Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit Irama (rythm): regular / irregular Zona transisi V1-V6 Axis Elektrik: sumbu (derajat), posisi (normal, left, right, indeterminate / right superior / northwest) Interval PR, QRS, dan QT dalam detik Lain-lain

ECG basics
.1 mv

paper

Voltage

.5 mv .04 seconds
Paper speed = 25mm / second Heart Rate = number of R-waves in a ECG 6 second strip divided by 10 Berapa kecepatan kertas bergerak: 25 mm/detik = 1500 divided by the number of small boxes between consecutive R-waves = large square estimation counts ( 300 - 150 - 100 - 75 - 60 - 50 - 43 )

Time

.20 seconds

1 mv beda potensial antara kedua elektroda akan terekam setinggi berapa cm ?

1 cm

Berapa Frekuensinya:
Bila jarak R ke R dalam kotak besar (5 mm) hitung 300/jarak R-R (150-100-75-60-50) Bila jarak R ke R dalam mm 1500/jarak R-R dlm mm Bila tidak teratur hitung jumlah kompleks QRS dlm rekaman sepanjang 15 cm (6 detik) kemudian hasilnya dikalikan 10

Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit Irama (rythm): regular / irregular Zona transisi V1-V6 Axis Elektrik: sumbu (derajat), posisi (normal, left, right, indeterminate / right superior / northwest) Interval PR, QRS, dan QT dalam detik Lain-lain

Beats and Rhythms

Atrial Escape Beat

normal ("sinus") beats

sinus node doesn't fire leading to a period of asystole

p-wave has different shape indicating it did not originate in the sinus node, but somewhere in the atria. It is therefore an "atrial" beat

Atrial and Junctional Ectopic Beats and Rhythms

Paroxysmal Atrial Tachycardia: An atrial ectopic focus takes over pacing the heart You suspect that it is "atrial" because you see the p-waves disappear Rhythm may produce chest palpitations If HR reaches about 300 beats per minute, Q may be compromised The term paroxysmal (of sudden onset) is applied to these types of rhythms

Paroxysmal Supraventricular Tachycardia: What if the only rhythm you saw was the one below: is it atrial or junctional? It comes from above the ventricles because QRS's are normal looking Since exact origin cannot be determined, it is termed "supraventricular"

Junctional Escape Beat

QRS is slightly different but still narrow, indicating that conduction through the ventricle is relatively normal

there is no p wave, indicating that it did not originate anywhere in the atria, but since the QRS complex is still thin and normal looking, we can conclude that the beat originated somewhere near the AV junction. The beat is therefore called a "junctional" beat

Ventricular Escape Beat

QRS is wide and much different ("bizzare") looking than the normal beats. This indicates that the beat originated somewhere in the ventricles

there is no p wave, indicating that the beat did not originate anywhere in the atria actually a "retrograde p-wave may sometimes be seen on the right hand side of beats that originate in the ventricles, indicating that depolarization has spread back up through the atria from the ventricles

Ectopic Beats or Rhythms beats or rhythms that originate in places other than the SA node
the ectopic focus may cause single beats or take over and pace the heart, dictating its entire rhythm

they may or may not be dangerous depending on how they affect the cardiac output

Ventricular Ectopic Beats

Premature Ventricular Contraction: A ventricular ectopic focus discharges causing an early beat Ectopic beat has no P-wave (maybe retrograde), and QRS complex is "wide and bizzare" QRS is wide because the spread of depolarization through the ventricles is abnormal In most cases, the heart circulates no blood because of an irregular squeezing motion - PVC's sometimes described as "skipped beats"

ventricles is abnormal In most cases, the heart circulates no blood because of an irregular squeezing motion - PVC's sometimes described as "skipped beats" R on T phenomemon

Multifocal PVC's

Compensatory pause after the occurance of a PVC

PVC's are Dangerous When: They are frequent (> 30% of complexes) or are increasing in frequency The come close to or on top of a preceeding T-wave (R on T) Three or more PVC's in a row (run of V-tach) Any PVC in the setting of an acute MI PVC's come from different foci ("multifocal" or "multiformed") Any of these dangererous phenomenon may preclude a deadly rhythm (Ventrcular Tachycardia)

Ventricular Ectopic Beats and Rhythms

Ventricular Tachycardia: Deadly rhythm - generates no Q - person usually loses consciousness Requires defibrillation....the sooner the greater chance of survival May result from MI or a variety of other pre-existing conditions R on T phenomemon

Ventricular Fibrillation: Deadly rhythm - generates no Q - last gasp of a dying heart Requires defibrillation - often not successful Usually follows ventricular tachycardia

Ventricular Fibrillation: Deadly rhythm - generates no Q - last gasp of a dying heart Requires defibrillation - often not successful Usually follows ventricular tachycardia

V-tach

V-fib

A Conceptual Model for Understanding Bundle Branch Blocks 1. Septum depolarization occurs first inscribing an initial upward deflection in V1 - V2 and a small downward deflection in V5 - V6 2. Left ventricular depolarization occurs next, inscribing a downward deflection in V1 - V2 and an upward deflection in V5 - V6. Since the right bundle branch is blocked, depolarization of the right ventricle is delayed. 3. Finally, depolarization spreads from the left ventricle over to the right ventricle and the right ventricle depolarizes. This inscribes a second R-wave (R) in V1 - V2, and sometimes, a slight V1 S-wave in V5 - V6.

Right BBB
1 2

3 V5 - V6 3 - V2 1 2
Wide QRS Complexes

Left BBB
1 2 1

13

1. Depolarization enters the right side of the right ventricle first and simultaneously depolarizes the septum from right to left. Since the septum has more mass (and thus contributes more electricity to the depolarization vector), the dominant force

left ventricle over to the right ventricle and the right ventricle depolarizes. This inscribes a second R-wave (R) in V1 - V2, and sometimes, a slight V1 S-wave in V5 - V6.

V5 - V6 3 - V2 1 2
Wide QRS Complexes

Left BBB
1 2 1 V5 - V6 V1 - V2 1 2
Wide QRS Complexes

13

1. Depolarization enters the right side of the right ventricle first and simultaneously depolarizes the septum from right to left. Since the septum has more mass (and thus contributes more electricity to the depolarization vector), the dominant force moves away from V1 - V2 and inscribes a negative deflection in those leads. Leads V5 - V6 show a positive deflection. 2. Having spread over from the right ventricle, left ventricular depolarization continues and generates the main cardiac vector. This too is moving away fromV1 - V2 and continues to inscribe a negative complex. Likewise, the vector proceeds toward V5 - V6 and continues to inscribe a positive complex. A slight notching of the R-wave may sometimes be seen in V5 - V6.

1 2

Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit Irama (rythm): regular / irregular Zona transisi V1-V6 Axis Elektrik: sumbu (derajat), posisi (normal, left, right, indeterminate / right superior / northwest) Interval PR, QRS, dan QT dalam detik Lain-laian

Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit Irama (rythm): regular / irregular Zona transisi V1-V6 Axis Elektrik: sumbu (derajat), posisi (normal, left, right, indeterminate / right superior / northwest) Interval PR, QRS, dan QT dalam detik Lain-lain

Depolarization Wave of a Strip of Nerve Cells (or Myocardial Muscle Cells minus the depiction of Ca influx)
+ +

Wave of Depolarization or Propigation of Action Potential moving from left to right

Polarized Cell

Repolarizing Depolarized Depolarizing Cell Cell Cell ( K+ efflux ) ( Na+ influx )

Polarized Cell

Na+ K+ Na+ K+ Na+ K+

Na+ K+

Na+ K+

++++

----

++++

----

++++

----

The needle of this recording electrode inscribes a totally negative complex because the wave of depolariztion is moving away from it during the entire time the strip is depoarizing

The needle of this recording electrode is biphasic because half of the time the wave of depolarization is moving towards it while the other half of the time it is moving away from it

The needle of this recording electrode inscribes a totally positive complex because the wave of depolariztion is moving towards it during the entire time the strip is depoarizing

The Concept of a "Lead"

Lead I

G
Electrocardiograph

Right arm (RA) negative, left arm (LA) positive, right leg (RL) groundthis arrangement of electrodes enables a "directional view" recording of the heart's electrical potentials as they are sequentially activated throughout the entire cardiac cycle

The Concept of a "Lead" Lead I

The directional flow of electricity from Lead I can be viewed as flowing from the RA toward the LA and passing through the heart. Also, it is useful to imagine a camera lens taking an "electrical picture" of the heart with the lead as its line of sight

The Concept of a "Lead" The Limb Leads

LEAD AVR LEAD AVL

-150o

-30o 0o
LEAD I

60o 120o
LEAD III

90o
LEAD AVF

LEAD II

Each of the limb leads (I, II, III, AVR, AVL, AVF) can be assigned an angle of clockwise or counterclockwise rotation to describe its position in the frontal plane

The Concept of a "Lead" Leads I II III

RA

RA

LA

+ LL

+ LA
LEAD I

LEAD III

+LL
LEAD II

Remember, the RL is always the ground By changing the arrangement of which arms or legs are positive or negative, two other leads ( II & III ) can be created and we have two more "pictures" of the heart's electrical activity from different angles

The Concept of a "Lead" Leads AVR AVL AVF

LEAD AVR RA +

RA & LA

LEAD AVL

+ LA

RA & RL LL + LEAD AVF

LL & LA

By combining certain limb leads into a central terminal, which served as the negative electrode, other leads could be formed to "fill in the gaps" in terms of the angles of directional recording. These leads required augmentation of voltage to be read and are thus labeled.

The Concept of a "Lead" The Precordial Leads

Each of the precordial leads is unipolar (1 electrode constitutes a lead) and is designed to view the electrical activity of the heart in the horizontal or transverse plane

V1

V2 V3 V4 V5 V6

aVR

aVL

aVF

Hexaxial Array for Axis Determination

determination of the angle of the main cardiac vector in the frontal plain

Lead I

Example 1

If lead I is mostly positive, the axis must lie in the right half of of the coordinate system

Lead AVF

If lead AVF is mostly positive, the axis must lie in the bottom half of of the coordinate system

AVF

Combining the two plots, we see that the axis must lie in the bottom right hand quadrant

AVF

AVL

Once the quadrant has been determined, find the most equiphasic or smallest limb lead. The axis will lie about 90o away from this lead. Given that AVL is the most equiphasic lead, the axis here is at approximately 60o.

AVF

AVL

Since QRS complex in AVL is a slightly more positive, the true axis will lie a little closer to AVL (the depolarization vector is moving a little more towards AVL than away from it). A better estimate would be about 50o.

Example 2
Lead I

If lead I is mostly negative, the axis must lie in the left half of of the coordinate system

Lead AVF

If lead AVF is mostly positive, the axis must lie in the bottom half of of the coordinate system

AVF

Combining the two plots, we see that the axis must lie in the bottom left hand quadrant (Right Axis Deviation)

AVF

II

Once the quadrant has been determined, find the most equiphasic or smallest limb lead. The axis will lie about 90o away from this lead. Given that II is the most equiphasic lead, the axis here is at approximately 150o.

AVF

II

Since the QRS in II is a slightly more negative, the true axis will lie a little farther away from lead II than just 90o (the depolarization vector is moving a little more away from lead II than toward it). A better estimate would be 160o.

Precise calculation of the axis can be done using the coordinate system to plot net voltages of perpendicular leads, drawing a resultant rectangle, then connecting the origin of the coordinate system with the opposite corner of the rectangle. A protractor can then be used to measure the deflection from 0. Consider the example:

Since Lead III is the most equiphasic lead and it is slightly more positive than negative, this axis could be estimated at about 40o.

Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit Irama (rythm): regular / irregular Zona transisi V1-V6 Axis Elektrik: sumbu (derajat), posisi (normal, left, right, indeterminate / right superior / northwest) Interval PR, QRS, dan QT dalam detik Lain-lain

= 1500 divided by the number of small boxes between consecutive R-waves = large square estimation counts ( 300 - 150 - 100 - 75 - 60 - 50 - 43 )

Penilaian hasil rekaman EKG:

Frekuensi (rate) dihitung / menit Irama (rythm): regular / irregular Zona transisi V1-V6 Axis Elektrik: sumbu (derajat), posisi (normal, left, right, indeterminate / right superior / northwest) Interval PR, QRS, dan QT dalam detik Lain-lain

ECG diagnosis