HOW TO READ ECG STRIPS?

usually don’t travel backwards because the cells can’t respond to a

stimulus immediately after depolarization
AUTONOMIC INNERVATION OF THE HEART
SA NODE
The two branches of the autonomic nervous system – the sympathetic (or
adrenergic) and the parasympathetic (or cholinergic) – abundantly supply From the SA node, the impulse travels through the right atrium by
the heart. Sympathetic fibers innervate all the areas of the heart, whereas way of three internodal tracts: the anterior, the middle (or Wenckebach’s),
parasympathetic fibers mainly innervate the SA and AV nodes. and the posterior (or Thorel’s).

Sympathetic nerve stimulation triggers the release of norepinephrine, At the same time, the impulse travels to the left atrium by
which increase the heart rate, increase SA node discharge, accelerates AV Bachmann’s bundle (interatrial of the tissue extending from the SA node to
node conduction time, and increase the force of myocardial contraction the left atrium). Transmission through the right and left atria occurs so
and cardiac output. Parasympathetic (vagal) stimulation triggers the rapidly that the atria contract almost simultaneously.
release of acetylcholine, which produces the opposite effects. The rate of
SA node discharge is decreased, thus slowing heart rate and conduction
through the AV node and reducing cardiac output.

DEPOLARIZATION AND REPOLARIZATION

Depolarization – when the cell is stimulated by an electrical impulse, an
action potential occurs. Sodium ion flow rapidly into the cell causing the
impulse of the cell to become more positively charge than the outside. This
change creates an impulse that cause myocardial contraction.
Repolarization – after depolarization and contraction, the cell attempts to
return to its resting state.

CARDIAC CONDUCTION SYSTEM

SINOATRIAL NODE (SA NODE)
The SA node – located in the right atrium near the superior vena
cava – it is the heart’s main pacemaker. Under resting conditions, the SA
node generates impulses from 60 to 100 times/minute. The impulses
ATRIOVENTRICULAR NODE (AV NODE) After traveling through the left and right bundle branches, the
impulses travel through the Purkinje fibers. Purkinje fibers – a diffuse
The AV node is located in the inferior right atrium near the ostium
muscle fiber network beneath the endocardium – transmit impulse quicker
of the coronary sinus. Although the AV node doesn’t possess pacemaker
than any other part of the conduction system. This pacemaker site usually
cells, the tissue surrounding it, referred to as junctional tissue, contains
doesn’t fire unless the SA and AV nodes fail to generate an impulse or if
pacemaker cells that can fire at a rate between 40 – 60 beats/minute. As
the normal impulse is blocked in both bundle branches. The automatic
the AV node conducts the atrial impulse to the ventricles, it delays the
firing rate of the Purkinje fiber ranges from 20-40 times/min. The entire
impulse by 0.04 second. This delay allows the ventricles to complete their
network of specialized nervous tissue that extends through the ventricles is
filling phase as the atria contract. It also allows the cardiac muscle to
known as the His-Purkinje system.
stretch to its fullest for peak cardiac output.
BUNDLE OF HIS
Rapid conduction the resumes through the bundle of His into the
ventricles. If the SA node fails to generate an impulse at a normal rate, or if
the impulse fails to reach the AV junction, the bundle of His can fire at a
rate between 40-60 times/min.
RIGHT AND LEFT BUNDLE BRANCHES
The bundles of His divides into the right and left bundle branches
and extends down either side of the interventricular septum. The right
bundle branch extends down the right side of the interventricular septum
and through the right ventricle. The left bundle branch extends down the
left side of the interventricular septum and through the left ventricle.
The left bundle branch then splits into the two branches, or
fasciculations. The left anterior fasciculus extends through the anterior
portion of the left ventricle. The left posterior fasciculus extends through
the lateral and posterior of the left ventricle. Impulses travel much faster
down the left bundle branch, which feeds the larger, thicker walled left
ventricle, than the right bundle branch, which feeds the smaller, thinner-
walled right ventricle. The difference in the conduction speed allows both
ventricles to contract simultaneously.
ELECTROCARDIOGRAM (ECG) BASIC PRINCIPLES 5. Wave forms are referred to as deflection relative to an isometric
line (a line that expresses no energy). The isoelectric line can be
1. Electric activity is generated by the cells of the heart as ions are
determined by looking at the T-P interval
exchanged across cell membranes
2. Electrodes that are capable of conducting electrical activity from a. The P wave is the first position deflection and represents atrial
the heart to the ECG machine are placed at strategic positions on depolarization
the extremities and chest precordium
b. The Q wave is the first deflection after the P wave; the R wave is
the first positive deflection after the P wave
c. The S wave is the negative deflection after the R wave
d. The QRS wave form is generally regarded as a unit and represents
ventricular depolarization
e. The T wave follows the S wave and is joined to the QRS complex by
the S-T segment. The T wave represented the return of ions to the
appropriate side of the cell membrane. This signifies relaxation of
the muscle fibers and is referred to as repolarization of the
ventricles.
f. The Q-T interval is the time between the Q wave and T wave

INDICATIONS
The ECG is a useful tool in the diagnosis of those conditions that may cause
aberrations in the electrical activity of the heart. Examples of these
Transmission of heart’s impulse to a graphic display by ECG machine. The
conditions are as follows:
electrodes that are capable of conducting electrical activity from the heart
to the ECG machine are placed at strategic positions on the extremities and 1. MI and other types of coronary artery diseases, such as angina
chest precordium. 2. Cardiac dysrhythmias
3. Cardiac enlargement
3. The electrical energy sensed is then converted to a graphic by the 4. Electrolyte disturbances, especially of calcium and potassium levels
ECG machine. This display is referred to as the electrocardiogram 5. Inflammatory diseases of the heart
6. Effect on the heart by drugs such as digoxin (Lanoxin) and tricyclic
4. A heart contraction is represented by wave forms on the ECG graph
antidepressants
paper, which are designated P, Q, R, S and T waves
ECG LEADS AND NORMAL WAVE FORM INTERPRETATION produces very high R waves because the hypertrophied muscles
requires a stronger electrical current to depolarize
1. The standard ECG consists of 12 leads (I, II, III, AVR, AVL, AVF, V1,
V2, V3, V4, V5, V6)
a. Each lead records the heart’s electrical activity from a different
anatomic position
b. Identifies specific myocardial changes on certain leads; assist in
defining pathologic conditions
2. The normal amplitude of the P wave is 3mm or less; the P waves
that exceed these measurements are considered to be a deviation
from normal
3. The P-R interval is measured from the upstroke of the P wave to
the Q-R junction and is normally between 0.12 and 0.20 second
a. The P-R interval represents the time of impulse transmission from
the sinoatrial (SA) node to the atrioventricular (AV) node
b. There is a built-in delay in time at the AV node to allow for
adequate ventricular filling to maintain normal stroke volume (the
amount of blood ejected with each contraction)
5. The S-T segment begins at the end of the S wave, the first negative
4. The QRS complex contains separate waves and segments, which deflection after the R wave, and terminated at the upstroke of the T
should be evaluated separately. Normal QRS complex should be wave
between 0.06 and 0.10 second
6. The T wave represents the repolarization of myocardial fibers or
a. The Q wave, or first downward stroke after the P wave, is usually provides the resting state of myocardial work; the T wave should
less than 3 mm in depth. A Q wave of significant deflection is not always be present
normally present in the healthy heart. The pathologic Q wave
a. Normally, the T wave should not exceed a 5 mm amplitude in all
usually indicates a completed MI.
leads except the precordial (V1 to V6 leads, where it may be as high
b. The R wave is the first positive deflection after the P wave, normally as 10mm)
5-10 mm in height. Increases and decreases in amplitude become
significant in certain disease states. Ventricular hypertrophy
 INTERPRET ECG. DEVELOP A SYSTEMATIC APPROACH TO ASSIST IN
ACCURATE INTERPRETATION FOR DYSRHYTHMIAS, MYOCARDIAL
DAMAGE, OTHER CHANGES
a. Determine the rate, is it fast, slow, normal?
i. A gross determination of rate can be accomplished by counting the
number of QRS complexes within a 6-second time interval (use the
superior margin of ECG paper) and multiplying the complexes by a
factor of 10. Note: One must be cautioned that this method is
accurate only rhythms that are occurring at normal intervals and
should not be used for determining rate always counted for 1 full
minute for accuracy
ii. Another means of obtaining rate is to divide the number of large
five-square blocks between each two QRS complexes into 300.
Three hundred large blocks represent 1 complexes #5 and #6
equals 5, or of 60
iii. (Sequence Method) For ventricular rate, find R wave that peaks on
a heavy black line and assign the following numbers to the next six
heavy black lines: 300, 150, 100, 75, 60, and 50. Then find the next
R wave peak and estimate the ventricular rate
SINUS BRADYCARDIA
 Paroxysmal atrial tachycardia
PREMATURE ATRIAL CONTRACTION

MANAGEMENT
1. Generally requires no treatment
2. PACs should be monitored for increasing frequency
ANALYSIS (ATRIAL FLUTTER)
P wave: not present; instead, it is replaced by a saw-toothed pattern that
is produced by the rapid firing of the atrial focus. These waves are also
referred to as “F” waves
P-R interval: not measurable
QRS complex: Normal configuration and normal conduction time
T-wave: present but may be obscured by flutter waves
VTACH
MOBITZ 1