BELAJAR EKG YUK

Kebanyakan para perawat kita ahli dalam pemasangan EKG, tapi sebagian besar dari mereka tidak tahu apa itu EKG, cara membaca dan bahkan lokasi pemasangan yang benar. Berikut sedikit tutorial yang dapat di berikan. Hal ini disajikan dalam bahasa sederhana, sehingga mudah dipahami, untuk mempelajari lebih mendalam silahkan baca buku dan jangan tidak semangat untuk membaca. Modul lengkap EKG dalam English ada di terakhir halaman, silahkan di Download Gratis!. ". #endahuluan Elektrokardiogra$i adalah ilmu yang mempelajari akti$itas listrik jantung. %edangkan Elektrokardiogram EKG! adalah suatu gra$ik yang menggambarkan rekaman listrik jantung. Kegiatan listrik jantung dalam tubuh dapat dicatat dan direkam melalui elektroda&elektroda yang dipasang pada permukaan tubuh. Prinsip utama belajar EKG adalah mengetahui anatomi fisiologi jantung, dan persyarafan jantung sehingga pada saat belajar EKG sudah dapat membayangkan keadaan jantung. '. (natomi )isiologi *antung *antung terdiri dari + bagian yaitu atrium de,tra - sinistra! - .entrikel de,tra - sinistra!. Jantung mempunyai aktifitas listrik meliputi: Sino Atrio odus, Atrio !entrikuler odus, "erkas #is dan Serabut Purkinje, inilah point penting dalam pemba$aan EKG. /ihat gambar dibawah bagaimana akti$itas listrik jantung bekerja0

Gambar " +. EKG 1ormal

Bagaimana sih gambaran EKG normal 2

E3G 3omponent # 6a.e #9 :nter.al ;9%

4ime sec! 7."7 7."' & 7.'7 7."7

%mall %5uares up to '.8 '.8&8.7 ".8&'.8

#ada dasarnya EKG terdiri dari banyak gelombang, yang tiap gelombang mewakilkan satu denyut jantung satu kali akti$itas listrik jantung!. /ihat gambar satu gelombang EKG0

Gambar ' Dalam satu gelombang EKG terdiri ada yang disebut titik (lihat gambar), interval dan segmen. %itik terdiri dari titik P, &, ', S, % dan ( )kadang sebagian referensi tidak menampilkan titik (* sedangkan +nter,al terdiri dari P' inter,al, &'S inter,al dan &% inter,al dan Segmen terdiri dari P' segmen, dan S% segmen. #enjelasan gambar 0 & 4itik # mempunyai arti bahwa terjadinya denyutan<kontraksi pada atrium jantung de,tra sinistra!

& 4itik ;, 9 dan % mempunyai arti bahwa terjadinya denyutan<kontraksi listrik! pada .entrikel jantung de,tra - sinistra! = %edangkan titik 4 berarti relaksasi pada .entikel jantung. Mungkin terlihat mudah belajar EKG dengan satu gelombang, coba lihat gambar di bawah0 Gambar > EKG "' sadapan normal

Gambar > adalah gambar EKG sebenarnya, melihat sepintas mungkin ga kebayang bisa membacanya. Kok ada tulisan :, ::, a?9 dan lain&lain 2 :, ::, a?9 dan lain&lain disebut dengan sadapan atau lead. (kti$itas listrik jantung hanya dapat direkam dari luar jantung yaitu tubuh!, ga mungkin langsung di tempelin ke jantung toh 2 makanya perlu lokasi&lokasi tertentu untuk penyadapan tersebut. #ada prinsipnya ada > jenis sadapan yaitu #rekordial dada!, Bipolar Kaki dan 4angan ' elektroda! dan @nipolar Kaki dan 4angan > elektroda!. 8. %andapan lokasi penempatan! EKG @ntuk memperoleh rekaman EKG dipasang elektroda&elektroda di kulit pada tempat&tempat tertentu. /okasi penempatan elektroda sangat penting diperhatikan, karena penempatan yang salah akan menghasilkan pencatatan yang berbeda.

Gambar + #emasangan /ead EKG 4erdapat > jenis sandapan lead! pada EKG, yaitu 0 a. %adapan #rekordial Merupakan sadapan ?", ?', ?>, ?+, ?8, dan ?A yang ditempatkan secara langsung di dada. & %adapan ?" ditempatkan di ruang intercostal :? di kanan sternum. & %adapan ?' ditempatkan di ruang intercostal :? di kiri sternum. & %adapan ?> ditempatkan di antara sadapan ?' dan ?+. & %adapan ?+ ditempatkan di ruang intercostal ? di linea sekalipun detak apeks berpindah!. & %adapan ?8 ditempatkan secara mendatar dengan ?+ di linea a,illaris anterior. & %adapan ?A ditempatkan secara mendatar dengan ?+ dan ?8 di linea mida,illaris. b. %andapan Bipolar, Merekam perbedaan potensial dari ' elektroda, yang ditandai dengan angka romawi :, :: dan ::: a! %andapan : 0 merekam beda potensial antara tangan kanan 9(! yang bermuatan negati$ &! tangan kiri bermuatan positi$ B!. b! %andapan :: 0 merekam beda potensial antara tangan kanan &! dengan kaki kiri /)! yang bermuatan B! c! %andapan ::: 0 merekam beda potensial antara tangan kiri /(! yang bermuatan &! dan kaki kiri B!. b. %andapan @nipolar a! %andapan @nipolar Ekstremitas C a?9 0 merekam potensial listrik pada tangan kanan 9(! yang bermuatan B!, dan elektroda &! gabungan tangan kiri dan kaki kiri membentuk elektroda indi$iren. C a?/ 0 merekam potensial listrik pada tangan kiri /(! yang bermuatan B!, dan muatan &! gabungan tangan kanan dan kaki kiri membentuk elektroda indi$iren.

C a?) 0 merekam potensial listrik pada kaki kiri /)! yang bermuatan B! dan elektroda &! dari gabungan tangan kanan dan kaki kiri membentuk elektroda indi$iren.

1. NORMAL SINUS RHYTHM

1ormal sinus rhythm not only indicate that the rhythm is normally generated by the sinus node and tra.eling in a normal fashion in the heart, but also that the heart rate, i.e. the rate at which the sinus node is generating impulses is within normal limits. 4here is no one normal heart rate, but this .aries by age. :t is normal $or a newborn to ha.e a heart rate up to "87 beats per minute, while a child o$ $i.e years o$ age may ha.e a heart rate o$ "77 beats per minute. 4he adultDs heart rate is e.en slower at about A7&E7 beats per minute. ". 6hat is the rate and is it regular2 4he heart rate is normal and the rhythm is regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is usually narrow, but it can be wide i$ there is a conduction delay. 4he ;9% comple, is normally less than 7."7 seconds. ;9% duration greater than 7."' seconds is prolonged. 9hythms with a narrow ;9% are almost always supra& .entricular. 6ide ;9% rhythms may originate in the .entricle or be supra.entricular with abnormal conduction.

>. (re # wa.es present and upright2 # wa.es are present and upright. +. How are the # wa.es related to the ;9% comple,2 4here is a $i,ed, "&to&" relationship between the # wa.es and ;9% comple,es. 4he impulse in normal sinus rhythm arises in the %( node and spreads through the atria to the (? node. 4he impulse then tra.els down the conducting system and spreads through the .entricles. 4he # wa.e is $ollowed by a narrow ;9% comple,. 4he ;9% comple, can be wide i$ there is aberrant conduction.

2. SINUS TACHYCARDIA

%inus tachycardia0 a $ast heart rate may occur with a normal heart rhythm, this is called sinus tachycardia. 4his means that the impulse generating the heart beats are normal, but they are occurring at a $aster pace than normal. 4his is termed sinus tachycardia and is seen normally with e,ercise or with e,citement. %inus tachycardia is usually a response to physiological stress such as e er!ise or an iet", and it may be the result o$ an abnormally heightened sympathetic tone. (bnormal pathological causes include fever, h"#otension, anemia, th"roto i!osis, h"#ovolemia, #$lmonar" emboli, m"o!ardial is!hemia, and sho!k. %i!otine, !affeine, al!ohol, and some medi!ations sympathetic agonists or parasympatholytic agents! are $re5uently the underlying cause o$ sinus tachycardia. 4he ;9% comple,es are preceded by # wa.es o$ normal morphology, duration, and a,is. %inus tachycardia alone does not re5uire any treatment, but the underlying cause should be determined ". 6hat is the rate and is it regular2 4he heart rate is $ast and the rhythm is regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is usually narrow, but it can be

wide i$ there is a conduction delay. >. (re # wa.es present and upright2 # wa.es are present and upright. +. How are the # wa.es related to the ;9% comple,2 4here is a $i,ed, "&to&" relationship between the # wa.es and ;9% comple,es. 4he impulse in normal sinus rhythm arises in the %( node and spreads through the atria to the (? node. 4he impulse then tra.els down the conducting system and spreads through the .entricles. 4he # wa.e is $ollowed by a narrow ;9% comple,, unless there is aberrant conduction. :n sinus tachycardia, the heart rate is greater than "77 beats per minute. %inus tachycardia can be di$$icult to distinguish $rom atrial tachycardia. Heart rate greater than "87 beats per minute and an abnormal # wa.e $a.or atrial tachycardia. # wa.es may be superimposed on 4 wa.es or @ wa.es and be di$$icult to recogniFe.

3. SINUS BRADICARDIA

%inus bradycardia0 4he heart may slow down, yet maintain the normal pattern o$ rhythm sinus!, this is known as sinus bradycardia. :t usually is benign and may be caused by medi!ations s$!h as beta blo!kers& 4his in a healthy athletic person may be DnormalD, but other causes may be due to increased vagal tone from dr$g ab$se, h"#ogl"!aemia and brain in'$r" with in!rease intra!ranial #ress$re (()*) as e,amples ". 6hat is the rate and is it regular2

4he heart rate is slow and the rhythm is regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is usually narrow, but it can be wide i$ there is a conduction delay. >. (re # wa.es present and upright2 # wa.es are present and upright. +. How are the # wa.es related to the ;9% comple,2 4here is a $i,ed, "&to&" relationship between the # wa.es and ;9% comple,es. 4he impulse in sinus rhythm arises in the %( node and spreads through the atria to the (? node. 4he impulse then tra.els down the conducting system and spreads through the .entricles. 4he # wa.e is $ollowed by a narrow ;9% comple,, unless there is aberrant conduction. :n sinus bradycardia, the heart rate is less than A7 beats per minute 4. ATRIAL TACHYCARDIA

(trial tachycardia can occur in the #resen!e of !ardia! or #$lmonar" disease at a rate .arying $rom "+7 to '+7 bpm. #&wa.e morphology is generally di$$erent $rom that during %9, but the #=;9% relationship remains "0". %ome atrial tachycardias are catecholamine sensiti.eG in this case, a H&blocker is appropriate therapy. 3urati.e radio$re5uency ablation o$ atrial tachycardia is e$$ecti.e in I7J o$ cases. )or re$ractory cases, creation o$ complete heart block by radio$re5uency catheter ablation with implantation o$ a permanent dual& chamber pacemaker pro.ides control o$ the rate and a.oids drug to,icity. ". 6hat is the rate and is it regular2

4he heart rate is $ast and regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is usually narrow but it can be wide i$ there is aberrant conduction. >. (re # wa.es present and upright2 # wa.es may be hidden in 4 wa.es. :$ .isible, the # wa.es are upright. +. How are the # wa.es related to the ;9% comple,2 4here is a $i,ed, "&to&" relationship between the # wa.es and ;9% comple,es or '&to&" block may be present. 4he impulse in atrial tachycardia arises in the atria and spreads to the (? node. 4he impulse tra.els down the conducting system and spreads through the .entricles resulting in a narrow ;9% comple,. :$ aberrant conduction is present, the ;9% will be wide. 4he heart rate in atrial tachycardia is "87 to '87 beats per minute. ( ;9% $ollows e.ery # wa.e or '&to&" block may occur. 4he # wa.e may be superimposed on the 4 wa.e and be di$$icult to identi$y. (trial tachycardia can be di$$icult to distinguish $rom sinus tachycardia. Heart rate greater than "87 beats per minute and an abnormal # wa.e $a.or atrial tachycardia. :t can be di$$icult to distinguish .entricular tachycardia $rom supra.entricular tachycardia with aberrant conduction. 4he presence o$ # wa.es or irregularity in rate $a.or supra.entricular tachycardia. 6hen in doubt assume the rhythm is .entricular tachycardia.

5. ATRIAL FIBRILATION

4he clinical mani$estations o$ () range $rom a complete absence o$ symptoms usually in the young and $it! to hemodynamic collapse in the elderly or those with systolic dys$unction!. :n addition to symptoms of #al#itations, patients with () ha.e an increased risk o$ stroke and may also de.elop decreased e,ercise tolerance and /? dys$unction. 4he incidence o$ () increases with age and its de.elopment is concentrated in patients with h"#ertensive heart disease, !ongestive heart fail$re, and rhe$mati! heart disease+ the asso!iation ,ith !oronar" arter" disease is not as strong as with these other conditions. (mong the noncardiac causes o$ (), the association is strongest with h"#erth"roidism, ele!trol"te abnormalities, and al!ohol e !ess& ". 6hat is the rate and is it regular2 4he heart rate is .ariable with an irregularly irregular rhythm. '. :s the ;9% wide or narrow2 4he ;9% comple, is narrow. >. (re # wa.es present and upright2 # wa.es are not present, but $ibrillatory wa.es may be present. +. How are the # wa.es related to the ;9% comple,2 4here is no relationship between the # wa.es and ;9% comple,es. (trial $ibrillation is chaotic. 4he atrial muscle is depolariFing .ery rapidly in a disorganiFed $ashion. 4here are no # wa.es since each depolariFation in.ol.es little muscle mass, but oscillations can sometimes be seen in the baseline. :mpulses are irregularly conducted to the (? node which conducts depending on its re$ractory state. 4he resulting ;9% comple,es are narrow with irregular 9&9

inter.als. 4he rhythm is atrial $ibrillation i$ there are no # wa.es and the ;9%Ds are irregularly irregular. :$ there is abnormal conduction with wide ;9% comple,es and a rapid .entricular rate, atrial $ibrillation can look like .entricular tachycardia. 4he irregular rhythm is the key to diagnosis o$ atrial $ibrillation with abnormal conduction.

6. ATRIAL FLUTTER

(trial $lutter is a rapid, regular rhythm with atrial rates o$ '87=>87 bpm. 4he .entricular response rate .aries, but it is usually a '0" block creating the classic "87 bpm regular .entricular rhythm!. 4he E3G pattern is typical = classic $lutter wa.es are positi.e in the in$erior leads and negati.e in lead ?" ". 6hat is the rate and is it regular2 4he heart rate is $ast and the rhythm is usually regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is narrow. >. (re # wa.es present and upright2 4he # wa.es are the sum o$ a positi.e and negati.e component and ha.e a sawtooth appearance. +. How are the # wa.es related to the ;9% comple,2 )re5uently there are more $lutter wa.es than ;9% comple,es so some degree o$ (? block can be present. 4he impulse in atrial $lutter tra.els around the atrium

in a circular $ashion. 4he atrial acti.ity is regular, usually with a rate between '+7 and >A7 per minute. 4he ;9% comple,es may not be regular since .ariable (? block is o$ten present. 4he most common presentation o$ atrial $lutter is an atrial rate o$ >77 with '0" block. 7. JUNCTIONAL RHYTHM

4he junctional rhythm initiates within the (? nodal tissue. (ccelerated junctional rhythm is a result o$ enhanced automaticity o$ the (?1 that supersedes the sinus node rate. During this rhythm, the (?1 is $iring $aster than the sinus node, resulting in a regular narrow comple, rhythm. 4hese rhythms may demonstrate retrograde # wa.es on E3G $indings, and the rates can .ary $rom +7&A7 beats per minute. 3hanges in autonomic tone or the presence o$ sinus node disease that is causing an inappropriate slowing o$ the sinus node may e,acerbate this rhythm. Koung healthy indi.iduals, especially those with increased .agal tone during sleep, are o$ten noted to ha.e periods o$ junctional rhythm that is completely benign, not re5uiring any inter.ention. 9arely, the (?1 de.elops enhanced automaticity and o.ertakes a LnormalL sinus node. 4his occasionally is obser.ed in digitalis to i!it", follo,ing !ardia! s$rger" (t"#i!all" valve re#la!ement), d$ring a!$te m"o!ardial infar!tion, or d$ring iso#roterenol inf$sion& J$n!tional brad"!ardia due to pro$ound sinus node dys$unction. 1o atrial acti.ity is apparent '$n!tional ta!h"!ardias are most o$ten obser.ed in the setting o$ digitalis to i!it", re!ent !ardia! s$rger", a!$te m"o!ardial infar!tion, or iso#roterenol inf$sion& -& .hat is the rate and is it reg$lar/ 0he heart rate is normal and the rh"thm is reg$lar& 1& (s the 2R3 ,ide or narro,/ 0he 2R3 !om#le is narro,& 4& Are * ,aves #resent and $#right/ * ,aves are absent or negative& 5& 6o, are the * ,aves related to the 2R3 !om#le /

(n high '$n!tional rh"thm inverted * ,aves !ome before the 2R3, in mid7'$n!tional rh"thm there are no * ,aves, and in lo, '$n!tional rh"thm an inverted * ,ave follo,s the 2R3& (n '$n!tional rh"thms the im#$lse arises in or near the A8 node& 0he rh"thm is reg$lar& (f the im#$lse arises high in the '$n!tion, an inverted * ,ave #re!edes the 2R3& 0he * ,ave is inverted sin!e the im#$lse is !ond$!ted retro7 grade thro$gh the atria& (f the im#$lse arises in the middle of the '$n!tion, the * ,ave is not #resent& (t is either b$ried in the 2R3 or the im#$lse ,as not !ond$!ted to the atria& (f the im#$lse arises lo, in the '$n!tion, the im#$lse takes a long time to #ass thro$gh the node and retrograde thro$gh the atria& 0he * ,ave is inverted and follo,s the 2R3 !om#le &

8. VENTRICULAR TACHYCARDIA

:n the acute situation, there is o$ten an ob.ious precipitating e.ent eg, M:!. Howe.er, the most common cause o$ recurrent ?4 is ischemic heart disease. (nother key aspect o$ the in.estigation will be distinguishing between polymorphic and monomorphic ?4. 4he $ormer, in which comple,es .ary within or between episodes in their pattern, has a stronger association with sudden death. :n di$$icult cases o$ ?4, in.asi.e electrophysiological testing o$ten with concurrent coronary angiography! is warranted. 3ontrol o$ chronic ?4 is pharmacological = typical drugs that are used include sotalol, $lecainide, amiodarone, propa$enone, and disopyramide = although radio$re5uency ablation o$ the right .entricular 9?! out$low tract ?4 can be success$ul, and in some cases an automatic implantable cardio.erter de$ibrillator (:3D! can sa.e li.es. ". 6hat is the rate and is it regular2 4he heart rate is $ast and the rhythm is regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is wide. >. (re # wa.es present and upright2 # wa.es are not apparent. +. How are the # wa.es related to the ;9% comple,2 4he relationship between the # wa.es and ;9% comple,es cannot be de$ined since # wa.es cannot be identi$ied. ?entricular tachycardia is present with three or more beats o$ .entricular origin in a row. ?entricular tachycardia is usually regular but it can be irregular. 4he ;9% comple,es are wide. # wa.es are sometimes identi$iable but they bear no relationship to the ;9% comple,es. :t can be di$$icult to distinguish .entricular tachycardia $rom supra.entricular tachycardia with aberrant conduction. 6hen in doubt assume the rhythm is .entricular tachycardia.

9. VENTRICULAR FIBRILATION

Disorganised electrical signals cause the .entricles to 5ui.er instead o$ contract in a rhythmic $ashion. ( patient will be unconscious as blood is not pumped to the brain. :mmediate treatment by de$ibrillation is indicated. 4his condition may occur during or a$ter a myocardial in$arct 1. W !" #$ " % &!"% !'( #$ #" &%)*+!&, T % %!&" &!"% #$ -%&. &!/#( !'( " % & ." 0 #$ '1"

&%)*+!&. 2. I$ " % 2RS 3#(% 1& '!&&13, T % 2RS 410/+%5 #$ !6$%'". 3. A&% 7 3!-%$ /&%$%'" !'( */&#) ", 7 3!-%$ !&% !6$%'". 4. H13 !&% " % 7 3!-%$ &%+!"%( "1 " % 2RS 410/+%5, T %&% !&% '1 7 3!-%$ 1& 2RS 410/+%5%$ $1 " %&% #$ '1 &%+!"#1'$ #/ 6%"3%%' " %0. I' -%'"&#4*+!& 8#6&#++!"#1' !&%!$ 18 " % -%'"&#4+%$ !&% (%/1+!&#9#') !'( &%/1+!&#9#') #' ! 410/+%"%+. (#$1&)!'#9%( 8!$ #1'. A++ /*0/#') 8*'4"#1' 18 " % -%'"&#4+%$ #$ +1$". T % %+%4"&14!&(#1)&!0 0!. $ 13 -1+"!)% 8+*4"*!"#1'$. T % !0/+#"*(% 18 " %$% 3!-%$ #$ (%$4&#6%( 6. " % "%&0$ :41!&$%: !'( :8#'%: 1;. TORSADE DE 7OINTES

4his is a $orm o$ polymorphic ?4 that occurs when the %9 shown on an E3G has a prolonged ;4 inter.al. 4he E3G e,hibits a continuously changing a,is hence, Lturning o$ pointsL which can look like .entricular $ibrillation ?)!. 4he prolonged ;4 inter.al can be caused by0 antiarrhythmic agents, hypokalemia, hypomagnesemia, bradycardia Howe.er, in .ery rare cases it may be congenital *er.ell and /ange=1ielsen syndrome or 9omano=6ard syndrome!. 1. W !" #$ " % &!"% !'( #$ #" &%)*+!&, T % %!&" &!"% #$ 8!$" !'( " % & ." 0 #$ &%)*+!&.

2. I$ " % 2RS 3#(% 1& '!&&13, T % 2RS 410/+%5 #$ 3#(% !'( " % (#&%4"#1' 18 /1+!&#". #$ 4 !')#'). 3. A&% 7 3!-%$ /&%$%'" !'( */&#) ", 7 3!-%$ !&% '1" !//!&%'". 4. H13 !&% " % 7 3!-%$ &%+!"%( "1 " % 2RS 410/+%5, T % &%+!"#1'$ #/ 6%"3%%' " % 7 3!-%$ !'( 2RS 410/+%5%$ #$ '1" (%8#'%( $#'4% " % 7 3!-%$ !&% '1" #(%'"#8#!6+%. T1&$!(%$ (% 71#'"%$ #$ ! -!&#!'" 81&0 18 -%'"&#4*+!& "!4 .4!&(#! #' 3 #4 " % /1+!&#". /%&#1(#4!++. 4 !')%$

8&10 /1$#"#-% "1 '%)!"#-%. T % '!0% 0%!'$ "3#$"#') 18 " % /1#'"$.

T % & ." 0 #$ *$*!++. &%)*+!& 6*" #" 4!' 6% #&&%)*+!&. T % 2RS 410/+%5%$ !&% 3#(%. 7 3!-%$ !&% $10%"#0%$ #(%'"#8#!6+% 6*" " %. 6%!& '1 &%+!"#1'$ #/ "1 " % 2RS 410/+%5%$. I" #$ #0/1&"!'" "1 (#$"#')*#$ T1&$!(% (% 71#'"%$ 8&10

-%'"&#4*+!& "!4 .4!&(#! $#'4% " % "&%!"0%'" #$ (#88%&%'". T1&$!(%$ (% 71#'"%$ #$ !$$14#!"%( 3#" A)%'"$ $*4 ! +1') 2T #'"%&-!+.

!$ <*#'#(#'% !'( /&14!#'!0#(% 4!' /&1+1') " %

2T #'"%&-!+ !'( 31&$%' " % !&& ." 0#!. O-%&(&#-% /!4#') !'( 0!)'%$#*0 !&% " % "&%!"0%'"$ 18 4 1#4% 81& T1&$!(% (% 71#'"%$.

11.

IDIOVENTRICULAR

:n idio.entricular rhythm the rate is >7&+8 bpm. 4he ;9% comple,es are wide M 7."' sec, o$ten M 7."A sec! because the .entricular signal is transmitted by cell&to&cell conduction between cardiomyocytes and not by the conduction system. (ccelerated idio.entricuar rhythm is a rapid $orm A7&"'7 bpm! o$ idio.entricular rhythm associated with reper$usion during myocardial in$arction. 1. W !" #$ " % &!"% !'( #$ #" &%)*+!&, T % %!&" &!"% #$ $+13 !'( " % & ." 0 #$ &%)*+!&.

2. I$ " % 2RS 3#(% 1& '!&&13, T % 2RS 410/+%5 #$ 3#(%.

3. A&% 7 3!-%$ /&%$%'" !'( */&#) ", 7 3!-%$ !&% '1" !//!&%'". 4. H13 !&% " % 7 3!-%$ &%+!"%( "1 " % 2RS 410/+%5, T % &%+!"#1'$ #/ 6%"3%%' " % 7 3!-%$ !'( 2RS 410/+%5%$ 4!''1" 6% (%8#'%( $#'4% 7 3!-%$ 4!''1" 6% #(%'"#8#%(. A44%+%&!"%( #(#1-%'"&#4*+!& & ." 0 !&#$%$ 8&10 " % &%)*+!& 8#&#') 18 ! -%'"&#4*+!& $#"%. T % &!"% #$ "./#4!++. 4; "1 99 6%!"$ /%& 0#'*"% 3#" 6#9!&&% 410/+%5%$. 3#(% !'(

12.

7REMATURE ATRIAL CONTRACTION

#remature atrial contraction #(3!0 4he atria $ires an early impulse which causes the heart to beat earlier causing irregularity in the heart rhythm. 1. W !" #$ " % &!"% !'( #$ #" &%)*+!&,

T %

%!&" &!"% #$ '1&0!+= 6*" " % & ." 0 #$ '1"

&%)*+!&. T %&% !&% %!&+. 6%!"$. 2. I$ " % 2RS 3#(% 1& '!&&13, T % 2RS 410/+%5 18 " % %!&+. 6%!" #$ *$*!++. '!&&13= 6*" #" 4!' 6% 3#(% #8 " %&% #$ !6'1&0!+ 41'(*4"#1'. 3. A&% 7 3!-%$ /&%$%'" !'( */&#) ", T % %!&+. 6%!"$ !-% */&#) " 7 3!-%$.

4. H13 !&% " % 7 3!-%$ &%+!"%( "1 " % 2RS 410/+%5, T %&% #$ ! 1>"1>1 &%+!"#1'$ #/ 6%"3%%' " % 7 3!-%$ !'( 2RS 410/+%5%$ 18 " % %!&+. 6%!"$. T % 7R #'"%&-!+ 0!. 6% '1&0!+= +1')%& 1& $+#) "+. $ 1&"%& #' " % %!&+. 6%!"$. 7&%0!"*&% !"&#!+ 410/+%5%$ !&% %!&+. 6%!"$ " !" !&#$% #' " % !"&#!. A' */&#) " 7 3!-% /&%4%(%$ " % 2RS !+" 1*) " % 7 3!-% 0!. 6% #((%' 6. " % /&%-#1*$ T 3!-%.

R%)*+!&#". #$ (%"%&0#'%( 8&10 #'$/%4"#1' 18 " % R>R #'"%&-!+$. A &%)*+!& & ." 0 !$ 41'$"!'" R>R #'"%&-!+.

S+#) " #&&%)*+!&#"#%$ 0!. '1" 6% !//!&%'" %$/%4#!++. 3#" #) %!&" &!"%.

I&&%)*+!&#"#%$ 4!' 6% 4!*$%( 6.? 1. 7%&#1(#4 $/%%(#') !'( $+13#') 3#" !$ #' $#'*$ !&& ." 0#! 2. 7&%0!"*&% 6%!" > ! 6%!" %!&+#%& " !' %5/%4"%( 3. 7!*$% > /&1+1')%( R>R #'"%&-!+ 4. I&&%)*+!&+. #&&%)*+!& 1& 4 !1"#4 &%$/#&!"#1'

T % 2RS #$ *$*!++. '!&&13 !'( $#0#+!& "1 " % '1&0!+ $#'*$ 6%!"$. T % 2RS 410/+%5 4!' 6% 3#(% #8 " %&% #$ !6%&&!'" 41'(*4"#1'= 13%-%&= ! /&%0!"*&% 6%!" 3#"

! 3#(% 2RS $ 1*+( 6% 41'$#(%&%( ! 7VC *'+%$$ ! 7 3!-% #$ 16-#1*$.

I" #$ #0/1&"!'" "1 (#$"#')*#$

7AC$ 3#"

!6%&&!'"

41'(*4"#1' 8&10 7VC$ $#'4% 7VC$ 0!. 6% /1"%'"#!++. (!')%&1*$ !'( $*/&!-%'"&#4*+!& 6%!"$ !&% *$*!++. 6%'#)'. W %' #' (1*6" !$$*0% " % 6%!" #$ ! /&%0!"*&% -%'"&#4*+!& 41'"&!4"#1'.

13.

7REMATURE JUNCTIONAL CONTRACTION

PJCs may occur in both healthy and diseased hearts. If they are occasional, they are insignificant. If they are frequent, junctional tachycardia may result. Treatment is usually not required. 1. W !" #$ " % &!"% !'( #$ #" &%)*+!&, T % %!&" &!"% #$ '1&0!+= 6*" " % & ." 0 #$ '1" &%)*+!&.

T %&% !&% %!&+. 6%!"$. 2. I$ " % 2RS 3#(% 1& '!&&13,

T % 2RS 410/+%5 #$ '!&&13. 3. A&% 7 3!-%$ /&%$%'" !'( */&#) ", 7 3!-%$ !&% !6$%'" 1& '%)!"#-% #' " % %!&+. 6%!"$. 4. H13 !&% " % 7 3!-%$ &%+!"%( "1 " % 2RS 410/+%5, T % %!&+. 6%!"$ !-% '1 7 3!-%$ 1& ! 8#5%(= 1>"1>1

&%+!"#1'$ #/ 6%"3%%' " % 7 3!-%$ !'( 2RS 410/+%5%$. A' #'-%&"%( 7 3!-% 410%$ 6%81&% " % 2RS #' @*'4"#1'!+ !'( !8"%& " % 2RS #' +13 @*'4"#1'!+. #)

7&%0!"*&% @*'4"#1'!+ 410/+%5%$ !&% %!&+. 6%!"$ " !" !&#$% #' " % AV '1(%. I8 " % #0/*+$% !&#$%$ #) #' " %

@*'4"#1'= !' #'-%&"%( 7 3!-% /&%4%(%$ " % 2RS. T % 7 3!-% #$ #'-%&"%( $#'4% " % #0/*+$% #$ 41'(*4"%( &%"&1)&!(% " &1*) " % !"&#!.

I8 " % #0/*+$% !&#$%$ #' " % 0#((+% 18 " % @*'4"#1'= " % 7 3!-% #$ '1" /&%$%'". I" #$ %#" %& 6*&#%( #' " % 2RS 1& " % #0/*+$% 3!$ '1" 41'(*4"%( "1 " % !"&#!. I8 " % #0/*+$% !&#$%$ +13 #' " % @*'4"#1'= " % #0/*+$% "!A%$ ! +1') "#0% "1 /!$$ " &1*) " &1*) " % '1(% !'( &%"&1)&!(%

" % !"&#!. T % 7 3!-% #$ #'-%&"%( !'( 81++13$ " %

2RS 410/+%5.

14.

7REMATURE VENTRICULAR CONTRACTION

4he .entricles $ire an early impulse which causes the heart to beat earlier causing irregularity in the heart rhythm ". 6hat is the rate and is it regular2 4he heart rate is normal, but the rhythm is not regular. 4here are early beats. '. :s the ;9% wide or narrow2 4he ;9% comple,es o$ the early beats are wide. >. (re # wa.es present and upright2 # wa.es are absent in the early beats. +. How are the # wa.es related to the ;9% comple,2 4he early beats ha.e no # wa.es so there is no relationship to the ;9%. #remature .entricular comple,es are early beats that arise in the .entricle. 4hey are conducted through the .entricle and ha.e a wide, o$ten biFarre ;9% comple,. :t is important to distinguish #?3s $rom supra& .entricular beats with aberrant conduction since #?3s may be potentially dangerous and supra.entricular beats are usually benign. 6hen in doubt assume the beat is a premature .entricular contraction.

15.

AV BLOCB 1ST DECREE

"st Degree (? block is caused by a conduction delay through the (? node but all electrical signals reach the .entricles. 4his rarely causes any problems by itsel$ and o$ten trained athletes can be seen to ha.e it. 4he normal #&9 inter.al is between 7."'s to 7.'7s in length, or >&8 small s5uares on the E3G. 4his is where there is a prolonged #9 inter.al o$ M'77 milliseconds 8 small s5uaresG see 1o speci$ic therapy is re5uired and the prognosis is e,cellent. Howe.er, it can be a marker $or an underlying problem such as myocarditis, M:, degenerati.e disease, or, most commonly, a drug e$$ect eg, tricyclic antidepressants!. ". 6hat is the rate and is it regular2 4he heart rate is slow to normal and the rhythm is regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is narrow. >. (re # wa.es present and upright2 4he # wa.es are upright. +. How are the # wa.es related to the ;9% comple,2 4here is a $i,ed, "&to&" relationship between the # wa.es and ;9% comple,es, but the #9 inter.al is prolonged. E.ery # wa.e causes a ;9% comple, in $irst degree (?

block. 4he #9 inter.al is $i,ed, but it is greater than 7.' seconds.

16.

AV BLOCB 2ND DECREE TY7E 1

4ype : occurs when there is a repeated pattern o$ progressi.e prolongation o$ the #9 inter.al, which e.entually results in the $ailure o$ conduction o$ one atrial beat. 4he cause is usually benign, but it can be a marker $or the same underlying cardiac problems as $irst&degree (? block. :n most cases, treatment is unnecessary. 9outine prophylactic permanent pacing is not recommended unless the patient is symptomatic with presyncope, recurrent syncope, or bradycardia that e,acerbates congesti.e heart $ailure or angina. ". 6hat is the rate and is it regular2 4he heart rate is slow to normal. 4he rhythm is not regular since some ;9% comple,es are missing. '. :s the ;9% wide or narrow2 4he ;9% comple, is narrow. >. (re # wa.es present and upright2 4he # wa.es are upright. +. How are the # wa.es related to the ;9% comple,2 4here are more # wa.es than ;9% comple,es. 4he #9

inter.al progressi.ely lengthens until a ;9% comple, is dropped. 4he shortest #9 inter.al $ollows the dropped beat. %econd degree type : (? block is also known as MobitF 4ype : or 6enkebach. 4he conduction block occurs in the (? node. 4he #9 inter.al progressi.ely lengthens until the impulse is not conducted to the .entricles. %econd degree type : (? block is most commonly associated with right coronary artery occlusion with in$erior wall in$arctions. 4his block generally has a good prognosis. 17. AV BLOCB 2ND DECREE TY7E II

:n type ::, most beats are conducted with a constant #9 inter.al, but occasionally atrial depolariFation is not $ollowed by .entricular depolariFation 4ype :: is pathological and indicates disease o$ the conduction system distal to the (? node. :t can $re5uently lead to complete (? block, causing %tokes=(dams attacks. 4here$ore, temporary and then permanent pacing DDD! is indicated in most patients, e.en those who initially present without symptoms. ". 6hat is the rate and is it regular2 4he heart rate is slow to normal and the rhythm is not

regular. ;9% comple,es are missing. '. :s the ;9% wide or narrow2 4he ;9% comple, is usually wide. >. (re # wa.es present and upright2 4he # wa.es are upright. +. How are the # wa.es related to the ;9% comple,2 4here are more # wa.es than ;9% comple,es. 4he #9 inter.al is $i,ed and usually has normal duration. %econd degree type :: (? block is also known as MobitF 4ype ::. 4he conduction block is in$ranodal. 4he #9 inter.al is $i,ed duration until the impulse is not conducted to the .entricles. %econd degree type :: (? block is most commonly associated with anterior wall in$arctions. 4his block has a propensity to progress to third degree (? block. 18. AV BLOCB 3RD DECREE

6ith complete heart block, there is complete dissociation o$ the # wa.es and ;9% comple,es 4he .entricular escape comple,es are usually wide and occur at around >7=+7 bpm. 4here is a signi$icant risk o$ asystole and thus permanent pacing DDD! is indicated, regardless o$ symptoms. (c5uired (? block is most commonly due to ischemic heart disease or drug to,icity in particular H&blockers, digitalis, and calcium&channel blockers!. ". 6hat is the rate and is it regular2 4he heart rate is slow to normal and the rhythm is regular. '. :s the ;9% wide or narrow2 4he ;9% comple, is wide. >. (re # wa.es present and upright2 4he # wa.es are upright. +. How are the # wa.es related to the ;9% comple,2 4here are usually more # wa.es than ;9% comple,es. 4here is usually atrial and .entricular regularity, but they are independent o$ each other. # wa.es march through ;9% comple,es. 4hird degree (? block is complete heart block. 4he atria beat at their rate while the .entricular rate is determined by a junctional or .entricular pacemaker. # wa.es Lmarch throughL or are unrelated to ;9% comple,es.

19.

ASYSTOLE

/ooking at the E3G youDll see that0 9hythm & )lat 9ate & 7 Beats per minute ;9% Duration & 1one # 6a.e & 1one 3arry out 3#9NN

2;.

MYOCARD INFARB

/ooking at the E3G youDll see that0 9hythm = 9egular 9ate & E7 Beats per minute ;9% Duration & 1ormal # 6a.e & 1ormal %&4 Element does not go isoelectric which indicates in$arction 1-& 3U*RA8E%0R()ULAR 0A)6Y)AR9(A

( narrow comple, tachycardia or atrial tachycardia which originates in the DatriaD but is not under direct control $rom the %( node. %?4 can occur in all age groups /ooking at the E3G youDll see that0 9hythm & 9egular

9ate & "+7&''7 beats per minute ;9% Duration & @sually normal # 6a.e & O$ten buried in preceding 4 wa.e #&9 :nter.al & Depends on site o$ supra.entricular pacemaker :mpulses stimulating the heart are not being generated by the sinus node, but instead are coming $rom a collection o$ tissue around and in.ol.ing the atrio.entricular (?! node 11& A0R(:8E%0R()ULAR BL:)K

(trio.entricular block (?B!0 the sinus node may be generating heart beats causing the atria to contract at a normal rate, howe.er not e.ery electrical impulse coming $rom the atria is being passed down to the .entricles by the atrio.entricular node due to a block in conduction. 4here are .arious types o$ (? block depending upon the mechanism o$ block. %econd degree (? block is when the impulse $rom the atria is blocked e.ery certain number o$ beats. 6hile in complete (? block non o$ the atrial impulses pass through the atrio.entricular node and the .entricles generate their own rhythm. 14& BU%9LE BRA%)K BL:)K

( problem in the bundle o$ His presents in an identical $ashion to a combined block o$ both bundles, ie, complete heart block. Howe.er, a more common occurrence is an isolated le$t or right bundle branch block. 4hese are usually distinct $rom any problem with (? conduction ie, they usually coe,ist with normal sinus rhythm P%9Q!. 4he patterns o$ the E3G are characteristic, but highly .ariableG the hallmark is a wide ;9% comple,.

Electrocardiogram patterns o$ le$t bundle branch block and right bundle branch block. :n le$t bundle branch block /BBB!, the pattern is best detected in ?A where there is an LML pattern, while in ?" there is a L6L pattern see :n right bundle branch block 9BBB!, the pattern is best detected in ?" where there is an 9%9 comple,, while in ?A there is a ;9% comple, see :n $act, both /BBB and 9BBB are $ound in the LnormalL population. 1ew /BBB is cause $or concern, and i$ it can clearly be related to an acute episode o$ chest pain then it probably indicates M:. Both 9BBB and /BBB probably indicate increased risk $or cardio.ascular diseaseG howe.er, neither on its own is an indication $or pacing

15& 30 segment de#ression

%4 segment depression can be caused by ischemia, digitalis, rapid heart rate, and temperature or electrolyte abnormality. :t can also be a Rre$lectedS or reciprocal %4 ele.ation showing an in.erted .iew o$ whatTs happening at another place in the heart!. 4he shape o$ the %4 segment, and whether the abnormality is localiFed to leads looking at one area o$ the heart, o$ten allows the cause o$ %4 depression to be diagnosed. %4 segment depression is considered signi$icant i$ the %4 segment is at least one bo, below baseline, as measured two bo,es a$ter the end o$ the ;9%. (s with in$arction, the location o$ the ischemia is re$lected in the leads in which the %4 depression occurs. 3auses o$ %4 Depression0 ". :schemia '. Hypothermia >. Hypokalemia +. 4achycardia 8. %ubendocardial in$arct A. 9eciprocal %4 ele.ation I. ?entricular Hypertrophy E. Bundle branch block U. Digitalis http0<<www.t.eatch.org<ekgs<ekgE8.html-usg.

1. NORMAL SINUS RHYTHM

2. SINUS TACHYCARDIA

3. SINUS BRADICARDIA

4. ATRIAL TACHYCARDIA

5. ATRIAL FIBRILATION

6. ATRIAL FLUTTER

7. JUNCTIONAL RHYTHM

8. VENTRICULAR TACHYCARDIA

9. VENTRICULAR FIBRILATION

1;.

TORSADE DE 7OINTES

11.

IDIOVENTRICULAR

12.

7REMATURE ATRIAL CONTRACTION

13.

7REMATURE JUNCTIONAL CONTRACTION

14.

7REMATURE VENTRICULAR CONTRACTION

15.

AV BLOCB 1ST DECREE

16.

AV BLOCB 2ND DECREE TY7E 1

17.

AV BLOCB 2ND DECREE TY7E II

18.

AV BLOCB 3RD DECREE

19.

ASYSTOLE

2;.

MYOCARD INFARB

1-& 3U*RA8E%0R()ULAR 0A)6Y)AR9(A

11& A0R(:8E%0R()ULAR BL:)K

14& BU%9LE BRA%)K BL:)K