Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit

Irama (rythm): regular / irregular
Zona transisi V1-V6
Axis Elektrik: sumbu (derajat), posisi
(normal, left, right, indeterminate /
right superior / northwest)
Interval PR, QRS, dan QT dalam detik
Lain-lain

ECG basics
Voltage
Time
.1 mv
.5 mv
.04 seconds .20 seconds
Paper speed = 25mm / second
Heart Rate = number of R-waves in a 6 second strip divided by 10
= 1500 divided by the number of small boxes between consecutive R-waves
= large square estimation counts ( 300 - 150 - 100 - 75 - 60 - 50 - 43 )
paper
Berapa kecepatan kertas ECG bergerak: 25 mm/detik
1 mv beda potensial antara kedua elektroda
akan terekam setinggi berapa cm ?
1 cm
Berapa Frekuensinya:
Bila jarak R ke R dalam kotak besar (5 mm)
hitung 300/jarak R-R (150-100-75-60-50)
Bila jarak R ke R dalam mm 1500/jarak
R-R dlm mm
Bila tidak teratur hitung jumlah kompleks
QRS dlm rekaman sepanjang 15 cm (6 detik)
kemudian hasilnya dikalikan 10
Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit
Irama (rythm): regular / irregular
Zona transisi V1-V6
Axis Elektrik: sumbu (derajat), posisi
(normal, left, right, indeterminate /
right superior / northwest)
Interval PR, QRS, dan QT dalam detik
Lain-lain

Beats and Rhythms
normal ("sinus") beats
sinus node doesn't fire
leading to a period of asystole
p-wave has different shape
indicating it did not originate
in the sinus node, but
somewhere in the atria. It is
therefore an "atrial" beat
Atrial Escape Beat
Atrial and Junctional Ectopic Beats and Rhythms
Paroxysmal Atrial Tachycardia:
An atrial ectopic focus takes over pacing the heart
You suspect that it is "atrial" because you see the p-waves disappear
Rhythm may produce chest palpitations
If HR reaches about 300 beats per minute, may be compromised
The term paroxysmal (of sudden onset) is applied to these types of rhythms
Q
Paroxysmal Supraventricular Tachycardia:
What if the only rhythm you saw was the one below: is it or
It comes from above the ventricles because QRS's are normal looking
Since exact origin cannot be determined, it is termed "supraventricular"
atrial junctional?
there is no p wave, indicating that it did not
originate anywhere in the atria, but since the
QRS complex is still thin and normal looking, we
can conclude that the beat originated
somewhere near the AV junction. The beat is
therefore called a "junctional" beat
QRS is slightly different but still narrow,
indicating that conduction through the
ventricle is relatively normal
Junctional Escape Beat
there is no p wave, indicating that the beat did
not originate anywhere in the atria

actually a "retrograde p-wave may sometimes
be seen on the right hand side of beats that
originate in the ventricles, indicating that
depolarization has spread back up through the
atria from the ventricles
QRS is wide and much
different ("bizzare") looking
than the normal beats. This
indicates that the beat originated
somewhere in the ventricles
Ventricular Escape Beat
Ectopic Beats or Rhythms
beats or rhythms that originate in places other than the SA node

the ectopic focus may cause single beats or take over and pace
the heart, dictating its entire rhythm

they may or may not be dangerous depending on how they affect
the cardiac output
Ventricular Ectopic Beats
PVC's are Dangerous When:
Any of these dangererous phenomenon may preclude
a deadly rhythm (Ventrcular Tachycardia)
Three or more PVC's in a row (run of V-tach)
Any PVC in the setting of an acute MI
PVC's come from different foci ("multifocal" or "multiformed")
They are frequent (> 30% of complexes) or are increasing in frequency
The come close to or on top of a preceeding T-wave (R on T)
Premature Ventricular Contraction:
A ventricular ectopic focus discharges causing an early beat
Ectopic beat has no P-wave (maybe retrograde), and QRS complex is
"wide and bizzare"
QRS is wide because the spread of depolarization through the
ventricles is abnormal
In most cases, the heart circulates no blood because of an irregular
squeezing motion - PVC's sometimes described as "skipped beats"
Multifocal
PVC's
Compensatory pause
after the occurance of a PVC
R on T
phenomemon
Ventricular Ectopic Beats
PVC's are Dangerous When:
Any of these dangererous phenomenon may preclude
a deadly rhythm (Ventrcular Tachycardia)
Three or more PVC's in a row (run of V-tach)
Any PVC in the setting of an acute MI
PVC's come from different foci ("multifocal" or "multiformed")
They are frequent (> 30% of complexes) or are increasing in frequency
The come close to or on top of a preceeding T-wave (R on T)
Premature Ventricular Contraction:
A ventricular ectopic focus discharges causing an early beat
Ectopic beat has no P-wave (maybe retrograde), and QRS complex is
"wide and bizzare"
QRS is wide because the spread of depolarization through the
ventricles is abnormal
In most cases, the heart circulates no blood because of an irregular
squeezing motion - PVC's sometimes described as "skipped beats"
Multifocal
PVC's
Compensatory pause
after the occurance of a PVC
R on T
phenomemon
R on T
phenomemon
Ventricular Ectopic Beats and Rhythms
Ventricular Tachycardia:
Deadly rhythm - generates no person usually loses consciousness
Requires defibrillation....the sooner the greater chance of survival
May result from MI or a variety of other pre-existing conditions
Q -
Ventricular Fibrillation:
Deadly rhythm - generates no last gasp of a dying heart
Requires defibrillation - often not successful
Usually follows ventricular tachycardia
Q -
V-tach V-fib
R on T
phenomemon
Ventricular Ectopic Beats and Rhythms
Ventricular Tachycardia:
Deadly rhythm - generates no person usually loses consciousness
Requires defibrillation....the sooner the greater chance of survival
May result from MI or a variety of other pre-existing conditions
Q -
Ventricular Fibrillation:
Deadly rhythm - generates no last gasp of a dying heart
Requires defibrillation - often not successful
Usually follows ventricular tachycardia
Q -
V-tach V-fib
A Conceptual Model for Understanding Bundle Branch Blocks
1. Septum depolarization occurs first
inscribing an initial upward deflection
in V1 - V2 and a small downward
deflection in V5 - V6
2. Left ventricular depolarization occurs
next, inscribing a downward deflection
in V1 - V2 and an upward deflection
in V5 - V6. Since the right bundle
branch is blocked, depolarization
of the right ventricle is delayed.

3. Finally, depolarization spreads from the
left ventricle over to the right ventricle
and the right ventricle depolarizes. This
inscribes a second R-wave (R) in
V1 - V2, and sometimes, a slight
S-wave in V5 - V6.

1
3
1
2
3
V1 - V2
V5 - V6
2
1
1
2
V1 - V2
V5 - V6
2
1. Depolarization enters the right side of the
right ventricle first and simultaneously
depolarizes the septum from right to left.
Since the septum has more mass (and
thus contributes more electricity to the
depolarization vector), the dominant force
moves away from V1 - V2 and inscribes
a negative deflection in those leads.
Leads V5 - V6 show a positive deflection.

2
1
3
1
2
1
Right BBB
Left BBB
Wide
QRS
Complexes
Wide
QRS
Complexes
2. Having spread over from the right
ventricle, left ventricular depolarization
continues and generates the main
cardiac vector. This too is moving away
fromV1 - V2 and continues to inscribe
a negative complex. Likewise, the vector
proceeds toward V5 - V6 and continues
to inscribe a positive complex. A slight
notching of the R-wave may sometimes
be seen in V5 - V6.
A Conceptual Model for Understanding Bundle Branch Blocks
1. Septum depolarization occurs first
inscribing an initial upward deflection
in V1 - V2 and a small downward
deflection in V5 - V6
2. Left ventricular depolarization occurs
next, inscribing a downward deflection
in V1 - V2 and an upward deflection
in V5 - V6. Since the right bundle
branch is blocked, depolarization
of the right ventricle is delayed.

3. Finally, depolarization spreads from the
left ventricle over to the right ventricle
and the right ventricle depolarizes. This
inscribes a second R-wave (R) in
V1 - V2, and sometimes, a slight
S-wave in V5 - V6.

1
3
1
2
3
V1 - V2
V5 - V6
2
1
1
2
V1 - V2
V5 - V6
2
1. Depolarization enters the right side of the
right ventricle first and simultaneously
depolarizes the septum from right to left.
Since the septum has more mass (and
thus contributes more electricity to the
depolarization vector), the dominant force
moves away from V1 - V2 and inscribes
a negative deflection in those leads.
Leads V5 - V6 show a positive deflection.

2
1
3
1
2
1
Right BBB
Left BBB
Wide
QRS
Complexes
Wide
QRS
Complexes
2. Having spread over from the right
ventricle, left ventricular depolarization
continues and generates the main
cardiac vector. This too is moving away
fromV1 - V2 and continues to inscribe
a negative complex. Likewise, the vector
proceeds toward V5 - V6 and continues
to inscribe a positive complex. A slight
notching of the R-wave may sometimes
be seen in V5 - V6.
Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit
Irama (rythm): regular / irregular
Zona transisi V1-V6
Axis Elektrik: sumbu (derajat), posisi
(normal, left, right, indeterminate /
right superior / northwest)
Interval PR, QRS, dan QT dalam detik
Lain-laian

Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit
Irama (rythm): regular / irregular
Zona transisi V1-V6
Axis Elektrik: sumbu (derajat), posisi
(normal, left, right, indeterminate /
right superior / northwest)
Interval PR, QRS, dan QT dalam detik
Lain-lain

Na+
K+
Na+ K+
Na+ K+
Na+
K+
Na+
K+
++++
----
++++
Polarized
Cell
Repolarizing
Cell
( ) K+

efflux
Depolarized
Cell
Depolarizing
Cell
( influx ) Na+
Polarized
Cell
Wave of Depolarization or Propigation of Action Potential moving from left to right
The needle of this
recording electrode
inscribes a totally
complex
because the wave
of depolariztion is
moving from
it during the entire
time the strip is
depoarizing
negative
away
The needle of this
recording electrode
is
because half of the
time the wave of
depolarization is
moving it
while the other half
of the time it is
moving
from it
biphasic
towards
away
The needle of this
recording
electrode inscribes
a totally
complex because
the wave of
depolariztion is
moving it
during the entire
time the strip is
depoarizing
positive
towards
Depolarization Wave of a Strip of Nerve Cells
(or Myocardial Muscle Cells minus the depiction of Ca influx)
+ +
---- ---- ++++
The Concept of a "Lead"
+
-
G
Right arm (RA) negative, left arm (LA) positive, right
leg (RL) groundthis arrangement of electrodes
enables a "directional view" recording of the heart's
electrical potentials as they are sequentially activated
throughout the entire cardiac cycle
Electrocardiograph
Lead I
The Concept of a "Lead"
Lead I
+
-
The directional flow of electricity from Lead I can be
viewed as flowing from the RA toward the LA and
passing through the heart. Also, it is useful to imagine a
camera lens taking an "electrical picture" of the heart
with the lead as its line of sight
The Concept of a "Lead"
The Limb Leads
0
o

LEAD AVR
LEAD AVL
LEAD AVF
LEAD II
LEAD I
LEAD III
60
o

90
o

120
o

-30
o
-150
o

Each of the limb leads (I, II, III, AVR, AVL, AVF)
can be assigned an angle of clockwise or
counterclockwise rotation to describe its position in
the frontal plane
The Concept of a "Lead"
Leads I II III
+ -
By changing the arrangement of which arms or legs
are positive or negative, two other leads ( II & III ) can be
created and we have two more "pictures" of the heart's
electrical activity from different angles
RA
RA
LL
+
+
-
-
LA
LL
LA
LEAD II
LEAD I
LEAD III
Remember, the RL
is always the ground
The Concept of a "Lead"
Leads AVR AVL AVF
+
-
By combining certain limb leads into a central
terminal, which served as the negative electrode,
other leads could be formed to "fill in the gaps" in
terms of the angles of directional recording. These
leads required augmentation of voltage to be read and
are thus labeled.
RA
RA & RL
LL & LA
+
+
-
LL
RA & LA
LA
LEAD AVR
-
LEAD AVL
LEAD AVF
The Concept of a "Lead"
The Precordial Leads
V1 V2
V4
V5
V3
V6
Each of the precordial leads is unipolar (1 electrode
constitutes a lead) and is designed to view the electrical
activity of the heart in the horizontal or transverse
plane
aVR aVL
aVF
Hexaxial Array for Axis Determination
determination of the angle of the main
cardiac vector in the frontal plain
If lead I is mostly positive, the
axis must lie in the right half of
of the coordinate system
Lead I
Example 1
If lead AVF is mostly positive, the
axis must lie in the bottom half of
of the coordinate system
Lead AVF
Combining the two plots, we see
that the axis must lie in the bottom
right hand quadrant
I AVF
Once the quadrant has been
determined, find the most
equiphasic or smallest limb lead.
The axis will lie about 90
o
away
from this lead. Given that AVL is
the most equiphasic lead, the axis
here is at approximately 60
o
.
I AVF AVL
Since QRS complex in AVL is a
slightly more positive, the true
axis will lie a little closer to AVL
(the depolarization vector is
moving a little more towards AVL
than away from it). A better
estimate would be about 50
o
.
I AVF AVL
If lead I is mostly negative, the
axis must lie in the left half of
of the coordinate system
Lead I
Example 2
If lead AVF is mostly positive, the
axis must lie in the bottom half of
of the coordinate system
Lead AVF
Combining the two plots, we see
that the axis must lie in the bottom
left hand quadrant (Right Axis
Deviation)
I AVF
Once the quadrant has been
determined, find the most
equiphasic or smallest limb lead.
The axis will lie about 90
o
away
from this lead. Given that II is the
most equiphasic lead, the axis
here is at approximately 150
o
.
I AVF II
I AVF II
Since the QRS in II is a slightly
more negative, the true axis will
lie a little farther away from lead II
than just 90
o
(the depolarization
vector is moving a little more
away from lead II than toward it).
A better estimate would be 160
o
.
Precise calculation of the axis can be done using the
coordinate system to plot net voltages of perpendicular
leads, drawing a resultant rectangle, then connecting the
origin of the coordinate system with the opposite corner
of the rectangle. A protractor can then be used to
measure the deflection from 0. Consider the example:
Since Lead III is the most
equiphasic lead and it is
slightly more positive than
negative, this axis could be
estimated at about 40
o
.
Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit
Irama (rythm): regular / irregular
Zona transisi V1-V6
Axis Elektrik: sumbu (derajat), posisi
(normal, left, right, indeterminate /
right superior / northwest)
Interval PR, QRS, dan QT dalam detik
Lain-lain

ECG basics
Voltage
Time
.1 mv
.5 mv
.04 seconds .20 seconds
Paper speed = 25mm / second
Heart Rate = number of R-waves in a 6 second strip divided by 10
= 1500 divided by the number of small boxes between consecutive R-waves
= large square estimation counts ( 300 - 150 - 100 - 75 - 60 - 50 - 43 )
paper
Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit
Irama (rythm): regular / irregular
Zona transisi V1-V6
Axis Elektrik: sumbu (derajat), posisi
(normal, left, right, indeterminate /
right superior / northwest)
Interval PR, QRS, dan QT dalam detik
Lain-lain

ECG diagnosis