EKG

DESKE MUHADI

l RATE
l RHYTHM
l AXIS
l HIPERTROPHIC SIGNS
l MYOCARDIAL INFARCTION
l ARRHYTHMIA
Anatomy Revisited
l SA node
l Intra-atrial
pathways
l AV node
l Bundle of His
l Left and Right
bundle branches
– left anterior fascicle
– left posterior fascicle
l Purkinje fibers
Anatomy Revisited
l RCA
– right ventricle
– inferior wall of LV
– posterior wall of LV
(75%)
– SA Node (60%)
– AV Node (>80%)
l LCA
– septal wall of LV
– anterior wall of LV
– lateral wall of LV
– posterior wall of LV
(10%)
Bipolar Leads
l 1 positive and 1 negative
electrode
– RA always negative
– LL always positive
l Traditional limb leads are
examples of these
– Lead I
– Lead II
– Lead III
l View from a vertical plane
Unipolar Leads
 1 positive electrode & 1
negative “reference point”
– calculated by using summation
of 2 negative leads
 Augmented Limb Leads
– aVR, aVF, aVL
– view from a vertical plane
 Precordial or Chest Leads
– V1-V6
– view from a horizontal plane
 The Electrocardiogram ( ECG )
l P wave : atrial
depolarisation
R
l QRS complex :
ventricular
depolarisation
P T

l T wave : ventricular
repolarisation
Q
S
l Atrial repolarisation
hidden by QRS
PR Interval
QRS Complex
ST Segment
 Waveform Components:
R Wave
First positive deflection;
R wave includes the
downstroke returning to
the baseline
 Waveform Components:
Q Wave

First negative deflection

before R wave; Q wave
includes the negative
downstroke & return to
baseline
 Waveform Components:
S Wave
Negative deflection
following the R wave; S
wave includes
departure from & return
to baseline
Waveform Components:
QRS
l Q waves
– Can occur normally in several
leads
• Normal Q waves called physiologic
– Physiologic Q waves
• < .04 sec (40ms)
– Pathologic Q
• >.04 sec (40 ms)
 Waveform Components:
QRS
l Q wave
– Measure width
– Pathologic if greater than or equal to
0.04 seconds (1 small box)
 Waveform Components:
QS Complex
Entire complex is
negatively
deflected; No R
wave present
Terminologi morfologi QRS
R
qRs Rs rS

QR Q/QS rSr’
RsR’
 Waveform Components:
J-Point
Junction between end of QRS
and beginning of ST segment;
Where QRS stops & makes a
sudden sharp change of
direction
 Waveform Components:
ST Segment
Segment between J-
point and beginning of
T wave
 Waveform Components:
ST Segment
l Need reference point
– Compare to TP segment
– DO NOT use PR segment as
reference!

ST TP
Waveform Components:
Practice

l Find J-points and ST

segments
Waveform Components:
Practice
l Find J-points and ST
segments
The Heartbeat
 Lead Groups

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6

Limb Leads Chest Leads

 SISTEM LEADS
 STANDARD LIMB LEADS
• I, II, III
 AUGMENTED UNIPOLAR LIMB LEADS
• aVR, aVL, aVF
 UNIPOLAR CHEST LEADS
• V1, V2, V3, V4, V5, V6
 PR interval = 0.12 – 0.20 sec
 QRS interval = 0.06 – 0.10 sec
 QT interval = 0.32 – 0.43 sec
 PEMASANGAN ELEKTRODE
l PEMASANGAN ELEKTRODE EXTREMITAS
• Lengan kanan dan lengan kiri
• Kaki kanan dan kaki kiri
l PEMASANGAN ELEKTRODE DADA
• V1 = Parasternal kanan di ICS-4
• V2 = Parasternal kiri di ICS-4
• V4 = MCL kiri di ICS-5
• V3 = Median antara V2 dgn V4
• V5 = Para Axillair Line kiri di ICS-5
• V6 = Median Axillair kiri di ICS-5
• V7, V8, V3R, V4R
Unipolar Precodial (Chest) Leads
Midclavicular line
Anterior axillary line
Midaxillary line

V6R V6
V5
V5R
V4
V4R V3
V3R V2
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
 Inferior Wall

 II, III, aVF

– View from Left Leg 
– inferior wall of left
ventricle
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
 Inferior Wall
l Posterior View
– portion resting on
diaphragm
– ST elevation suspect
inferior injury
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6 Inferior Wall
 Lateral Wall
 I and aVL
– View from Left Arm 
– lateral wall of left
ventricle

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
 Lateral Wall
l V5 and V6
– Left lateral chest
– lateral wall of left ventricle

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
 Lateral Wall

l I, aVL, V5, V6
I aVR V1 V4
– ST elevation
II aVL V2 V5
suspect lateral wall
injury III aVF V3 V6

Lateral Wall
 Anterior Wall
l V3, V4
– Left anterior chest
–  electrode on anterior
chest

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Anterior Wall
l V3, V4
– ST segment
elevation suspect
anterior wall injury

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
 Septal Wall
l V1, V2
– Along sternal borders
– Look through right ventricle &
see septal wall

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Septal
l V1, V2
– septum is left
ventricular tissue

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
 ST Segment Analysis

For each complex, determine whether the ST

segment is elevated one millimeter or more above
the TP segment
I. Sebutkan iramanya :
Normal Sinus Rhythm
Normal Sinus Rhythm

Rhythm : Regular
Rate : 60 – 100
P wave : Normal in configuration; precede each QRS
Constant R – R Interval
Negative P wave in aVR and positive in II
PR : Normal ( 0. 12 – 0.20 seconds )
QRS : Normal ( less than 0.12 seconds )
II. MENGHITUNG DENYUT
JANTUNG :
MENGHITUNG LAJU JANTUNG :
A. Jarak R – R : 300/kotak besar

-1 kotak sedang = 300 x / menit

-2 kotak sedang = 150 x / menit
-3 kotak sedang = 100 x / menit
-4 kotak sedang = 75 x / menit
-5kotak sedang = 60 x / menit
-6 kotak sedang = 50 x / menit

B. Hitung jumlah R- R dalam 6 kotak besar = 6 detik

Jumlah R x 10 = heart rate / menit

C. 1500 / jarak R-R ( dlm mm )(kotak kecil) = heart

rate / menit
300/…. =…. bpm

300/…. =…bpm
3. Menentukan Axis
 4. PJK
l ISCHEMIA : ST depresi atau T
inverted

l INFARCT : ST Elevasi

l NECROSIS (OLD INFARCT) :

gel. Q patologis atau QS
Ischemia Lateral
Ischemia Anterolateral
Acute anteroseptal STEMI
Acute inferoposterior STEMI
Acute Anterior MI
Acute Inferoposterior MI
T Inverted
ST Depresi
ST Elevasi
QS Patologis
 5. Pembesaran Ruang
Jantung
 LVH
 RVH
 P Mitral : Notch P wave
 P Pulmonal : P wave tajam dan
hampir ½ dari QRS
LVH
LVH
LVH
LVH strain
RVH
RVH
RVH
RVH
P Pulmonale
P Pulmonal
P Mitrale
 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

 QRS sempit : Supraventricular origin

QRS sempit

Irama
Irama Teratur
Tidak teratur

Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia

Atrial Flutter
PSVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
SVT
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”
Atrial Flutter
Atrial flutter
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
AF
 QRS Lebar : Ventricular origin

QRS lebar

Irama
Irama Teratur
tidak teratur

Ventricular Ventricular
Tachycardia Fibrillation
VT

VF
VT
VT
VF
Ventricular flutter
Torsade de Pointes
Torsade de Pointes
SR

VES
 Sinus rhythm
with
Multifocal VES

VES VES

SR SR
SR SR SR SR
Sinus rhythm with VES couplet
Sinus Rhythm with VES, R on T
 Bradyarrhytmia
(rate < 60 x/min)

Failure of impulse AV conduction

formation abnormalities
l Sinus l 1st and 2nd AV
Bradycardia Block
l Sick Sinus l Total AV Block
Syndrome l BBB (Bundle
Branch 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
2ND AV Block Type 1 :
Wenkebach

Missing QRS
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
2ND AV Block : Mobitz 2
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
Third-degree AV block
Sick Sinus Syndrome
RBBB
LBBB
Atherosklerosis
Angina Pectoris
Chronic PJK
 Gradasi beratnya angina pectoris
( Canadian Cardiovascular Sosciety )

1. Aktifitas sehari-hari tidak menimbulkan

angina,angina baru timbul pada aktifitas berat,
tergesa-gesa, cepat atau berkepanjangan

2. Aktifitas sehari-hari terganggu sedikit. Angina

timbul waktu berjalan atau naik tangga dengan
cepat, berjalan lebih dari 2 blok ( 400 m )

3. Aktifitas sehari-hari sangat terganggu.

4. Tidak mampu melakukan aktifitas apapun tanpa

angina
Acute Coronary Syndrome
 Atherothrombosis: the
Pathologic Process

Atherosclerotic Plaque Thrombus Thrombus Embolism

Plaque Fissure/ Formation Incorporated
Cracking into Atheroma
/
Rupture

Stabilized Occlusion
Plaque
Chronic Ischemia Acute Event
3L Medical Training Asia Middle East
 The Role of Platelets in
Atherothrombosis
1
Adhesion Aggregation
3

2 Activation
 Surface of a Thrombus

Nilsson, 1984 M3
 Atherothrombosis

3R Medical Training Asia Middle East

 Acute Coronary Syndrome

EKG: ST Elevation (-) ST Elevation (+)

Trop T (+)

UAP NSTEMI/ STEMI/

Non-Q MI Q MI

UAP: Unstable angina pectoris, Non-Q MI: Non-Q wave myocardial infarction
NSTEMI: Non ST-elevation myocardial infarction
STEMI: ST-elevation myocardial infarction, Q MI: Q wave myocardial infarction
 Kriteria Diagnosis
1. Nyeri dada khas infark atau ekuivalen lebih dari 20
menit, tidak hilang dengan pemberian nitrat

2. Gambaran EKG dan evolusinya yang khas IMA

a) Pada STEMI ditandai oleh elevasi 2mm di
precordial lead atau 1 mm di extremity lead atau new
BBB, semua perubahan terjadi minimal pada dua lead
yang berhubungan
b) Pada non STEMI EKG bisa normal atau berubah
tapi tidak memenuhi kriteria STEMI

3. Gambaran laboratorium : peningkatan enzim ( CK,

CK MB ) dan biomarker ( Troponin T, )
 Pertolongan Pertama

 Morphine (M)
 Oksigen (O)
 Nitrat (N)
 Aspirin (A)
 Plavix
PRINCIPLES MANAGEMENT AND
THERAPY OF THROMBOSIS

PATHOGENESIS THERAPY

PROTHROMBOTIC STATE REDUCED OF

RISK FACTOR

- PLATELET ADHESION
ANTIPLATELET
-PLATELET AGGREGATION

-BLOOD COAGULATION ANTI-

COAGULANT

-THROMBOSIS THROMBOLYTIC
AGENT
Infark Miokard Akut
 SAKIT DADA ISKEMIK

Pemeriksaan Pengobatan segera:

Monitor EKG
Akses IV
Saturasi O2
EKG 12 sandapan
Riwayat Penyakit
Kontra indikasi trombolitik
Foto Rho Thorax
 O2 4 L/menit
 Aspirin 160-325 mg
 Nitrogliserin SL atau spray
 Morphin IV (bila sakit dada
tidak hilang dgn nitrogliserin)
 Plavix
Ingat :MONA

Elevasi ST Depresi ST Tidak ada

atau atau perubahan
ST & gel. T
LBBB Baru inversi T
 Tidak ada perubahan ST & gel. T

Pertimbangkan : •Serum serial

 Heparin IV
 Nitrogliserin IV EKG serial
 Aspirin (+) Echo/radionuklir
 Plavix
 Penyekat beta

(-)

Boleh rawat jalan

& kontrol teratur
 Depresi ST atau inversi T
Pertimbangkan :
 Heparin IV
 Nitrogliserin IV
 Aspirin
 Plavix
 Penyekat beta

•Gejala menetap
•Iskemia berulang
Klinis stabil
•Penurunan fungsi ventrikel kiri
•Perubahan EKG luas
•Baru mengalami IMA, PTCA, CABG Teruskan terapi
•Pasien risiko tinggi

Kateterisasi jantung: Revaskularisasi

Anatomi tepat untuk • PTCA
revaskularisasi ? • CABG
 Elevasi ST atau LBBB Baru
< 12 jam > 12 jam
Pertimbangkan :
Reperfusi Waktu  Heparin IV
 Nitrogliserin IV
 Aspirin
 Plavix
 Penyekat beta

Thrombolytic Primary
terapi
jika tidak ada PTCA Masuk ke
Algoritme
kontra indikasi sebelumnya
(UAP dan NSTEMI)
ST depresi
T inverted
ST elevasi
Bradycardia
 BRADYCARDIAS
• Slow (absolute bradycardia=rate < 60 bpm
or
• Relatively slow (rate less than expected relative to
underlying condition or cause)

PRIMARY ABCD SURVEY

• Assess ABCs
• Secure airway noninvasively
• Ensure monitor / defibrillator is available

SECONDARY ABCD SURVEY

• Assess secondary ABCs (invasive airway
management needed?)
• Oxygen - IV access - monitor - fluids
• Vital signs, pulse oximeter, monitor BP
• Obtain and review 12-lead ECG
• Obtain and review portable chest x-ray
• Problem-focused history
• Problem-focused physical examination
• Consider causes (differential diagnoses)

Next slide
 SERIOUS SIGNS OR SYMPTOMS ?
Due to the bradycardia?

No Yes

Type II second-degree AV block Intervention Sequence

or • Atropine 0.5 – 1.0 mg
Third-degree AV block? • Transcutaneous pacing if available
• Dopamine 5-20 µg/kg per minute
• Epinephrine 2-10 µg/min
• Isoproterenol 2-10 µg/min

No Yes
• Prepare for transvenous pacer
Observe • If symptoms develop, use
transcutaneous pacemaker until
transvenous pacer placed
 The
Deadly
Rhythms

PEA
VT VF (Pulse less
Electrical
Activity)
A systole
 • Pasien tidak sadar
• Diduga henti jantung
• Periksa respon

Respon (-)
Mulai survey ABCD Primer
(Mulai algoritm BLS)
• Aktifkan EMS
• Siapkan defibrilator
• (A) Periksa nafas (buka jalan nafas, lihat,dengar,rasakan)

Nafas (-)
• (B) Beri 2 nafas lambat
• (C) Periksa nadi, jika nadi(-) 
• (C) Kompresi dada
• (D) Pasang monitor/ defibrilator

Nadi (-)
•Lanjutkan CPR
•Periksa irama
 Nadi (-)

• Lanjutkan CPR
• Periksa Irama

VF/VT Non-VF/VT
Lakukan Defibrilasi (Asistol atau PEA)

(sampai 3 shock bila VF terus)

Survey ABCD Sekunder
• Airway: usahakan segera pasang peralatan jalan nafas
• Breathing : pastikan dan amankan jalan nafas, ventilasi dan
oksigenasi
• Circulation : pasang jalur IV; berikan obat adrenergik;
pertimbangkan antiaritmia, buffer, pacu jantung

Pasien Non-VF/VT
CPR selama CPR selama
•Epinephrine 1 mg IV, ulang tiap 3 sampai 5 menit
1 menit Pasien VF/VT 3 menit
•Vasopressin 40 U I, dosis tunggal, hanya 1 kali, atau
•Epinephrine 1 mg IV, ulang tiap 3 sampai 5 menit
(jika respon (-) setelah dosis tunggal vasopressin, boleh
diulangi lagi epinefrin 1 mg IV bolus cepat, ulangi tiap 3
sampai 5 menit)
• Differential Diagnosis: cari dan obati penyebab yang reversibel
Simulasi 1
Simulasi 2
Simulasi 3
Simulasi 4