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Normal Impulse Conduction: Sinoatrial Node AV Node Bundle of His Bundle Branches Purkinje Fibers

The document describes the normal conduction system of the heart and the waves seen on an electrocardiogram (ECG). It begins with the sinoatrial node and travels through the atrioventricular node, Bundle of His, bundle branches, and Purkinje fibers to the ventricles. It then discusses the P wave, QRS complex, T wave, and intervals seen on an ECG like the PR and QT. The document provides information on ECG leads, calculating heart rate from the rhythm strip, and determining the electrical axis. It includes examples of normal sinus rhythm and various arrhythmias like blocks, premature beats, and tachycardias.

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Indra Toshiway
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347 views

Normal Impulse Conduction: Sinoatrial Node AV Node Bundle of His Bundle Branches Purkinje Fibers

The document describes the normal conduction system of the heart and the waves seen on an electrocardiogram (ECG). It begins with the sinoatrial node and travels through the atrioventricular node, Bundle of His, bundle branches, and Purkinje fibers to the ventricles. It then discusses the P wave, QRS complex, T wave, and intervals seen on an ECG like the PR and QT. The document provides information on ECG leads, calculating heart rate from the rhythm strip, and determining the electrical axis. It includes examples of normal sinus rhythm and various arrhythmias like blocks, premature beats, and tachycardias.

Uploaded by

Indra Toshiway
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Normal Impulse Conduction

Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

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The PQRST

P wave - Atrial
depolarization

QRS - Ventricular
depolarization
T wave - Ventricular
repolarization
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Impulse Conduction & the ECG
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

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Nilai Normal Interval

Interval P (durasi): < 0,12 detik


Interval PR : 0,12 0,20 detik
Interval QRS : 0,07 0,10 detik
Interval QT tergantung frekuensi jantung
QTc: QT/ R-R
Systematic evaluation of the ECG

1. Rythm
2. Electrical axis
3. Rate and regularity
4. P-wave
5. PR interval
6. QRS-complex
7. ST-segment
8. T-wave
9. U-wave
10. QTc interval
The ECG Paper
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV

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Step 1: Calculate Rate
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0

Option 2 (cont)
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50

Interpretation?
Approx. 1 box less than
100 = 95 bpm
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Sandapan permukaan ((surface ECG Leads)

Limb Leads
(I,II,III)
Augmented
Limb Leads
(aVR,aVL, aVF)
Precordial Leads
(V1 V6)
Standard Limb Leads
Standard Limb Leads
Augmented Limb Leads
Sandapan precordial
V1: 4th IC space, R sternal
border
V2: 4th IC space, L sternal
border
V3: Between V2 and V4
V4: 5th IC space midclavicular
line
V5: 5th IC space ant axillary
line
V6: 5th IC space mid axillary
line
Sandapan precordial

Adapted from: www.numed.co.uk/electrodepl.html


Aksis/Sumbu Listrik Vektor QRS

Disebut Sumbu/Aksis QRS saja


Sumbu QRS pada bidang frontal ditentukan:
Cukup dengan 2 dari 6 sandapan
Cara praktisnya :
Pilih 2 sandapan, yang termudah, yang saling tegak
lurus, misal I dan aVF
Tentukan jumlah aljabar dari defleksi pada masing-
masing sandapan
Gambar sebagai vektor pada masing-masing sumbu
Dibuat Resultante yang menggambarkan sumbu
QRS
Menentukan sumbu QRS bid. frontal

I: aVF :

18
Cara lain penentuan sumbu QRS

Pilih satu sandapan yang mempunyai


jumlah aljabar defleksi nol (defleksi positif
sama dengan defleksi negatif)
Sumbu QRS tegak lurus pada sandapan ini

19
Menentukan sumbu QRS pada bidang frontal
dengan mencari sandapan yang
jumlah defleksinya nol

20
Kelainan Sumbu QRS pada bidang frontal
Normal : -30o hingga +90o
Deviasi Ke Kiri (DSKi) : -30o hingga -90o
Deviasi Ke Kanan(DSKa) : +90o hingga -180o
Sumbu Superior : +180o hingga -90o
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.
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.
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


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)
Axis: Leads I, II, III
Determining Axis: An Example
Sinus Tachycardia
Sinus Bradycardia
Sinus Arrhythmia
First Degree Heart Block
Second Degree Block Type I
Second Degree Block Type II
Rhythm #13

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
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Third Degree Heart Block
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.

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Premature Atrial Contraction
Atrial Bigeminy & Trigeminy
Bigeminy

Trigeminy
Premature Junctional Contraction
Teaching Moment
Atrial tissue
Multiple micro re-
entrant wavelets
refers to wandering
small areas of
activation which
generate fine chaotic
impulses. Colliding
wavelets can, in turn,
generate new foci of
activation. For more presentations
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Atrial Fibrillation
Atrial Flutter
Atrial Tachycardia
Teaching Moment

A re-entrant
pathway occurs
when an impulse
loops and results
in self-
perpetuating
impulse
formation.
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Supraventricular Tachycardia
Junctional Escape Rhythm
Premature Ventricular Contraction
Ventricular Bigeminy & Trigeminy
Bigeminy

Trigeminy
Ventricular Tachycardia
Torsade de Pointes
Ventricular Fibrillation
Ventricular Asystole
Bundle Branch Blocks
Characteristic
QRS pattern in
lead I, V1, and V6
Left Bundle Branch Block

*
Right Bundle Branch Block

*
Sick Sinus Syndrome
Atrial Hypertrophy
Ventricular Hypertrophy
Right (RVH) Left (LVH)
Right axis Left axis deviation
deviation and and rotation
rotation Tall QRS on left
Tall QRS on right (V4, V5, V6)
side leads
(V1, V2, V3)
Hypertrophy
Right ventricular hypertrophy
To diagnose RVH you can use the following criteria:
Right axis deviation, and
V1 R wave > 7mm tall

A common
cause of RVH
is left heart
failure.
Hypertrophy
Left ventricular hypertrophy
Take a look at this ECG. What do you notice about the axis and QRS
complexes over the left ventricle (V5, V6) and right ventricle (V1, V2)?

The deep S waves


seen in the leads over
the right ventricle are
created because the
heart is depolarizing
left, superior and
posterior (away from
leads V1, V2).

There is left axis deviation (positive in I, negative in II) and there


are tall R waves in V5, V6 and deep S waves in V1, V2.
Myocardial Infarction
Significant Q wave = Necrosis
ST elevation = Injury
T wave inversion = Ischemia
Significant Q Waves
MI Location
MI Location
Non-STEMI versus STEMI
Non-STEMI STEMI
Infark Non ST Elevasi Inferior dan Anterior Ekstensif
STEMI Progression
STEMI Progression

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