Prepared by: Dr. S.Punitha Josephine, M.Sc, Ph.

D
Vice Principal,
Department of Medical Surgical Nursing ,KVCN

ELECTROCARDIOGRAM

General objective
On completion of the class the learner will acquire knowledge on electrocardiogram and apply
it in nursing practice with desirable attitude.
Specific objectives
At the end of the class the learner will be able to
1. define electrocardiogram.
2. understand the evolution of ECG.
3. enumerate the principles of ECG
4. explain the cardiac action potential
5. correlate the normal impuse conduction with the ECG
6. list the leads of ECG.
7. describe the ECG graph paper
8 . realize the wave forms and intervals in the ECG.
9. assess the cardiac rhythm in ECG.
10.illustrate the clinical lead groups.
11. appreciate the axis deviation in the ECG
Duration: 2 hrs

An electrocardiogram is a graphic produced by an electrocardiograph ,which records the

electrical activity of the heart over time.

Historical perspectives
 Einthoven's ECG device

1856- Kollicker and Mueller Discovered the Electrical activity of the heart from a Frog.

1872- Alexander Muirhead Attached wires to a feverish patient’s wrist to record the heart beat.

1887 – Cardiac Electrical Activity was first recognized by Augustus Desire Waller

1903 – Human Electrocardiography was invented by Willem Einthoven, and he was awarded
the Nobel Prize in 1924.

Principles

The ECG records electrical changes in heart muscle. It does not record the mechanical
contraction.
ECG is based on the cardiac action potential that causes electrical changes in the heart
muscle.

Cardiac action potential

The cardiac action potential is a specialized action potential in the heart, necessary for
the electrical conduction system of the heart .
During phase 0 (depolarization), the electrical potential changes rapidly from a baseline of – 90
mV to + 20 mV and stabilizes at about 0 mV.There is a significant electrical change appears on
the ECG.Phase 1 and 2 represent an electrical plateau,during that time mechanical contraction
occurs. There is no significant electrical change at this time ,nothing shows on the ECG.During
phase 3 (repolarization)the electrical potential again changes,this time a little more slowly,from 0
mV back to -- 90 mV .It causes another major electrical event and it is reflected on the
ECG.Phase 4 represents the resting period during which chemical balance is restored by the
sodium pump, but since positively charged ions are exchanged on a one- for- one basis ,there is
no electrical activity and no visible changes occurs on the ECG tracing.

Myocardial cell has a negative membrane potential when at rest. Stimulation above a threshold
value induces the opening of voltage-gated ion channels with inducted flow of cations into the
cell.

The positively charged ions entering the cell cause the depolarization characteristic of an action
potential. After depolarization, there's a brief repolarization that takes place with the efflux of
potassium through fast acting potassium channels.

Depolarization causes the opening of voltage-gated calcium channels - meanwhile potassium

channels have closed and are followed by a release of Ca2+.
This influx of calcium causes, calcium-induced calcium release from the sarcoplasmic reticulum,
and free Ca2+ causes muscle contraction. After a delay, slow acting Potassium channels reopen
and the resulting flow of K+ out of the cell causes repolarization to the resting state.Mechanisms
of polarization give rise to unique properties of SA node cells, most importantly the spontaneous
depolarizations necessary for the SA node's pacemaker activity.

Normal Impulse Conduction& the ECG

• P wave - Atrial depolarization

 QRS - Ventricular depolarization

 T wave - Ventricular repolarization

SA node: P wave

Under normal conditions, electrical activity is spontaneously generated by the SA node, the
physiological pacemaker. This electrical impulse is propagated throughout the right atrium, and
through Bachmann's bundle to the left atrium, stimulating the myocardium of both atria to
contract. The conduction of the electrical impulse throughout the left and right atria is seen on
the ECG as the P wave.

As the electrical activity is spreading throughout the atria, it travels via specialized pathways,
known as internodal tracts, from the SA node to the AV node.

AV node/Bundles: PR interval

The AV node functions as a critical delay in the conduction system. Without this delay, the atria
and ventricles would contract at the same time, and blood wouldn't flow effectively from the
atria to the ventricles. The delay in the AV node forms much of the PR segment on the ECG.
Part of atrial repolarization can be represented by the PR segment.

The distal portion of the AV node is known as the bundle of His. The bundle of His splits into
two branches in the interventricular septum, the left bundle branch and the right bundle branch.
 The left bundle branch activates the left ventricle, while the right bundle branch activates the
right ventricle. The left bundle branch is short, splitting into the left anterior fascicle and the left
posterior fascicle. The left posterior fascicle is relatively short and broad, with dual blood supply,
making it particularly resistant to ischemic damage.

The left posterior fascicle transmits impulses to the papillary muscles, leading to mitral valve
closure. As the left posterior fascicle is shorter and broader than the right, impulses reach the
papillary muscles just prior to depolarization, and therefore contraction, of the left ventricle
myocardium. This allows pre-tensioning of the chordae tendinae, increasing the resistance to
flow through the mitral valve during left ventricular contraction.

Purkinje fibers/ventricular myocardium: QRS complex

The two bundle branches taper out to produce numerous purkinje fibers, which stimulate
individual groups of myocardial cells to contract.

The spread of electrical activity (depolarization) through the ventricular myocardium produces
the QRS complex on the ECG.

Ventricular repolarization: T wave

The last event of the cycle is the repolarization of the ventricles.

An impulse (action potential) that originates from the SA node at a relative rate of 60 - 100bpm
is known as normal sinus rhythm.

Leads

Electrode placed on the body is called as leads.Connections in ECG are described as being
made to the two terminals of a galvanometer. A lead records the electrical signals of the heart
from a particular combination of recording electrodes which are placed at specific points on the
patient’s body.

 When a depolarization wave front moves toward a positive electrode it creates a

positive deflection on the ECG in the corresponding lead.
 When a depolarization wave front moves away from a positive electrode it creates a
negative deflection on the ECG in the corresponding lead.
 When a depolarization wave front moves perpendicular to a positive electrode it
creates an equiphasic complex on the ECG.

There are 3 bipolar, 6 unipolar and 3 augmented unipolar leads.

Bipolar leads : Lead I,II,III

Unipolar leads: V1,V2,V3,V4,V5,V6(Precordial leads)

 Augmented unipolar leads: aVR, , aVL,aVF

Limb leads

In both the 5- and 12-lead configuration, leads I, II and III are called limb leads. The electrodes
that form these signals are located on the limbs—one on each arm and one on the left leg. The
limb leads form the points of what is known as Einthoven's triangle.

 Lead I is the voltage between the (positive) left arm (LA) electrode and right arm (RA)
electrode: Records the difference of potential between the Left arm and Right arm.

I = LA − RA.
 Lead II is the voltage between the (positive) left leg (LL) electrode and the right arm
(RA) electrode: Records the difference of potential between the left leg and the right arm.

II = LL − RA.
 Lead III is the voltage between the (positive) left leg (LL) electrode and the left arm (LA)
electrode: Records the difference of potential between the left leg and the right arm.

III = LL − LA.

Unipolar vs. bipolar leads

There are two types of leads: unipolar and bipolar. Bipolar leads have one positive and one
negative pole. The 12-lead ECG, the limb leads (I, II and III) are bipolar leads. Unipolar leads
also have two poles, as a voltage is measured; however, the negative pole is a composite pole
(Wilson's central terminal, or WCT) made up of signals from lots of other electrodes. In a 12-
lead ECG, all leads besides the limb leads are unipolar (aVR, aVL, aVF, V 1, V2, V3, V4, V5, and
V6).

Augmented limb leads

Leads aVR, aVL, and aVF are augmented limb leads (after their inventor Dr. Emanuel
Goldberger known collectively as the Goldberger's leads). They are derived from the same
three electrodes as leads I, II, and III. However, they view the heart from different angles (or
vectors) because the negative electrode for this lead is the modification of Wilson's central
terminal. This zeroes out the negative electrode and allows the positive electrode to become
the "exploring electrode".

 Lead augmented vector right (aVR) has the positive electrode (white) on the right arm.
The negative electrode is a combination of the left arm (black) electrode and the left leg
(red) electrode, which "augments" the signal strength of the positive electrode on the
right arm:
  Lead augmented vector left (aVL) has the positive (black) electrode on the left arm. The
negative electrode is a combination of the right arm (white) electrode and the left leg
(red) electrode, which "augments" the signal strength of the positive electrode on the left
arm:

 Lead augmented vector foot (aVF) has the positive (red) electrode on the left leg. The
negative electrode is a combination of the right arm (white) electrode and the left arm
(black) electrode, which "augments" the signal of the positive electrode on the left leg:

The augmented limb leads aVR, aVL, and aVF are amplified because the signal is too small to
be useful when the negative electrode is Wilson's central terminal. Together with leads I, II, and
III, augmented limb leads aVR, aVL, and aVF form the basis of the hexaxial reference system,
which is used to calculate the heart's electrical axis in the frontal plane.

Precordial leads

The electrodes for the precordial leads (V1, V2, V3, V4, V5 and V6) are placed directly on the
chest. Because of their close proximity to the heart, they do not require augmentation. Wilson's
central terminal is used for the negative electrode, and these leads are considered to be unipolar.
12 leads
Electrode
Electrode placement
label
RA On the right arm, avoiding thick muscle.
LA In the same location that RA was placed, but on the left arm.
RL On the right leg, lateral calf muscle
LL In the same location that RL was placed, but on the left leg.
In the fourth intercostal space (between ribs 4 & 5) just to the right of the sternum
V1
(breastbone).
V2 In the fourth intercostal space (between ribs 4 & 5) just to the left of the sternum.
V3 Between leads V2 and V4.
In the fifth intercostal space (between ribs 5 & 6) in the mid-clavicular line (the
V4
imaginary line that extends down from the midpoint of the clavicle (collarbone)).
Horizontally even with V4, but in the anterior axillary line. (The anterior axillary
line is the imaginary line that runs down from the point midway between the middle
V5
of the clavicle and the lateral end of the clavicle; the lateral end of the collarbone is
the end closer to the arm.)
Horizontally even with V4 and V5 in the midaxillary line. (The midaxillary line is
V6
the imaginary line that extends down from the middle of the patient's armpit.)

Additional electrodes
The classical 12-lead ECG can be extended in a number of ways in an attempt to improve its
sensitivity in detecting myocardial infarction involving territories not normally "seen" well. This
includes an rV4 lead which uses the equivalent landmarks to the V4 but on the right side of the
chest wall and extending the chest leads onto the back with a V 7, V8 and V9.

Image showing a patient connected to the 10 electrodes necessary

for a 12-lead ECG.

ECG graph paper

 3sec 3sec

 25 mm = 1 sec

• 1mm = 1/25thsec

• 1mm = 0.04 sec

• Horizontally

– One small box - 0.04 s

– One large box - 0.20 s (0.04 X 5 =0.20)

– Every 3 seconds (15 large boxes) are marked by a horizontal line.

• Vertically

- One small box= 0.1mv

– One large box = 0.5 mV

• An ECG is printed on paper covered with a grid of squares. It has five small squares on
the paper form a larger square. The width of a single small square on ECG paper
represents 0.04 seconds. Each small square represents 0.04 seconds, then a second will be
25 small squares across.
• The output of an ECG recorder is a graph with time represented on the x-axis and
voltage represented on the y-axis. The graph paper which has a background pattern of
1mm squares (often in red or green), with bold divisions every 5mm in both vertical and
horizontal directions.
• It is possible to change the output of most ECG devices but it is standard to represent
each mV on the y axis as 1 cm and each second as 25mm on the x-axis (that is a paper
speed of 25mm/s).
• At a paper speed of 25 mm/s, one small block of ECG paper translates into 40 ms. Five
small blocks make up one large block, which translates into 200 ms. Hence, there are five
large blocks per second.
Wave forms and intervals

A typical ECG tracing of a normal heartbeat (cardiac cycle)consists of a Pwave, QRS complex
and T wave.A small U wave is normally visible in 50 % to 75 % of ECGs.The baseline voltage
of the electrocardiogram is known as the isoelectric line . Typically the isoelectric line is
measured as the portion of the tracing following the T wave and preceding the next P wave.

The P wave represents atrial depolarization.The QRS complex represents ventricular

repolarization, corresponding to phase 0 of the ventricular action potential.It is referred to as a
complex because it can actually consist of several different waves ,depending on the placement
of positive electrode and the direction of the spread of electrical activity in the heart.The T wave
represents ventricular repolarization, corresponding to phase 3 of the ventricular action
potential.

The onset of the QRS to approximately the midpoint or peak of the T wave represents an
absolute refractory period, during which the heart muscle cannot respond to another stimulus no
matter how strong that stimulus might be .From the midpoint to the end of the T wave ,the heart
muscle is in the relative refractory period.The heart muscle has not yet fully recovered ,but it
could be depolarized again if a strong stimulus were received.This can be a particularly
dangerous time for ectopy to occur,especially if any portion of the myocardium is ischemic
,because the ischemic muscle takes even longer to fully repolarize.
 P wave: Represents the sequential activation (depolarization) of the right and left
atria, should be up right.

QRS complex: Right and left ventricular depolarization (normally the ventricles
are activated simultaneously)

ST-T wave: Ventricular repolarization,T wave should be upright.

U wave: Origin for this wave is not clear - but probably represents "after
depolarizations" in the ventricles

PR interval: Time interval from onset of atrial depolarization (P wave) to onset

of ventricular depolarization (QRS complex)

QRS duration: Duration of ventricular muscle depolarization

QT interval: Duration of ventricular depolarization and repolarization

RR interval: Duration of ventricular cardiac cycle (an indicator of ventricular

rate)

PP interval: Duration of atrial cycle (an indicator of atrial rate)

Waves and intervals Duration (sec)

P wave 0.06 sec
PR interval 0.12-0.20
QRS interval 0.04-0.12
ST segment 0.12
T wave 0.16
QT interval 0.34-0.43

Rhythm analysis

Basic rules:

1. What is the rate?

2. Is it regular or irregular?

3. Are P waves present?

4. Are QRS complexes present?

5. Is there 1:1relationship between P waves and QRS complexes?

6.Is the PR interval constant?

Parameters Normal sinus rhythm

Rate 60 -100 / mt
Rhythm Regular
P wave Present with one per QRS
PR interval 0.12- 0.20 sec and constant
QRS 0.06 – 0.10 sec

The different waves that comprise the ECG represent the sequence of depolarization and
repolarization of the atria and ventricles. The ECG is recorded at a speed of 25 mm/sec, and the
voltages are calibrated so that 1 mV = 10 mm in the vertical direction. Therefore, each small 1-
mm square represents 0.04 sec (40 msec) in time and 0.1 mV in voltage. Because the recording
speed is standardized, one can calculate the heart rate from the intervals between different waves.
 The term "heart rate" normally refers to the rate of ventricular contractions. However, because
there are circumstances in which the atrial and ventricular rates differ (e.g., second and third
degree AV block), it is important to determine both atrial and ventricular rates. This is easily
done by examining an ECG rhythm strip, which is usually taken from Lead II. In the example
below, there are four numbered R waves, each of which is preceded by a P wave. Therefore, the
atrial and ventricular rates will be the same because there is a one-to-one correspondence. Atrial
rate can be determined by measuring the time intervals between P waves (P-P intervals).
Ventricular rate can be determined by measuring the time intervals between the QRS complexes,
which is done by looking at the R-R intervals.

There are different short-cut methods that can be used to calculate rate, all of which assume a
recording speed of 25 mm/sec. One method is to divide 1500 by the number of small squares
between two R waves. For example, the rate between beats 1 and 2 in the above tracing is
1500/22, which equals 68 beats/min, alternatively, one can divide 300 by the number of large
squares (red boxes in this diagram), which is 300/4.4 (68 beats/min).

The second method can be used with an irregular rhythm to estimate the rate. Count the number
of R waves in a 6 second strip and multiply by 10. For example, if there are 7 R waves in a 6
second strip, the heart rate is 70 (7x10=70).

The third method, which gives a rough approximation, is the "count off" method. Simply count
the number of large squares between R waves with the following rates: 300 - 150 - 100 - 75 - 60.
For example, if there are three large boxes between R waves, then the rate is 100 beats/min. One
must extrapolate, however, between boxes. Atrial rate can be determined like the ventricular rate,
but using the P waves. Remember, if the heart in in sinus rhythm and there is a one-to-one
correspondence between P waves and QRS completes, then the atrial rate will be the same as
ventricular rate.
In the above examples, the ventricular rate was determined based on the interval between the
first two beats. However, it is obvious that the rate would have been faster had it been calculated
using beats 2 and 3 (104 beats/min) because of a premature atrial beat, and slower if it had been
calculated between beats 3 and 4 (52 beats/min). This illustrates an important point when
calculating rate between any given pair of beats. If the rhythm is not steady, it is important to
determine a time-averaged rate over a longer interval (e.g., over ten seconds or longer). For
example, because the recording time scale is 25 mm/sec, if there are 12.5 beats in 10 seconds, the
rate will be 75 beats/min.

P wave

The P wave represents the wave of depolarization that spreads from the SA node throughout the
atria, and is usually 0.08 to 0.1 seconds (80-100 ms) in duration. The brief isoelectric (zero
voltage) period after the P wave represents the time in which the impulse is traveling within the
AV node (where the conduction velocity is greatly retarded) and the bundle of His. Atrial rate
can be calculated by determining the time interval between P waves.

The period of time from the onset of the P wave to the beginning of the QRS complex is termed
the P-R interval, which normally ranges from 0.12 to 0.20 seconds in duration. This interval
represents the time between the onset of atrial depolarization and the onset of ventricular
depolarization. If the P-R interval is >0.2 sec, there is an AV conduction block, which is also
termed a first-degree heart block if the impulse is still able to be conducted into the ventricles.

QRS complex

The QRS complex represents ventricular depolarization. Ventricular rate can be calculated by
determining the time interval between QRS complexes. Click here to see how ventricular rate is
calculated.

The duration of the QRS complex is normally 0.06 to 0.1 seconds. This relatively short duration
indicates that ventricular depolarization normally occurs very rapidly. If the QRS complex is
prolonged (> 0.1 sec), conduction is impaired within the ventricles. This can occur with bundle
branch blocks or whenever a ventricular foci (abnormal pacemaker site) becomes the pacemaker
driving the ventricle. Such an ectopic foci nearly always results in impulses being conducted
over slower pathways within the heart, thereby increasing the time for depolarization and the
duration of the QRS complex.
ST segment

The isoelectric period (ST segment) following the QRS is the time at which the entire ventricle is
depolarized and roughly corresponds to the plateau phase of the ventricular action potential. The
ST segment is important in the diagnosis of ventricular ischemia or hypoxia because under those
conditions, the ST segment can become either depressed or elevated.

T wave

The T wave represents ventricular repolarization and is longer in duration than depolarization
(i.e., conduction of the repolarization wave is slower than the wave of
depolarization). Sometimes a small positive U wave may be seen following the T wave (not
shown in figure at top of page). This wave represents the last remnants of ventricular
repolarization. An inverted or prominent U wave indicates underlying pathology or conditions
affecting repolarization.

Q-T interval

The Q-T interval represents the time for both ventricular depolarization and repolarization to
occur, and therefore roughly estimates the duration of an average ventricular action potential.
This interval can range from 0.2 to 0.4 seconds depending upon heart rate. At high heart rates,
ventricular action potentials shorten in duration, which decreases the Q-T interval. Because
prolonged Q-T intervals can be diagnostic for susceptibility to certain types of tachyarrhythmias,
it is important to determine if a given Q-T interval is excessively long. In practice, the Q-T
interval is expressed as a "corrected Q-T (QTc)" by taking the Q-T interval and dividing it by the
square root of the R-R interval (interval between ventricular depolarizations). This allows an
assessment of the Q-T interval that is independent of heart rate. Normal corrected Q-Tc intervals
are less than 0.44 seconds.

There is no distinctly visible wave representing atrial repolarization in the ECG because it occurs
during ventricular depolarization. Because the wave of atrial repolarization is relatively small in
amplitude (i.e., has low voltage), it is masked by the much larger ventricular-generated QRS
complex.
Clinical lead groups

There are twelve leads in total, each recording the electrical activity of the heart from a different
perspective, which also correlate to different anatomical areas of the heart for the purpose of
identifying acute coronary ischemia or injury.

Correlation between ventricular surfaces ,ECG leads and coronary arteries

ventricular ECGLeads Coronary artery involved
surfaces

Anterior V1 to V4 Left anterior decending artery

Inferior II, III, aVF Right coronary artery

Lateral V5, V6, I, aVL Left circumflex

Septal V1 – V2 Left anterior decending artery

Posterior V1 – V2

(reciprocal changes) Left circumflex

Axis Deviation:

Use Lead I, II, and aVF to diagnois Axis Deviation

Vectors and Axis

 Vector: A quantity of electrical force that has a known magnitude and direction.

 Axis: A hypothetical line which joins the poles of a lead which measure electrical force.
 Mean Cardiac Vector: The avaerage of all the instananeous vectors. ( AKA mean
electrical axis ).

The postion of the mean cardiac vector provides information about the electrical "position" of the
heart, and is influenced by the relationship of the heart within the chest, as well as by the
anatomy of the heart itself.

The heart's electrical axis refers to the general direction of the heart's depolarization wavefront
(or mean electrical vector) in the frontal plane. With a healthy conducting system the cardiac
axis is related to where the major muscle bulk of the heart lies. Normally this is the left ventricle
with some contribution from the right ventricle. It is usually oriented in a right shoulder to left
leg direction, which corresponds to the left inferior quadrant of the hexaxial reference system,
although −30° to +90° is considered to be normal. If the left ventricle increases its activity or
bulk then there is said to be "left axis deviation" as the axis swings round to the left beyond -30°,
alternatively in conditions where the right ventricle is strained or hypertrophied then the axis
swings round beyond +90° and "right axis deviation" is said to exist. Disorders of the conduction
system of the heart can disturb the electrical axis without necessarily reflecting changes in
muscle bulk.
Steps in determining Axis

1.Find the most isoelectric limb lead.

2.Using the hexaxial reference system,find the lead that is perpendicular to the one identified in
step 1.

3.Determine whether the QRS is positive or negative in the perpendicular lead.

4.Look at the corresponding positive or negative pole of the perpendicular lead on the hexaxial
reference system

5.The degree listed on the hexaxial reference system is the axis.

−30° to
Normal Normal Normal
90°
Left axis deviation is considered
Left axis −30° to May indicate left anterior fascicular
normal in pregnant women and
deviation −90° block or Q waves from inferior MI.
those with emphysema.
May indicate left posterior fascicular Right deviation is considered
Right axis +90° to
block, Q waves from high lateral MI, normal in children and is a
deviation +180°
or a right ventricular strain pattern. standard effect of dextrocardia.
Extreme right +180° Is rare, and considered an 'electrical
axis deviation to −90° no-man's land'.

 Normal Deviation:

The QRS deflection is upright or positive in I and either aVF or Lead II. A normal axis
means the QRS axis falls between -30 and 90 degress in the chest. The heart is lying in an
angle between these parameters.

 Right Axis Deviation:

The QRS is downward or negatively deflected in I and positive in aVF or Lead II.
The heart is lying in an angle lower the 30 dgress in the chest.It can be normal in young
adults or "thin peolpe.".It may be abnormal in peolpe who have a block in the posterior
division of the left bundle.This can imply delayed activation of the right ventricle ( as
seen in RBBB ) or Right Ventricular enlargement.

Ex.,Pathology: Right Ventricular enlargemnet and hypertrophy. C.O.P.D. Pulmonary

Embolism, Congenital heart Disease, Inferior wall MI.

 Left Axis Deviation:

 The QRS is uright or postively deflection in I and negative in aVF or Lead II.
The heart is lying in an angle greater than 90 degress in the chest.This can be normal in
the presence of acites, abdominal tumors, pregnancy or obesity.Abnormalities are due to
Left Ventricular enlargement or a Left anterior hemiblock.

Ex., Pathology: Left ventricular enlargement, and hypertrophy, Hypertension, Aortic

Stenosis. Ischemic Heart Disease. Inferior wall MI.

As stated above. the electrical current should flow to the positive lead. If it does not flow in a
positive direction, the heart is pointing toward the upper right or the left. So, if the QRS is
negative in aVF, the heart is pointing more to the left than noraml; hence, Left Axis Deviation. If
the QRS is negative in Lead I, the heart is pointing more to the right than normal; hence, Right
Axis Deviation.

Conclusion

The ECG analysis involves the systematic approach as discussed above which depicts the cardiac
electrical activity. This guides the way to understand the deviation from normal.

Multiple choice questions

1.The graphic representation of the electrical current is called as----- [B ]

A) Electro cardiograph B) Electrocardiogram C)Encephalogram D) Waves

2.When an depolarization process flows towards a unipolar electrode ,the galvanometer will
record a--------. [A ]

A) Positive deflection B) negative deflection C) Isoelectric line D) right axis deviation

3. The------ represents the wave of depolarization that spreads from the SA node throughout the
atria.

A) P wave B) Q wave B) R wave D) QRS complex [A ]

4.The------ represents ventricular depolarization .

A) T wave B) R wave C)QRS complex) P wave [C ]

5. The ------represents ventricular repolarization

A) T wave B) R wave C)QRS complex D)T wave [D ]

6.The duration of P wave is -----

A) .04 sec B)0.06 sec C)0.08 D)0.10 [B ]

7..The duration of PR interval is -----

A) .04 sec B)0.06 sec C)0.12-0.20 sec D)0.10 [C ]

8. The duration of QRS complex is -----

A) .04 sec B)0.06 sec C)0.12-0.20 sec D)0.04- 0.12sec [D ]

9. A normal axis means the QRS axis falls between ------degress in the chest.

A)-30 and 90 B) 20 -40 C) 10- 30 D) -30 to -80 [A ]

10) A right axis deviation is ------.degree.

A) 50-60 B) 30 -90 C) +90 to +180 D) 100- 120 [C ]