EKG Dasar medis michael johandadasdas.ppt

ekg dasar

1. BASIC ECG

2. ECG
•Electrophysiology
•Electrode placement
•ECG analysis
•Myocardial ischemia or infarct
•Enlargement of cardiac chambers
•Aritmia

4. Action potentials from different myocardial cells

5. ECG
•Electrophysiology
•Electrode placement
•ECG analysis
•Myocardial ischemia or infarct
•Enlargement of cardiac chambers
•Aritmia

6. ECG leads
•Two general types :
a. Bipolar leads : lead I, II and III
b. Unipolar leads :
1.Six unipolar precordial leads (V1-V6)
2.Three modified unipolar limb leads (aV
r,
aV
land aV
f)

7. The standard
leads and their
axes

8. The unipolar
limb leads and
their axes

9. Locations of unipolar
precordial leads
V1 = ICS IV linea sternalis dextra
V2 = ICS IV linea sternalis
sinistra
V3 = pertengahan V2-V4
V4 = LMCS ICS V
V5 = LAAS sejajar dengan V4
V6 = LMAS sejajar dengan V4-V5

10. The precordial leads and their axes

11. Paper speed and voltage calibration in ECG recording

12. ECG
•Electrophysiology
•Electrode placement
•ECG analysis
•Myocardial ischemia or infarct
•Enlargement of cardiac chambers
•Aritmia

13. Diagram of
ECG
complexes,
interval, and
segments
J Point
I Point

14. The wave and intervals in ECG
•P wave activation of the atria
•PR segment duration of atrioventricular
(AV) conduction
•QRS complex activation of both ventricles
•ST-T wave ventricular recovery

15. Quality check(Q.C) setiap Elektrokardiogram!
1.Identitas (nama, umur, tanggal dan jam
pembuatan) jika perlu nama pembuat EKG
2.Standarisasi EKG
3.Kecepatan EKG, apakah 25 mm/det atau 50
mm/detik
4.Apakah EKG layak dibaca, dengan melihat :
•Gel P, defleksikeatas (positif) di leadI
•Gel P, defleksi kebawah (negatif) di leadaVR

16. Normal value for durations
Wave / Interval Duration (sec)
P wave duration < 0.12
PR interval 0.12 –0.20
QRS duration < 0.11-0.12
QT interval (corrected)≤ 0.44-0.46

17. P wave
Atrial activation
Activation beginning high in right atrium 
leftward toward the left atrium and inferiorly
toward AV node
Frontal plane axis 60degrees
Positiveor upright P waves in leads I, II, aV
l
and aV
f
Normal : duration less than 120 msecand the
amplitude in the limb leads less than 0.25 mV
and the terminal negative deflection in the
right precordial leads is less than 0.1 mV in
depth

18. PR segment
•Isoelectric region beginning with the end of
the P wave and ending with the onset of the
QRS complex

19. QRS complex
•Product of two : endocardial activation
(guided by His-Purkinje system) and
transmural activation
•Q wave: initial negative deflection
•R wave: first positive wave
•S wave: first negative wave after a positive
wave
•Duration : less than 120 msecin the lead with
the widest QRS duration

20. R R R
SQ
R
QS QS
R
S
R’

21. T wave
•Upright in leads I, II, aV
l, aV
fand lateral
precordial leads
•Negative in lead aVr
•Variable in leads III and V1 through V3
QT interval
Bazzet’s formula (1920) :
QT corrected = QT / RR
½
Normal : less than 440 –460 msec

22. Axis of QRS complex
Frontal plane :
•Normal axis -30 –+90 degrees
•Right axis deviation (RAD) ≥ +90 degrees
•Left axis deviation (LAD) ≤ -30 degrees
•Extreme axis deviation +180 –+270 degrees

23. AKSIS JANTUNG

25. Rhythm
•P followed by QRS complex ? Sinus?
•Reguler ?
•RR = PP ?
•Normal QRS complex ?

26. Sinus Rhythm Criteria
•P wave (+)
•Positive P wave on II and Negative P wave on
aVR
•Regular P-P
•Same size and form of P wave on the same
lead
•P wave followed by regular QRS wave
•Normal PR interval

27. Heart rate
Reguler
•Paper speed 25 mm/sec
1 minute 25 x 60 mm = 1500 mm
•Measure RR / SS / PP use small boxes
or large boxes ?
•Small boxes = 1500 / RR
•Large boxes = 1500 / 5 300 / RR

28. Heart rate
Irreguler
•Use prolonged Lead II
•Measure in 2 sec or 3 sec or ….
•Count how many RR or in that time after
that multiply it into 1 minute

29. P wave
•Measure duration and amplitude in lead II
and V
1
•Is it in normal range ?
•Positiveor upright P waves in leads I, II,
aV
land aV
f
•Normal : duration less than 120 msec
and the amplitude less than 0.25 mV

30. PR interval
•Measure duration from beginning of P wave to
beginning QRS complex
•Normal : 0,12 –0,20 second
•Prolonged block
•Shortened excitation

31. QRS complex
•Duration
•Axis frontal plane, transitional zone
•Infarct ?
•Ventricle hypertrophied
•Ventricular extrasistole
•RSr’ formation

33. ST segment
•Isoelectric ? Depressed ? Elevated ?
•Measure it from J point
T wave
•Inverted ?
•Peaked and tall T wave ?
QT interval
Measure from beginning QRS complex to
end of T wave

36. Analisis / pembacaan rekaman EKG
1. Irama : sinus / aritmia
2. Heart rate : bradikardi / normal / takikardi
3. GelP: lama (det), amplitudo (mV), adakah
extrasystole ?
4. Interval PR :normal / memanjang (block) /
memendek (eksitasi) 0,12 –0,20 det
5. Kompleks QRS : QRS axis, QRSinterval ( < 0,12
det), Kelainankompleks QRS, Adakah extrasystole
6. ST segment: Isoelektrik, depresi, elevasi
7. Gel T :peaked and tall T wave, Flattened, inverted ?
8. Gel U :ada atau tidak ?
9. QT atau QTCinterval
Kesimpulan :………………………..

37. ECG
•Electrophysiology
•Electrode placement
•ECG analysis
•Myocardial ischemia or infarct
•Enlargement of cardiac chambers
•Aritmia

38. Myocardial Infarction
When the blood supply to an
area of the heart is obstructed, a
section of heart musscle may
die. This is known as infarction
of the heart muscle or
myocardial infarction

39. Normal Coronary Arteries
Blood is supplied to the heart by
the right and left coronary
arteries. The right coronary
artery remains a major trunk
throughout its length, whereas
the left coronary artery, after a
short main stem, divides into the
left anterior descending and
circumflex arteries

40. Anatomi A. Coronaria

41. Perhatian !!!
•Gambaran EKG tunggal ( single ECG
tracing) tidak merupakan gambaran yang
spesifik untuk keadaan iskemia miokard.
•Keadaan klinis !
•EKG hanyalah alat bantu.
•Diagnosa kerja ditentukan oleh
keadaan klinis dan EKG

42. CONDITION ECG
1. Ischemia
Represented by symmetrical T wave inversion
(upside down). The definitive leads for
ischemia are: I, II, V2 -V6.
2. Injury
Acute damage -look for elevated ST
segments. (Pericarditis and cardiac
aneurysm can also cause ST elevation;
remember to correlate it with the patient.
3. Infarct
Look for significant "pathologic" Q waves. To
be significant, a Q wave must be at least one
small box wide or one-third the entire QRS
height. Remember, to be a Q wave, the
initial deflection must be down; even a tiny
initial upward deflection makes the apparent
Q wave an R wave.

43. Current-of-injury patterns with acute
ischemia
ST elevation / depression

44. Diagrammatic
representation of the
various surfaces of the
left ventricular
anatomical cone, and
their relationship to the
frontal and horizontal
plane leads

45. GELOMBANG T
Gel T normal-iskemik (?)
Iskemik -Gel T normal
Hiperakut T -“early repolarization” / prainfark
Pocket Guide To Basic Dysrhythmias 3
rd
Ed . Robert J Huszar

46. ST Segment Diagram -Marquette-KH
Marquette Electronics Copyright 1996

47. A normal resting ECG does not exclude the diagnosis
EXERCISE INDUCED ISCHEMIA

49. Evolutionary Changes Following Blood Flow Obstruction
Note that the ST segment elevation occurs prior to the formation of the Q wave. During these early hours,
interventions are often undertaken to reverse the process. As time passes, the Q wave forms, the ST segment is less
elevated, and the T wave inverts. The final outcome varies greatly, depending on the amount of myocardial damage

53. ECG
•Electrophysiology
•Electrode placement
•ECG analysis
•Myocardial ischemia or infarct
•Enlargement of cardiac chambers
•Aritmia

54. Atrial Enlargement
1.Left atrial enlargement
2.Right atrial enlargement

55. Left atrial abnormalities
•Prolonged P wave duration of > 120 msecin lead II
•Prominent notching of the P wave, usually most
obvious in lead II, with an interval between the
notched of > 40 msec (P mitrale)
•Ratio between the duration of the P wave in lead II
and duration of the PR segment of > 1.6
•Increased duration and depth of terminal negative
portion of the P wave in lead V1 (the P terminal force)
so that the area subtended by it exceeds of 0.04 mm-
sec

56. Right atrial abnormalities
•Peaked P waves with amplitude greater
than 0.25 mV in lead II (P pulmonale)
•Rightward shift of the mean P wave axis
to above 75 degrees
•Increased area under the initial positive
portion of the P wave in lead V1 to > 0.06
mm-sec

57. The changes in P-wave
morphology typical of atrial
enlargement as they appear
in leads II and V1

58. Twelve-lead ECGs from a 23-year old intravenous drug addict with
tricuspid valve disease (A)

59. Twelve-lead ECGs from a 68-year-old man with aortic valve
disease (B)

60. Ventricular Hypertrophy and
Enlargement
•Left ventricular hypertrophy and
enlargement
•Right ventricular hypertrophy and
enlargement
•Biventricular enlargement

61. The changes in the QRS
complex typical of ventricular
enlargement as they appear
in leads I and V1.
A. Normal,
B. Left-ventricular
enlargement (LVE),
C. Right-ventricular
enlargement (RVE),
D. Biventricular enlargement
(LVE + RVE)

62. Sokolow-Lyon Criteria for LVH
S wave in lead V1 + R wave in lead V5 or V6 > 3.50 mV
or
R wave in aV
l
> 1.1 mV

63. Cornell Voltage Criteria for LVH
Females
Males
R wave in lead aVL+ S wave in lead V3 > 2.00 mV
R wave in lead aVL+ S wave in lead V3 > 2.80 mV

64. Twelve-lead
ECG from a
70-year-old
man with
severe aortic
valve
stenosis just
prior to
surgical
replacement

65. Twelve-lead
ECG from a
75-year-old
woman with
symptoms of
heart failure
caused by
longstanding
hypertension

66. Laki-laki, 65 tahun, datang dengan keluhan sesak nafas
Pasien mempunyai riwayat tekanan darah tinggi

67. Right Ventricular Hypertrophy
Diagnostic criteria Sensitivity (%)Specificity (%)
R in V
1≥ 0.7 mV < 10 -
QR in V
1
< 10 -
R/S in V
1> 1 with R > 0.5 mV < 25 89
R/S in V
5or V
6< 1 < 10 -
S in V
5or V
6≥ 0.7 mV < 17 93
R in V
5or V
6≥ 0.4 mV with
S in V
1≥ 0.2 mV < 10 -
Right axis deviation < 14 99
S
1Q
3pattern < 11 93
S
1S
2S
3pattern < 10 -
P pulmonale < 11 97

68. Twelve-lead ECG from a 59-year old man with severe chronic obstructive
lung disease

69. Twelve-lead ECG from an 18-year old man with congenital heart disease
and pulmonary hypertension

70. Biventricular enlargement
Produces complex ECG patterns
Specific ECG criteria for either RVH or LVH are
seldom observed
1.Tall R waves in both the right and left precordial
leads
2.Vertical heart position or right axis deviation in the
presence of criteria for LVH
3.Deep S waves in the left precordial leads in the
presence of ECG criteria for LVH
4.a shift in precordial transitional zone to the left in
the presence of LVH

71. Twelve-lead
ECG from a
40-year-old
man with both
systemicand
pulmonary
hypertension

72. ECG
•Electrophysiology
•Electrode placement
•ECG analysis
•Myocardial ischemia or infarct
•Enlargement of cardiac chambers
•Aritmia

74. Important aspects in understanding arrhythmias
1. The mechanism :
-problems of impulse formation(automaticity)
-problems of impulse conduction (block or
reentry)
2. The site of origin : -supraventricular
-ventricular
I

75. The Parts of Supraventricular and Ventricular Areas

76. (SAN)
(AVN)
(BB)
(HB)
RA
LA
V
V
SAN
LA
HB
BB
V
RA
AVN

77. MECHANISM ABNORMAL IMPULS FORMATION
1.Depressed automaticity
2.Enhanced automaticity
3.Triggered automaticity
4.Reentry

78. Depressed automaticity
Intrinsic rate
(bradycardia)

79. Enhanced automaticity
Atrial or junctional or ventricular
rate exceed sinus rate (tachycardia)

80. AVRT (Accesory
Pathway)
AVNRT
(nodal)
-typical
-atypical
RE-ENTRY

81. A B C
D E
Triggered activity

82. Aritmia
•Asystole
•Sinus bradycardia, sinus tachycardia
•Extrasystoles
•Atrioventricular (AV) block
•Tachycardias
-Supraventricular tachycardia (SVT)
-Ventricular tachycardia (VT)
-Atrial Flutter
-Atrial Fibrillation

83. Sinus tachycardia

84. The QRST complex
in ventricular
arrhythmia

85. The
apprearance of
the QRST
complex in
ventricular
extrasystole

86. Regular
appearance of
extrasystole

87. First-degree AV block. The PR interval is prolonged to 0.31 second

88. Second-degree AV block type I

89. Second-degree AV block type II.

90. Third-degree AV block occuring at level of AV node.

92. Paroxysmal supraventricular tachycardial (PSVT)

93. Ventricular tachycardia

94. Ventricular tachycardia and the diagnostic significance of ventricular
extrasystole

96. Coarse ventricular fibrillation

97. Fine ventricular fibrillation (“coarse” asystole)

98. 1X 2X
Complete compensatory pause
Junctional
interference

99. Intraventricular
interference
Fusion beat

101. Diagnostic criteria
for bundle branch blocks
Complete left bundle branch block
•QRS duration ≥ 120 msec
•Broad, notched R waves in lateral precordial
leads (V
5and V
6) and usully leads I and aV
l
•Small or absent initial r waves in right
precordial leads (V
1and V
2) followed by deep
S waves
•Absent septal q waves in left-sided leads

102. Diagnostic criteria
for bundle branch blocks
Complete right bundle branch block
•QRS duration ≥ 120 msec
•Broad, notched R waves (rsr’, rsR’, or rSR’)
pattern in right precordial leads (V
1and V
2)

104. Pocket Guide To Basic Dysrhythmias 3
rd
Ed . Robert J Huszar

105. Systemic conditions

106. Calcium
Hypercalcemia and hypocalcemia alter
the action potential duration
Hypercalcemia shortening QT interval
Hypocalcemia prolonged QT interval
Severe hypercalcemia (serum Ca > 15
mg/dL) decreased T wave amplitude, T
wave notching or inversion

107. Potassium