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Elektrokardiograf

Prof. dr. Peter Kabo

1. Irama

: Sinus
Bukan Sinus

Atrial Fibrilasi
SVT

Irama JUNSION
60-100 x/menit (normal)
2. Laju QRS

: HR?
Regularitas
3. Aksis: Normal
RAD/LAD
Superior Aksis
4. Interval PR : 0.20 Detik (Normal)
5. Morfologi
a. Gelombang P
: Normal P.Pulmonal P.Mitral
b. Kompleks QRS
: Q patologis
RSR pattern di V1&V2
Interval-QRS (0.08 detik)
c. Segmen ST
: ST-elevasi, ST-depresi
d. Gel.T
: Flat-T, Inverted-T, tall-T

PA interval : 0.01-0.45 detik


P dur
: 0.06 0.2 detik
Max
: 0.1 detik
AH interval
: 0.05-0.13 detik
PR-interval
: 0.2 detik
Max
: 0.24 detik
HV interval
: 0.03-0.05 detik
PRS dur
: 0.08 detik
Max
: 0.1 detik

6.7 x 20 = 134x/menit

300 : 5.8 = 52x/menit

3.3 x 50 = 165x/menit

Gambar 3.2. Perhitungan aksis


A. Aksis Normal
: Lead I: I= +4.5; lead aVF : +12.5; aksis = 72
B. Deviasi aksis ke kanan : Lead I = -10; lead aVF : +8; aksis = +140
C. Deviasi aksis ke kiri : Lead I = +5; lead aVF : -10; aksis = - 60

CARDIAC ARRHYTHMIAS
CLASSIFICATION :
1. Sinus Node diseases :
Sinus tachycardia / bradycardia
SA block
Wandering pace maker
Hypersensitive carotid sinus syndrome (SSS)

2. Disturbance of atrial rhytim :


Atrial fibrilation
Atrial flutter

3. Disturbance of AV junction rhytim :


Supraventricular tachycardia

4. Pre-excitation syndrome :
Woeff Parkinson White syndrome (S-wave)

5. Disturbance of ventricular rhytim :


Ventricular extra systole
Ventricular tachycardia
6. Heart Block :
1 o HB
2 o HB : - Wenckebach ( Mobits type I)
- Mobitz type II
o
3 HB (total AV block) : - Temporary pace-maker
- Permanent pace-maker
R/ : - Simpatomimetik : Ephedrin
- Anti cholinergic: Atropine

Jenis Aritmia

Sinus takikardi/sinus bradikardi


Venticular -/Atrial extrasystole
Supra-ventricular tachycardia
Ventricular tachycardia
Atrial fibrillation
Block

Phases of action potential of


cardiac cells

Phase 0 rapid depolarisation


(inflow of Na+)
Phase 1 partial repolarisation
Phase 1
(inward Na+ current deactivated,
outflow of K+)
Phase 2 plateau (slow inward
0 mV
calcium current)
Phase 3 repolarisation (calcium
Phase 0
I
current inactivates, K+ outflow)
Phase 4 pacemaker potential
(Slow Na+ inflow, slowing of K+
-80mV
Phase 4
outflow) autorhythmicity
II
Refractory period (phases 1-3)

IV

Phase 2

III

Phase 3

Sinus rhythm
Sinoatrial node is cardiac
pacemaker
Normal sinus rhythm 60100 beats/min
Depolarisation triggers
depolarisation of atrial
myocardium (forest fire)
Conducts more slowly
through AV node
Conducts rapidly through
His bundles and Purkinje
fibres

Sinus rhythm
Sinoatrial rate controlled by autonomic nervous
system
Parasympathetic system predominates (M2
muscarinic receptors)
Sympathetic system (1 receptors)
Increased heart rate (positive chronotropic
effect)
Increased automaticity
Facilitation of conduction of AV node

ECG
Recording of electrical activity of the heart
Net sum of depolarisation and repolarisation
potentials of all myocardial cells
P-QRS-T pattern
P - atrial depolarisation
QRS - ventricular depolarisation
T - ventricular repolarisation

COMMON UNDERLYING DISEASES CAUSING


ARRHYTHMIAS
1. Ischemic Heart Disease :
Acute myocardial infarction
Myocardial ischemia ( HHD, LVH, CAD)
Left ventricle aneurysma
2. CARDIOMYOPATHY
3. Valvular Heart disease
4. Myocarditis
5. Congenital Hearth disease
6. Conduction system abnormalities :
Sinus R AV-node disease
By pass tract
7. Chronic pulmonary disease : Hypokemia
8. Endocrine : Thyrotoxicosis
9. Electrolide imbalance
10. Drug-induce : Sympathomimetic, caffeine
11. Increase Symphatetic / vagal activity

Mechanisms of Cardiac Arrhytmias


1. Enhanced Automaticity :
2. Triggered Automaticity :

Sinus tachycardia
Multifocal atrial tachycardia. VES

Delayed after depolarization

Early after depolarization

3. Reentry
Atrial fibrillation (AF)
Atrial Flutter
Supraventricular tachycardia (SVT)
Ventricular tachycardia (VT)
Woeff-Parkinson-White Syndrome

4. Block
1o AV block
2o AV block
3o AV block (Total AV Block)

VT. Torsade de pointes

PVC (ESV)

Bigeminism

PVC (ESV)

paired

PVC (ESV)

Polymorphic

PVC (ESV)

Triplet

PVC (ESV)

Ischemic
Ventricle irritation

http://www.emedu.org

RESUSITASI KARDIO - PULMONAL

CLASSIFICATION OF ANTIARRHYTMIC
DRUGS
I. Sodium channel blockers
A. Sodium channel (++)
Blocks K+ effluks (+)
B. Sodium Channel (+)

C. Sodium Channel (+++)

Disopyramide
Quinidine
Procainamide
Lidocaine
Mekiletine
Tocainide
Flecamide, Encamide,
Propafenone

II. Anti adrenergic

Beta blockers

III. K+ channel effluks blockers


also Na+ Blockers

Amiodarone
Sotalol

IV. Ca++ channel blockers

Verapamil, Diltiazem

V. Autonomic effects
Vagal stimulation
Adenosine receptor activation

Digoxin
Adenosine

DRUG

Quinidine
Procamamide
Disopyramide
Lidocaine
Propafenone
Amiodarone

+
+
+

Sotalol

+
+

+
+
+

BIO
(%)

T
(hari)

40 %

4-10
3-4
4-10
2
2-32
25-60

100%

10

Doses
Loading

1 mg/kg BB
800-1600
(2 weeks)

Doses Maintenance
300-600
750
400-800
4-3-2-1mg/kg BB
450-900
100-400
80-320

Mechanisms of Antiarrhytmic Drug Action


Decreased Phase 4 Slope

B-blocker

Increased Threshold

Na+ channel
blocker
Ca++ channel
blocker

Increased Max-diastolic
potential

Adenosine
Acetylcholine

Increased action potential


duration

K+ channel
blocker

Antiarrhytmic drugs can cause


arrhytmias
Some arrthythmias should not be treated

DRUGS

INDICATIONS

Quinidine

AF

Procamamide
Disopyramide
Lidocaine

VES
VES
VES,VT

Propafenone
Amiodarone

VES,VT,AF,SVT
VES,VT,AF,SVT

Sotalol

VT,VES

ADVERSE EFFECTS
Cinchronism, Long QT
syndrome, Hypotension,
Diarrhea/Hepatitis,
Thrombocytopenia
Hypotension, Nausea, Lupus
(-) miotropic, Anti cholinergic :
dry mouth
Constipation, urine retention,
Glaukoma attack
Hypotension, nystagmus,
Seizure
Hypotension, Hepatic
disfunction, Pulmonary fibrosis,
Hypo/Hyper thyroidism, Cornea
microdeposit
Heart failure, Bradycardia

Tachycardia
Unstable

Stable

Serious sign or symptoms


prepare for immediate
cardioversion

Atrial fibrillation
Atrial flutter

Narrow-complex
tachycardias

Stable monomorphic
VT or Polymorphic VT

Narrow-complex Supra Ventricular Tachycardia (SVT)


Vagel Stimulation
Adenosine

Juctional
tachycardia

Heart function
preserved

Amiodarone, B-blokers,
Verapamil

EF < 40%

Amiodarone

Heart function
preserved
Paroxysmal SVT
EF < 40%

Ectopic / multifocal
atrial tachycardia

Heart function
preserved
EF < 40%

Verapamil, B-blokers,
Digoxin, Cardioversion,
Amiodarone, Sotalol,
Adenosine
Digoxin, Amiodarone
Verapamil, B-blockers,
Amiodarone
Amiodarone

ATRIAL FIBRILLATION / FLUTTER


CONTROL RATE
Normal Cardiac
Function

Verapamil
B-Blocker

Impaired Heart
(EF < 40% or CHF )

Digoxin

CONVERT RHYTIM
Amiodarone
Propafenone
Sulfas quinidine
DC Cardioversion

If AF > 48 hours duration : use anti arrithmic agents with extreme


caution patients not receiving adequate anti coagulation because of
possible embolic complication.
Delayed cardioversion :
Anti coagulation 3 weeks cardioversion anti coagulation 4 weeks

RBBB

Preoperative: Normal (10%), RVH


New RBBB

poor RV myocardial protection (imperfect retrograde


cardioplegia)
incomplete revascularization to RCA
Technical problem with graft (Kink, Twist) to RCA
Air embolism in the RCA ostium (+++ valve surgery)
http://www.emedu.org
Lesion to conduction tissues (tricuspid)

1 Degree AV block
st

Beta blockers
Frequent in elderly
AV node (valve surgery, MI)

http://www.emedu.org

1 Degree AV block
st

Beta blockers
Frequent in elderly
AV node (valve surgery, MI)

http://www.emedu.org

2 Degree AV block type 1


nd

Lesion to conduction tissues (AVR, MVR, TVR)

2 Degree AV block type 2


nd

Lesion to conduction tissues (AVR, MVR, TVR)

http://www.emedu.org

3 Degree AV block
rd

Lesion to conduction tissues (AVR, MVR, TVR)

http://www.emedu.org

Bradicardy
Sinus Bradicardy
1.Ephedrine
2.Aminophyline
3.Atropine (I.V.)

Heart Block
1. Atropine (I.V.)
2. Temporary Pacemaker
3. Permanent Pacemaker

Permanent Pacemaker

Narrow QRS Complex


Retrograde P
Vent-rate : 140 200 x / min
Vagal Maneuver Response
Wide QRS Complex, V1(+), LAD/Superior
AV dissociation / fusion beat
Vent-rate : 150 250 x / min
Vagal Maneuver No Response

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