EKG Basics

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EKG Basics
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What is an EKG?

• The electrocardiogram (EKG) is a representation
  of the electrical events of the cardiac cycle.
• Each event has a distinctive waveform, the study
  of which can lead to greater insight into a
  patients cardiac pathophysiology.

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Rules of ECG

• Wave of depolarization traveling towards
  apositive electrode causes an upward deflection
  on the ECG
• Wave of depolarization traveling away from a
  positive electrode causes a downward deflection
  on the ECG

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Resting Myocardial Cell

Na
K
Ca

K
Na
Ca
K
K
K
K
K
K
Na
Ca
Na
Ca
Na
Ca
Na
Ca
Na
Ca
Ca
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Characteristics of ECG Recordings

• Duration
• Amplitude
• Configuration

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Time and voltage
Amplitude
Duration
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Configuration
Negative
Positive
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Outline

• Review of the conduction system
• EKG waveforms and intervals
• EKG leads
• Determining heart rate
• Determining QRS axis

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The Normal Conduction System
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What types of pathology can we identify and study
from EKGs?

• Arrhythmias
• Myocardial ischemia and infarction
• Pericarditis
• Chamber hypertrophy
• Electrolyte disturbances (i.e. hyperkalemia,
  hypokalemia)
• Drug toxicity (i.e. digoxin and drugs which
  prolong the QT interval)

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Waveforms and Intervals
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Atrial Depolarization

• P wave small, round deflection on the ECG
• Right atrial component
• Left atrial component
• Normal amplitude ? 0.25 mV (2.5 mm)
• Normal duration 0.04 0.12 msec
• AV node conduction pause

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Ventricular Depolarization

• Includes
• Bundle of His
• Bundle Branches
• Right
• Left
• Septal
• Anterior
• Posterior
• Terminal Purkinjie fibers

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Ventricular Depolarization

• Ventricular Waves
• Q wave first downward deflection after P wave
• Rwave first upward deflection after Q wave
• R wave any second upward deflection
• S wave first downward deflection after the R
  wave
• QRS duration 0.06 to 0.12 msec
• QRS configurations

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Ventricular Repolarization

• T wave
• small to moderate size positive deflection wave
  after the QRS complex,
• Height is 1/3 to 2/3 that of the corresponding R
  wave
• U wave
• Septal repolariztion (not always seen on ECG)

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Segments and Intervals

• Segment strait line between waves
• Interval wave plus a segment
• PR interval 0.12 0.20 msec
• QRS Interval (Duration)
• ST segment end of ventricular depolarization to
  start of vent. repolariztion
• QT interval ventricular cycle, 40 of each
  cardiac cycle

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EKG Leads

• Leads are electrodes which measure the difference
  in electrical potential between either

• 1. Two different points on the body (bipolar
  leads)
• 2. One point on the body and a virtual reference
  point with zero electrical potential, located in
  the center of the heart (unipolar leads)

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EKG Leads

• The standard EKG has 12 leads

3 Standard Limb Leads 3 Augmented Limb Leads 6
Precordial Leads
The axis of a particular lead represents the
viewpoint from which it looks at the heart.
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Standard Limb Leads
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Standard Limb Leads
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Augmented Limb Leads
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All Limb Leads
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Precordial Leads
Adapted from www.numed.co.uk/electrodepl.html
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Precordial Leads
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Summary of Leads
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Arrangement of Leads on the EKG
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Anatomic Groups(Septum)
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Anatomic Groups(Anterior Wall)
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Anatomic Groups(Lateral Wall)
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Anatomic Groups(Inferior Wall)
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Anatomic Groups(Summary)
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Determining the Heart Rate

• 2 Beat Rule
• Rule of 300
• 10 Second Rule
• 6 (3 x 2) Second Rule

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Calculation

• Distance between Ventricular beats 20 mm
• Time of one ventricular beat
• 20 X 0.04 0.80 sec
• Heart Rate
• 60 / 0.80 75 beats/min

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Rule of 300

• Take the number of big boxes between
  neighboring QRS complexes, and divide this into
  300. The result will be approximately equal to
  the rate
• Although fast, this method only works for regular
  rhythms.

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What is the heart rate?
www.uptodate.com
(300 / 6) 50 bpm
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What is the heart rate?
www.uptodate.com
(300 / 4) 75 bpm
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What is the heart rate?
(300 / 1.5) 200 bpm
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The Rule of 300

• It may be easiest to memorize the following table

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10 Second Rule

• As most EKGs record 10 seconds of rhythm per
  page, one can simply count the number of beats
  present on the EKG and multiply by 6 to get the
  number of beats per 60 seconds.
• This method works well for irregular rhythms.

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What is the heart rate?
The Alan E. Lindsay ECG Learning Center
http//medstat.med.utah.edu/kw/ecg/
33 x 6 198 bpm
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Six Second Rule

• Count the number of beats per 3
• Repeat again
• Add the two
• Multiply by 10

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The QRS Axis

• The QRS axis represents the net overall direction
  of the hearts electrical activity.
• Abnormalities of axis can hint at
• Ventricular enlargement
• Conduction blocks (i.e. hemiblocks)

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The QRS Axis
By near-consensus, the normal QRS axis is defined
as ranging from -30 to 90. -30 to -90 is
referred to as a left axis deviation (LAD) 90
to 180 is referred to as a right axis deviation
(RAD)
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Determining the Axis

• The Quadrant Approach
• The Equiphasic Approach

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Determining the Axis
Predominantly Positive
Predominantly Negative
Equiphasic
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The Quadrant Approach

• 1. Examine the QRS complex in leads I and aVF to
  determine if they are predominantly positive or
  predominantly negative. The combination should
  place the axis into one of the 4 quadrants below.

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The Quadrant Approach

• 2. In the event that LAD is present, examine lead
  II to determine if this deviation is pathologic.
  If the QRS in II is predominantly positive, the
  LAD is non-pathologic (in other words, the axis
  is normal). If it is predominantly negative, it
  is pathologic.

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Quadrant Approach Example 1
The Alan E. Lindsay ECG Learning Center
http//medstat.med.utah.edu/kw/ecg/
Negative in I, positive in aVF ? RAD
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Quadrant Approach Example 2
The Alan E. Lindsay ECG Learning Center
http//medstat.med.utah.edu/kw/ecg/
Positive in I, negative in aVF ?
Predominantly positive in II ? Normal Axis
(non-pathologic LAD)
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The Equiphasic Approach

• 1. Determine which lead contains the most
  equiphasic QRS complex. The fact that the QRS
  complex in this lead is equally positive and
  negative indicates that the net electrical vector
  (i.e. overall QRS axis) is perpendicular to the
  axis of this particular lead.
• 2. Examine the QRS complex in whichever lead lies
  90 away from the lead identified in step 1. If
  the QRS complex in this second lead is
  predominantly positive, than the axis of this
  lead is approximately the same as the net QRS
  axis. If the QRS complex is predominantly
  negative, than the net QRS axis lies 180 from
  the axis of this lead.

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Equiphasic Approach Example 1
The Alan E. Lindsay ECG Learning Center
http//medstat.med.utah.edu/kw/ecg/
Equiphasic in aVF ? Predominantly positive in I ?
QRS axis 0
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Equiphasic Approach Example 2
The Alan E. Lindsay ECG Learning Center
http//medstat.med.utah.edu/kw/ecg/
Equiphasic in II ? Predominantly negative in aVL
? QRS axis 150