12 lead ECG

- Electrode placement

PQRST Significance

- P wave: fist positive deflection <.12

o Inferior (II, III), avf)
- PR interval : onset of P wave to start QRS, conduction through the AV node .12-.2
- QRS interval: <.12
- QT interval: .42
- QRS complex <.12
o Ventricular depolarization
o Q wave: 1st – deflection after P
o R wave: 1st + deflection after P
o R prime: 2nd positive deflection= BBB
J point & ST segment
- J point: QRS ends and ST begins
o Even with isoelectric line
- ST segment: completion of ventricular depolarization, prior to ventricular repolarization
- TP segment: end of T wave to next P wve
 o Electrical silence in heart

- QT interval: time it takes for ventricles to depolarize and repolarize

o .36-.44
o Longer when the HR is slower, shorter when the HR is faster
o Bazzette formula: determines QTc or QT interval
o Long= VT or VF

Axis determination
- QRS is most important to determine
- Normal: -30 to +90, downward and to the left
- Left axis deviation: -30 to -90
o QRS is + in Lead I and – in lead aVF
o Causes: inferior wall MI, LV hypertrophy, LBBB, ventricular ectopy
- Right axis deviation: +90 to +180
o QRS is – in Lead I and + in aVF
o Causes: lateral wall MI, RBBB, right ventricular hypertrophy, dextrocardia, pulmomary
embolism

Bundle Branch Blocks

- Problem with conduction system
- QRS >.12
- LBBB
o Deep S in V1 V2 and broad R in V5, V6

o
o Causes: MI, CAD, aortic stenosis, cardiomyopathies, myocarditis, hyperkalemia, dig toxicity
- RBBB
o Large R wave in V1, V2, slurred S wave in V1, V5, V6
 o
o Causes: 2/2 HTN, MI, myocarditis, COPD, cor pulmonae, RHF, pulmonary embolism

Rhythm Patterns
- NSR: 60-100
o P before QRS followed by T wave
- Sinus brady: <60
o SSS, BB, hypothermia, hypoglycemia, hypothyroid, CAD
- Sinus tachy : >100
o Fever, anxiety, hyperthyroid, albuterol, dobutamine, anemia, pain

Atrial Rhythms
- Premature atrial contraction (PAC)
o Ectopic focus within atria conduction to ventricles
o Frequent= palpiatations

o
- Atrial Fibrillation
o Irregularly irregular
o Rapid firing within atria
o No P waves, no PR interval
o s/s= SOB, dizy, fatigue, chest pain

o
- Atrial Flutter
o More organized
o “sawtooth”

o
 - Supraentricular tachycardia
o Originates in AV node
o Narrow complex tachycardia appearing rapid and regular

Ventricular rhythms
- Premature ventricular contraction (PVC)
o Early impulse originating from ventricle
o P wave is absent, QRS is wide and bizarre
o MI, cardiomyopathy, electrolytes (hypokalemia), hypoxia

o
- Ventricular tachycardia
o Abnormal electrical signals from ventricle
o Loss of pulse and consciousness
o ACLS

o
- Ventricular fibrillation
o High frequency disorganization excitation of myocardium
o No P wave or QRS, instead fibrillatory waves
o Sudden cardiac death defib

AV blocks
- 1st degree AV block
o rhythm with prolonged PR interval >.2
o Well trained atheletes, inferior MI, hypokalemia
o s/s: dizzy, dyspnea, fatigue

o
 - 2nd AV block (Mobitz I or wenchebach)
o Gradual increase in PR interval until blociked impulse and subsequent PR is shorter

o
nd
- 2 degree AV block II (Mobitz II)
o Constant PR interval leading to dropped QRS
o Dixzzy, syncome, hypotension or brady
o ? pacemaker

o
rd
- 3 degree AV block (complete heart block)
o No conduction through AV leading to AV dissociation
o Regular P-P interval, regular R-R, failure of P and QRS
o AMS, SOB, CP, syncope
o Pacemaker

Pacing
- Oversensins: device does not initiate when it should
- Undersensisng: fails to turn off
- Capture: sufficient impulse
- Atrial pacing: pacing prior to P wave

o
- Ventricular pacing: pacing prior to QRS

o
- AV pacing: pacing prior to P and prior to QRS
 o

Digitalis toxicity
- Parasoxysmal atrial tachycardia
- Accelerated junctional rhythm
- Bidirectional ventricular tachycardia
- AV blocks

Hypothermia
- Bradyarrythmias
- Prolonged PR, QRS, QT
- Osborn and J waves

-
Pericarditis
- Stage I: Diffuse, concave upward ST segment elevation in most leads and subtle or overt PR depression
- Stage II: ST segment elevation and PR depression return to baseline; may have normal or flattened T
waves
- Stage III: T waves are inverted; the ECG is otherwise normal
- Stage IV: ECG returns back to normal

Pulmonary Embolism
- Tachycardia
- S1Q3T3 pattern
- Classic findings of right heart strain
o Tall, peaked p waves in Lead II
o Right axis deviation
 o Right bundle branch block