2023 ECG Session 02

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

MSc Physician Associate Studies

Module: Clinical Medicine & Practice
Lecturer: Sean Robinson
Enter subtitle herePA-C
(24pt, Arial Regular)
Enter date: 25.06.13
Learning Outcomes
By the end of this learning session, the first-year physician associate student should be able to:
• Provide a definition of each of the terms described in the "Glossary" of the 9th Edition of Hampton and Hampton's The ECG Made Easy (a PDF copy of the
glossary is provided in the ECG Resources link in the ECG section of the CMP module in Moodle).
• Describe what is meant by "depolarization" and "repolarization" how these terms relate to myocardial contraction.
• Describe the purpose of the sinoatrial node.
• List the normal sequence of conduction of a depolarization signal starting from the SA node and ending in the myocytes of the ventricles; be sure to include
specialized structures such as the AV node, the bundle of His, the left and right bundle branches, and the Purkinje fibres.
• Compare and contrast the ECG features associated with atrial depolarization and contraction with ventricular depolarization and contraction.
• Identify a P wave, PR interval QRS complex, ST segment, T wave and U wave on an ECG.
• Explain what is meant by a standard ECG tracing rate of "25 mm/sec" and what would happen if this rate is not perfectly replicated by an ECG machine.
• Provide the length (in mm) of one "small" vs one "large" squares of ECG paper and how each of these translates to time (in seconds or milliseconds).
• Provide the length (in mm) of two "large" squares of ECG paper and how this relates to voltage.
• Calculate how many large boxes represent 1 second.
• List the normal duration of a PR interval.
• List the normal duration of the QRS complex.
• Compare and contrast the terms lead and electrode.
• List the 6 limb leads
• List the 6 chest leads
CARDIAC A&P
Cardiac Anatomy

• Located in the mediastinum, behind the sternum

• Shaped like an inverted blunt cone
• Apex is directed anteriorly and slightly inferiorly at the level of the
5th ICS in the MCL
intercostal space
Blood Flow from upper extremetites

to lungs- drop CO2 pickup O2

systemic circulation
http://www.nhlbi.nih.gov/health/dci/images/heart_interior.gif
 start at atrium (SAN), generates
electrical signals —> through AV
Conduction Pathway node (job is to slow down SAN
signals to allow for contraction) -
pauses - atriums contract - splits
into right and left ventricle —> to
Purkinje Fibers —> pulmonary

septal branch
 If SA node not working AV node will kick
in- drop in cardiac output- all tissues will get
Pacemaker Sites less O2- lethargic, not alert

• SA node: 60 – 100 bpm If SA and AV node dont work- Ventricles kick in-
very low dont want to be this low for long- will start
• AV Node: 40 – 60 bpm to have infarction events at this low
• Ventricles: 20 – 40 bpm
• This includes the Bundle Branches and Purkinje fibers
• Impulses can be generated anywhere in the atria and ventricles
External Influences on the Heart

• Barorecptors: sense changes in blood pressure

• Chemoreceptors: sense changes in chemical composition of
blood
• These changes trigger response from autonomic nervous system
• Sympathetic – “Fight or Flight”
• Parasympathetic - “Rest and Digest”
Sympathetic Influence

• Stimulation of β receptors on heart:

• Enhancement of myocardial cell excitability
• Increased rate of pacemaker firing
• Increased conduction speed
• Increased contractility signals can get to cells more
quickly, will get faster heart rate
Parasympathetic Influence

• Vagus nerve stimulation of SA node, atria, AV node, and

ventricles:
• Slowing of heart rate
• Slowing of AV conduction
How it works together
ECG: RECORDING THE HEART’S
ELECTRICAL ACTIVITY
The Electrocardiogram

• “EKG” from Elektrokardiogram (German)

• “ECG” refers to Electrocardiogram
• Definition: Tracing or graphic representation of the heart’s
electrical activity
 Depolarization and Repolarization
ions moving over and backtowards
a membrane
Detecting Depolarization and Repolarization Events

https://gfycat.com/gifs/detail/zanyradiantamericanwigeon

can either make a negative or

positive deflection
ECG Paper: Voltage & Time
Electrical Activity: 1 View

Time

beats happening more than 1 per 1

second

https://apps.media.unc.edu/crashcart/Resources/HeartRhythms.html
Electrical Activity: 3 Views depolarisation inside the ventricle

all seem to occur at the same time Time

3 different angles looking at same

thing
Electrical Activity: 12 Views

Time continuoum of time at bottom

 A “view” is what we call a “lead”

• 12 leads look at heart from 12 different points of view

lead 3- arrow represents movement

of electrical event
Would expect to have very positive
deflections (very tall) in lead 3
ECG Lead Polarity

• Bipolar has negative and positive electrode (leads I, II, and III)
• Unipolar has positive electrode only; the negative electrode is
substituted by a reference point calculated by the ECG machine
(leads aVR, aVL, aVF, and V1 – V6
Leads and Planes

• Limb leads look at frontal plane

(red)
• Chest leads look at horizontal
plane (green)
Limb Leads and Chest Leads

• Limb leads: I, II, III, aVR, aVL, aVF

• I, II, III = standard Limb leads (bipolar)
• aVR, aVL, aVF = augmented vector right, left and foot (unipolar)
• Chest (precordial) leads: V1-V6 (unipolar)
But wait… is “lead” the same thing as “electrode”?
Electrode Placement: Limb Leads

Two options for lead placement…

1. Right arm, Left arm and Left leg
2. Right upper chest, Left upper
chest and Left lower chest
 Lead 1— movement in this field
Standard Limb Leads

lead 2- Lead 3
movement movement
top R to top L to
bottom L bottom R
Augmented Limb Leads

have 3 electrodes but get 6 different

views
Limb Leads and the Hexaxial System

https://www.unm.edu/~lkravitz/EKG/hexaxial.html
 most interested in ventricles with
Electrode Placement: Chest Leads the chest leads

4th intercostal space, just to the right of

V1 the sternum

4th intercostal space, just to the left of

V2 the sternum

V3 Midway between V2 and V4

V4 5th intercostal space, mid-clavicular line

V5 Anterior axillary line, between V4 and V6

V6 Mid-axillary line, horizontal with V4

Chest Leads

Leads Ventricular Region

V1-V2 anteroseptal

V3-V4 anteroapical

V5-V6 anterolateral
ECG WAVEFORMS
 P wave- depolarization- inducing contraction (0.06-0.1 seconds)
The Normal ECG QRS- < seconds
T wave- polarization- back to resting phase

R Wave QT Interval

PR Interval
ST Segment
P Wave

T Wave PR Interval- time to go through

ventricle and pause at AV node

Q Wave
S Wave
QRS Complex
The Normal ECG

U wave- may see in young or older

patients
P Waves and Atrial Depolarization
 P Waves from Within the Sinus Node

Risk Prediction of Atrial Fibrillation Based on Electrocardiographic Interatrial Block - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Examples-of-interatrial-block-as-well-as-a-normal-ECG-IAB-
indicates-interatrial-block_fig1_325453907
P Waves from Outside the Sinus Node
Questions