Attention

1. Name yourself using Full Name, Hospital, Title when

joining training (e.g. CHAN Mei Yan, GH (PMU), APN)
2. Join with video, show your face and keep mute during
forum unless in Q&A session or necessary.
3. No photo taking, video and audio recording during the
forum
4. No sharing of unauthorized course materials
 Basic ECG

Anatomy

沈文萍專科護師
Sun Man Ping Nurse Specialist GH
肝手術後停心跳呼吸 瑪麗搶救涉連環失誤
B女恐變植物人

【本報訊】12/ 2017剛一歲生日的B女小予恩因
患先天性膽管閉塞上周五在瑪麗醫院進行「肝
腸脗合手術」，但家屬疑院方涉連環失誤，包
括手術後未有按原定計劃把B女送到深切治療部
（ICU），以及護士誤把B女的心跳及呼吸停頓
當成是醫療儀器故障，耽誤了6分鐘搶救時間。
予恩疑因腦缺氧昏迷4天，恐有變植物人之虞，
瑪麗已成立跨部門小組調查事件。
 Anterior View of the Heart
• The right ventricle
(RV) dominates the
anterior view.

• Most of the anterior

surface of the
ventricles consists of
the RV surface.
 The Heart as a Pump
The heart consists of four main chambers: Two atria and two
ventricles.

The left ventricle empties

into the peripheral
circulatory system.
The right ventricle
empties into the
pulmonary system.
 Veins bring blood to
the heart.
 Arteries take blood
away from the heart.
6
 Things to Keep in Mind About
the Conduction System

 Actually inside the heart walls

 Atrial myocytes are innervated by
direct contact from one cell to
another.
 Internodal pathways transmit the
impulse from the SA node to the
AV node.
 Purkinje system is the final
component—innervates
myocardial cells.
 Pacemaker Function
The Pacemaker:
 Dictates the rate at which the heart will cycle through its
pumping action to circulate the blood
 Creates an organized beating of all cardiac cells in a
specialized sequence
 Sets the pace of all other cells that will follow
SA node:
 The main area that acts as the heart’s pacemaker.
 Controls the beat based on information it receives from the
nervous, circulatory, and endocrine systems.
 Pacemaker Settings
SA node 60–100 BPM

Atrial cells 55–60 BPM

AV node 45–50 BPM

Bundle of His 40–45 BPM

Bundle branch 40–45 BPM

Purkinje cells 35–40 BPM

Myocardial cells 30–35 BPM

 Sinoatrial (SA) Node

 Heart’s main pacemaker

 Found in the wall of the right
atrium at its junction with the
superior vena cava
 Atrioventricular (AV) Node

 Located in the wall of the right

atrium next to the opening of the
coronary sinus, the largest vein of
the heart, and the septal leaflet of
the tricuspid valve
 Responsible for slowing down
conduction from atria to ventricles
long enough for atrial contraction
 Helps maintain output of heart at
the maximum level
 Always supplied by right coronary
artery
 The Bundle of His

 Starts at the AV node

 Found partially in right
atrium, and interventricular
septum
 The ONLY route of
communication between the
atria and ventricles
 Left Bundle Branch (LBB)
 Begins at the end of bundle of His
 Travels through interventricular
septum
 Right Bundle Branch (RBB)
 Also starts at bundle of
His
 Gives rise to fibers that
innervate RV and right
face of interventricular
septum
 Terminates in Purkinje
fibers
 Purkinje System
• Made up of individual
cells just beneath
endocardium
• Directly innervates
myocardial cells
• Initiates ventricular
depolarization cycle
 Electrolytes

 Electrolytes are how a cell develops “electricity.”

 ECG is altered by electrolyte abnormality.
 Imbalances can cause life-threatening problems.
 Ion Movement and Polarity
Inside the body:
• Main positively charged ions:
+ Sodium (Na+)
+ Potassium (K+)
+ Calcium (Ca++)
• Main negatively charged ion:
- Chloride (Cl-)

Electrical potential = The difference between the charges

outside and inside of the cell wall
 Electrodes and Waves
• Positive impulse moving away from electrode is converted
into downward wave
• Positive impulse moving toward electrode is converted into
upward wave
• An ECG shows positive deflection for energy coming
toward it, negative deflection for energy moving away
from it
Depolarization
Repolarization
Depolarization & Repolarization
upward wave
Depolarization

Repolarization
The T Wave
 Leads: Pictures of the Heart
 Electrodes placed at certain
angles to the main axis give:
 Multiple pictures of the
heart
 3-D perspective
 Information about where
pathologic processes
occur
 Lead Placement (1 of 2)
 Limb leads (extremity leads)
o Right arm (RA)
o Left arm (LA)
Placed
o Right leg (RL)
at least
o Left leg (LL) 10 cm
from Insert fig 3-7 left-
heart hand part only
 Lead Placement (2 of 2)
 Precordial leads (chest
leads)
o V1 and V2—Each side
of sternum at 4th
intercostal space
o V3, V4, V5, and V6
* Follow diagram for
placement
 How the Machine Manipulates
Leads
• ECG reads positive and
negative poles of limb
electrodes
– Produces leads I, II,
and III

Insert fig 3-8

 Hexaxial System

• Leads are 30° apart

 Precordial System

• Precordial (Chest) leads are on a plane perpendicular

to the limb leads.
• Result is cross-section: six leads produced by six chest
electrodes
 The Heart in Three Dimensions
• Cutting the heart in both coronal and transverse planes gives
a 3-D picture of the heart.
The Actual ECG:
Paper and Ink
 Boxes and Sizes (1 of 2)
 Height measured in millimeters (mm)
 Width measured in milliseconds (ms)
 ECG paper passes under pen at rate of 25 mm/sec
 Each small box is 1/25 of a second (or 0.04 sec)
 Each big box is 5 x 0.04 sec = 0.20 sec
 Five big boxes = 1 second
 Each lead is represented for 3 seconds
 Full ECG is 12 seconds long
Boxes and Sizes
 Lead Representation
 Standard format for most ECGs:

 Several variations occur due to multiple

manufacturers. Be familiar with the format used at
your institution.
The Rate
 P Wave Rate vs. QRS Rate
• The P wave rate may be different from the QRS rate.
• For this discussion, we consider QRS rates only.

Obtaining the Rate

• Rate can be obtained in various ways:
 Ruler
 Using ECG and basic knowledge of time intervals
involved
 Computerized interpretation at top of ECG
- HOWEVER
• If it appears to be wrong, calculate it yourself.
 Calculating the Rate

The easiest way to calculate rate is shown here:

0.04 sec

0.2 sec
 Irregular Rates

• Knowing time intervals is

useful when calculating
bradycardic rhythms:
– Count number of cycles
present in 6-sec strip
and multiply by 10 (gives
you number of beats in
60 sec).
– OR, count number of
cycles in 12-sec strip
and multiply by 5.
 Basic Components
• Wave: Deflection from baseline that represents a cardiac
event
• Segment: Specific portion of the complex as
represented on ECG
• Interval: Distance, measured as time, between two
cardiac events
 The P Wave

• Usually the first in the ECG complex

• Represents electrical depolarization of both atria
• Starts when the SA node fires
• Duration can vary between 0.08 and 0.11 seconds
in adults
 The PR Interval
• From beginning of P wave to beginning of QRS
complex
• Includes P wave and PR segment
• Normal duration: 0.12 to 0.20 sec
 The QRS Complex
• Represents ventricular depolarization
• Main components are Q, R, and S waves
 Q wave can be present or absent.
 R wave: First positive deflection after P; will be initial
wave of QRS complex if no Q is present.
• Normal duration: 0.06 to 0.11 sec
 Q, R, and S
• Q wave
 First negative deflection after P wave
• R wave
 First positive deflection after P wave
• S wave
 First negative deflection after R wave
 Q Wave Significance
• Can be benign, or sign of dead myocardial
tissue
• Significant Q wave
 Indication of MI over region involved
 0.03 sec or wider
 Height equal to or greater than 1/3 height of R
wave
• Insignificant Q wave
 Commonly found in I, aVL, and V6
Insignificant Q Wave
Significant Q Wave
 The T Wave
• Represents ventricular repolarization
• Is next deflection (+ or –) after ST segment
• Normal T wave:
 Begins in same direction as QRS complex
 Asymmetrical (first part rising/dropping slowly, latter part
moving faster)
 QT Interval
• Encompasses QRS complex, ST segment, T wave
• Represents all events of ventricular systole
– From beginning of ventricular depolarization to end of
repolarization
• Normal duration is variable, but usually less than 1/2 of
R-R interval
• Prolonged QT interval is a sign of possible life-
threatening arrhythmias
 U Wave
• A small, flat wave sometimes seen after T wave
and before next P wave.
• No one knows for sure what it represents.
• Important: Can sometimes cause an inaccuracy
in measuring QT interval.
Rhythms
 Rhythms: Major Concepts

 General: Is rhythm fast or slow?

• Bradycardia <60 BPM
• Tachycardia >100 BPM
 Regular vs. Irregular Rhythms
 Is rhythm regular or irregular?
 If irregular, is it:
• Regularly irregular (some form of regularity to the
pattern)
• Irregularly irregular (no pattern at all)
 Using Calipers

• Place one of the pins at

beginning of object to
be measured, and
move the other pin to
the end.
• Transfer distance to
uncluttered part of ECG
to evaluate height or
time of measured
object.
 Walking Calipers

• You can walk

calipers back and
forth across an ECG
to check the
regularity of
complexes.
• You can take that
distance and move
it anywhere on the
paper.
 Comparing Wave Heights

• Use calipers to measure

heights of waves
• Useful when determining the
axis of the heart
• In this figure:
– Depth of negative wave is
7.0 mm
– Height of positive wave is
10.8 mm
 P Waves
 Do you see any P waves?
 P waves indicate atrial or supraventricular component
 Are all P waves identical?
 Identical P waves are generated by same pacemaker
site
 Should have identical PR intervals
 P Waves

 Are P waves not identical? Two possible causes:

 Additional pacemaker cell firing

 Does each QRS complex have a P wave?

 Abnormal number of P waves suggests AV nodal
block
 Is the PR interval constant?
 QRS complexes

 Are P waves and QRS complexes associated with

one another? If yes:
 Entire complex is a normal beat.
 Entire complex is a premature beat.
 Entire complex is a low-grade AV nodal block.
 Are QRS complexes narrow or wide?
 Narrow indicates impulses usually found in
supraventricular rhythms.
 Wide indicates impulses transmitted by direct
cell-to-cell contact.
 Rhythms: Summary

 Do P waves and QRS complexes follow a

regular pattern (same intervals separating them)?
or
 Are intervals different between some or all of the
beats?
 Individual Rhythms

 Supraventricular rhythms
 Ventricular rhythms
 Heart blocks
 Normal Sinus Rhythm (NSR)
Rate: 60-100 BPM
Regularity: Regular
P wave: Present
P:QRS ratio: 1:1
PR interval: Normal
QRS width: Normal
Grouping: None
Dropped beats: None
 Sinus Arrhythmia
Rate: 60-100 BPM
Regularity: Varies w/ respiration
P wave: Normal
P:QRS ratio: 1:1
PR interval: Normal
QRS width: Normal
Grouping: None
Dropped beats: None
 Sinus Bradycardia
Rate: <60 BPM
Regularity: Regular
P wave: Present
P:QRS ratio: 1:1
PR interval: Normal to prolonged
QRS width: Normal
Grouping: None
Dropped beats: None
 Sinus Tachycardia
Rate: >100 BPM
Regularity: Regular
P wave: Present
P:QRS ratio: 1:1
PR interval: Normal to short
QRS width: Normal to short
Grouping: None
Dropped beats: None
 Sinoatrial Block
Rate: Varies
Regularity: Irregular
P wave: Present except in areas of dropped beats
P:QRS ratio: 1:1
PR interval: Normal
QRS width: Normal
Grouping: None
Dropped beats: Yes
 Sinus Pause/Arrest
Rate: Varies
Regularity: Irregular
P wave: Present except in areas of pause/arrest
P:QRS ratio: 1:1
PR interval: Normal
QRS width: Normal
Grouping: None
Dropped beats: Yes
Atrial Premature Contraction (APC)
Rate: Depends on underlying sinus rate
Regularity: Irregular
P wave: Present; in APC, may be different shape
P:QRS ratio: 1:1
PR interval: Varies in APC
QRS width: Normal
Grouping: Sometimes
Dropped beats: None
 Ectopic Atrial Tachycardia
Rate: 100-180 BPM
Regularity: Regular
P wave: Morphology of ectopic focus is different
P:QRS ratio: 1:1
PR interval: Ectopic focus has different interval
QRS width: Normal, but aberrant at times
Grouping: None
Dropped beats: None
 Wandering Atrial Pacemaker
Rate: 100 BPM
Regularity: Irregularly irregular
P wave: At least 3 different morphologies
P:QRS ratio: 1:1
PR interval: Variable depending on focus
QRS width: Normal
Grouping: None
Dropped beats: None
 Multifocal Atrial Tachycardia
Rate: >100 BPM
Regularity: Irregularly irregular
P wave: At least 3 different Morphologies
P:QRS ratio: 1:1
PR interval: Variable
QRS width: Normal
Grouping: None
Dropped beats: None
 Atrial Flutter
Rate: Atrial commonly 250–350 BPM, ventricular
commonly 125–175 BPM
Regularity: Usually regular
P wave: Saw toothed, “F waves”
P:QRS ratio: Variable, most commonly 2:1
PR interval: Variable
QRS width: Normal
Grouping: None
Dropped beats: None
 Atrial Fibrillation
Rate: Variable, ventricular response
can be fast or slow
Regularity: Irregularly irregular
P wave: None; chaotic atrial activity
P:QRS ratio: None
PR interval: None
QRS width: Normal
Grouping: None
Dropped beats: None
 Junctional Rhythm
Rate: 40–60 BPM
Regularity: Regular
P wave: Variable (none, antegrade, or retrograde)
P:QRS ratio: None; or 1:1 if antegrade or retrograde
PR interval: None, short, or retrograde
QRS width: Normal
Grouping: None
Dropped beats: None
 Junctional Premature Contraction
Rate: Depends on underlying rhythm
Regularity: Irregular
P wave: Variable (none, antegrade, or retrograde)
P:QRS ratio: None, or 1:1 if retrograde
PR interval: None, short, or retrograde
QRS width: Normal
Grouping: Usually none
Dropped beats: None
 Ventricular Premature Contraction
Rate: Depends on underlying rhythm
Regularity: Irregular
P wave: Not present on VPC
P:QRS ratio: No P waves on VPC
PR interval: None
QRS width: Wide (0.12 sec), bizarre appearance
Grouping: Usually not present
Dropped beats: None
 Ventricular Escape Beat
Rate: Depends on underlying rhythm
Regularity: Irregular
P wave: None in VPC
P:QRS ratio: None in VPC
PR interval: None
QRS width: Wide (0.12 sec), bizarre appearance
Grouping: None
Dropped beats: None
Ventricular Tachycardia (VTach)
Rate: 100–200 BPM
Regularity: Regular VT
P wave: Dissociated atrial rate
P:QRS ratio: Variable
PR interval: None
QRS width: Wide, bizarre
Grouping: None
Dropped beats: None
Paired
 Idioventricular Rhythm
Rate: 20–40 BPM
Regularity: Regular
P wave: None
P:QRS ratio: None
PR interval: None
QRS width: Wide (≥0.12 sec), bizarre appearance
Grouping: None
Dropped beats: None
 Torsade de Pointes
Rate: 200–250 BPM
Regularity: Irregular
P wave: None
P:QRS ratio: None
PR interval: None
QRS width: Variable
Grouping: Variable sinusoidal pattern
Dropped beats: None
 Torsade de Pointes
• Special form of VT, QRS appears to be
constantly changing
– Etiology : drug toxicity, electrolytes
imbalance
– Treatment : ACLS Guideline
 Ventricular Flutter
Rate: 200–300 BPM
Regularity: Regular
P wave: None
P:QRS ratio: None
PR interval: None
QRS width: Wide, bizarre
Grouping: None
Dropped beats: None
 Ventricular Fibrillation (VFib)
Rate: Indeterminate
Regularity: Chaotic rhythm
P wave: None [Link]

P:QRS ratio: None

PR interval: None
QRS width: None
Grouping: None
Dropped beats: No beats at all
Ventricular Asystole (standstill)
• Ventricular rate : none
• Ventricular rhythm : none
• P wave : when sinus node is functioning, P wave will
be present
• PR interval : none
• QRS complex : none
• Etiology : MI CAD
• Treatment : ACLS Guideline
Post Lecture Questions
This ECG rhythm is called:

a) Sinus bradycardia changing to ventricular tachycardia

b) Junctional rhythm with a run of ventricular tachycardia
c) Sinus rhythm terminating in ventricular fibrillation
d) Sinus bradycardia changing to junctional tachycardia
Post Lecture Questions
This ECG rhythm is called:

a) Atrial flutter with multifocal PVCs

b) Atrial fibrillation with multifocal PVCs
c) Sinus tachycardia with multifocal PVCs
d) Accelerated junctional rhythm with PACs
 Attention
1. Name yourself using Full Name, Hospital, Title when
joining training (e.g. CHAN Mei Yan, GH (PMU), APN)
2. Join with video, show your face and keep mute during
forum unless in Q&A session or necessary.
3. No photo taking, video and audio recording during the
forum
4. No sharing of unauthorized course materials