate Rate
34
Rate Rate
A note one ventricular automacticty A note one ventricular automacticty
In a physiological or pathological In a physiological or pathological
emergency, an irritable automaticity focus emergency, an irritable automaticity focus
may suddenly discharge at a rapid rate. may suddenly discharge at a rapid rate.
Frequently this rate is around 150 Frequently this rate is around 150 200 200
bpm bpm
This is a life threatening emergency called This is a life threatening emergency called
ventricular tachycardia (VT) ventricular tachycardia (VT)
More about this later More about this later
Rate Rate
Easy rate determination Easy rate determination
In an emergency you will not have time In an emergency you will not have time
to find or use a calculator, or the to find or use a calculator, or the
presence of mind to spend a long time presence of mind to spend a long time
analyzing an EKG strip. analyzing an EKG strip.
So here is a real quick & simple So here is a real quick & simple
method method
Rate Rate
Memorize Memorize
Rate Rate
First find an R wave that peaks on a heavy First find an R wave that peaks on a heavy
black line, this is START black line, this is START
Rate Rate
Now, count off: 300, 150, 100 Now, count off: 300, 150, 100
The line the R wave peaks on is START, then the The line the R wave peaks on is START, then the
heavy black lines that follow get counted heavy black lines that follow get counted
Rate Rate
One more time One more time
START, 300, 150, 100, 75, 60, 50, START, 300, 150, 100, 75, 60, 50,
35
Rate Rate
What you are doing is called the triplet What you are doing is called the triplet
method method
It works best for regular rhythms It works best for regular rhythms
Rate Rate
What is the rate? What is the rate?
Rate Rate
Practice Practice
Rate Rate
What is the rate? What is the rate?
Rate Rate
A = 100 A = 100
B = about 150 B = about 150
C = 60 C = 60
D = 75 D = 75
Rate Rate
Triplet method Triplet method
Why does it make sense? Why does it make sense?
36
Rate Rate Rate Rate
The small lines have values as well The small lines have values as well
In the back of your Jane Huff workbook In the back of your Jane Huff workbook
there is a card for there is a card for counting the boxes counting the boxes
This is the triplet method This is the triplet method
Rate Rate Rate Rate
Stop counting!!!
Your patient is dead!!!
Rate Rate
Another method for rate determination Another method for rate determination
On the top of all EKG strips are 3 On the top of all EKG strips are 3- -second second
interval hash marks interval hash marks
They could be noted as dots, lines, They could be noted as dots, lines,
triangles, circles, etc triangles, circles, etc
Rate Rate
37
Rate Rate
We like to use a 6 We like to use a 6- -second strip to determine second strip to determine
rate rate
Rate Rate
Count the number of R to R cycles in a 6 Count the number of R to R cycles in a 6- -
second strip second strip
Rate Rate Rate Rate
Rate Rate
1 = 20 1 = 20
2 = about 45 2 = about 45
3 = 50 3 = 50
Rhythm Interpretation Rhythm Interpretation
Now that you have all the basics lets get Now that you have all the basics lets get
ready to identify rhythms ready to identify rhythms
38
Rhythm Interpretation Rhythm Interpretation
At this point we will only be looking at 1 lead at At this point we will only be looking at 1 lead at
a time a time
It is important to remember that using only 1 It is important to remember that using only 1
lead cannot lead cannot
Identify/locate an infarct Identify/locate an infarct
Identify axis deviation or chamber enlargement Identify axis deviation or chamber enlargement
Identify right Identify right- -to to- -left differences in conduction left differences in conduction
Provide feedback about the quality or presence of Provide feedback about the quality or presence of
pumping action pumping action
Rhythm Interpretation Rhythm Interpretation
Time Intervals Time Intervals
P P R Interval: R Interval:
0.12 0.12 0.20 0.20
sec sec
QRS Interval: QRS Interval:
0.08 0.08 0.12 sec 0.12 sec
S S T T
Segment: Segment:
0.33 0.33 0.42 sec 0.42 sec
Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation
Absolute refractory period Absolute refractory period
Onset of the QRS to the peak of the T Onset of the QRS to the peak of the T
Cardiac cells are depolarized & are in the Cardiac cells are depolarized & are in the
process of repolarizing process of repolarizing
At this time the cells cannot be stimulated, At this time the cells cannot be stimulated,
conduct, or contract conduct, or contract
Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation
Relative refractory period Relative refractory period
Peak of the T to end of the T Peak of the T to end of the T
Cells are repolarized Cells are repolarized
This is a vulnerable period This is a vulnerable period
A strong stimulus can potentially take over A strong stimulus can potentially take over
the primary pacemaker of the heart the primary pacemaker of the heart
This is called This is called R on T phenomena R on T phenomena
Potential for sudden cardiac death Potential for sudden cardiac death
39
Rhythm Interpretation Rhythm Interpretation
Arrhythmia literally means without Arrhythmia literally means without
rhythm rhythm
Dysrhythmia means bad rhythm & is Dysrhythmia means bad rhythm & is
the correct terminology the correct terminology
Rhythm Interpretation Rhythm Interpretation
Always be consistent & analytical Always be consistent & analytical
Always use the 5 Always use the 5- -step method step method
Learn the rules for each dysrhythmia Learn the rules for each dysrhythmia
Analyze a given rhythm strip according to Analyze a given rhythm strip according to
a specific format a specific format
Compare your analysis to the rules for each Compare your analysis to the rules for each
dysrhythmia dysrhythmia
Identify the dysrhythmia by its similarity Identify the dysrhythmia by its similarity
to established rules to established rules
Rhythm Interpretation Rhythm Interpretation
The 5 step method The 5 step method
Determine the regularity (rhythm) of the R Determine the regularity (rhythm) of the R
waves waves
Calculate the heart rate Calculate the heart rate
Identify & examine the P waves Identify & examine the P waves
Measure the PRI (P Measure the PRI (P- -R interval) R interval)
Measure the QRS complex Measure the QRS complex
Rhythm Interpretation Rhythm Interpretation
Step 1: Determine the regularity Step 1: Determine the regularity
Regular Regular
Irregular Irregular
Regularly Irregular Regularly Irregular
Irregularly Irregular Irregularly Irregular
Rhythm Interpretation Rhythm Interpretation
Step 2: Calculate the rate Step 2: Calculate the rate
6 6- -second strip second strip
Triplet method Triplet method
Heart rate calculator (counting the boxes) Heart rate calculator (counting the boxes)
Rhythm Interpretation Rhythm Interpretation
Step 3: Identify & examine the P waves Step 3: Identify & examine the P waves
Are P waves present? Are P waves present?
Are the P waves upright or inverted? Are the P waves upright or inverted?
Do all the P waves look alike? Do all the P waves look alike?
Are the P waves regular (P Are the P waves regular (P- -P interval)? P interval)?
40
Rhythm Interpretation Rhythm Interpretation
Step 4: The PRI Step 4: The PRI
Is there one P wave for each QRS complex? Is there one P wave for each QRS complex?
Analyzing the P Analyzing the P R Interval R Interval
Within normal limits Within normal limits
Long Long
Short Short
Changing Changing
Rhythm Interpretation Rhythm Interpretation
Step 5: Step 5: The QRS complex The QRS complex
Do all the QRS complexes look alike? Do all the QRS complexes look alike?
What is the QRS duration? What is the QRS duration?
R to R interval R to R interval
Rhythm Interpretation Rhythm Interpretation
In addition you can also look at In addition you can also look at
T wave configuration T wave configuration
Check to see if there is a P wave hidden Check to see if there is a P wave hidden
Review of SA Node & Atrial Review of SA Node & Atrial
Rhythms Rhythms
Review of SA Node & Atrial Review of SA Node & Atrial
Rhythms Rhythms
Review of SA Node & Atrial Review of SA Node & Atrial
Rhythms Rhythms
41
Review of SA Node & Atrial Review of SA Node & Atrial
Rhythms Rhythms
Review of SA Node & Atrial Review of SA Node & Atrial
Rhythms Rhythms

You might also like