Dr. David D Ariwibowo, Sp.

JP

Standard 12 leads ECG

Limb Lead Precordial Lead

Exercise Configuration
The right & left arm electrodes are transferred to the upper torso while the leg electrodes are transferred to the lower torso

Standard Configuration Right Arm (white) Left Arm (black)

Standard Configuration Right Leg (green - ground) Left Leg (red)

Precordial Leads

V1 red V2 yellow

V3 green V4 blue

V5 orange V6 violet

Anatomical Placement of Electrodes

Electrode Right Arm (RA) Left Arm (LA) Right Leg (RL) Left Leg (LL) V1 V2 Anatomical Location The base of the right shoulder against the deltoid border about 2 cm below the clavicle but above the border of pectoralis (in deltoid fossa). The base of the left shoulder against the deltoid border about 2 cm below the clavicle but above border of pectoralis (in deltoid fossa). Right anterior axillary line a few centimeters above the umbilicus Left anterior axillary line a few centimeters above the umbilicus Fourth intercostal space at right sternal border. Fourth intercostal space at left sternal border.

V3
V4 V5 V6

Midway between positions for V2 and V4.

Fifth intercostal space at left midclavicular line. Horizontal level of V4 at left anterior axillary line. Horizontal level of V4 at left midaxillary line.

The Concept of a "Lead"

Limb Leads
LEAD I

LEAD III Remember, the RL is always the ground

LEAD II

Limb Leads

Precordial Leads

V9

Standard 12 leads ECG

The ECG waves

P wave : atrial

depolarisation

QRS complex :

ventricular depolarisation
repolarisation

T wave : ventricular Atrial repolarisation

hidden by QRS

Local action potential

The ECG Complex

QRS duration
< 0.10 sec

R
P

ST segment

U Q

0.12 - 0.20 sec

0.35 - 0.45 sec

The depolarization traveling acros the heart continue traveling through the body By examining the different leads, shape, time intervals, contour, frequency, and type of the ECG complexes, we can diagnose cardiac illnesses.

PR interval

QT
interval

ECG Paper

Standard recording: - Speed: 25 mm/s - Voltage: 1 mV

Standard 12 leads ECG

Standard 12 leads ECG

++++ ++ ++

---- --

Generation of the ECG complexes

A wave of depolarization

++++ ++

---- --

---- --------++ ---++++

++++

++++

++++

++++

++++

-------

moving toward an electrode will cause an upward deflection on the ECG.

-- ++ ++++ ++++ ---- ---- ++ ---- ---++++ -++++ ++++ -++++ ---- ++ ++ ----------++++ ++++
++++ -++ ---- ++ ---++++ ----++++ ++++ ++++ ++++ -++++ ---- ---- ++ ++ -------++++

----

---- ---- ------- ++++ ++++ ++++ ++++ ++++ ++++ ++++ ---------- ------++++

----

++++ ++++

Depolarization of the atria in Lead II

Atrial depolarization proceeds from the top down in all directions.
Summing these vectors of

depolarization the main atrial depolarization vector (large green arrow). It is moving towards the lead II resulting in an upward deflection of the ECG.
.

o 60

Depolarization of the LV in Lead II.

Septum depolarizes from inside out

resulting depolarization wave moves away from Lead II. The rest ventricle depolarizes counter-clockwise from inside out main cardiac vector (large arrow) which is sum of all of the small depolarization vectors. This vector in normal heart, almost always moving directly toward Lead II a mostly positive QRS complex. The RV is much smaller and contributes little to the overall main vector of depolarization

60

Repolarization of the LV in Lead II

Repolarization is the beginning of

depolarization left off . Proceeding clockwise from the lateral wall back to the septum. The vector is moving away from the Lead II T-wave is always positive. The process much slower than depolarization T-wave is wide & rounded.

Pacemaking & conduction System

Rules of pacemaker & Conduction

1. 2. 3. 4. 5.

6.
7.

Setiap sel jantung dapat berperan sebagai pacemaker. Pacemaker dengan frekuensi pulsus tertinggi yang menentukan frekuensi denyut jantung. Pulsus secara normal di konduksikan dari atrium ke ventrikel hanya melalui AV node. Pulsus dari atrium mengalami perlambatan di AV node sebelum dikonduksikan ke ventrikel. AV node memiliki masa refrakter tertentu(masa tidak dapat dirangsang). Pulsus yang berasal dari supra ventrikel akan mengeksitasi ventrikel dengan cepat gambaran QRS sempit. Pulsus yang berasal dari ventrikel akan mengeksitasi ventrikel dengan lambat gambaran QRS lebar.

Heart Excitation Related to ECG

Figure 18.17

Thank You