Electrocardiogram: Edit By: Pea Vuthy Edited From: CMMC/JH

Electrocardiogram
Edit by: Pea Vuthy

Edited from: CMMC/JH
The
Electrical
Conduction
System
• Sinoatrial Node: 60 to100 beats per minute
(BPM).
• Internodal Pathways:
o Transmit the impulse from the SA node
to the AV node.
o The internodal tracts consist of anterior,
middle, and posterior divisions
• Interatrial Pathways:
o Bachmann’s bundle, Weckebach’s
bundle and Thorel’s pathway
• Atrioventricular Node :
oA secondary pacemaker
oRate of 40 to 60 BPM
oThree regions: AV junctional tissue,
the nodal area, and the AV junctional
tissue.
oThe region where the AV node joins
the bundle of His is called the AV junction.
Similar to the SA node
• Bundle of His :This bundle receives its
blood supply from the left anterior and
posterior descending coronary arteries.
The bundle of His is also referred to as the
atrioventricular bundle or the common
bundle.
• Purkinje Fibers: Conduct the impulse to
the myocardial cells of the ventricles to
contract.
EKG
waveforms
and intervals
Term of Electrocardiogram
Electrical Basis of the EKG
• 3 lead EKG cable : positive, negative, and ground
• Eindhoven,s Triangle ：
Electrical Basis of the EKG
 Lead 5 : Electrode Placement
• RA (white): below R clavicle, 2nd ICS, R
midclavicular line.
• RL (green): R Lower rib cage, 8th ICS, R
midclavicular line.
• LA (black): below L clavicle, 2nd ICS, L
midclavicular line.
• LL (red): L lower rib cage, 8th ICS, L midclavicular
line.
• V1 (brown): 4th ICS, R sternal border
Electrical Axis
EKG waveforms and intervals
• The baseline (isoelectric line) is

the straight line seen on an EKG
strip.
• EKG Waveform are produced on
the graph paper
• Biphasic Deflection: EKG
waveform that moves both below
and above the isoelectric line.
P wave
• Atrial depolarization
• (+) deflection from the baseline
• Lead II (see clearly)
• Amplitude 0.5mm and 2.5mm

and a duration of 0.10s or less.
QRS complex
• Measured from the beginning of
the QRS to point where the last
wave of the complex begin to
flatten out into the ST segment.
• Impulse to depolarization the
ventricles.
• Q wave(-) ,R wave(+) ,S wave(-)
• QRS complex in lead II of
duration 0.12s or less than.
T Wave
• The latter phase of ventricular

repolarization
• Positive deflection
• Amplitude less than 5 mm
ST Segment
• The end of ventricular

depolarization and the beginning
of ventricular repolarization
( End of QRS start of T )
• Flat ( Isoelectric )
• Duration 0.8s or two squares ( J
point )
• Myocardial injury, acute
myocardial infarction…
QT Interval
• Onset of ventricular
depolarization and the end
ventricular repolarization
( beginning QRS the end T wave)
• Duration 0.4s – 0.43s
U wave
• Follow T wave
• Part of the ventricular
repolarization
• Height less than 2mm
• > 2mm maybe cause by left
ventricular hypertrophy,
cerebrovascular…
• P wave: duration of 0.10s or less.
• PR interval : duration 0.12s - 0.20s
• QRS complex: duration10s or less
than.
• ST segment: duration 0.8s
• QT interval: duration 0.4s – 0.43s

• P wave: duration of 0.10s or less. • QT interval: duration 0.4s – 0.43s
• PR interval : duration 0.12s - 0.20s • Normal sinus rhythm
• QRS complex: duration0.06-0.10s. • Rate: 75 bpm
• ST segment: duration around 0.08 sec
General rules
• 1. Fist, and the most important, look at your patient

• 2. Read every strip from left to right
• 3. Apply the five steps systematic approach
• 4. Avoid shortcuts and assumptions
• 5. Ask and answer each question in the five steps
approach in the order that it is presented
• 6. You much master the accepted limits, or parameters,
for each dysrhythmia and then apply them to each of the
five steps when analyzing the strip
The Five-Step Approach
• Step 1 : Heart rate

• Step 2 : Heart rhythm
• Step 3 : P wave
• Step 4 : PR interval
• Step 5 : QRS complex
How is the heart rate determined on e
lectrocardiography (ECG)?
Step1: Heart Rate
6 second method RR interval method

Step2: Heart Rhythm
• The sequential beating of the heart rate as the result of generation of electrical
impulses.
• > Regular
• > Irregular
• . Regularly irregular
• . Occasionally irregular
• . Irregularly irregular
• R-R : ventricular rhythm
• P-P : atrial rhythm
• >0.08 considered
Step3: P wave
• Atrial depolarization
• (+) deflection from the baseline
• Lead II (see clearly)
• Amplitude 0.5mm and 2.5mm

and a duration of 0.10s or less.
Step3: P wave
There are five questions that should be asked in evaluating P Wave:
1. Are P wave present?
2. Are the P wave occurring regularly?
3. Is there one P wave present for each QRS complex present?
4. Are the P waves smooth, rounded, and upright (positive) in
appearance, or are they
5. Do all the P wave look similar?
Step4: PR Interval

the P wave as it leaves baseline to
the beginning of the QRS
complex.
• Electrical impulse from the atrial
to the Purkinje network.
• PR interval : duration 0.12s -
0.20s
Step5: QRS complex
the QRS to point where the last
wave of the complex begin to
flatten out into the ST segment.
• Impulse to depolarization the
ventricles.
• Q wave(-) ,R wave(+) ,S wave(-)
• QRS complex in lead II of
duration 0.12s or less than.
EKG Graph Paper
EKG Grid Paper
Artifact
Cause of artifact:
1. Patient movement
2. Loose or defective electrode
3. Improper grounding
4. Faulty EKG apparatus
References
• Beasley, M. (2014). Understanding of EKGs A Practical Approach (Fourth Edition ed.). New
Jersey: Pearson Education.

THANK YOU !
Please Answer the provided EKG strips
1. Rate: BPM?
2. Rhythm: Normal versus tachycardia versus
bradycardia?
3. PR interval: Measuring?
4. QRS: Measuring?
5. P wave: Present? Are they 1:1 QRS

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Electrocardiogram

Edit by: Pea Vuthy

• 3 lead EKG cable : positive, negative, and ground

• The baseline (isoelectric line) is

• (+) deflection from the baseline

• Lead II (see clearly)

• Amplitude 0.5mm and 2.5mm

• The latter phase of ventricular

• The end of ventricular

• PR interval : duration 0.12s - 0.20s

• QRS complex: duration10s or less

• ST segment: duration 0.8s

• QT interval: duration 0.4s – 0.43s

• 1. Fist, and the most important, look at your patient

• Step 1 : Heart rate

6 second method RR interval method

• (+) deflection from the baseline

• Lead II (see clearly)

• Amplitude 0.5mm and 2.5mm

• Measured from the beginning of

Jersey: Pearson Education.

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