ELECTROCARDIOGRAPHY

(ECG)

PELATIHAN KEGAWATDARURATAN
KARDIOVASKULAR
FAKULTAS KEDOKTERAN
UNIVERSITAS PRIMA INDONESIA
OUTLINE

ECG in acute coronary syndrome

ECG in tachyarrhythmia
ECG in bradyarrhythmia
ECG in cardiac arrest
Introduction
The electrocardiogram (EKG) is
a representation of the
electrical events of the cardiac
cycle.
Each event has a distinctive
waveform
The study of waveform can
lead to greater insight into a
patients cardiac
pathophysiology.
Impulse Conduction & the ECG

Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers
NORMAL ECG
The PQRST
P wave -
Atrial depolarization

QRS complex -
Ventricular
depolarization
T wave -
Ventricular
repolarization
Standard calibration The ECG
25 mm/s Paper
0.1 mV/mm
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
 ECG Leads

The standard ECG has 12 leads:

3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads
Precordial Leads
Localization of ischemia and
infarct
in ECG (left ventricle)
Anteroseptal V1 V4
Anterior extensive V1 V6, I and aVL
Anterolateral V4 V6, I and aVL
Anterior V3 V5
Inferior II, III, and aVF
High lateral I and aVL
Posterior Mirror effect in V1-
V3
Right Sided & Posterior Chest
Leads
 ECG IN
ACUTE CORONARY
SYNDROME

PELATIHAN KEGAWATDARURATAN
KARDIOVASKULAR
FAKULTAS KEDOKTERAN
UNIVERSITAS PRIMA INDONESIA
 The 12 Lead ECG is at the center of the
decision pathway in the management of
patients with ischemic chest pain.
- AHA Guidelines 2000 -
 Coronary Heart Disease

ISCHEMIC : ST depression
or T inversion

INJURY : ST Elevation

NECROSIS (OLD INFARCT) :

pathologic Q wave or QS
G in ST Elevation Myocardial Infarct ( Evolutio
ST Elevation

One way to
diagnose an
acute MI is to
look for elevation
of the ST
segment.
 Myokardial Injury:
a. Downsloping (convex) ST elevation
epicardial injury
b. Upsloping (concave) not spesific
c. Deep ST depression
subendokardial injury
 ISKEMIA
MIOKARD

ST Depression myocardial ischemia

3 type of ST depression :
1. Horizontal spesific
2. Downsloping spesific
3. Upsloping

New horizontal or down-sloping ST

depression 0.05 mV in two contiguous
leads and/or T inversion 0.1 mV in two
contiguous leads with prominent R wave or
R/S ratio >1 myocardial ischemia
 T inversion in ischemia:
a. Not spesific
b. Spesific sharp and symmetrical
Ischemia

Spesific for
Iskemia:
Diameter 2
mm with
dynamic T wave
inversion

Circulation 2010

22
Now, where do you think this person is
having a myocardial infarction?

Putting it all Together

STEMI Anterior extensive
NSTEMI/ UAP

5/2/17 24
 ECG in
Tachyarrythmia

PELATIHAN KEGAWATDARURATAN
KARDIOVASKULAR
FAKULTAS KEDOKTERAN
UNIVERSITAS PRIMA INDONESIA
TACHYARRHYTHMIA

QRS wide or narrow??

QRS regular or irregular??
P wave absent or not??
 QRS lebar

Irama
Irama Teratur
tidak teratur

Ventricular Ventricular
Tachycardia Fibrillation
Rhythm #1

Rate? 130 bpm

Regularity? regular
P waves? normal
PR interval? 0.16 s
QRS duration? 0.08 s
Interpretation? Sinus Tachycardia
Rhythm #2

Rate? 100 bpm

Regularity? irregularly irregular
P waves? none
PR interval? none
QRS duration? 0.06 s
Interpretation? Atrial Fibrillation
Rhythm #3

Rate? 70 bpm
Regularity? regular
P waves? flutter waves
PR interval? none
QRS duration? 0.06 s
Interpretation? Atrial Flutter
Rhythm #4

Rate? 74 148 bpm

Regularity? Regular regular
P waves? Normal none
PR interval? 0.16 s none
QRS duration? 0.08 s
Interpretation? Paroxysmal Supraventricular
Tachycardia (PSVT)
Rhythm #5

Rate? 160 bpm

Regularity? regular
P waves? none
PR interval? none
QRS duration? Wide (>0.12 s)
Interpretation? Ventricular Tachycardia
Rhythm #6

Rate? none
Regularity? irregularly irreg.
P waves? none
PR interval? none
QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
 ECG in
Bradyarrythmia

PELATIHAN KEGAWATDARURATAN
KARDIOVASKULAR
FAKULTAS KEDOKTERAN
UNIVERSITAS PRIMA INDONESIA
BRADYARRHYTHMIA
Classification:
Sinus Bradycardia
Junctional Rhythm
Atrioventricular block derajat 1,2,3
Sinus Bradycardia
Junctional Rhythm
AV Block
FirstDegree AV Block
Second Degree AV Block
Third Degree AV Block
First Degree AV Block
Delay in the conduction through the conducting system
Prolong P-R interval
AllP waves are followed by QRS
Associated with : AC Rheumati Carditis, Digitalis, Beta

Blocker, excessive vagal tone, ischemia, intrinsic

disease in the AV junction or bundle branch system.
Second Degree AV Block

Intermittent failure of AV conduction

Impulse blocked by AV node
Types:
Mobitz type 1 (Wenckebach
Phenomenon)
Mobitz type 2
 ECG in
Cardiac Arrest

PELATIHAN KEGAWATDARURATAN
KARDIOVASKULAR
FAKULTAS KEDOKTERAN
UNIVERSITAS PRIMA INDONESIA
Rhythm
Ventricular Tachycardia
Ventricular Fibrillation
Pulseless electrical activity (PEA)
Asystole
Ventricular Tachycardia

Regular, wide QRS Complex

Ventricular Fibrillation

Irregular, wide QRS Complex

Pulseless Electrical Activity

Rhythm (+), pulse (-)

Asystole

Rhythm (-), pulse (-)