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6/16/2009

Basic Physics behind EKG


12 Lead ECG: Depolarization and Repolarization
SOM Review  At rest myocyte is polarized (resting state):
Negative inside and positive outside.
 Depolarization (contraction) inside cell is
positive, outside negative.
 Repolarization (relaxation) is when myocyte
returns to resting state (Inside negative and
Todd LeCesne, MPAS, PA-C outside positive).
UNM PA Program  When positive wave of depolarization travels
toward the positive electrode on the skin, the
EKG registers positive deflection.
 Wave moving away creates a downward
deflection.

Standard Limb Leads Augmented limb leads


(Frontal plane)

Would you buy this car as is?

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Precordial Leads

Dubin’s Method
Determine:
1. Rate
2. Rhythm
3. Axis
4. Hypertrophy
5. Infarction, Ischemia, Injury

Overall Impression?

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To Determine Rate
 1500/number of small squares between two
adjacent R waves.

 Or 300, 150, 100, 75, 60, 50…. method!

Normal Sinus Rhythm


 Determine the basic rhythm:
– P in front of every QRS?
– Check PR Intervals for AVB
– Check QRS Intervals for BBB

 …quick look:
– Pauses, PAC’s, PVC’s, dropped beats or
abnormal waves?

Other Arrhythmia Types Other Arrhythmia Types


 Irregular Rhythm  Irregular Rhythm
– Varies with respiration. w/ P-waves – Varies with respiration. w/ P-waves
regular considered normal regular considered normal
 “Escape” and premature beats  “Escape” and premature beats
 Rapid Ectopic Rhythms  Rapid Ectopic Rhythms
 Heart Blocks  Heart Blocks

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Sinus arrhythmia Other Arrhythmia Types


 Irregular Rhythm
– Varies with respiration. w/ P-waves
regular considered normal
 “Escape” and premature beats
 Rapid Ectopic Rhythms
 Heart Blocks

Escape Rhythms
Native pacemaker (SA node) = 60 - 100bpm
•< 60bpm = sinus Bradycardia
•> 100bpm = sinus Tachycardia

Other Arrhythmia Types


 Irregular Rhythm
– Varies with respiration. w/ P-waves
regular considered normal
 “Escape” and premature beats
 Rapid Ectopic Rhythms
 Heart Blocks

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Arrhythmias Rapid Ectopic Rhythms


 Irregular Rhythms  Paroxysmal Tachycardia = Sudden, Rapid
Heart Rate (150-250bpm) from an ectopic
 “Escape” and premature Beats focus.
 Atrial (PAT) or Junctional tachycardia (called SVT’s)
 Rapid Ectopic Rhythms if AV block present, think Digoxin Toxicity.
 Heart Blocks  Ventricular - runs of VT may signify CAD or hypoxia.
 Flutter (ectopic Focus) and Fibrillation (ectopic
Foci).
1. Atrial.
2. Ventricular

Irritable atrial focus – P Waves are visible Focus at AV junction – see: rapid QRS – T cycles; P’s absent

Continuous “saw tooth” sequence


Series of wide (PVC-like) ventricular complexes of atrial complexes.
From a single ectopic focus!

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Torsades de Pointes

 Ventricular flutter (rate of 250-350)


 Series of smooth sine waves, single, rapid,
ventricular focus.
Multiple atrial ectopic foci  Can lead to VF
Rate of 350-450 min

Ventricular Fibrillation Arrhythmias


 Irregular Rhythms
 “Escape” and premature Beats
 Rapid Ectopic Rhythms
 Heart Blocks

AVB criteria?
Heart Blocks
1. AV Block (first, second and third).
2. Bundle Branch Block

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Bundle Branch Block


Bundle Branch Block
 Look for a wide QRS (normal 0.4-0.10 or
within 3 small squares)
 Look for “Rabbit ears”
– RBBB – R/Ŕ in V1, V2
– LBBB – R/Ŕ in V5, V6

Axis

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Axis

Hypertrophy Ischemia, Injury, Infarct.


 Ischemia: T wave inversion.
Large, biphasic P,
with tall terminal
 Injury: ST elevation or Depression.
component
 Infarct: significant Q waves. (0.04 sec and
Large, biphasic P,
with tall initial
or 1/3 of QRS).
component

= >35 mm.
R>S,
Or, R > 11 mm
RAD, (in aVL).
R regression in V1-6

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