EKG

Rachmat Kamaluddin

Intrinsic Conducting System
‡ Sinoatrial node
± Electrical pace maker

‡ Atrioventricular node
± Receives impulses originating from SA node

‡ Bundle of His
± Electrical link between atria and ventricles

‡ Purkinje fibres
± Distribute impulses to ventricles

Sistem Konduksi Jantung

SANDAPAN UNIPOLER PREKORDIAL V1 parasternal Ka. ICS 4 V2 parasternal Ki. V3 dan V4 gambar an septum interventrikel sedang V5 dan V6 merupakan gambaran ventikel kiri . ICS 4 V3 titik tengan V2 dan V4 V4 grs mid klavikula ICS 5 V5 grs aksila depan ICS 5 V6 grs aksila tengah ICS 5 Pada posisi normal V1 dan V2 gambaran epikardial kanan.

III (elektroda positif di LA dan LL.SANDAPAN BIPOLER SANDAPAN STANDART Bipolar standart limb lead untuk beda potensial anara 2 tempat Lead I. LL positif dan pada L III LA negatif dan LL positif) RL dihubungkan pada arde(ground) Segitiga Einthoven Rumus Einthoven II = I + III . II. LA positif. pada L I RA negatif. pada L II RA negatif.

30o aVF = sudut + 90o Sudut + searah jam Sudut berlawanan jam .SISTEM SUMBU FRONTAL I = garis mendatar 0o II = sudut + 60o dg I III = sudut +120o dg I aVR = sudut 150o aVL = sudut .

Kalibrasi Standar Defleksi 10 mm=1 mV. kecepatan kertas 25 mm/detik.04 detik. 1 mm=0.20 detik. 5 mm=0.40 detik . 10 mm=0.

Bacalah EKG berikut dengan lengkap.  Irama  Frekwensi  Aksis       : sinus / tidak sinus : kali / menit : normal / LAD ( bergeser ke kiri ) / RAD ( bergeser ke kanan ) / Superior Gelombang P : normal / LAE ( P mitral ) / RAE ( P Pulmonal ) Interval PR : normal / memendek / memanjang Lebar QRS : normal / melebar Morfologi QRS : normal / LVH / RVH / RBBB / LBBB / WPW Segmen ST : normal / depresi / elevasi ( ukuran dan letak ) Gelombang T : normal / negatif ( letak ) Kesan .

12 seconds ) . 12 0.Normal Sinus Rhythm Rhythm : Regular Rate : 60 100 P wave : Normal in configuration. precede each QRS PR : Normal ( 0.20 seconds ) QRS : Normal ( less than 0.

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AXIS .

Right Axis Deviation Left Axis Deviation LAD RAD .

NILAI NORMAL DEVIASI FRONTAL Normal Axis No Axis deviation Abnormal Left Axis Deviation : .30o sd +110o : +30o sd + 90o : .90o .30o sd -90o Abnormal Right Axis Deviation : +110o sd + 180o atau Superior Axis : +110o sd 90o : + 180o sd .

PENENTUAN SUMBU LISTRIK JANTUNG 1 Pilih 2 sandapan yang saling tegak lurus misal I dan aVF Tentukan jumlah aljabar dari defleksi dan gambarkan vektor QRS pada sumbu X untuk L I dan pada sumbu Y untuk aVF Kemudian tentukan resultante kedua vektor Sudut deviasi = arc tg(7/5) = 54.46 .

Pada contoh aVL dengan jumlah aljabar = nol. sumbu listrik tegak lurus pada aVL.PENENTUAN SUMBU LISTRIK JANTUNG 2 Pilih sandapan dengan jumlah aljabar = nol (defleksi positif = negatif) Sumbu jantung (QRS) tegak lurus pada sandapan itu. besar vektor tergantung pada jumlah aljabar vektor L I .

angka 0.8 Resultante = . lebar 1 mm luas = 0.PENENTUAN SUMBU LISTRIK JANTUNG 3 Cara lain yang lebih tepat ialah menghitung luas area di bawah defleksi bukan hanya dari tinggi defleksi Dari contoh : Untuk L I R= 4 mm.5x4x1 tertulis 4.5x4x2 = .lebar 2 mm luas = 0.4 Untuk aVF resultante = .4 Sudut = arc tg (-4/-4) = .4 mm.45 atau + 135 .5 di abaikan S =.

L A D ‡ LVH ‡ Inferior wall MCI ‡ ‡ ‡ ‡ ‡ R A D ‡ RVH ‡ Lateral wall MCI ‡ ‡ ‡ ‡ ‡ Chronic Lung Disease Hyperkalemia LAFB LBBB ASD ostium primum Chronic lung disease Dextrocardia Emboli paru LPFB ASD ostium secundum .

Dengan mengukur beda potensial dari ke enam sumbu tadi kita dapat seolah olah memotret jantung dari berbagai sisi frontal. Dari enam sumbu tadi kita kira kira dapat melihat keadaan jantung dari : Sisi Lateral Kiri Sisi Inferior : aVL dan I : II. aVF dan III Sisi Lateral Kanan : aVR (biasanya diabaikan) .

300 Heart Rate = kotak besar 1500 Heart Rate = kotak kecil Dengan rumus ini heart rate dapat dihitung secara tepat dengan menggunakan kakulator .

3 mvolt Lebar : < 0.GELOMBANG P Gambaran yang ditimbulkan oleh depolarisasi atrium Normal Tinggi : < 0.12 detik Selalu positif di L II Selalu negatif di aVR Kepentingan Mengetahui kelainan di Atrium ´Gelombang P Mitralµ ´ Gelombang P Pulmonal ´ .

20 detik .Interval PR Diukur dari permulaan P s/d permulaan QRS Normal : 0.0.12 .

20 detik waspada adanya AV Block 2nd atau 3rd / complete heart block). .Mengapa kita harus menghitung PR interval? ‡ PR interval mengukur waktu antara mulainya depolarisasi atrium sampai mulainya depolarisasi ventrikel. ‡ PR interval > 0. (1st.

GELOMBANG QRS Gambaran yang ditimbulkan oleh depolarisasi ventrikel Normal : Lebar : 0.06 .12 detik Tinggi : Tergantung lead Normal gelombang Q Lebar : < 0.04 detik Dalam : < 1/3 tinggi R .0.

Gelombang Komplek QRS .

Mengapa kita harus menghitung QT interval ? QT interval mengukur waktu yang diperlukan ventrikel dalam melaksanakan systole (depolarisasi dan repolarisasi ventrikel) QT int QT= O.4 RR atau QTc = RR < 0.40-0.44 Memanjang ‡ ‡ ‡ ‡ ‡ Subarachnoid bleeding Ischaemia / MCI Quinidine. Procainamide Hypokalemia Hypocalcemia Memendek (?) ‡ ‡ Digitalis dosis terapetik Hypercalcemia .

HIPERTROFI .

Left Ventricular Hypertrophy ‡ ‡ ‡ ‡ R V5/V6 + S V1/V2 > 35 mm R V5 > 27 mm R V6 > 18 mm R V6 > RV5 .

Left Ventricular Hypertrophy ‡ ‡ ‡ ‡ R aVL > 13 mm R I > 14 mm R I + S III > 25 mm ( R aVF > 21 mm ) .

Right Ventricular Hypertrophy ‡ V1 : R > S ‡ V6 : S > R .

Right Ventricular Hypertrophy ‡ QRS axis > 100o ‡ RI < SI .

Right Atrial Enlargement (RAH) P Normal P Pulmonal .

Left Atrial Enlargement (LAH) P Normal P Mitral .

INFARK .ISCHEMIA .

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Non-Iskemik Jika terjadi pengurangan aliran darah dalam arteri koroner maka akan terjadi iskemia myocardium yang ditandai dengan adanya inverted T yang simetris. .

Elevasi ST segmen saja sudah menunjukkan adanya infark myocard. .Jika aliran darah sampai terhenti dan berlangsung lama maka ischemia akan ber-kembang menjadi infark atau kematian jaringan yang ditandai dengan timbulnya elevasi ST segmen.

Q wave tanpa persyaratan ini dianggap sebagai q wave yang tidak berhubungan dengan proses MCI.Jika jika telah terjadi nekrosis jaringan maka akan muncul Q wave yang khas yaitu Q wave dengan lebar 1 mm dan dengan dalam 1/3 QRS complex. .

ST depresi dan perubahan gelombang T ‡ ST depresi dianggap bermakna bila > 1 mm di bawah garis dasar PT di titik J ‡ Titik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen ST Bentuk segmen ST : ‡ up-sloping ( tidak spesifik ) ‡ horizontal ( lebih spesifik untuk iskemia ) ‡ down-sloping ( paling terpercaya untuk iskemia ) Perubahan gelombang T pada iskemia kurang begitu spesifik Gelombang T hiperakut kadang2 merupakan satu-satunya perubahan EKG yang terlihat .

III dan avF menghadap dinding inferior ventrikel kiri .Anatomi Koroner dan EKG 12 sandapan ‡ Sandapan V1 dan V2 menghadap septal area ventrikel kiri ‡ Sandapan V3 dan V4 menghadap dinding anterior ventrikel kiri ‡ Sandapan V5 dan V6 ( ditambah I dan avL ) menghadap dinding lateral ventrikel kiri ‡ Sandapan II.

V1 V4

anterior

Occlusion of diagonal branch ( arrow )

ST elevation in I and aVL

large Anterior Infarction .ECG.

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Proximal large RCA occlusion ST elevation in leads II. aVF. V5. and V6 with precordial ST depression . III.

ARITMIA .

MEKANISME ‡ Gangguan automatisasi (impuls keluar sblm impuls normal) ‡ Triggered activity (Impuls muncul saat repolarisasi) ‡ Re-Entry (impuls menstimulasi jaringan yg sdh terdepolarisasi) .

atrial flutter. VF. SVT dgn BBB ‡ Sempit ± Reguler : SVT. atrial flutter ± Ireguler : AF. SA) ‡ Takikardia (takiaritmia) ± QRS ‡ Lebar : VT. S3. atrial flutter ± Atrial ‡ AF. PAC ± Ventrikel ‡ VT. syncope ± Gangguan konduksi (Blok AV. PVC .‡ Bradikardia (bradiaritmia) ± Gangguan pmbentukan impuls : SA.

DISRITMIA ATRIAL .

Premature atrial complex .

Supraventrikel takikardi .

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DISRITMIA VENTRIKEL .

Premature ventricular complex .

PVC multiform .

PVC trigemini .

Triplet PVC .

Accelerated idioventricular tachycardia .

COARSE TYPE .

and then open the file again. you may have to delete the image and then insert it again. or the image may have been corrupted. If the red x still appears.The image cannot be displayed. Restart your computer. Your computer may not have enough memory to open the image. MONOMORFIK > 30s = sustained VT < 30s = non sustained VT .

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Lethal arrythimias ‡ ‡ ‡ ‡ VT VF PEA (pulseless electricity activity) asistol .

IRAMA JUNCTIONAL .

Junctional escape beats .

Takikardia junctional/ irama junctional .

GANGGUAN KONDUKSI .

one P wave to each QRS PR : Prolonged ( greater than 0.First-degree AV block Rhythm : Regular Rate : Usually normal P wave : Sinus P wave present.20 seconds ) QRS : Normal .

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Mobitz I Rhythm : Irregular Rate : Usually slow but can be normal P wave : Sinus P wave present.Second -degree AV block. some not followed by QRS complexes PR : Progressively lengthens QRS : Normal .

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wide if block involves bundle branches . can be irreguler if conduction ratios vary Rate : Usually slow P wave : Two. three. or four P waves before each QRS PR : PR interval of beat with QRS is constant.Second-degree AV block. PR interval may be normal or prolonged QRS : Normal if block in His bundle. Mobitz II Rhythm : Regular usually.

Mobitz II .

bear no relationship to QRS. wide if block involves bundle branches . 30 40 if block involves bundle branches P wave : Sinus P wave present.Third-degree AV block Rhythm : Regular Rate : 40 60 if block in His bundle. can be found hidden in QRS complexes and T waves PR : Varies greatly QRS : Normal if block in His bundle.

Your computer may not have enough memory to open the image. or the image may have been corrupted. Restart your computer. If the red x still appears. you may have to delete the image and then insert it again.The image cannot be displayed. and then open the file again. .

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04 .0.

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Right Bundle Branch Block .

Left Bundle Branch Block .

LAFB/LPFB ‡ LAFB ± LAD (without LVH) ‡ LPFB ± RAD (without RVH) Both no ST or T changes and QRS normal .

Left anterior fascicular block .

Left posterior fascicular block .

ARITMIA KONDISI LAIN .

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Wolff-Parkinson-White syndrome .

Wolff-Parkinson-White syndrome .

Torsade de pointes .

Sick sinus syndrome .

Brugada syndrome .

hyperkalemia .

hypokalemia .

or the image may have been corrupted. Your computer may not have enough memory to open the image. Restart your computer. and then open the file again. you may have to delete the image and then insert it again. If the red x still appears. .Emboli pulmonal (S1Q3T3) The image cannot be displayed.

Acute Anterior Myocardial Infarction

Acute Anterolateral Myocardial Infarction

Acute Lateral Myocardial Infarction

Atrial Fibrilasi .

Acute Inferoposterior Myocardial Infarction .

Restart your computer. If the red x still appears. Your computer may not have enough memory to open the image. or the image may have been corrupted. Incomplete Right Bundle Branch Block .The image cannot be displayed. you may have to delete the image and then insert it again. and then open the file again.

Right Bundle Branch Block .

Second degree AV Block -Weckenbach .

First degree AV Block .

Third degree AV Block .

Second degree AV Block ±Mobitz II .

Diagnosis ? The image cannot be displayed. and then open the file again. depresi di: . Kesimpulan: Twave: inverted/ flat / bifasik di: QRS axis: normal/LAD/RAD/ERAD ST segmen elevasi di: . you may have to delete the image and then insert it again. or the image may have been corrupted. If the red x still appears. Your computer may not have enough memory to open the image. PR interval: QRS duration: SV5+SVI: mm. P wave : normal/ mitral/pulmonal. HR: . Restart your computer.

16´ QRS axis: normal. Restart your computer. biphasic pada V1. Flat (-). PR interval: 0. or the image may have been corrupted.08´ Twave: inverted aVR. Kesimpulan: Sinus bradycardia . ST segmen elevasi (-). HR: 50/m. Your computer may not have enough memory to open the image.Diagnosis ? The image cannot be displayed. and then open the file again. If the red x still appears. depressi (-) SV5+SVI: 19 mm. you may have to delete the image and then insert it again. QRS duration: 0. P wave : normal.

Diagnosis EKG ? HR: QRS axis: QRS duration: P wave: PR int. inverted di: .: R V5 + S V1: Kesimpulan: . ST segmen. elevasi di: depressi di: T wave: flat di. bifasik di: .

Kesimpulan: Lateral wall ischaemia & LVH . aVL. R V5 + S V1: 39 mm.Diagnosis EKG ? HR:68/m. ST segmen. Inverted pada I. QRS axis: normal.: 0.5 kotak kecil).16 . P wave: normal. PR int. V5 dan V6. QRS duration: 0.06 (1.

Your computer may not have enough memory to open the image. you may have to delete the image and then insert it again. Restart your computer.Diagnosis ? The image cannot be displayed. QRS rate : P wave: n/m/p PR int: axis: (n) / ab (n) QRS duration: (n) / ab (n). and then open the file again. or the image may have been corrupted. Q wave (+) / (-) di: ST elevasi : ST depresi : Diagnosis: . If the red x still appears.

Q wave (+) di aVL. or the image may have been corrupted. aVL.The image cannot be displayed. V2 V4 ST elevasi : I. QRS duration: normal. PR int: 0. III. and then open the file again. V2-v6 ST depresi : II. you may have to delete the image and then insert it again.16 detik. QRS rate : 88/m P wave: normal. aVF Diagnosis: Acute extensive anterior MCI . axis: normal. Your computer may not have enough memory to open the image. Restart your computer. If the red x still appears.

Hiperkalemia .

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