Elektrokardiogram

Dr. Yunny Safitri

The Conduction system
Prinsip pengukuran arus listrik
pada jantung

+
-
positive

- +
negative

- +
Bifasik
Cardiac conduction system
SA node
Sumber impuls normal/
alamiah , 60 – 100

AV node
Bisa mengeluarkan
impuls 40-60x/menit

Berkas His
Serabut Purkinje

Ventrikel
Bisa mengeluarkan impuls
20-40 x/menit
Impulse Transmission

SA Node
→ Internodal branch
→ AV Node
→ Hiss Bundle
→ Purkinje Fiber
→ Contraction
The Heartbeat

6
Sandapan EKG (standar - 12 lead)
● Sandapan bipolar
Merekam perbedaan potensial dari 2 elektroda
I = lengan kanan (-) → lengan kiri (+) II
= lengan kanan (-) → tungkai kiri (+)
III = lengan kiri (-) → tungkai kiri (+)
● Sandapan unipolar
- Merekam potensial listrik pada satu elektroda
yang lain sebagai elektroda indiferen (0) -
Ada dua sandapan: ekstremitas & prekordial
Sandapan unipolar ekstremitas
avR, avL, avF -
Sandapan prekordial
V1,V2,V3,V4,V5,V6
Sandapan EKG (non standar)
● Pada keadaan tertentu diperlukan sandapan ditempat
yang bukan standar
● Pada kecurigaan infark Ventrikel Kanan

V3R, V4R (merupakan cermin V3, V4)

● Pada kecurigaan infark miokard porterior
V7,V8,V9 ( selevel V4,V5,V6 ke arah posterior)
Unipolar Precodial (Chest) Leads
Midclavicula
r Anterior
line
axillary line
Midaxillary
line

V6
V6
R V5 V5
R V4 V4
V3 V3
R V2
R
V1

Mervin J. Goldman, MD. 11th edition Principles of clinical Electrocardiography. Clinical Professor of Medicine University of
California School of Medicine San Francisco @1995-1982
Unipolar Precodial (Chest) Leads

Horizontal plane of V4-6

V7 V8 V9 V9RV8RV7R

Mervin J. Goldman, MD. 11th edition Principles of clinical Electrocardiography. Clinical Professor of Medicine University of
California School of Medicine San Francisco @1995-1982
Nomenclature ECG
Gelombang P
• Depolarisasi Atrium
R • Diikuti kontraksi
atrium
• Sinus Ritme : + di II
• Sinus Ritme : - di avR
• N ; lebar < 0,12 dtk
P
• N : tinggi < 0,3 mV
T
U

Q
S
Depolarisasi
atrium
 Nomenclature ECG
Gelombang QRS
• Depolarisasi ventrikel
• Diikuti kontraksi ventrikel
• Lebar 0,06 - 0,12 dtk
Depolarisasi ventrikel
• Tinggi tergantung lead
R • Q patologis: tanda infark miokard
• Transisisonal zone untuk gel. R

Q
S
Terminologi morfologi QRS

R
qRs Rs rS

QR Q/QS rSr’
RsR’
Nomenclature ECG

Gelombang T
• Repolarisasi ventrikel
• Diikuti relaksasi ventrikel
• + di lead : I,II,V3-V6
• - di lead avR

Repolarisasi ventrikel
ECG INTERPRETATION
1. RATE
2. RHYTHM
3. AXIS
4. HIPERTROPHIC SIGNS
5. MYOCARDIAL INFARCTION
6. ARRHYTHMIA
1. RATE
Normal heart rate : 60 – 100 x/minutes
• > 100 x/minutes : Sinus
Tachycardia
• < 60 x/minutes : Sinus Bradicardia

Determination heart rate (normal paper speed 25 mm/s):

• 300
Count number of large square (bold boxes in one R – R’ interval)
• 1500
Count number of small square in one R – R’ intervals
• Number of QRS complex in 6 seconds, multiply by 10
2. RHYTHM

Normal cardiac rhythm : SINUS rhythm

Sinus rhythm characteristics :

• Rate 60-100 bpm
• Constant R – R interval
• Negative P wave in aVR and positive di II
• P wave is always followed by QRS
complex
♀22 th , datang ke poliklinik untuk check up
♀ 40 th datang untuk check up
3. AXIS
4. HYPERTROPHIC SIGNS
LVH
MYOCARDIAL INFARCTION

● Ischemia
● Injury
● Necrosis
Block intraventrikular
a. RBBB :
-QRS memanjang ≥ 0,10 detik (3 ktk kecil)
-S yang lebar di lead I dan V6
-r’ yang lebar di V1 dan V2.

RBBB inkomplit ( QRS : 0,10-0,12 detik)

RBBB komplit ( QRS ≥ 0,12 detik)
b. LBBB
depolarisasi ventrikel kiri mengalami perlambatan
EKG :
-QRS melebar > 0,10 detik
-Gelombang R yang melebar, berlekuk di I, V5, V6
-r S atau QS di V1.
-komplit dan inkomplit.
 6. ARRHYTHMIAS
ARRHYTHMIAS

BRADYARRHYTHMIAS TACHYARRHYTHMIAS

FAILURE OF IMPULSE
FORMATION (SINUS
ARREST)
REENTRY
AUTOMATICITY
(AVNRT, AVRT,
AT, AFlut)
FAILURE OF
PROPAGATION
TRIGGERED
(SA EXIT BLOCK, AV ACTIVITY
BLOCK, RBBB, LBBB)
ECG interpretation…?
1. Calibration
2. Rate and rhythm
3. QRS axis
4. P morphology
5. PR interval
6. QRS duration
7. QRS morphology
8. ST segment morphology
9. T morphology
10. Others: LVH, LV strain, BBB
11. Conclusion: normal/abnormal
Kegawatdaruratan dalam
EKG
 ACUTE CORONARY SYNDROME

No ST Elevation ST Elevation

NSTEMI

Unstable Angina
ST Segment
STEMI Non STEMI
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, III dan avF menghadap dinding inferior ventrikel

kiri
EKG PADA ISKEMIA MIOKARD
EKG PADA ISKEMIA MIOKARD
EKG PADA INJURI MIOKARD
EVOLUSI EKG PADA STEMI
EVOLUSI EKG PADA STEMI ANTERIOR
EVOLUSI EKG PADA STEMI INFERIOR
 Mid LAD occlusion
after the first septal
perforator (arrow)

ECG : large anterior MI

Occlusion of diagonal
branch ( arrow )

ST elevation in I and aVL

 Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression
Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

Early repolarization
Unstable angina
Subendocardial ischemia.
Anterolateral ST-segment depression
Acute anteroseptal myocardial infarction.
Hyperacute T-wave changes are noted
Acute anterolateral myocardial infarction
High lateral infarction
Lateral myocardial infarction
Inferior myocardial infarction
Inferior myocardial infarction.
Inferior Q waves with T-wave inversions
Left ventricular aneurysm
Thank You
ARRHYTHMIAS
The Heartbeat

73
CAUSE OF CARDIAC ARRHYTHMIAS :

• Disturbances in automaticity : bertambah cepat

atau bertambah lambatnya suatu daerah otomatisitas.
Misal di sinus node, AV node, abnormal beats/
depolarisasi atrium, AV junction, ventrikel, VT, dll.

• Disturbances in conduction : konduksi terlalu cepat

(WPW) atau terlalu lambat (blok AV).

• Combinations of altered automaticity and

conduction.
 Arrhytmia

Tachyarrhythmia Bradyarrhytmia
(rate >100 x/min) (rate < 60 X/min)

• QRS sempit (<0.12 ms) • AV blok derajat 1, 2 & 3

• QRS lebar (>0.12 ms) • RBBB & LBBB
Diagnostic
Tachyarrhytmia

● Lebar gel. QRS

● Keteraturan gel. QRS

P wave ??
 QRS sempit : Supraventricular
origin

QRS sempit

Irama
Irama Teratur
Tidak teratur

Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia

Atrial Flutter
SVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
SVT
Atrial Fibrillation :

-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
-no uniform atrial depolarization
Atrial Flutter :
-The result of a re-entry circuit within
the atria
-Irregular / regular QRS rate
-Narrow QRS complex
-Rapid P waves (300x/min), “sawtooth”
QRS Lebar : Ventricular origin

QRS lebar

Irama
Irama Teratur
tidak teratur

Ventricular Ventricular
Tachycardia Fibrillation
Ventricular
Tachycardia
VT
VT
Torsade de Pointes
Ventricular
Fibrillation
Bradyarrhytmia
(rate < 60 x/min)

Failure of impulse AV conduction

formation abnormalities
● Sinus Bradycardia ● 1st and 2nd AV Block
● Sick Sinus Syndrome ● Total AV Block
● BBB (Bundle Branch
Block)
Sick Sinus Syndrome
AV BLOCK
First-degree AV block

Rhythm : Regular
Rate : Usually normal
P wave : Sinus P wave present; one P wave to each QRS
PR : Prolonged ( greater than 0.20 seconds )
QRS : Normal
Second -degree AV block, Mobitz I

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

Rhythm : Regular usually;

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;
PR interval may be normal or prolonged
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Third-degree AV block

Rhythm : Regular
Rate : 40 – 60 if block in His bundle;
30 – 40 if block involves bundle branches
P wave : Sinus P wave present; bear no relationship to QRS;
can be found hidden in QRS complexes and T waves
PR : Varies greatly
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Treat the patient not the monitor