Well we're in here in

the Sim Lab today and we've been joined by Sim Man
who you haven't met before. But we're going to use Sim Man to
do some demonstrations of what happens when a clinician collects
Electrocardiogram, or ECG data. This week in lecture I
talked about the fact that, we have a conduction system in the heart. And the cells
that make up the conduction
system are able to self-excite and stimulate, or excite other parts of the heart
after
they are their excitation has begun. So we talked about the SA node, which
is the first portion of the conduction system to normally get activated. And the SA
node gets activated and it causes, causes an excitation
signal to spread across the atrium. That signal is then conducted to
the AV node, where there is a delay in impulse conduction for
a short period of time, tenth of a second, is the exact period
of time we normally expect to see. Then the signal gets
passed into the AV bundle, which is in the intraventricular septum. The signal goes
from the AV bundle into
the left and right bundle branches. The bundle branches continue down
the intraventricular septum. And, down at the apex of the heart,
the bundle branches branch a lot, to form small Purkinje fibers that pass
into the free walls of the ventricles. And we're here to talk about the ECG's,
because ECG's are devices that
we use to actually detect. The electrical activity
that's going on in the heart. When we set up an ECG, what you'll
see happening is that electrodes, and there are many types of electrodes. But
electrodes of one type or
another will be positioned on the body. Megan. [LAUGH]
>> Where? >> Well, we need ten if we're
going to do a 12-lead EKG, or ECG, which is typically what will
be done in a practitioner's office. So you're going to have two limb leads. And
those are either kind of here
on the upper chest or on the arms. Even down as far as the wrist, right? >> Right.
And then two lower leads. One on each leg or, or down at the foot. And then you're
going to
have six precordial leads. Which go across the chest
starting at about the sternum and kind of down around
the left side of the heart. And so these electrodes are sometimes
called leads, but the electrodes will actually have wires attached to them,
that are also called leads. So this can be a very confusing kind
of terminology for lay people to, to get a handle on. Why do we need 12, Megan?
Well, if you do a 12 lead EKG, that means that you have 12
different views of the heart. So, basically we're able to look at the
electrical activity of the heart from 12 different angles. And that gives us, 12
different pictures of different
sections of the heart, basically. So the basic electrical
activity is the same, but if there is some problem in
a particular portion of the heart. With if the heart muscle is damaged and there's
a problem with the ability of
that muscle to conduct the electricity. Then we can pinpoint when we have twelve
leads, which area that is happening in. >> So, the, the basic theory
of using these electrodes is that when cardiac muscle
cells are excited, there is an electrical current that
passes along the membrane of the cell. And that electrical current not
only passes along the membrane. But it also passes through
the body fluids, and can actually pass to the body surface. And so we put
electrodes on the body
surface so that they will be able to detect that electric current when
it arrives at the body's surface. And then the leads. Conduct that current into a
machine that
has to boost or amplify the current. So that we can actually raise it up to a
level that's detectable by our machinery. One thing that I didn't talk
about in lecture this week but I think I should mention now is
that when the SA node gets excited. And passes that excitation
signal across the atrial walls. That excitation is really
associated with a positive current, and so the positive current
passes across the atrial walls. And then after that positive
current passes across the atrial walls there's a negative current that restores the
electrical potential
of the atrium back to normal. So this positive current that spreads out across the
atrium is
called a depolarization. And then,
the restoring of the walls back to their normal resting
point is repolarization. And those are important
terms to remember as we think about what the ECG is really
going to tell us when, when we look at it. >> Great. >> So today, Megan,
what are we looking at? >> So today, we're just going
to look at one lead, lead two. And so, we are going to put on the, limb
leads, the upper and the lower limb leads. And sim, sim Man actually is able to,
show us a heart rate,
which is really neat an, an actual EKG. Here's the picture. And, the first thing
that you'll see, the first wave is called the P wave, and
that represents atrial depolarization. And the second thing that you see is
actually a couple waves and so
this is called the QRS complex. And it's got the Q, the R, and the S wave. And this
represents
ventricular depolarization. And
>> Now, I, It might be important to know that the reason that wave has such
a funny shape is that it's showing us. The depolarization of
the intraventricular septum, which kind of is oriented in
one direction in the body. And it's also showing us
the free walls of the ventricles, which have a different kind
of spatial orientation. So that causes the QRS
complex to have a really. It's a much, you know,
more complex shape than the P-wave is. >> Mm-hm. Great that's. >> Yeah.
>> Thank you for adding that. >> Yep. >> And then the next thing that
you'll notice is the T-wave. Which is a representation of
ventricular repolarization. So, you mentioned ventricular
repolarization being the T wave, but is there,
an atrical repolarization, and if so, like,
when slash where does that occur? >> That's a great question. The atrium does
repolarize, but it occurs,
at the same time that ventricular depolarization is occurring, so you can't
see it on this wave because it's lost. By the more prominent, thing that's oc,
occurring at that time, which is ventricular depolarization. >> I see, because
remember
that the atrial, you know, the atrial walls are thinner,
so there's less atrial muscle. The ventricular walls are thicker, there's
more muscle there and so, the electrical currents in the ventricles are just so
much higher than they kind of hide the. Atrial Repolarization. So, now, I have a
question for you. In between these waves forms
there are flat lines and we call those Isoelectric lines. So in between the P wave.
And the beginning of the QRS complex,
there is one of those flatlines or iso electric lines, what do you think
is happening in the heart during the period that iso electric
line is being recorded? Well, if it's isoelectric,
could it mean that there's no activity? >> There's, like,
not any new activity going on, right? Mm-hm. So, the P wave,
if it represents atrial depolarization, the P wave is telling us that the SA node.
Self excited and then the depolarization spread
across the atrium right? And then what happens after the SA node? >> The AV node
>> Mm-hm and what is the significant functional
thing that goes on in the AV node? Stacy.
>> Mm, it regulates. >> It does, but remember that
10th of a second when there is a. >> It gives time for the heart to. >> Exactly
>> Depolarize. >> because there is a delay in the signal,
right. So it gives time. For the,
Atrial contraction to occur before- The ventricle- the ventricles get activated
right, okay,
so that's what's happening during that first first iso-electric line. And,. And
during the second one,
I see an isoelectric line between, the QRS complex where it ends and
the T wave begins. That's a time when there's just
no new electrical activity being generated, right? The ventricles have
already depolarized and that we're waiting for
them to begin to repolarize. Okay.
>> Do you feel like you understand? >> I think I understand a lot more
than I did before definitely. Good.
That's what it's all about. >> So, would this be normal sinus rhythm? >> Right.
This is normal sinus rhythm. So these are the components
of normal sinus rhythm and if somebody had an abnormal heart rhythm. Then you would
see different waves and
we won't really get into what that is. But yes, this is normal sinus rhythm. >>
Great.
>> Great.