1. 2. 3. 4. 5.
Review of the conduction system EKG waveforms and intervals EKG leads Determining heart rate Identify dysrhytmias
The electrocardiogram (EKG) is a representation of the electrical events of the cardiac cycle. Each event has a distinctive waveform, the study of which can lead to greater insight into a patient·s cardiac pathophysiology.
hyperkalemia.e. digoxin and drugs which prolong the QT interval)
. Arrhythmias Myocardial Pericarditis Chamber
ischemia and infarction
hypertrophy Electrolyte disturbances (i. hypokalemia) Drug toxicity (i.e.
when there are no positive or negative electrical wave deflections.
the first wave of the cardiac cycle & represents atrial depolarization. Disorders that change atrial size cause alterations in P wave shape & size.
. the P wave normally appears rounded & symmetrical . When the SA node fires. There is 1 P wave in a normal cardiac cycle .
20 seconds.12 to 0.
. Counting the number of small boxes horizontally that the interval covers determines the length of the PR interval. Normal PR interval is 0. It starts at the beginning of the P wave & ends at the beginning of the QRS complex. Represents
the time it takes the electrical impulse to travel down the atrium to the AV node.
ventricular depolarization & is composed of 3 waves. Presence of p wave in the following cardiac cycle ind. Atrial repolarization occurs during the interval of the QRS but is not seen because of powerful ventricular activity. R.
. the Q. Atrial repolarization has occurred. and S.
first downward deflection after the P wave but before the R wave.last part of the QRS complex. R ² first upward deflection after the P wave. w/c is the second negative deflection after the P wave . -ends when it returns to the isoelectric line. S.
measure the QRS interval.
. Measure from the beginning of the Q wave to the end of the S wave. Normal QRS interval is < 0. count the number of boxes from the wave that begins the QRS complex to the end of the wave that completes the QRS complex.12 seconds.
when ventricles are filling w/ blood & preparing to receive the next impulse. & ends w/ a return to the isoelectric line. Starts at the next upward (positive) deflection. Resting state of the heart. after the QRS complex. Represents
ventricular repolarization .
not present .
. w/c is low serum K level. Seen in patients w/ hypokalemia.
Ischemia. Changes in ST segment ind. ST inversion/ depression----ischemia ST segment elevates from the isoelectric line-----------cardiac injury.
. injury pattern suggestive of myocardial damage. Reflects
the time from completion of a contraction (depolarization) of myocardial muscle for the next impulse. Starts at the end of the QRS and ends at the beginning of the T wave .
the rhythm is regular.can be determined by looking at the R-R interval on the ECG.if the distance is the same.
Regularity of the rhythm.
(6 sec X 10= 60 sec.) boxes between 2 R waves & divide that number into 1500. method: used for irreg. Six
sec. or count large boxes & divide by 300. strips & multiply the total by 10.
At the top of ECG graph paper there are 3 vertical marks at 3-seconds intervals.04-sec. rhythms or rapid estimate.) Count the number of small (0.300/5= 60 used for regular rhythms. Count the number of R waves in a sec.
w/c is 0. Try to find a wave that starts at the beginning of 1 small box.
. If the wave starts or ends in the middle of a box. count it as 1-half of a box.02 sec. To
make measuring waves easier:
Identify the isoelectric line as you measure waveform tracings to help you determine the type of wave.
there 1 P wave for every QRS complex? Are the P waves regular 7 constant? Do the P waves look alike? Are the p waves upright and in front of every QRS complex?
the PR interval normal? Is the PR interval constant or varying?
the QRS interval normal ? Is the QRS interval constant? Do the QRS complexes all look alike?
is an irregularity or loss of rhythm
. disordered . Dysrhythmias
abnormal. or disturbed rhythm. Arrhythmia.
rhythm.rhythm arising from the SA
pacemaker of the heart. 1. fires normally 60-100 bpm. Sinus tachycardia-
Sinus Bradycardia. Normal rhythm in aerobically trained athletes and during sleep
.eg. MI. Digoxin. electrolyte imbalance.slower than normal heart rate (less than 60 bpm).
heart rate greater than 100 bpm. Phy. fever. hemorrhage. Activity. shock. anxiety. epinephrine.
. atropine. fear.
they become primary pacemaker. P wave produced look different from the rounded P waves from the SA node(flatter. that the SA node is not controlling the heart rate. Are usually faster than 100bpm & can exceed 200 bpm. or peaked).
. notched.impulses faster than the SA node. w/c ind. When an impulse originates outside the SA node.
Heart rate: depends on the underlying rhythm. Normal conduction to ventricles)
. P waves: early beat is abnormally shapes. if normal sinus rhythm (60-100bpm). but premature beat could have shortened or prolonged PE interval. PR interval: usually appears normal. ( ind.12 sec. QRS interval: < 0.Rhythm : premature beats interrupts underlying rhythm where it occurs.
and an atrial rate of 250 to 350 bpm. Classic characteristic: more than 1 P wave before a QRS complex.12 seconds
. or flutter . at a rate of 250 to 350 bpm. a saw toothed pattern of P waves. QRS complex: < 0.contract . Heart rate: ventricular rate varies P waves: Flutter or F waves w/ saw toothed pattern. PR interval: none measurable.
QRS complex: 0. Rhythm:
irregularly irregular Heart rate: atrial rate not measurable: ventricular rate under 100 is rapid ventricular response.06 to 0. greater than 100 is rapid ventricular response P waves: no identifiable P waves PR interval: none can be measured because no P waves are seen.10 sec.
. First degree 2.is a conduction defect within the AV junction that impairs conduction of atrial impulses to ventricular pathways. Second degree 3.AV block . Types: 1.
Characteristics: 1. 2nd degree ² rate is slowed. atrial rate is 2 to 4 times faster than the ventricular rate 3rd degree ² rate is slowed. usually 40 to 60 beats per minute or the inherent ventricular rate
. Rate 1st degree ² 60 to 100 bpm or the inherent ventricular rate.
20 second 2nd degree ² PR intervals may be progressively lengthening 3rd degree ² no relationship between P waves & QRS complexes exist. P wave is normal & present in each type of block 3.2. PR intervals cannot be measured
. PR intervals: 1st degree ² PR intervals are prolonged at 0.
4. Conduction 1st degree ² is delayed in the AV junction 2nd degree ² impulses are not regularly conducted through the AV junction 3rd degree . QRS complex 1st & 2nd degree ² normal 3rd degree ² QRS is widened 5. conduction through the ventricles is abnormal 6. Rhythm ² is regular in each type of block
.all sinus impulses are blocked.
angina & heart failure Nursing Management: 1st degree ² no treatment. weakness & irregular pulse 3rd degree ² hypotension. discontinue causative drug if indicated 2nd degree ² administer Atropine SO4 3rd degree ² Atropine SO4.Clinical Manifestations: 1st degree ² asymptomatic 2nd degree ² vertigo. pacemaker
.11 sec. Premature
Ventricular Contractions. T upright). T downward or QRS downward. . QRS upright. P waves: absent before PVC QRS complex PR interval: none for PVC QRS complex: if PVC. T wave is in the opposite direction of QRS complex( ie.originate in the ventricles from an ectopic focus ( a site other than the SA node) Rhythm: depends on the underlying rhythm Heart rate: depends on the underlying rhythm. it is greater than 0.
rapidly if left ventricle fails & complete cardiac arrest results. P waves: absent PR interval: none QRS complex: greater than 0. slow VT is below 150bpm.
usually regular.11 sec Sustained VT compromises cardiac output. The severity of symptoms can inc. Heart rate: 150-250 ventricular bpm. may have some irregularity.
Heart rate: not measurable P waves: none PR interval: none QRS complex: none Pt. lose consciousness immediately . Rhythm:
chaotic & extremely irregular. indicative of circulatory collapse. peripheral pulses.
. No heart sounds. or BP.
effective method of terminating ventricular fibrillation Ideally performed within 15 to 20 seconds of onset of arrhythmia Passage of direct current electrical shock through heart to depolarize cells
therapy for hemodynamically unstable ventricular or supraventricular tachyarrhythmias Delivers countershock during QRS complex Done on non-emergency basis
for life-threatening ventricular arrhythmias Lead system placed via subclavian vein to endocardium Pulse generator is implanted over pectoral muscle
backup pacing for bradyarrhythmias after defibrillation
device used in place of SA node Paces both the atrium as well as the ventricle
Increases HR when appropriate
in management of heart failure. and neurocardiogenic syncope
. symptomatic bradyarrhythmias.
delivers shock to the patient·s heart muscle Initiate overdrive pacing of supraventricular and ventricular tachycardias
.sensing system defects in lethal arrhythmia.
and in atrial flutter
energy used to ´burnµ (ablate) areas of conduction system as treatment for tacharrhythmias Used for AV nodal reentrant tachycardia to control ventricular response to certain tachyarrhythmias.
are electrodes which measure the difference in electrical potential between either:
Two different points on the body (bipolar leads) One point on the body and a virtual reference point with zero electrical potential.
. located in the center of the heart (unipolar leads)
. The 3 3 6
standard EKG has 12 leads:
Standard Limb Leads Augmented Limb Leads
Precordial Leads The axis of a particular lead represents the viewpoint from which it looks at the heart.
and divide this into 300. The result will be approximately equal to the rate Although fast.Take the number of ´big boxesµ between neighboring QRS complexes.
. this method only works for regular rhythms.
It may be easiest to memorize the following table: # of big boxes 2 3 4 5 6 75 6 5 Rate 3 5
As most EKGs record 10 seconds of rhythm per page. one can simply count the number of beats present on the EKG and multiply by 6 to get the number of beats per 60 seconds.
This method works well for irregular rhythms.
33 x 6 = 198 bpm
. When stimulated. the muscle cell will respond completely or not at all or none at all principle
.Absolute refractory period: No stimulus (no matter how powerful) can excite the tissue. Refers
to a state of unresponsiveness following excitation of the cardiac muscle cell. if the cell is stimulated during this period. the stimulus is rejected.
Relative refractory period: some of the cells have returned to their original state (repolarized) & a strong stimulus can excite the tissue. This period also referred as ´vulnerable period ´ because an impulse striking at this time can initiate life threatening dysrhythmias (ventricular tachycardia & ventricular fibrillation)
The electrical impulses originates in the SA Node, specialized electrical cells called pcells (pacemaker cells) in the SA Node discharge impulses at a rate of 60-100/ min in rhythmic fashion. It controls the heart rate it is designated as the pacemeker.
mass and viscosity of blood in the great arteries)
Contractility: Speed and shortening capacity at a given instantaneous load (inotropy)
Diastolic Compliance: The ability to fill at a given diast. PVR. (aortic impedance. intraventricular P. P
Heart Rate: Frequency of contraction
Preload: Passive load that establishes the initial muscle length of the cardiac fibers prior to contraction
Afterload: Sum of all loads against which the the myocardial fibers must shorten during systole. arterial R.
The outside of these cells is now negatively charged with respect to ground. the cardiac cells are positively charged on the outside and negatively charged on the inside. Thus. Thus. Table
Zero potentials Depolarization Repolarization
Normal Voltages in the Electrocardiogram References
ECGs are merely recordings of voltage differences between two electrodes on the body surface as a function of time. the recording shows no deflection. a potential difference exists between the depolarized cells and the neighbouring. Depolarization
Depolarization causes a reversal of membrane potential in a cardiac cell. isoelectric line on the ECG.
. Zero potentials
During diastole. nonexcited cells. Electrodes on the skin do not detect voltage differences because all parts of the heart are equally polarized. when the heart is relaxed. you see the flat line.
Both electrodes again "see" the same potential. Repolarization
Repolarization is the reverse process were cells get back to the zero potential.
. and the galvanometer reading returns to zero. nonexcited cells.
Depolarization causes a reversal of membrane potential in a cardiac cell. all of the cells are negatively charged outside. When the entire heart has been depolarized. and the direction of its deflection depends on the polarity of the electrodes. a potential difference exists between the depolarized cells and the neighbouring. Surface electrodes record this potential difference. The outside of these cells is now negatively charged with respect to ground. Thus.
the voltage of the P wave is between 0.5 millivolt from the top of the R wave to the bottom of the S wave.
A wave of depolarization approaching the negative electrodes results in an downward deflection of the EKG tracing. A depolarization wave perpendicular to the electrode axis produces no net deflection of the tracing (the positive and negative waves are equal). When electrocardiograms are recorded from electrodes on the two arms or on one arm and one leg.1 and 0. When one electrode is placed directly over the ventricles and a second electrode is placed elsewhere on the body remote from the heart.3 millivolt. the voltage of the QRS complex usually is 1.0 to 1. By convention: A wave of depolarization approaching the positive electrodes results in an upward deflection of the EKG tracing. the voltage of the QRS complex may be as great as 3 to 4 millivolts.2 and 0.3 millivolt. and that of the T wave is between 0. A wave of depolarization proceeding parallel to an electrode axis (the line connecting two electrodes) produces the maximal deflection of that dipole.
Normal Voltages in the Electrocardiogram The recorded voltages of the waves in the normal electrocardiogram depend on the manner in which the electrodes are applied to the surface of the body and how close the electrodes are to the heart.