Electrocardiography

Bernardo D. Morantte Jr.M.D. Department of Medicine College of Medicine Pamantasan Ng Lungsod Ng Maynila

Electrocardiography (EKG)
 The electrical activation of the muscle
cells and the conduction system of the heart is the basis for electrocardiography.

 The EKG is the recording of the electrical
activation of the heart.

Action potential
Electrical stimulus


40 0 - 40 - 80 -100 mV 1 msec threshold

Na, Ca 1

Phases of repolarization

extracellular 2 3 Cell Membrane K Intracellular

0

4

ARP Resting membrane potential

RRP

ARP = absolute refractory period RRP = relative refractory period

Electrical activation of the heart
SA node
RA LA

AV node
LV RV LBB

EKG

P

RBB

Q RS
T

EKG
R R R on T pattern Hyper-repolarized p 0 T (vulnerable period ) U PR Q S ARR ST T QRS

RRP

Electrode placement -90
0

- 120
aVR

0

-600

Posterior I aVL aVR - 150
0

-300 aVL P

4th v1 RICS V2 V3 V6 V4 V5 III II

+1800

QRS

00 I V6 V5 +300 V4

+150 Frontal plane Hexaxial reference aVF

P QRS +1200 III

Anterior0 + 90 V1 aVF

+600 II V3 V2 R/S progression

Horizontal plane hexaxial reference

P and QRS vector frontal plane
SA node
RA LA

EKG

AV node

LV Left axis deviation -90 -60 -30

RV

P

Q RS
T

+180 +150 Right axis deviation +120 +90 +60

0 +30

QRS axis determination -90
0

- 1200

Frontal Plane
R P aVR - 1500

-600 -300 aVL

*
EKG

T

1800

00 I

1500

300

*Tallest R wave

120 III

0

600 II 900 aVF

EKG Time Measurements at 25 mm / second paper speed
Time intervals
R T p

10 mm = 1mV

PR QRS
40 msec.

QT calibration signal

200 msec. 1 second

Voltage Measurements
Time intervals
R T P

10 mm = 1mV

S
40 msec.

= 0.1 mV calibration signal

200 msec. 1 second

EKG
V1 RAH= P > 2.5 mm RVH= R/S > 1 : RAD or R V1 >7.5 V5 LVH= S V1 +R V5 > 35 mm + LAD or R V5 > 26 mm LAH = broad notched P inV5 or biphasic P in V1 with deep negative component

RVH and RAH LVH and LAH

Atrial (AR) and ventricular rates (VR) at paper speed of 25 mm per second for regular rhythm

Time intervals
R T P

Ex: 300/5 = 60 R

P

Formula:
40 msec.

1. VR =

200 msec. 1 second 2 VR =

300 No. of large squares 1500 No. of small squares

Caution before reading the EKG
Make sure that the paper speed is at 25 mm per second Make sure that the calibration is 10 mm = 1mV Make sure that the electrodes have been placed properly

Non-standard EKG recordings Be aware !
R P T 5 mm =1mV

Calibration signal

12.5 mm / sec. paper speed

PR interval

QRS

QT interval

50 mm / sec paper speed.

Inversion of right and left limb leads
-900 - 120
aVR
0

-600

I

aVL aVR - 150 +1800 QRS +150 Frontal plane aVF +1200 III V1 + 900 aVF V2 P
0

-300 aVL P QRS 00 I V6 V5 +300 V4 +600 II V3

v1 V2 V3 V6 V4 V5 III II

Horizontal plane hexaxial reference

Dextrocardia
- 120
aVR
0

-900

-600

Posterior I aVL aVR - 1500 +1800 P P QRS +150 Frontal plane aVF +1200 V2R III QRS -300 aVL

v1 V2 V3 V6 V4 V5 III II

V6 V5 +300 V4

Anterior0 + 90 V1 aVF

+600 II V3 V2

Horizontal plane hexaxial reference

Inversion of right arm and left foot -90 leads- 120 -60
0 0 0

aVR

I

aVL aVR - 1500 +1800 QRS +150 Frontal plane aVF +1200 III V1 + 900 aVF V2 P P QRS

-300 aVL

v1 V2 V3 V6 V4 V5 III II

00 I V6 V5 +300 V4 +600 II V3

Horizontal plane hexaxial reference

Inversion of left arm and left foot leads -90 -60 - 120
0 0 0

aVR

I

aVL aVR - 1500 +1800
90

-300 aVL P QRS V6 QRS P +1200 III V1 + 900 aVF V2 00 I V6 V5 +300 V4

v1 V2 V3 V6 V4 V5 III II

+150 Frontal plane aVF

+600 II V3

Horizontal plane hexaxial reference

EKG

EKG

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