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Lectro Ardio Raphy: by Dr. Omprakash Sah Medical Officer NAMS, Bir Hospital
Lectro Ardio Raphy: by Dr. Omprakash Sah Medical Officer NAMS, Bir Hospital
By
Dr. Omprakash sah
Medical Officer
NAMS, Bir Hospital
1
ECG = Electrocardiogram
Is graphical representation of electrical activity of
the heart
Each event has a distinctive waveform, the study of
which can lead to greater insight into a patient’s
cardiac pathophysiology.
2
History
• 1842- Carlo Matteucci -electricity is a/w hrt beat
4
Photograph of a complete Electrocardiograph Showing
the manner in which the electodes are attached to the
patient – in this case hands and one foot being immersed
in the Jars of Salt solution
5
• Review of the conduction system/
Electrophysiology
• ECG leads
• ECG waveforms and intervals
• Determining heart rhythm / rate
• Determining QRS axis
6
Conduction system
Electrophysiology
7
8
Cardiac Electrophysiology
– 3. Cardiac myocytes
9
Pacemakers of Heart
• AV Node - 40 - 60 beats/minute.
10
Cardiac Impulse
1. Cardiac impulse originates in the SA
node
2. Traverses the atria simultaneously –
no special conduction wires in atria
3. Reaches AV node – the check post –
so delay
4. Enters bundle of His and branches –
through specialized conducting wires
called Purkinje network - activates
both ventricles – quick QRS
5. First the septum from L to R, then
right ventricle and then the left
ventricle and finally the apex
6. Then the ventricles recover for next
impulse
11
12
Normal Sinus Rhythm ( NSR )
13
ECG Leads
14
Leads are electrodes which measure
the difference in electrical potential
between either:
15
The standard ECG has 12 leads:
16
Electrode Placement
17
18
18
ECG Chest Leads
Chest Lead Position
• V1 Fourth ICS, right sternal border
• V2 Fourth ICS, left sternal border
• V3 Equidistant between V2 and V4
• V4 Fifth ICS, left Mid clavicular Line
• V5 Fifth ICS Left anterior axillary line
• V6 Fifth ICS Left mid axillary line
19
20
The Six Chest Leads
TRANSVERSE PLANE
21
ECG Bipolar Limb Leads
22
ECG Bipolar Limb Leads
- + - -
R L R L
F
+ +
F
23
24
ECG Unipolar Limb Leads
25
ECG Unipolar Limb Leads
+ +
R L
+ F
26
27
The axis of a particular lead represents the
viewpoint from which it looks at the heart.
28
V1, V2: Septum
V5, V6: lateral wall
29
I aVL: high lateral wall
II, III, aVF: inferior wall
30
31
(Septum)
32
(Anterior Wall)
33
(Lateral Wall)
34
(Inferior Wall)
35
36
ECG Waves and intervals
37
• Segment – Straight line b/w waves
• Interval – wave + segment
• 3 waves, 2 intervals, 2 segments
38
• 3 distinct waves are produced during cardiac cycle
39
• P wave
caused by atrial depolarization
40
13-63
41
42
43
P Wave
44
P Wave
45
46
P Pulmonale
P MITRALE
47
P pulmonale
Peaked p waves (>2.5mm) indicate right atrial
enlargement.—due to pulmonary hypertension
P MITRALE ( P-sinistrocardiale ) :
48
PR INTERVAL
49
50
Short PR Interval
• WPW Sx (Wolff-Parkinson White Syndrome)
51
Short PR Interval
52
• QRS complex
caused by ventricular depolarization
53
Ventricular Depolarization
Includes
• Bundle of His
• Bundle Branches
– Right
– Left
• Septal
• Anterior
• Posterior
• Terminal Purkinjie fibers
54
Ventricular Depolarization
• Ventricular Waves
55
Ventricular depolarization
56
V1, V2: rS R / S<1
V3, V4: RS R / S near 1
V5, V6: Rs R / S>1 57
ST Segment
• It starts at the J point (junction between the QRS complex and ST
segment) and ends at the beginning of the T wave
• Duration = 0.08 - 0.12 sec
•Flat, downsloping, or depressed ST segments may indicate coronary
ischemia.
•ST elevation may indicate myocardial infarction.
58
• T wave
results from ventricular repolarization
59
13-63
T Wave
U Wave
60
QT Interval
61
ECG Complex
64
ECG interpretation - step-by-step
• P – wave
• PR - interval
• QRS Complex
• ST Segment
• QT interval
• T wave
• Rate
• Rhythm
• Cardiac Axis
65
Heart Rate
66
ECG Graph Paper
Y- Axis Amplitude in mill volts
68
RR Interval – One Cardiac cycle
69
Rate
Determination
No. of Big R – R Interval Rate Rate
Boxes Cal.
T
One 0.2 sec 60 ÷ 0.2 300 A
C
Two 0.4 sec 60 ÷ 0.4 150 H
Y
Three 0.6 sec 60 ÷ 0.6 100 N
O
Four 0.8 sec 60 ÷ 0.8 75 R
M
Five 1.0 sec 60 ÷ 1.0 60 A
L
Six 1.2 sec 60 ÷ 1.2 50 B
R
Seven 1.4 sec 60 ÷ 1.4 43 A
D
Eight 1.6 sec 60 ÷ 1.6 37 Y
70
71
Rate Determination
QRS
Next
QRS
71
CALCULATING RATE
• Rule of 300
300
Rate =
number of BIG SQUARE b/w R-R
73
74
74
75
75
What is the Heart Rate ?
76
77
77
What is the Heart Rate ?
To find out the heart rate we need to know
The R-R interval in terms of # of Big Squares
If the R-R intervals are constant
In this ECG the R-R intervals are not constant
R-R are varying from 2 boxes to 3 boxes
It is an irregular rhythm – Sinus arrhythmia
Heart rate is 300 ÷ 2 to 3 = 150 to 100 approx
78
What is the Heart Rate ?
79
10 Second Rule
As most ECGs record 10 seconds of rhythm per
page, one can simply count the number of beats
present on the ECG and multiply by 6 to get the
number of beats per 60 seconds.
80
What is the Heart Rate ?
33 x 6 = 198 bpm 81
CALCULATING RATE
Rhythm irregular- # of beats in a 6-sec X by 10
1 2 3 4 5 6 7 8
83
(300 / 6) = 50 bpm
84
(300 / ~ 4) = ~ 75 bpm
85
(300 / 1.5) = 200 bpm
86
Normal Sinus Rhythm (NSR)
87
Normal Sinus Rhythm (NSR)
the P waves are normal on the ECG
88
Determining ECG Axis
89
Axis Determination & Deviation
• What is Axis?
NW
QRS Axis
NE
SW SE
91
QRS Axis
• Normal Axis - when it is downward and to the left – southeast quadrant –
from -30 to +90 degrees
• Right Axis – when it is downward and to the right – southwest quadrant –
from +90 to 180 degrees. Right Axis Deviation (RAD):
Right Ventricular Hypertrophy (RVH) — most common
92
Two Leads Method
94
Axis Determination
ALL UPRIGHT MEET LEAVE
95
Axis Determination
Axis I III or aVF TIP
Peak-Peak: Right
96
1. Lead I & aVF divide thorax into quadrants,
2. If Lead I & aVF (III) are both upright- Axis is
normal.
97
Tests
98
99
I
aVR
II aVL
III aVF
99
ECG With Normal Axis
100
101
II
III
101
ECG With Right Axis
• Note the QRS voltages are positive and
upright in leads L2, L3
• Negative in Lead 1
• L2, L3 tell that it is downward
• L1 tells that it is not to the left but to right
• Downward and rightward is Right Axis
• See the Right –Meet criterion QRS in
L1 and L3 meet
• Right Axis Deviation - RAD
102
103
I aVR
II aVL
III aVF
103
ECG With Left Axis
Normal Axis
105
More info for determing the axis
AXIS
leads.
c
atrial walls
• Cannot propagate across the
boundary b/w atria & ventricle
• Resultant vector - in yellow
• Projections on Leads I, II and III
are all +ve
ECG Signal
• AV node located on A-V
boundary & provides
conducting path
• Delay - allow ventricles to fill.
• Definitions
• Axis Quadrants
• Axis Determination
• Axis Deviation
Axis Determination & Deviation
• What is Axis?
- + =
Basics of 12 Lead ECG Vector
- + =
Basics of 12 Lead ECG Vector
- + =
AXIS
Basics of 12 Lead ECG's
Determining AXIS
Lead I aVF
N axis
LAD
RAD
ERAD
The Quadrant Approach
Quadrant Approach: Example 1
/
Quadrant Approach: Example 2
/
Basics of 12 Lead ECG Vector
aVR
LAD
-30°
Axis scale
-150° aVL
180° 0°
I
150°
30°
120° II
III 60°
Normal Axis
90° aVF
-30° to +100°
RAD
Hexaxial Array for Axis Determination
Determination of
angle of HEART
AXIS in frontal
plain
Example 1
• Lead I
• Lead aVF
• Lead aVL
Lead I
If lead I is mostly
+ve, the
axis must lie in Rt
½
of coordinate
system
Lead AVF
If lead AVF is
mostly +ve, the
axis must lie in
the bottom ½ of
coordinate
system
I AVF
Combining the 2
plots, we see
that axis must lie
in bottom
right hand
quadrant
I AVF AVL
Example 2
• Lead I
• Lead aVF
• Lead II
Example 2
Lead I
Lead I is
mostly -ve, the
axis must lie in
the Lt ½ of the
coordinate.
Lead AVF
Lead aVF is
mostly +ve, the
axis must lie in
the bottom ½
of the coordinate
I AVF
Combining the
two plots- axis
must lie in
bottom
Lt hand
quadrant (RAD)
I AVF II
Precise Axis
Calculation
Precise calculation of
the axis can be done
using the coordinate
system to plot net
voltages of
perpendicular leads,
drawing a resultant Net voltage = 12
rectangle, then Since Lead III is the
connecting the origin most equiphasic
Net voltage = 7
of the coordinate lead and it is
system with the slightly more
opposite corner of positive than
the rectangle. A negative, this axis
protractor can then could be estimated
be used to measure at about 40o.
the deflection from
0.
CARDIAC AXIS
CARDIAC AXIS
Positive
Positive
Positive
N Axis
CARDIAC AXIS
CARDIAC AXIS
Positive
Negative
Negative
LAD
CARDIAC AXIS
CARDIAC AXIS
Negative
Positive
Positive
RAD
CARDIAC AXIS