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Electrocardiogram (ECG)
Depolarization wave passes through the heart and the electrical currents pass into surrounding tissues. Small part of the extracellular current reaches the surface of the body. The electric potential generated can be recorded from electrodes placed on the skin An EKG is a comparison of two vectors It compares the heart vector showing current flow on the heart with the reference, recording lead vector on the body.
(Non-invasive) Heart Rate Signal conduction Heart tissue (enlarged) Conditions (MI) electrolyte and hormone imbalances
Vector diagrams
Vectors are used to describe depolarization and repolarization events Vectors are arrows which show two things:
Direction or pathway (of charge spread) Magnitude or size (amt of charge)
Q S
Depolarization: spread of surface neg charge Repolarization: spread of surface positive charge Vectors will always be positioned so that head of vector is in area of positive charge; tail is in area of negative charge.
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+++++++++++ ------------------
Rest
No current flow, no vector.
The following vectors represent the spread of negative charge during depolarization; Then the spread of positive charge during repolarization
- +
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+
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+
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The atria would start to repolarize down and to the left, as the current continues downward to the ventricles We dont detect this on the EKG, but what would the repolarizing vector look like? (review your specialized cells/contractile cells lecture!)
+
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+
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Atria now have repolarized and now have positive surface charge again.
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IV Septal Depolarization
Moving down bundle of His; Current moves down R and L bundle branches from L toward Rwhy?
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Rest
End of cycle;
No current flow, no vector.
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II
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+
-
II
III
Atrial depolarization
Pen here
II
V
T
The heart vector is parallel to the lead, but how can you confirm?34
II
1.
Atrial depolarization
2.
Draw a perpendicular line to the lead vector Draw a line toward from the perpendicular vector toward your cardiac vector
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Atrial depolarization
II
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AV nodal depolarization
II
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II
Draw it!
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II
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II
Draw it!
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II
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II
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II
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Ventricular Repolarization
II
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II
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II
What does that tell you about the recording you obtain from each lead?
Each lead describes the events on the heart from its own point of view
Reading from several leads gives you different points of view about the same set of repeating events (depol, repol) What if the recording lead was oriented this way? Use the words down or up to note the deflection compared to the five cardiac vectors above
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12 Lead EKGs
Read from each lead independently; one at a time over several heartbeats. See what each lead shows. 12 leads 3 bipolar limb leads (I, II, III) 3 augmented unipolar limb leads (aVR, aVL, aVF) 6 precordial leads (chest leads, V1V6)
V6 V4
V5
V1
V2
V3
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Summary of Events
P wave atrial depolarization- SA node to the AV node (mechanical event that will result: atrial systole) QRS complex- depolarization of ventricles Q wave- due to left to right depolarization at bundle branch (right has detour) atrial repolarization and diastole (signal obscured) AV node fires, ventricular depolarization (mechanical event that will result: ventricular systole) T wave ventricular repolarization (mechanical event that will result: ventricular diastole. ventricles remain somewhat contracted until a few milliseconds after the end of the T repolarization wave.)
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Segments are flat lines, do not include waves: PR segment, ST segment. Intervals include at least one wave P-R interval- from beginning of P to the Q wave. Is time for atrial depolarization plus delay from AV node. Also, time of atrial contraction (more than .2 sec could be 1st degree block) P-R segment- delay in impulse through AV node. 53
Phases of EKG
Q-T interval- includes Q and T waves, total time for ventricular depolarization and repolarization; this approximates the time of total ventricular contraction. T-P segment - end of one cycle to beginning of next P-P interval - time for one complete cycle (could also use R-R or T-T, etc.) S-T segment: time between ventricular depolarization and repolarization; time of peak ventricular contraction (maximum 54 tension)
Cardiac Arrhythmias
Tachycardia: abnormally fast heart rate Bradycardia: Abnormally slow heart rate Incomplete Atrioventricular Block: Prolonged P-R interval (1st degree) Complete Atrioventricular Block: P waves and QRS complexes become dissociated (3rd degree) Fibrillation: Complete lack of coordination
Arrhythmia: conduction failure at AV node
No P waves
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Electrolyte imbalance
Hypernatremia:
Inhibits calcium entry into the cell Depresses overall heart activity and becomes flaccid; (negative inotropy)
Hypercalcemia:
(-, +) Increased heart irritability More calcium into cytoplasm What reflex could augment the decreased chronotropy?
Hyperkalemia:
Peaked T waves.
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Electrolyte imbalance
Hyponatremia:
Depolarization delay Decreased heart rate
Hypocalcemia:
(+,-) Less heart contractility What reflex could augment the increased chronotropy?
Hypokalemia:
Lowers RMP (makes it more negative) Decreases heart rate U waves
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- 90 o
aVR
aVL I
- 30 o
0o
III
II
aVF
+60 o
-90 o
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+ 10 mm
Lead I
- 2mm
-90o 180o
0
+90o
Lead I
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+ 1mm
- 8 mm
aVF
-90o 180o
0
+90o
+
Lead aVF
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Step 2:
Superimpose the two diagrams of the heart, and see where the hatched areas overlap. This will be the area which must contain the MEA vector
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-90o 180o
+ -
0
+90o
+
MEA vector must lie in the zone of overlap
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-90o 180o
+ -
0
+90o
+
MEA vector must lie in the zone of overlap
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-90o 180o
+ -
0
+90o
+
Conclusion: LAD
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Heres Step 1: Visually, Lead I examine the profiles of leads I and aVF
aVF
another example:
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Lead I
-90o 180o
0
+90o
Lead I
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aVF
-90o 180o
0
+90o
+
Lead aVF
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Step 2:
Superimpose the two diagrams of the heart, and see where the hatched areas overlap. This will be the area which must contain the MEA vector
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-90o 180o
+ -
0
+90o
+
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-90o 180o
+ -
0
+90o
+
MEA vector must lie in the zone of overlap
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-90o 180o
+ -
0
+90o
+
Conclusion: RAD
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How does the current normally flow down the IV septum? Left to right? OR Right to Left? How would this change if there was a LBBB? RBBB? Why does a LBBB cause a LAD? (think about the vector!)
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