THE ELECTROCARDIOGRAM

Leads: Leads record the electrical activity of the heart occurring between two electrodes. Placement of leads on the body allows view of the heart in two planes frontal and transverse. The 12-lead EKG views the heart from 12 different angles 6 frontal and 6 transverse. There are three types of leads standard limb leads (bipolar), augmented leads (unipolar), and chest leads (precordial.) Each lead has a positive electrode which sees the magnitude and direction of electrical forces in a specific part of the heart. If electrical activity moves towards the positive electrode, the EKG shows an upward waveform if the electrical activity is away, it is a downward waveform. No electrical activity is represented by a straight line (isoelectric.) No leads view the posterior surface of the heart. Frontal Plane: Has 3 standard leads and 3 augmented leads. Standard leads: Lead I (Rt. Shoulder) views lateral lt. ventricle, QRS is + Lead II (Lt. Shoulder) views inferior lt. ventricle, QRS is + Lead III (Lt. Foot) views inferior lt. ventricle, QRS is +, P ]may be +, -, or both Augmented leads: AVR (Rt. Shoulder) view of the base of the heart, QRS is AVL (Lt. Shoulder) view of lateral lt. ventricle, QRS is 0 AVF (Lt. Foot) view of inferior lt. ventricle, QRS is + Transverse Plane: Has 6 precordial (chest) leads. V1 (4th intercostal space rt.) P +, -, or 0, QRS is V2 (4th intercostal space lt.) same as V1 V3 (midway btw V2 and V4) Same as V1, V2 V4 (5th intercostal space, lt. midclavicular line) P + V5 (5th intercostal space, lt. ant. axillary line) P +, QRS + V6 (5th intercostal space, lt. midaxillary line) P +, QRS + EKG stip paper: X axis = Time (sec), Y Axis = Voltage (mV). Speed = 25mm/sec. 1 box = 1mm = 0.04 sec. One large box = 5mm = 0.2 sec P Wave: Smooth and round, no more than 2.5mm tall. No more than 0.11 sec duration. + in I, II, AVF, V2-V6. PR Segment: Line btw P wave end and QRS beginning. PR Interval: P wave + PR segment. Represents depolarization of the atria and propagation through the AV node, bundles of His and Purkinje fibers. Normal = 0.12-0.2 sec. Long PR interval = delayed impulse (heart block), digitalis toxicity Short PR interval = impulses originating from ectopic focus QRS Complex: Q downward, depolarization of IV septum R,S Simultaneous depolarization of ventricles (mainly lt.) Overall positive, may be missing one component (variable) Normal = 0.06 0.10 sec Long QRS complex = ectopic purkinje/myocardial pacemaker ST Segment: Line btw QRS complex and T wave. Represents early ventricular repolarization. Displacement up or down from the isoelectric line is termed ST elevation or depression. ST depression (>1mm) = myocardial ischemia, digitalis tox. ST elevation (>1mm limb, >2mm chest) = myocardial injury T Wave: Represents ventricular repolarization, should be in the same direction as the QRS complex. Inverted T waves = myocardial ischemia Tall, pointed T waves = Hyperkalemia Rate: Pulse rate measured from the EKG, in 1 of 2 ways: 1) Count # of QRS complexes in 6 sec, multiply by 10 2) Count # of large boxes btw QRS complexes, divide into 300 Rhythm: Regular amount of time btw QRS complexes. Normal Sinus Rhythm = 60-100 beats/sec, uniform P waves, PRI 0.12-0.2 sec, QRS <0.11 Sinus Bradycardia = Regular rhythm, <60 beats/min Sinus Tachycardia = Regular rhythm, 100-180 beats/min Arrhythmia = Irregular rhythm (P waves, QRS uniform)

ATRIAL DYSRHYTHMIAS: Atrial dysrhythmias reflect abnormal electrical formation and conduction in the atria. The two mechanisms whereby electrical impulses are altered are changes in automaticity and triggered activity. Factors that cause a change in automaticity include ischemia, drug toxicity, hypocalcemia, and electrolyte imbalance. Factors that cause triggered activity are hypoxia, catecholamines, hypomagnesia, myocardial ischemia/infarct, and any medication that increases the repolarization time. (Triggered activity occurs in runs.) Most atrial dysrhythmias are non-life threatening, unless they affect the ventricular rate.

PRE-ATRIAL CONTRACTIONS (PACS): Appear early, before an expected beat. They are identified by their site of origin either atrial, junctional, or ventricular. They occur when an irritable focus discharges out of sync with the SA node pacemakers thus the rhythm and rate are unchanged, but there are premature atrial beats coexisting in the EKG. These P waves on the EKG may not be followed by QRS complexes. The PR interval may be normal or prolonged. PACs are common findings and may not signify pathology emotional stress, fatigue, and CHF are all causes of PACs. They do not require intervention unless there is risk of

progression to atrial flutter, in which case you should use betablockers, calcium channel blockers, or anti-anxiety meds to reduce the risk. SUPRA-VENTRICULAR TACHYCARDIA (SVT): SVT is a tachyarrythmia originating in the heart above the level of the bundles of His. Sudden onset SVT is described as paroxysmal or PSVT. Characteristically, SVTs have a rate of 150-250 bpm, with regular rhythm and different looking P waves. SVTs are treated with synchronized cardioversion (fibrillation.) ATRIAL FLUTTER: is a rapid atrial rate due to an ectopic pacemaker usually an irritable focus that is firing regularly. Pulse rate is >300 bpm. It lasts for seconds to hours, brought on by PE, thyroid

VENTRICULAR FIBRILLATION: is distinguished by the lack of organized contraction of the ventricles. 80% of pts post-MI develop V-Fib if not tx in a hospital. Rate and rhythm are incalculable. Tx w/ CPR and cardioversion. toxicosis, chronic ventilatory failure, ethanol abuse, CAD, hypoxia, and digitalis/quinidine toxicity. It is precipitated by PACs and is also assoc. w/ mitral/tricuspid valve dz. 5-10% of post-MI pts develop atrial flutter. It is treated with meds if cardiac function is normal. If not, digitalis or cardioversion is indicated.

1ST DEGREE AV BLOCK: Distinguished by a PR interval >0.2 seconds that is the same for every beat. This situation can be normal if no Hx of heart dz, ischemia, injury, meds, etc. ATRIAL FIBRILLATION: can be spontaneous and last an hour to days. Pulse rate is 400-600 bpm, which results in a decrease in output due to total dysfunction of the atria. The rate is variable, the rhythm is irregularly regular, P waves are indistinguishable, and the PR interval immeasurable. It is seen in pts. w/ rheumatic heart dz, CAD, PE, HTN, ethanol abuse, carbon monoxide poisoning, electrolyte imbalances, hyperthyroidism. Classic presentation is from overimbibing of alcohol at holidays, resulting in holiday heart syndrome. Tx is same as for atrial flutter, except pt also needs to be put on anticoagulants to prevent blood clot formation in the atria.

2ND DEGREE AV BLOCK (TYPE I): Here the conduction delay occurs in the AV node. It is characterized by progressively lengthening PR intervals that result eventually in entirely missed beats. It usually is a sign of ischemia, typically in the area of distribution of the rt. coronary artery, or of medication.

PRE-VENTRICULAR CONTRACTIONS (PVCS): form from an irritable focus in the ventricles. The normal rate of ventricular contraction originating from the VA node when the SA node is malfunctioning is only 20-40 bpm. The distinguishing feature on EKG is that PVCs show an elongated QRS complex (>0.12 sec) with a compensatory pause. Like PAC, PVC is a single beat, so rate and rhythm are not affected. It is also a normal finding that can be brought on by exercise, hypoxia, stress, and excess catecholamines. Tx depends on the S/Sx; usually no tx is required.

2ND DEGREE AV BLOCK (TYPE II): Here the conduction delay occurs somewhere below the AV node, usually the bundle branches. The bundle branches are supplied by the left coronary artery and are injured in anterior wall infarcts. The EKG shows variably displaced or absent P waves and QRS complexes. This condition may progress suddenly to a complete AV block. Tx is by pacemaker; otherwise the prognosis is very bad.

VENTRICULAR TACHYCARDIA: is distinguished by a rate of 150-250 bpm. P waves are often absent, and the PR interval is elongated when they are seen. The QRS is >0.12 sec and is difficult to distinguish from the T wave.