Rhythm Interpretation

Conduction System of the Heart

Heart is a pump mechanism

Pump action is brought about by electrical
changes in the heart

Depolarisation and repolarisation



When cardiac cells are at rest their surface
is more positively charged than the interior
of the cells.
Depolorisation occurs forcing NA+ into
cells and K+ out. Once neutrality is
reached Ca++ can enter cell which
stimulates cells contraction.
Repolarisation occurs when Na+ returns to
outside cell and K+ returns inside cell.
Cells relax.


Depolarisation

Na+ Ca++
Na+
Na+


K+ Ca+
K+ Na+





K+
K+
K+


Cell Contraction
stimulated by Ca++ = Depolarisation
K+
K+
K+
Na+
Na+
K+
Ca++
Na+
Na+
Na+

Normal Conduction Pathway
Normal
Signal moves rapidly
through the ventricles
Path of Conduction
There is an electrical gate at the junction of the
atria and ventricles.
Conduction is funnelled along the
intraventricular septum
AV node slows conduction in order for atria to
finish contraction prior to ventricles contracting.
This mechanism allows complete emptying of
the atria into the ventricles
Rhythm interpretation

The ECG Paper
Horizontally
One small box - 0.04 s
One large box - 0.20 s


P Wave & PR Interval
P Wave= Atrial Depolarisation

PR Interval =Impulse from sino atrial node to
venticular myocardium

Normal = 3-5 small boxes (0.12-0.2secs)




QRS
Depolarisation of both ventricles
Normal = < 3 small boxes (0.12sec)


T Wave

Ventricular repolarisation

HR Calculation
Count the number of large squares between two
R waves 300 by that number

Count number of small squares between two R
waves 1500 by that number

Count number of R waves in a 6 second strip X
10 = 60 seconds
Rhythm analysis
Rate- normal, fast or slow
Rhythm Regular/irregular/pattern
P waves normal/ constant/ before QRS/
absent
PR interval 0.12 0.20 secs or 3-5 small
boxes, constant
QRS normal/narrow/wide
Ratio P:QRS =1:1???
Quiz
What is depolarisation?
What is repolarisation?
How do you calculate Rate?
What is normal PR interval?
What is normal QRS interval?

12 Lead ECG
Bipolar leads: The leads are termed I, II,
and III.
Unipolar leads: AVR, AVL, AVF
The V leads, which extend across the
precordium, V1 in the fourth right
interspace, V2 4th left, V4 at the apex (5th
interspace, midclavicular line), V3 halfway
in between V2 and V4, and V5 & V6 in the
5th interspace at the anterior and mid
axillary lines respectively.
It's usual to group the leads according to which part of
the left ventricle (LV) they look at.

AVL and I, as well as V5 and V6 are lateral, while II, III
and AVF are inferior.

V1 through V4 tend to look at the anterior aspect of the
LV (some refer to V1 and V2 `septal).

Changes in depolarisation in the posterior aspect of the
heart are not directly seen in any of the conventional
leads, although "mirror image" changes will tend to be
picked up in V1 and V2.

ST Segment Analysis
Indicates myocardial tissue ischaemia,
injury or infarction.
Myocardial Injury. ST elevation on ECG
over area of tissue damaged in early
stages.
Injured myocardial tissue can be saved if
blood flow is restored promptly
Thrombolysis or PTCA necessary
ST Elevation
Occurs in the early
stages
Occurs in the leads
facing the infarction
Slight ST elevation
may be normal in
V1 or V2
Deep Q Wave
Only diagnostic
change of myocardial
infarction
At least 0.04 seconds
in duration
Depth of more than
25% of ensuing R
wave
T Wave Changes
Late change
Occurs as ST
elevation is
returning to normal
Apparent in many
leads
Sequence of changes in
evolving AMI
1 minute after onset 1 hour or so after onset A few hours after onset
A day or so after onset Later changes A few months after AMI



Q
R
P
Q
T
ST
R
P
Q
ST
P
Q
T
ST
R
P
S
T
P
Q
T
ST
R
P
Q
T
References:
Hampton, J.R. (2003) the ECG Made
easy. 6
th
edition. Edinburgh: Churchill
Livingstone.
Thaler, M.S. (1999) The only EKG Book
Youll Ever need. 3
rd
edition. Lippincott,
Williams and Wilkins, London.
ACLS Provider Manual. American Heart
Association


1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?
1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before
QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?




1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?

1. Is there any electrical activity?
2. Rate?
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?




1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before
QRS/Absent?
5. PR interval. Is it
normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?
1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before
QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?
1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before
QRS/Absent?
5. PR interval. Is it
normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?

1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?

1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before
QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?


1. Is there any electrical activity?
2. Rate
3. Is the Rhythm regular/irregular/pattern?
4. P waves Normal/ Constant/Before QRS/Absent?
5. PR interval. Is it normal/prolonged/constant?
6. Is the QRS normal/narrow/prolonged?
7. Ratio- 1:1?