ELEKTROKARDIOGRAFI At a Glance

Originally composed by: Adi Bestara

Ada yang aneh ?

Outline
Basics Sadapan Ekg Morfologi Ekg + Nilai normal Apa yang dapat kita kenali pada Ekg ? Reading Ekg systematically

Basic

Sadapan EKG

Morfologi EKG

Terminologi morfologi QRS

Nilai normal
On the board !

QTc interval
Man < 0,39 Woman < 0,41
Normal >N
Long QT

Long QT
Torsades de Pointes

A prolonged QT can be very dangerous. It may predispose an individual to a type of ventricular tachycardia called Torsades de Pointes. Causes include drugs, electrolyte abnormalities, CNS disease, post-MI, and congenital heart disease. QTc = QT int / R-R int Qt Int N : < 0,46 or < 40% R-R int

Transitional Zone

Reading Ekg systematically

Kelayakan Baca : identitas, waktu, kalibrasi, kecepatan , pemasangan sadapan Voltage :E<=5, P <=10 Irama : --------------------------------- Rate : Reguler, Irreguler Axis : N, LAD, RAD, Extreme RAD Morfologi P : p atrial, p pulmonal PR interval : pre eksitasi, AV block QRS complex : lebar/sempit, Ventrikel enlargement, RBBB, LBBB, Q patologis, Poor R wave progression ST segmen : PJK, electrolite abnormalities, drug, Carditis T : PJK, electrolyte abnormalities QT interval : Long QT U : electrolyte abnormalities

Axis

AXIS: NORMAL EKG - positive polarity(tall R) in inferior and lateral leads with increasing positive polarity (r-wave progression) across the precordium V1-6
I
AVR

V 1

V 4

II

AVL

V 2

V 5

V 3 III AVF

V 6

In a normal patient the only leads that should have negative polarity are AVR and V1-2 ---To determine axis: Look at leads AVL and AVF
I
AVR

V 1

V 4

II

AVL

V 2

V 5

V 3 III AVF

V 6

Rate?

- Regular

- Irregular

Apa yang dapat kita kenali pada Ekg ?

Cardiac Chamber Hypertrophy : Atrium: RAH, LAH Ventrikel: RVH, LVH/ Enlargement (Pressure & Volume) Coronary Heart Disease : Iskemia Injury Infark Stemi, Nstemi / Subendocard Pre-excitation Syndromes : WPW LGL Others: Electrolite Drug Carditis Pace Maker

Apa yang dapat kita kenali pada Ekg ?

Aritmia Ectopic rhytm & Extra systole : Atrial : AES, A Fib, A Flutter Juctional : Juctional Rhytm, JES (atas, tengah, bawah) Supraventricular : SVT Ventricular : VES, VT, Vfib, Ventricular Asystole Block of Conduction : SAN : Sinus drop beat / paused, NSR, sinus Bradicardia, Sinus Tachicardia, Sinus Aritmia AVN : 1 2 : Mobitz I, Mobitz II High Grade AV Block 3 / Complete Heart Block Bundle Branch: RBBB LBBB

Cardiac Chamber Hypertrophy :

 Depolarisasi atrium menghasilkan gelombang P. Kelainan atrium : klainan gelombang P Gelombang P normalnya lebar < 3 kotak kecil, tinggi < 2,5 kotak kecil

HIPERTROFI ATRIUM KANAN

Gelombang P > 2,5 mm P pulmonale

HIPERTROFI ATRIUM KIRI

Notched P > 0,12 P mitral

- gel. R yg tinggi di V1 (yg biasanya - mjd +) - Gel.S yg masih tetap ada diambil sadapan V3R, klo QRS + kesimpulannya RVH

HIPERTROFI VENTRIKEL KIRI

Sokolow + Lyon (Am Heart J, 1949;37:161) S V1+ R V5 or V6 > 35 mm Cornell criteria (Circulation, 1987;3: 565-72) SV3 + R avl > 28 mm in men SV3 + R avl > 20 mm in women Framingham criteria (Circulation,1990; 81:815-820) R avl > 11mm, R V4-6 > 25mm S V1-3 > 25 mm, S V1 or V2 + R V5 or V6 > 35 mm, R I + S III > 25 mm

Coronary Heart Disease/ PJK

In order to perform work, the heart needs oxygen and nutrients. There are two main arteries: Right coronary artery (RCA) Left coronary artery (LCA). The left coronary artery divides into: Left anterior descending (LAD) branch Left circumflex branch(LCX) The right coronary artery and the branches of the left coronary artery provide numerous smaller branches which penetrate the heart muscle, supplying it with blood.

Both coronary arteries originate from the aorta and run along the surface of the heart. In the majority of human hearts, coronary circulation follows a predictable pattern.

Left Main Coronary Artery Branches quickly into the LAD & LCX. Involves almost 2/3 of the heart muscle
Right Coronary Artery (RCA) The RCA supplies blood to the bottom (inferior) portion and part of the back (posterior) portion of the left ventricle. The posterior portion of the septum is also supplied with blood from the RCA. SA Node 55% AV Node 90% AV Blocks Left Anterior Descending Branch (LAD) The LAD supplies blood to the front (anterior) portion of the left ventricle, apical including most of the anterior portion of the septum separating the ventricles. Bundle Branch Block, AMI, CHF Left Circumflux Branch (LCX) The LCX supplies blood to the left side (lateral) portion and the back (posterior) portion of the left ventricle. SA Node 45% AV Node 10% Lateral & posterior MI

Sino-Atrial (SA) Node: natural cardiac pacemaker. The heartbeat starts here and spreads throughout the network of conduction fibers in the two atria causing them to contract.
Normally, the heartbeat can only reach the ventricles (the two lower chambers), after it has passed through the atrioventricular (AV) node. Atrioventricular (AV) Node: slows down the electrical signal so that the atrial contractions can finish filling the ventricles completely. The AV node also prevents the lower chambers from beating too fast if the atria develops a fast rhythm (tachyarrhythmia).

His Bundle, bundle branches, and the Purkinje system : The electrical signal finally passes to the ventricles causing the ventricles to contract

KELAINAN PADA EKG

1. ISKHEMIK : ST depresi : Up sloping Down sloping // isoelektris T inverted

2. INJURY : 3. NECROSIS :

ST elevasi Q patologi QS

Phase : awal / hiperakut akut (hari 1-7) recent (hari 7- 1bln) lama / Old

DD. Kardiomiopathy, LVH, WPW

ISKEMIK : Otot jantung kekurangan O2 namun belum mengalami kerusakan. EKG : depresi ST dan atau inversi T. Depresi ST

- Inversi T :
a. Inversi T : kurang spesifik untuk iskemia b. Inversi T lancip & simetris (anak panah) : spesifik untuk iskemia

a = horizontal, b = landai ke bawah, c = landai ke atas

GAMBARAN ISCHEMIA PADA EKG

T inversi, biasanya simetreis

ST depresi yang spesifik Horizontal

Sagging (downsloping)/menurun

ST depresi kurang spesifik (upsloping=naik)

INJURY : - otot jantung telah mulai rusak dan dalam waktu singkat akan mengalami infark. - EKG : ST elevasi

INFARK Otot jantung telah mengalami nekrosis/mati Gambaran khas : Q patologis.

- Lebar > 1kotak kecil - Dalam > 1 kotak kecil - Dalam > 1/3 tinggi R

GAMBARAN INJURY PADA EKG

Disebut Injury pattern apabila :

ST elevasi, yg spesifik (konvex ke atas/ cembung ke atas)

ST elevasi tidak spesifik (cekung ke atas)

GAMBARAN NECROSIS PADA EKG

Disebut necrosis pattern apabila : Gambaran Q wave yg lebar dan dalam Q wave dianggap patologis apabila dalamnya > 1/3 dari tinggi R Dalamnya Q menunjukkan tebalnya jaringan necrosis Tinggnya R menunjukkan sisa jaringan myocard yg sehat Adanya QS menunjukkan necrosis seluruh myocard

ISKEMIA

Gelombang T iskemik : inverted simetris

NOMENKLATUR PENENTUAN LOKASI PATOLOGI

KELAINAN EKG V1 dan V2 V3 dan V4 V1 s/d V4 1, AVL 1, AVL, V5-V6 1,AVL, V3 s/d V6 1, AVL, V1 s/d V6 11, 111, AVF Gel R lebar pd V1. V2 LOKASI INFARK Septum Anterior Anteroseptal Lateral tinggi Lateral Anterolateral Anterior Ektensif Inferior Posterior

Pre-Excitation Syndromes-WPW & LGL

Accessory pathway connects atria to the ventricles, bypassing the AV node Wolff-Parkinson-White: short PR (< 0.12 s), Delta wave (slurred upstroke QRS), slight wide QRS >0.10s, and frequently a psuedoinfarction pattern in the inferior leads and RBBB pattern. Lown-Ganong-Levine: short PR (< 0.12 s), NO Delta wave, normal QRS & episodes of tachydysrhythmias

WPW

LGL

AV Blocks

BBB

LEFT BUNDLE BRANCH BLOCK Left bundle branch

block
QRS > 0.12 sec Deep S in V 1-3 No q in V 5-6 Tall R and RsR in lateral leads: I, AVL, & V 5-6 Axis LAD

LEFT BUNDLE BRANCH BLOCK

RsR ( M shape ) di V6 QS or rS di lead V1 Durasi QRS complex >= 120 ms

Right Bundle Branch Block

QRS > 0.12 sec Predominantly positive rSR in V 1-3 Wide slurred S in lead I, V5, V6

RIGHT BUNDLE BRANCH BLOCK

rSR Slurred S di lead I dan V6

Arrhytmias
CAUSE OF CARDIAC ARRHYTHMIAS :

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

Disturbances in automaticity : bertambah cepat atau

atau terlalu lambat (blok AV).

Disturbances in conduction : konduksi terlalu cepat (WPW)

Combinations of altered automaticity and conduction.

Aritmia Ectopic rhytm & Extra systole : Sinus : Sinus Arrtytmia Atrial : Atrial rhtytm, Atrial tachicardia, AES, A Fib, A Flutter Juctional : Juctional Rhytm, JES, Junctional tachicardia, Junctional bradicardia : (atas, tengah, bawah) Supraventricular : SVT Ventricular : Idioventricular rhytm, VES, VT, Vfib, Ventricular Asystole Block of Conduction : SAN : Sinus drop beat / paused, NSR, sinus Bradicardia, Sinus Tachicardia, Sinus Aritmia AVN : 1 2 : Mobitz I, Mobitz II High Grade AV Block 3 / Complete Heart Block Bundle Branch: RBBB LBBB

SA ARRHYTMIAS

ATRIAL ARRHYTMIAS

Junctional Arrytmias

Ventricular Arrhytmias

Artificial Pacemaker

Artifact

Ya. Sinus MANIS

Alur Singkat ARITMIA

Ya. Sinus TAPI dengan PAC/PVC, AV Block, dll

Sempit -AF : P tak jelas, tdk teratur -A. Flutter : gigi gergaji -SVT : P tak jelas, teratur, biasanya HR>150 -AV/Junctional Rhythm Lebar/aneh -VT : P tak jelas, teratur -VF : Undulasi tak teratur -Ventricular Rhythm
Note : Tidak berlaku untuk kondisi RBBB/LBBB maupun kondisi khusus lain

SINUS?

Bukan.

QRS sempit
atau Lebar/Aneh?

Irama Sinus dengan Premature Atrial Contraction (PAC)

Irama Sinus dengan Premature Ventricular Contraction (PVC)

Ada QRS yang datang sebelum waktunya (premature), QRS-nya

Atrial Flutter :
gambaran khas gigi gergaji

Atrial Fibrilasi
RR interval tidak teratur, tak tampak gelombang P yang jelas.

Supra Ventricular Takikardi

P TIDAK JELAS, QRS Sempit, TERATUR, HR > 150 x/menit

Ventricular Takikardi
P tidak Jelas, QRS LEBAR, Teratur HR > 100 x/mnt

Ventrikel Fibrillasi
Undulasi-undulasi yang tidak teratur dan cepat, diikuti henti ventrikel ( asistol ventrikuler ) tak ada kompleks QRS

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

A 16 yo young man ran into a guardrail while riding a motorcycle. In the ED he is comatose and dyspneic. This is his ECG.

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

What is the rate? Approx. 132 bpm (22 R waves x 6)

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

What is the rhythm? Sinus tachycardia

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

What is the QRS axis? Right axis deviation (- in I, + in II)

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

What are the PR, QRS PR = 0.12 s, QRS = 0.08 s, QTc = 0.482 s and QT intervals?

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

Is there evidence of atrial enlargement? No (no peaked, notched or negatively deflected P waves)

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

Is there evidence of No (no tall R waves in V1/V2 or V5/V6) ventricular hypertrophy?

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

Infarct: Are there abnormal Q waves?
30

Yes! In leads V1-V6 and I, avL

Any

R40

20

30

30

Any

R50

30

30

Any

30

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

Infarct: Is the ST elevation or depression? Yes! Elevation in V2-V6, I and avL. Depression in II, III and avF.

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

Infarct: Are there T wave changes? No

SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct

ECG analysis: Sinus tachycardia at 132 bpm, right axis deviation, long QT, and evidence of ST elevation infarction in the anterolateral leads (V1-V6, I, avL) with reciprocal changes (the ST depression) in the inferior leads (II, III, avF).
This young man suffered an acute myocardial infarction after blunt trauma. An echocardiogram showed anteroseptal akinesia in the left ventricle with severely depressed LV function (EF=28%). An angiogram showed total occlusion in the proximal LAD with collaterals from the RCA and LCX.

Differential Diagnosis

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