3.3 Ecg
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Electrocardiogram ECG/EKG Dr. PANKAJ
Electrocardiogram When impulses passes through heart then electrical current also spreads to the surrounding tissues and to surface of body. When electrodes are placed on the surface then it can record the electrical activity . This is known as EC G.
ECG paper -ECG paper: contains small and large squares. -Each small square is 1 mm and large square is 5mm -Time is measured along horizontal line and each small square is 0.04 sec and each large square is 0.2 sec. -Voltage is measured along vertical line and 10 mm is equal to 1 mV -ECG paper moves at 25 mm/s speed, i.e. 1500 squares/min
ECG leads 3 t ypes o f le ads : Hor izont al pl ane leads : 1.Chest leads/precordial leads: V1, V2, V3, V4,V5,V6 Fro nta l p la ne leads : 2.Bipolar leads/standard/Einthoven’s leads: I,II,III 3.Augmented unipolar leads: aVR, aVL, aVF
Placement of leads Augmented leads: aVR: right arm aVL: left arm aVF: left foot Ch est le ad s V1: in 4th ICS at right sternal border V2: in 4th ICS at lft sternal border V3: midway between V2 and V3 V4: 5th ICS in lft MCL V5: anterior axillary line in 5th ICS V6: mid axillary line in 5th ICs
12 leaded ECG/EKG
Chest leads
Einthoven’s triangle
Einthoven’s triangle
Hexaxial reference system
In tri nsi c Co ndu cti on Sys tem Functi on : in iti ate & d istri bute imp ulse s s o heart depol ari zes & con trac ts in o rd erl y man ner from atri a to ventri cles .
SA node AV node Bundle of His Bundle Branches Purkinje fibers
In tri nsi c Co ndu cti on Sys tem Functi on : in iti ate & d istri bute imp ulse s s o heart depol ari zes & con trac ts in o rd erl y man ner from atri a to ventri cles .
SA node AV node Bundle of His Bundle Branches Purkinje fibers
In trin sic C ard ia c Con duct ion Sy stem Approximately 1% of cardiac muscle cells are autorhythmic rather than contractile 75/min 40-60/min
30/min
ECG D eflectio n Wa ves
(Pacemaker)
Atrial repolarization
ECG D eflectio n Wa ves
(Pacemaker)
Atrial repolarization
ECG D eflecti on Wa ve Irreg ularit ies
Enlarged QRS = Hypertrophy of ventricles
ECG D eflecti on Wa ve Irreg ularit ies
Prolonged QT Interval = Repolarization abnormalities increase chances of ventricular arrhythmias.
ECG D eflecti on Wa ve Irreg ularit ies
Elevated T wave : Hyperkalemia
ECG D eflecti on Wa ve Irreg ularit ies
Flat T wave : Hypokalemia or ischemia
ECG D eflecti on Wa ve Irreg ularit ies
Elevated T wave : Hyperkalemia
Hea rt B locks P T Normal ECG QRS
2nd Degree Block
3rd Degree Block
Not a QRS for each P wave No P waves. Rate determined by autorhythmic cells in
Card ia c Cy cle All
events associated with a single heart beat including atrial systole & diastole followed by ventricular systole & (V. Systole) (V. Diastole) diastole.
Systolic BP Diastolic BP
ECG D eflectio n Wa ves 60 seconds ÷ 0.8 seconds = resting heart rate of 75 beats/minute
Frank St arlin g La w of t he Heart
The more cardiac muscle is stretched within physiological limits, the more forcibly it will contract. Rubber band analogy Increasing volumes of blood in ventricles increase the stretch & thus the force generated by ventricular wall contraction. Greater stretch means more blood volume is pumped out, up to physical limits.
Frank St arlin g La w of t he Heart
The more cardiac muscle is stretched within physiological limits, the more forcibly it will contract. Rubber band analogy Increasing volumes of blood in ventricles increase the stretch & thus the force generated by ventricular wall contraction. Greater stretch means more blood volume is pumped out, up to physical limits.
Frank St arlin g La w of t he Heart
=
Increased blood volume = increased stretch of myocardium
Increased force to pump blood out.
ECG waves & genesis P wave: normally upright , signifies atrial depolarisation <2.5mm height and 0.11 sec duration QRS complex: ventricular depolarisation N: 0.08 – 0.12 sec T wave: ventricular repolarisation U wave: it is positive deflection which comes after T wave. Is due to slow repolarization of interventricular purkinje fiber. Often it is not evident in ECG R-R interval: distance between two successive R wave P-R interval : time taken for impulse to travel from SA node to ventricles 0.12-0.22sec QT interval: total time for ventricular depolarisation and repolarisation <0.42 sec
Axis Normal axis lies between -30 and +110 degree Left axis deviation: -30 and -90 degree Right axis deviation: +110 and +/- 180 degree Intermediate axis : -90 and +/- 180 degree
Electrical axis of heart
Tec hn iqu e of rea din g and report ing ECG 1.Heart rate 2.Rhythm 3.Voltage 4.Axis 5.P wave 6.PR interval 7.QRS complex 8.ST segment 9.T wave 10.U wave 11.QT duration 12.Final diagnosis
Standardisation
Determination of axis Many methods are there Measure the overal height in leads I and aVF and then plot in graph paper. Then find the vector angle.
Heart rate HR= 1500/ RR interval in small squares
Uses of ECG 1. 2. 3. 4. 5.
Aids diagnosis, prognosis and treatment Gives information regarding functioning of atria and ventricles Identify damage to heart (infarction) Identify abnormal rhythm and rate Identify change in size of chambers of heart
Some A bn orm ali ti es i n ECG
P wa ve : a) p wave wide and notched (p-mitral)-left atrial hypertrophy b) p wave tall and peaked ( p-pulmonale) –right atrial hypertrophy
QRS compl ex: Tall QRS- ventricular hypertrophy Tall peaked T wave- hyperkalemia Low or inverted T wave- myocardial ischemia
U wave : Prominent U wave- hypokalemia
ST seg men t: Elevated with convexity upward-myocardial infaction Depressed- angina pectoris
PR i nter va l: Increased PR interval -Bradycardia Decreased PR interval- tachycardia No PR interval- complete heart block
Normal sinus rhythm
RVH
Coronary infarction
Sinus tachycardia
Ventricular tachycardia following extrasystole
Ventricular fibrillation
ECGs (lead II) showing abnormal rhythms A:Respiratory sinus arrhythmia. B:Sinus arrest with vagal escape. C:Atrial fibrillation. D:Premature ventricular complex. E:Complete atrioventricular block.
Wol f pa rki nson white ( WPW ) syndro me: 3. 4. 5.
Extra path is formed between atrium and ventricle Features: Short PR interval Wide QRS complex Delta wave
Heart blo ck: 1.First degree heart block: prolonged PR interval 2.Second degree heart block a. Mobitz type I b. mobitz type II 3.Complete heart block
Electrocardiogram When impulses passes through heart then electrical current also spreads to the surrounding tissues and to surface of body. When electrodes are placed on the surface then it can record the electrical activity . This is known as EC G.
ECG paper -ECG paper: contains small and large squares. -Each small square is 1 mm and large square is 5mm -Time is measured along horizontal line and each small square is 0.04 sec and each large square is 0.2 sec. -Voltage is measured along vertical line and 10 mm is equal to 1 mV -ECG paper moves at 25 mm/s speed, i.e. 1500 squares/min
ECG leads 3 t ypes o f le ads : Hor izont al pl ane leads : 1.Chest leads/precordial leads: V1, V2, V3, V4,V5,V6 Fro nta l p la ne leads : 2.Bipolar leads/standard/Einthoven’s leads: I,II,III 3.Augmented unipolar leads: aVR, aVL, aVF
Placement of leads Augmented leads: aVR: right arm aVL: left arm aVF: left foot Ch est le ad s V1: in 4th ICS at right sternal border V2: in 4th ICS at lft sternal border V3: midway between V2 and V3 V4: 5th ICS in lft MCL V5: anterior axillary line in 5th ICS V6: mid axillary line in 5th ICs
12 leaded ECG/EKG
Chest leads
Einthoven’s triangle
Einthoven’s triangle
Hexaxial reference system
In tri nsi c Co ndu cti on Sys tem Functi on : in iti ate & d istri bute imp ulse s s o heart depol ari zes & con trac ts in o rd erl y man ner from atri a to ventri cles .
SA node AV node Bundle of His Bundle Branches Purkinje fibers
In tri nsi c Co ndu cti on Sys tem Functi on : in iti ate & d istri bute imp ulse s s o heart depol ari zes & con trac ts in o rd erl y man ner from atri a to ventri cles .
SA node AV node Bundle of His Bundle Branches Purkinje fibers
In trin sic C ard ia c Con duct ion Sy stem Approximately 1% of cardiac muscle cells are autorhythmic rather than contractile 75/min 40-60/min
30/min
ECG D eflectio n Wa ves
(Pacemaker)
Atrial repolarization
ECG D eflectio n Wa ves
(Pacemaker)
Atrial repolarization
ECG D eflecti on Wa ve Irreg ularit ies
Enlarged QRS = Hypertrophy of ventricles
ECG D eflecti on Wa ve Irreg ularit ies
Prolonged QT Interval = Repolarization abnormalities increase chances of ventricular arrhythmias.
ECG D eflecti on Wa ve Irreg ularit ies
Elevated T wave : Hyperkalemia
ECG D eflecti on Wa ve Irreg ularit ies
Flat T wave : Hypokalemia or ischemia
ECG D eflecti on Wa ve Irreg ularit ies
Elevated T wave : Hyperkalemia
Hea rt B locks P T Normal ECG QRS
2nd Degree Block
3rd Degree Block
Not a QRS for each P wave No P waves. Rate determined by autorhythmic cells in
Card ia c Cy cle All
events associated with a single heart beat including atrial systole & diastole followed by ventricular systole & (V. Systole) (V. Diastole) diastole.
Systolic BP Diastolic BP
ECG D eflectio n Wa ves 60 seconds ÷ 0.8 seconds = resting heart rate of 75 beats/minute
Frank St arlin g La w of t he Heart
The more cardiac muscle is stretched within physiological limits, the more forcibly it will contract. Rubber band analogy Increasing volumes of blood in ventricles increase the stretch & thus the force generated by ventricular wall contraction. Greater stretch means more blood volume is pumped out, up to physical limits.
Frank St arlin g La w of t he Heart
The more cardiac muscle is stretched within physiological limits, the more forcibly it will contract. Rubber band analogy Increasing volumes of blood in ventricles increase the stretch & thus the force generated by ventricular wall contraction. Greater stretch means more blood volume is pumped out, up to physical limits.
Frank St arlin g La w of t he Heart
=
Increased blood volume = increased stretch of myocardium
Increased force to pump blood out.
ECG waves & genesis P wave: normally upright , signifies atrial depolarisation <2.5mm height and 0.11 sec duration QRS complex: ventricular depolarisation N: 0.08 – 0.12 sec T wave: ventricular repolarisation U wave: it is positive deflection which comes after T wave. Is due to slow repolarization of interventricular purkinje fiber. Often it is not evident in ECG R-R interval: distance between two successive R wave P-R interval : time taken for impulse to travel from SA node to ventricles 0.12-0.22sec QT interval: total time for ventricular depolarisation and repolarisation <0.42 sec
Axis Normal axis lies between -30 and +110 degree Left axis deviation: -30 and -90 degree Right axis deviation: +110 and +/- 180 degree Intermediate axis : -90 and +/- 180 degree
Electrical axis of heart
Tec hn iqu e of rea din g and report ing ECG 1.Heart rate 2.Rhythm 3.Voltage 4.Axis 5.P wave 6.PR interval 7.QRS complex 8.ST segment 9.T wave 10.U wave 11.QT duration 12.Final diagnosis
Standardisation
Determination of axis Many methods are there Measure the overal height in leads I and aVF and then plot in graph paper. Then find the vector angle.
Heart rate HR= 1500/ RR interval in small squares
Uses of ECG 1. 2. 3. 4. 5.
Aids diagnosis, prognosis and treatment Gives information regarding functioning of atria and ventricles Identify damage to heart (infarction) Identify abnormal rhythm and rate Identify change in size of chambers of heart
Some A bn orm ali ti es i n ECG
P wa ve : a) p wave wide and notched (p-mitral)-left atrial hypertrophy b) p wave tall and peaked ( p-pulmonale) –right atrial hypertrophy
QRS compl ex: Tall QRS- ventricular hypertrophy Tall peaked T wave- hyperkalemia Low or inverted T wave- myocardial ischemia
U wave : Prominent U wave- hypokalemia
ST seg men t: Elevated with convexity upward-myocardial infaction Depressed- angina pectoris
PR i nter va l: Increased PR interval -Bradycardia Decreased PR interval- tachycardia No PR interval- complete heart block
Normal sinus rhythm
RVH
Coronary infarction
Sinus tachycardia
Ventricular tachycardia following extrasystole
Ventricular fibrillation
ECGs (lead II) showing abnormal rhythms A:Respiratory sinus arrhythmia. B:Sinus arrest with vagal escape. C:Atrial fibrillation. D:Premature ventricular complex. E:Complete atrioventricular block.
Wol f pa rki nson white ( WPW ) syndro me: 3. 4. 5.
Extra path is formed between atrium and ventricle Features: Short PR interval Wide QRS complex Delta wave
Heart blo ck: 1.First degree heart block: prolonged PR interval 2.Second degree heart block a. Mobitz type I b. mobitz type II 3.Complete heart block
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