GRAPHIC SEQUENCE INTERPRETATION

One small square

1. Length in mm is 1mm
2. Height in mm is 1 mm
3. Length in duration is 0.04 seconds when paper is moving 25m/second
4. Height in potential difference is 0.1mv

One big squares length is made up by 5 small squares and height made by 5 small squares

1. Length in mm is 5 x 1mm = 5mm

2. Height in mm is 5 x 1mm = 5mm
3. Length in duration is 5 x 0.04sec = 0.2 seconds
4. Height in potential difference is 5 x 0.1mv = 0.5mv

A. SAN
1. Automatically as a pace-maker generates AP
2. Relays this impulse to Inter Nodal Pathways
B. Inter Nodal Pathways
1. Receive AP from SAN
2. Relay AP to
i. Right atrium
ii. Left atrium
iii. AVN
C. Rt Atrium and Lft Atrium (??? Do they have PF as well)
1. Receives AP from INP
2. Becomes depolarized
3. Contracts to empty blood through AV-valves into ventricles below
D. AVN
1. Receives AP from INP
2. Delays AP, so that Atria finishing empting blood into ventricles
3. Relays AP to Bundle of His (BH)
E. Bundle of His
1. Receives AP from SAN
2. Relays AP to
i. RBB
ii. LBB
F. RBB
1. Receives AP from BH
2. Relays AP to Purkinje fibers ramificating into Right ventricle
G. LBB
1. Receives AP from BH
2. Relays AP to
i. Septal brunch > AP to Inter-ventriculum septum from left to right
ii. Left (broad) posterior fascicle > AP to PF in LV Posterior & Inferior
surfaces
 iii. Left (narrow) anterior fascicle > AP to PF in LV Anterior & Superior
surfaces
H. NB PF (purkinje fibers traverse entire Ventricular wall thickness beginning from End-
ocardium to Mid-myocardium to Epi-cardium

De-polarization

Reversal of charges, of the inner and outer surface, of a CM of an excitable cell

The cell then assumes from the RMP state to Excitable state
Eg. Cardio-myocyte

At RM-Potential state At Excitable state/ depolan

Outer surface ++++++ charge --------- charge

Inner surface ---------- ++++++
Net P-difference -90mv -70-100-30mv = Thr-hold

Resting Membrane Potential

Is a state in which an excitable cell exists under no stimulation and

Na and K cations on either side of the cell membrane assume a unique
o concentration,
o diffusion along concentration gradient
o permeability and hence a
o net pd .

For Sodium For Potassium Net phase

Concentration Na Na Na x 3Xs K
Diffusion Begins but More +ve
CM permeability -------------- Eflux of K
Pd
CM permeability -------------- Permeable till equim
Diffusion No influx Begins Lesser +ve
Concentration Na K K K x 3times Xs

Depolarization in cardio-myocyte

1. Fast Na channels open up after stimulation, eg by AP from Purkinje fibers

2. This time, through both Electrical gradient and Conentration gradient Na influxes
3. Inner surface +ve charge increases and eventually positive, when +ve 30mv, threshold to
spike
4. Opening of Na channels is very fast and short lived (??? Speed) and they close, such that
only one phase, phase 0 accounts for depolarization

Propagation of an AP long the surface of CM of one cardio-myocyte

 1. Stimulus/ AP depolarizes one portion of the CM (??? Mm) (Reversal of charges)
2. It depolarizes adjacent CM (reversal of charges)
3. And so on

Propagation of an AP from one cardiomyocyte to the adjacent cardiomyocyte

1. AP in the Cardio-myocyte one CM portion adjacent to another Cardiomyocyte two

activates its adjacent CM portion
2. Propagation of AP along CM till it reaches AM of another Cardio-myocyte three

ECG

1. If flow of the AP is towards and parallel +ve electrode of lead it gives >
+ve or upward deflection and maximum height or voltage
2. If flow of the AP is towards but oblique +ve electrode of lead it gives >
+ve or upward deflection and small height/ voltage
3. If flow of the AP is away from and parallel +ve electrode of lead it gives >
-ve or downward deflection and maximum height or voltage
4. If flow of the AP is away from and parallel +ve electrode of lead it gives >
-ve or upward deflection and minimum height or voltage
5. If flow of the AP is perpendicular +ve electrode of lead it gives >
Nill/ Iisoelectric or Bi/ Di-phasic deflection and equal height or voltage or amplitude

ECG LEADS

Standard/ Limb leads

Denoted by Roman numericals

Lead I Right UL cathode- left UL anode+
Lead II Right UL cathode- left LL anode+
Lead III Left UL cathode- & left LL anode+

Augmented unipolar limb leads

Denoted by combination of lower case and upper case Letters

aVR Lead Right UL Electrode
aVL Lead Left UL Electrode
aVLF Lead Left LL Electrode

Precordial/ Chest unipolar leads

Denoted by letter V and Arabic numerical

Lead V1 4ICS Right side-parasternum
Lead V2 4ICS Left side-parasternum
Lead V3 midpoint between V2 & V4
Lead V4 5ICS - MCL
Lead V5 AAL 5ICS intersection (or with V4)
Lead V6 MAL 5ICS intersection (or with V4)
Right sided chest limbs: placed same position as counterparts

Lead V1R
Lead V2R
Lead V3R
Lead V4R
Lead V5R
Lead V6R
For Dx of RVH, RVMIn, Dextro-cardia

Posterior wall leads at level of Lead V4

Lead V7 Post.Axil.Line 5ICS intersection (or with V4)

Lead V8 L.Spinal.Line 5ICS intersection (or with V4)
Lead V9 Left.Para.Vert.Line 5ICS intersection (or with V4)