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ELEKTROKARDIOGRAFI

At a Glance

Originally composed by:

Adi Bestara


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Ada yang aneh ?


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Outline

Basics

Sadapan Ekg

Morfologi Ekg + Nilai normal Apa yang dapat kita kenali pada Ekg ?

Reading Ekg systematically


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Basic


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Sadapan EKG


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Morfologi EKG


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Nilai normal

On the board !


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QTc interval

Man < 0,39

Woman < 0,41> N

Normal Long QT

A prolonged QT can be very dangerous. It may predispose an individual to a type of

ventricular tachycardia called Torsades de Pointes. Causes include drugs, electrolyte

abnormalities, CNS disease, post-MI, and congenital heart disease.

QTc = QT int / R-R int

Qt Int N : < 0,46 or < 40% R-R int

Torsades de Pointes

Long QT


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Reading Ekg systematically

Kelayakan Baca : identitas, waktu, kalibrasi, kecepatan ,pemasangan sadapan

Voltage :E


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Axis


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AXIS: NORMAL EKG positive polarity(tall R) in


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AXIS: NORMAL EKG - positive polarity(tall R) ininferior and lateral leads with increasing positive

polarity (r-wave progression) across the

precordium V1-6

AVF

I

II

III

AVL

V

1

V

2

V

3

V

4

V

5

V

6

AVR


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In a normal patient the only leads that should

have negative polarity are AVR and V1-2

AVF

I

II

III

AVL

V

1

V

2

V

3

V

4

V

5

V

6

AVR

---To determine axis: Look at leads AVL and AVF


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Rate?

- Regular

- Irregular


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Apa yang dapat kita kenali pada

Ekg ? Cardiac Chamber Hypertrophy :

Atrium: RAH, LAH

Ventrikel: RVH, LVH/ Enlargement (Pressure & Volume)

Coronary Heart Disease :

IskemiaInjury Infark Stemi, Nstemi / Subendocard

Pre-excitation Syndromes :

WPW

LGL Others:

Electrolite

Drug

Carditis

Pace Maker


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Apa yang dapat kita kenali pada

Ekg ? Aritmia

Ectopic rhytm & Extra systole :

Atrial : AES, A Fib, A Flutter

Juctional : Juctional Rhytm, JES (atas, tengah, bawah)

Supraventricular : SVT

Ventricular : VES, VT, Vfib, Ventricular Asystole Block of Conduction :

SAN :

Sinus drop beat / paused, NSR, sinus Bradicardia, Sinus

Tachicardia, Sinus Aritmia

AVN :

1

2 : Mobitz I, Mobitz II

High Grade AV Block

3 / Complete Heart Block

Bundle Branch:

RBBB LBBB


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Cardiac Chamber

Hypertrophy :


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Depolarisasi atrium menghasilkan gelombang P.

Kelainan atrium : klainan gelombang P

Gelombang P normalnya lebar < 3 kotak kecil, tinggi < 2,5

kotak kecil


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HIPERTROFI ATRIUM KANAN

Gelombang P

> 2,5 mm

P pulmonale


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HIPERTROFI ATRIUM KIRI

NotchedP

> 0,12 P mitral


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- gel. R yg tinggi di V1 (yg biasanya - mjd +)

- Gel.S yg masih tetap adadiambil sadapan V3R,

klo QRS + kesimpulannya RVH


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HIPERTROFI VENTRIKEL KIRI

Sokolow + Lyon (Am Heart J , 1949;37:161)

S V1+ R V5 or V6 > 35 mm

Cornell criteria (Circ ulati on , 1987;3: 565-72)

SV3 + R avl > 28 mm in men

SV3 + R avl > 20 mm in women

Framingham criteria (Circu latio n,1990; 81:815-820)

R avl > 11mm, R V4-6 > 25mm

S V1-3 > 25 mm, S V1 or V2 +

R V5 or V6 > 35 mm, R I + S III > 25 mm


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Coronary Heart Disease/ PJK


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In order to perform work, the heart

needs oxygen and nutrients.

There are two main arteries:

Right coronary artery (RCA)

Left coronary artery (LCA).

The left coronary artery divides into:

Left anterior descending (LAD)

branchLeft circumflex branch(LCX)

The right coronary artery and the

branches of the left coronary artery

provide numerous smaller branches

which penetrate the heart muscle,

supplying it with blood. Both coronary arteries originatefrom the aorta and run along the

surface of the heart.

In the majority of human hearts,

coronary circulation follows a

predictable pattern.


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Left Main Coronary Artery

Branches quickly into the LAD & LCX.

Involves almost 2/3 of the heart muscle

Right Coronary Artery (RCA)

The RCA supplies blood to the bottom

(inferior) portion and part of the back

(posterior) portion of the left ventricle. The

posterior portion of the septum is also

supplied with blood from the RCA.SA Node 55%

AV Node 90%

AV Blocks

Left Anterior Descending Branch (LAD)

The LAD supplies blood to the front (anterior)portion of the left ventricle, apical including

most of the anterior portion of the septum

separating the ventricles.

Bundle Branch Block, AMI, CHF

Left Circumflux Branch (LCX)

The LCX supplies blood to the left side(lateral) portion and the back

(posterior) portion of the left ventricle.

SA Node 45%

AV Node 10%

Lateral & posterior MI


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Sino-Atrial (SA) Node:natural cardiac

pacemaker. The heartbeat starts here and

spreads throughout the network of

conduction fibers in the two atria causing

them to contract.

Normally, the heartbeat can only reach the

ventricles (the two lower chambers), after it

has passed through the atrioventricular (AV)

node.

Atrioventricular (AV) Node:slows down

the electrical signal so that the atrial

contractions can finish filling the ventricles

completely. The AV node also prevents the

lower chambers from beating too fast if theatria develops a fast rhythm

(tachyarrhythmia).

His Bundle, bundle branches, and

the Purkinje system :The electricalsignal finally passes to the ventricles

causing the ventricles to contract


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KELAINAN PADA EKG

1. ISKHEMIK : ST depresi : Up sloping

Down sloping// isoelektris

T inverted

2. INJURY : ST elevasi

3. NECROSIS : Q patologi

QS

DD. Kardiomiopathy, LVH, WPW

Phase : awal / hiperakut

akut (hari 1-7)recent (hari 7- 1bln)

lama / Old


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GAMBARAN ISCHEMIA PADA EKG

T inversi , biasanya sim etreis

ST depresi yang s pesif ik Hor izontal

Sagging (dow nslop ing) /menurun

ST depresi kurang spesi f ik (upsloping=naik)

INJURY : INFARK


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INJURY :

- otot jantung telah mulai

rusak dan dalam waktu

singkat akan mengalamiinfark.

- EKG : ST elevasi

INFARK

Otot jantung telah

mengalami

nekrosis/mati Gambaran khas : Q

patologis.

- Lebar > 1kotak kecil

- Dalam > 1 kotak kecil

- Dalam > 1/3 tinggi R


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GAMBARAN INJURY PADA EKGDisebut Injury pattern apabi la :

ST elevasi, yg spesifik (konvex ke atas/ cembung ke atas)

ST elevasi tidak spesifik (cekung ke atas)


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GAMBARAN NECROSIS PADA EKG

Disebut necrosis pattern apabila :

Gambaran Q wave yg lebar dan dalam

Q wave dianggap patologis apabila dalamnya > 1/3 dari tinggi R Dalamnya Qmenunjukkan tebalnya jaringan necrosis Tinggnya R menunjukkan sisa jaringan

myocard yg sehat Adanya QS menunjukkan necrosis seluruh myocard


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ISKEMIA

Gelombang T iskemik :

invertedsimetris


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NOMENKLATUR PENENTUAN


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NOMENKLATUR PENENTUAN

LOKASI PATOLOGI KELAINAN EKG LOKASI INFARK

V1 dan V2 Septum

V3 dan V4 Anterior

V1 s/d V4 Anteroseptal 1, AVL Lateral tinggi

1, AVL, V5-V6 Lateral

1,AVL, V3 s/d V6 Anterolateral

1, AVL, V1 s/d V6 Anterior Ektensif

11, 111, AVF Inferior

Gel R lebar pd V1. V2 Posterior


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Pre-Excitation

Syndromes-WPW & LGL Accessory pathway connects atria to the ventricles,

bypassing the AV node

Wolff-Parkinson-White: short PR (< 0.12 s), Delta

wave (slurred upstroke QRS), slight wide QRS>0.10s, and frequently a psuedoinfarction pattern in

the inferior leads and RBBB pattern.

Lown-Ganong-Levine: short PR (< 0.12 s), NO Delta

wave, normal QRS & episodes of tachydysrhythmias

LGLWPW


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AV Blocks


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BBB


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LEFT BUNDLE BRANCH


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BLOCKLeft bundle branch

block

QRS > 0.12 sec

Deep S in V 1-3 No q in V 5-6

Tall R and RsR in

lateral leads: I, AVL,& V 5-6

Axis LAD


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LEFT BUNDLE BRANCH BLOCK

RsR ( M shape ) di V6

QS or rS di lead V1

Durasi QRS complex >= 120 ms

Right Bundle Branch Block


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Right Bundle Branch Block

QRS > 0.12 sec

Predominantly

positive rSR in

V 1-3 Wide slurred S

in lead I, V5, V6


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RIGHT BUNDLE BRANCH BLOCK

rSR

SlurredS di lead I dan V6


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Arrhytmias

CAUSE OF CARDIAC ARRHYTHMIAS :

Disturbances in automaticity: bertambah cepat ataubertambah lambatnya suatu daerah otomatisitas. Misal di sinusnode, AV node, abnormal beats/ depolarisasi atrium, AV junction,ventrikel, VT, dll.

Disturbances in conduction: konduksi terlalu cepat (WPW)atau terlalu lambat (blok AV).

Combinations of altered automaticity and conduction.


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Aritmia

Ectopic rhytm & Extra systole :

Sinus : Sinus Arrtytmia Atrial : Atrial rhtytm, Atrial tachicardia, AES, A Fib, A Flutter

Juctional : Juctional Rhytm, JES, Junctional tachicardia, Junctional

bradicardia : (atas, tengah, bawah)

Supraventricular : SVT

Ventricular : Idioventricular rhytm, VES, VT, Vfib, Ventricular Asystole

Block of Conduction :

SAN :

Sinus drop beat / paused, NSR, sinus Bradicardia, Sinus

Tachicardia, Sinus Aritmia

AVN :

1

2 : Mobitz I, Mobitz II

High Grade AV Block

3 / Complete Heart Block

Bundle Branch:

RBBB

LBBB


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S


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ATRIAL ARRHYTMIAS


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J ti l A t i


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Junctional Arrytmias


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V t i l A h t i


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Ventricular Arrhytmias


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A tifi i l P k


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Artificial Pacemaker


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Artifact


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Ya.Sinus MANISAlur


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SINUS?

Ya.Sinus TAPIdengan PAC/PVC, AV Block, dll

Bukan.

QRS sempit

atau

Lebar/Aneh?

Sempit

-AF : P tak jelas, tdk teratur

-A. Flutter : gigi gergaji

-SVT : P tak jelas, teratur, biasanyaHR>150

-AV/Junctional Rhythm

Lebar/aneh

-VT : P tak jelas, teratur

-VF : Undulasi tak teratur

-Ventricular Rhythm

Alur

Singkat

ARITMIA

Note : Tidak berlaku untuk kondisi RBBB/LBBB maupun kondisi khusus lain

Irama Sinus dengan


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Ada QRS yang datang

sebelum waktunya

(premature), QRS-nya

Irama Sinus dengan

Premature Ventricular

Contraction (PVC)

Irama Sinus dengan

Premature Atrial

Contraction (PAC)


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Atrial FibrilasiRR interval tidak teratur, tak

tampak gelombang P yang

jelas.

Atrial Flutter :gambaran khas gigi gergaji

Supra Ventricular Takikardi


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p

P TIDAK JELAS,

QRS Sempit, TERATUR,

HR > 150 x/menit

Ventricular Takikardi Ventrikel Fibrillasi


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P tidak Jelas,

QRS LEBAR,Teratur

HR > 100 x/mnt

Undulasi-undulasi yang

tidak teratur dan cepat,

diikuti henti ventrikel

( asistol ventrikuler )

tak ada kompleks QRS

SUMMARY


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SUMMARYRateRhythm Axis Intervals Hypertrophy Infarct

A 16 yo young man ran into a guardrail while riding a motorcycle.

In the ED he is comatose and dyspneic. This is his ECG.


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SUMMARY


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SUMMARYRate Rhythm Axis Intervals Hypertrophy Infarct

What is the rate? Approx. 132 bpm (22 R waves x 6)

SUMMARY


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SUMMARYRateRhythmAxis Intervals Hypertrophy Infarct

What is the rhythm? Sinus tachycardia

SUMMARY


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SUMMARYRateRhythmAxis Intervals Hypertrophy Infarct

What is the QRS axis? Right axis deviation (- in I, + in II)

SUMMARY


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SUMMARYRateRhythm AxisIntervalsHypertrophy Infarct

What are the PR, QRS

and QT intervals?PR = 0.12 s, QRS = 0.08 s, QTc = 0.482 s

SUMMARY


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SUMMARYRateRhythm AxisIntervals HypertrophyInfarct

Is there evidence of

atrial enlargement?No (no peaked, notched or negatively

deflected P waves)

SUMMARY


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SUMMARYRateRhythm AxisIntervals HypertrophyInfarct

Is there evidence of

ventricular hypertrophy?No (no tall R waves in V1/V2 or V5/V6)

SUMMARY


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SUMMARYRateRhythm AxisIntervals Hypertrophy Infarct

Infarct: Are there abnormal

Q waves?Yes! In leads V1-V6 and I, avL

Any

Any

Any

20

30

30

30

3030

30

R40

R50

SUMMARY


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Infarct: Is the ST elevation

or depression?Yes! Elevation in V2-V6, I and avL.

Depression in II, III and avF.

SUMMARY


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Infarct: Are there T wave

changes?No

SUMMARY


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SUMMARYRate Rhythm Axis Intervals Hypertrophy Infarct

ECG analysis: Sinus tachycardia at 132 bpm, right axis deviation,

long QT, and evidence of ST elevation infarction in the

anterolateral leads (V1-V6, I, avL) with reciprocal changes (the

ST depression) in the inferior leads (II, III, avF).

This young man suffered anacute myocardial infarction after

blunt trauma. An

echocardiogram showed

anteroseptal akinesia in the left

ventricle with severely

depressed LV function(EF=28%). An angiogram

showed total occlusion in the

proximal LAD with collaterals

from the RCA and LCX.


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Terima Kasih


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