NORMAL STRUCTURE

AND FUNCTION OF
HEART
 Chambers of the heart

ü Left atrium
ü Left ventricle
ü Right atrium
ü Right ventricle
Normal Impulse Conduction
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
INTRODUCTION TO ECG
Meaning of
ECG(Electrocardiogram):

Electrocardiogram (ECG) is a
graphical
representation that describes about
the heart activities.
Impulse Conduction & the ECG
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
The “PQRST”

P wave - Atrial depolarization

•QRS - Ventricular
depolarization
• T wave - Ventricular
repolarization
 The PR Interval

Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)
Components of ECG
Click to edit Master text styles
Second level
● Third level

● Fourth level

● Fifth level
 The ECG Paper

Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
 The ECG Paper (cont)
3 sec 3 sec

Every 3 seconds (15 large boxes) is

marked by a vertical line.
ECG monitoring
 Purpose of ECG monitoring

Ø To assess the heart rate & rhythm.

Ø To check for ectopy (abnormal heart beat) or arrhythmia.
 Placement of electrodes
Note: To recall lead placement for the 3-
leadaccording to color
system, remember coding
“white is right”
and “smoke over fire”. The white lead
goes on the right arm, and the black lead
goes over the red lead on the left.
 Causes of abnormal ECG
pattern
Patient’s movement
Loose electrodes
Damaged or broken wires
Improper connections
Improper placement of electrodes
Electrical interferences eg. Oily skin, excessive sweating,
inadequate conduction jelly.
Faulty equipment.
Introduction to Normal Sinus
Rhythm and arrhythmias
 Rhythm Analysis

Step 1: Calculate rate.

Step 2: Determine regularity.
Step 3: Assess the P waves.
Step 4: Determine PR interval.
Step 5: Determine QRS duration.
 Step 1: Calculate Rate

a. Atrial rate:

Count the number of small squares between two

consecutive P waves and divide 1500 by this
number (Rule of 1500). OR count the number of
large squares between two consecutive P waves
and divide 300 by this number (Rule of 300).
 Contd…
b. Ventricular rate:
Count the number of small squares between the R
waves of two consecutive QRS complexes and divide
1500 by this number (Rule of 1500). OR count the
number of large squares between the R waves of two
consecutive QRS complexes and divide 300 by this
number (Rule of 300).

Note: Normally atrial and ventricular rates are identical.

Calculation of heart rate using 6
second strip:
3 sec 3 sec

Count the number of R waves in a 6

second rhythm strip, then multiply by 10.

9 x 10 = 90 bpm
Step 2: Determine regularity
R R

Look at the R-R distances.

Regular (are they equidistant apart)? Occasionally
irregular? Regularly irregular? Irregularly irregular?

Interpretation? Regular
Step 3: Assess the P waves

Are there P waves?

Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation? Normal P waves with 1 P
wave for every QRS
Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)

Interpretation? 0.12 seconds

Step 5: QRS duration

Normal: 0.08 - 0.11 seconds.

(1 - 3 boxes)

Interpretation? 0.08 seconds

 Rhythm Summary

Rate 90-95 bpm

Regularity regular
P wavesnormal
PR interval 0.12 s
QRS duration 0.08 s
Interpretation? Normal Sinus Rhythm
 Arrhythmias

When the heart rate,rhythm,conduction

or contour of any of the individual wave is
abnormal,the disorder is called arrhythmia
or dysrhythmia.
Arrhythmias can arise from problems in
the:
• Sinus node
• Atrial cells
• AV junction
• Ventricular cells
Arrhythmias arising in SA
node
 Sinus Rhythms

Sinus Bradycardia

Sinus Tachycardia
Sinus arrest.
• Rate? 30 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.12 s
• QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
 Sinus Bradycardia

Deviation from NSR

- Rate < 60 bpm
 Sinus Bradycardia

Etiology: SA node is depolarizing slower

than normal, impulse is conducted
normally (i.e. normal PR and QRS
interval).
Treatment:
Treatment is indicated if one or more of the
following signs are present:
- Any symptoms of decreased cardiac output or
heart rate <40 when patient is awake.
- Systolic blood pressure 80-90 mm Hg or less.
- Weak or absent pulse
- Pale, cold and clammy skin
- Confusion or mental cloudiness
- Premature ventricular contractions
• Rate? 130 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.16 s
• QRS duration? 0.08 s
Interpretation? Sinus Tachycardia
 Sinus Tachycardia

Deviation from NSR

- Rate > 100 bpm
 Sinus Tachycardia

Etiology: SA node is depolarizing faster

than normal, impulse is conducted normally.
Remember: sinus tachycardia is a response
to physical or psychological stress, not a
primary arrhythmia.
Treatment
Treat the underlying cause of tachycardia
(pain, anxiety, fever etc.)
If a drug overdose is suspected, adjust
the dose of the drug. Notify the physician
and follow the medical orders.
 Sinus arrest

The condition in which SA node fails to

fire is called Sinus arrest.
ARRHYTHMIAS ARISING
IN ATRIA
• Rate? 70 bpm
• Regularity? occasionally irreg.
• P waves? 2/7 different contour
• PR interval? 0.14 s (except 2/7)
• QRS duration? 0.08 s
Interpretation? NSR with Premature Atrial
Contractions
Premature Atrial Contractions

Deviation from NSR

These ectopic beats originate in the atria (but not
in the SA node), therefore the contour of the P
wave, the PR interval, and the timing are different
than a normally generated pulse from the SA node.
Premature Atrial Contractions

Etiology: Excitation of an atrial cell forms

an impulse that is then conducted
normally through the AV node and
ventricles.
Treatment:
Monitor the patient continuously and watch for
other arrhythmias.
Inform the doctor if more than 8 to 10 PACs
appear per minute, and follow medical orders.
If digitalis overdose is suspected, withhold the
drug.
Intravenous potassium may be ordered, if
serum potassium level is low.
Oral quinidine may be ordered for frequent
PACs.
Verapamil (Isoptin) may be given if PAC leads
to atrial tachycardia.
 Note

When an impulse originates anywhere in

the atria (SA node, atrial cells, AV node,
Bundle of His) and then is conducted
normally through the ventricles, the QRS
will be narrow (0.04 - 0.12 s).
• Rate? 100 bpm
• Regularity? irregularly irregular
• P waves? none
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Fibrillation
 Atrial Fibrillation

Deviation from NSR

No organized atrial depolarization, so no normal P
waves (impulses are not originating from the sinus
node).
Atrial activity is chaotic (resulting in an irregularly
irregular rate).
Common, affects 2-4%, up to 5-10% if > 80 years old
 Atrial Fibrillation

Etiology: Recent theories suggest that it is due to

multiple re-entrant wavelets conducted between the
R & L atria. Either way, impulses are formed in a
totally unpredictable fashion. The AV node allows
some of the impulses to pass through at variable
intervals (so rhythm is irregularly irregular).
A re-entrant
pathway occurs
when an impulse
loops and results
in self-perpetuating
impulse formation.
Treatment:
The most commonly used drugs are
digitalis and verapamil.
Elective cardio version is required in
selected cases.
• Rate? 70 bpm
• Regularity? regular
• P waves? flutter waves
• PR interval? none
• QRS duration? 0.06 s
Interpretation? Atrial Flutter
 Atrial Flutter

Deviation from NSR

No P waves. Instead flutter waves (note
“sawtooth” pattern) are formed at a rate of
250 - 350 bpm.
Only some impulses conduct through the AV
node (usually every other impulse).
 Atrial Flutter

Etiology: Reentrant pathway in the right

atrium with every 2nd, 3rd or 4th impulse
generating a QRS (others are blocked in
the AV node as the node repolarizes).
Treatment:
Treatment is required if any one of the following signs and
symptoms are present:
Systolic blood pressure is 80 to 90 mm Hg. or less.
Weak or absent pulse
Pale, cold and clammy skin
Confusion and unconsciousness of patient
Drug treatment consists of digoxin and/or propranolol
In resistant cases, synchronized D.C. shock (elective cardio
version) may be required.
Arrhythmias arising in
Ventricles
• Rate? 60 bpm
• Regularity? occasionally irreg.
• P waves? none for 7th QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
 PVCs(Premature Ventricular
Contractions)

Deviation from NSR

Ectopic beats originate in the ventricles resulting in
wide and bizarre QRS complexes.
When there are more than 1 premature beats and
look alike, they are called “uniform”. When they look
different, they are called “multiform”.
 PVCs

Etiology: One or more ventricular cells are

depolarizing and the impulses are
abnormally conducting through the
ventricles.
Treatment
Monitor the patient continuously for the
development of lethal arrhythmias.
If PVCs are associated with bradycardia, the
heart rate should be accelerated by the
administration of atropine or by pacing.
If bradycardia is not present, IV lidocaine is
given -50 to 100mg bolus, followed by an IV
infusion at a rate of 2 to 3 mg/minute.
 Note

When an impulse originates in a ventricle,

conduction through the ventricles will be
inefficient and the QRS will be wide and
bizarre.
 Ventricular Conduction

Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
• Rate? 160 bpm
• Regularity? regular
• P waves? none
• PR interval? none
• QRS duration? wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
 Ventricular Tachycardia

Deviation from NSR

Impulse is originating in the ventricles (no P
waves, wide QRS).
 Ventricular Tachycardia

Etiology: There is a re-entrant pathway

looping in a ventricle (most common cause).

Ventricular tachycardia can sometimes

generate enough cardiac output to produce
a pulse; at other times no pulse can be felt.
Treatment:
Intravenous lidocaine 50 to 100 mg given as IV bolus and
followed by intravenous infusion at a rate of 2-3mg/minute
is the treatment of choice.
Other useful drugs are intravenous phenytoin and
procainamide.
In critically ill patients, or when the drug therapy is
unsuccessful, cardioversion (synchronized DC shock) is the
treatment of choice.
Sometimes, the ventricular tachycardia can be terminated
by striking the patient’s chest (over the lower part of the
sternum) with a closed fist (thumpversion)
• Rate? none
• Regularity? irregularly irreg.
• P waves? none
• PR interval? none
• QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
 Ventricular Fibrillation

Deviation from NSR

Completely abnormal.
 Ventricular Fibrillation

Etiology: The ventricular cells are

excitable and depolarizing randomly.

Rapid drop in cardiac output and death

occurs if not quickly reversed
Treatment:
Cardio-pulmonary resuscitation (CPR)
should be initiated within seconds.
The treatment of choice ( infact, the only
specific treatment) is electrical
defibrillation.
Ventricular Asystole
Etiology:
Lethal arrhythmias. Eg: Ventricular
fibrillation.
Cardiogenic shock or heart failure
Complete heart block.
Hyperkalaemia
Treatment:
Cardio-pulmonary resuscitation (CPR) is
the treatment of choice which should be
initiated within seconds.
Electrical defibrillation should be carried
out promptly, if the required apparatus
(defibrillator) is available.
ARRHYTHMIAS
ARISING IN
 AV Nodal Blocks

1st Degree AV Block

2nd Degree AV Block, Type I

2nd Degree AV Block, Type II

3rd Degree AV Block

• Rate? 60 bpm
• Regularity? regular
• P waves? normal
• PR interval? 0.36 s
• QRS duration? 0.08 s
Interpretation? 1st Degree AV Block
 1st Degree AV Block

Deviation from NSR

PR Interval > 0.20 s
 1st Degree AV Block

Etiology: Prolonged conduction delay in

the AV node or Bundle of His.
Treatment:
The causative factor must be identified
and appropriately treated.
No special measures are required for first
degree A.V. block itself.
• Rate? 50 bpm
• Regularity? regularly irregular
• P waves? normal, but 4th no QRS
• PR interval? lengthens
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type I
 2nd Degree AV Block, Type I

Deviation from NSR

PR interval progressively lengthens, then
the impulse is completely blocked (P wave
not followed by QRS).
 2nd Degree AV Block, Type I

Etiology: Each successive atrial impulse

encounters a longer and longer delay in the
AV node until one impulse (usually the 3rd
or 4th) fails to make it through the AV node.
Treatment:
No treatment is necessary if the heart rate
remains near normal. However, the
causative factor, if any, should be treated.
• Rate? 40 bpm
• Regularity? regular
• P waves? normal, 2 of 3 no QRS
• PR interval? 0.14 s
• QRS duration? 0.08 s
Interpretation? 2nd Degree AV Block, Type II
2nd Degree AV Block, Type II

Deviation from NSR

Occasional P waves are completely
blocked (P wave not followed by QRS).
2nd Degree AV Block, Type II

Etiology: Conduction is all or nothing (no

prolongation of PR interval); typically
block occurs in the Bundle of His.
Treatment:
Treatment is indicated if symptomatic
bradycardia exists.
Artificial cardiac pacing usually required.
The drug treatment includes those drugs
that increase the heart rate such as
atropine, isoproterenol etc.
• Rate? 40 bpm
• Regularity? regular
• P waves? no relation to QRS
• PR interval? none
• QRS duration? wide (> 0.12 s)
Interpretation? 3rd Degree AV Block
 3rd Degree AV Block

Deviation from NSR

The P waves are completely blocked in the
AV junction; QRS complexes originate
independently from below the junction.
 3rd Degree AV Block

Etiology: There is complete block of conduction

in the AV junction, so the atria and ventricles
form impulses independently of each other.
Without impulses from the atria, the ventricles
own intrinsic pacemaker kicks in at around 30 -
45 beats/minute.
Treatment:
Drugs to accelerate heart rate include
atropine and isoprenaline.
Temporary pacemaker is indicated
urgently.
 Remember

When an impulse originates in a ventricle,

conduction through the ventricles will be
inefficient and the QRS will be wide and
bizarre.
 Critical care nurses
responsibilities in monitoring
and interpreting ECG
Recognize and identify the type of
arrhythmia. Inform the physician as
necessary. Never consider any
arrhythmias as unimportant.
Always try to correlate ECG changes with
physical signs and symptoms of the
patient before taking any decisions.
 Contd…

Examine the patient at regular intervals.

Record the rate and rhythm of the heart
beat at frequent intervals (through ECG
strips).This is particularly important after
drug therapy is initiated.
 Contd…

Watch for other complications secondary

to arrhythmia, such as fall in blood
pressure, cyanosis etc.Inform the
physician at the earliest.
If toxicity of the drug is suspected as the
cause of arrhythmia, further dosage of the
drug should be withheld until approved by
the physician.
.
 Contd…

Always keep ready emergency drugs and

resuscitation equipment near the patient. See
that the equipments are in working condition
Never leave the patient unattended. Reassure
the patient.
 Contd…

Give adequate information to the patient’s

relatives.
Always apply simple measures first, eg.a
patient in pain or anxiety may develop sinus
tachycardia. The nurse’s primary responsibility
is to observe the patient for any underlying
causes and remove the same as far as
possible.
Thank you