NORMAL ELECTROCARDIOGRAPHY

EKG normal: 1. EKG 12 sadapan standar : prinsip dan teknik 2. Membaca EKG normal dan interpretasi 3. Artefak dan salah letak sadapan

Introduction

In 1913, Wilhelm Einthoven contributed significantly to the study of the heart by inventing the electrocardiogram (EKG). Einthoven attached wires or electrodes to the right arm, left arm, and left leg. This formed a theoretical triangle. The contraction and relaxation of cardiac muscle results from the depolarisation and repolarisation of myocardial cells. These electrical changes are recorded via electrodes placed on the limbs and chest wall and are transcribed on to graph paper to produce an electrocardiogram.

What does the ECG actually record?

ECG machines record the electrical activity of the heart. By convention, the main waves on the ECG are given the names P, Q, R, S, T and U. Each wave represents depolarization (electrical discharging) or repolarization (electrical recharging) of a certain region of the heart

How does the ECG look at the heart?

ECG machine uses the information it collects via its four limb and six chest electrodes to compile a comprehensive picture of the electrical activity in the heart as observed from 12 different viewpoints, and this set of 12 views or leads gives the 12-lead ECG its name. Each lead is given a name (I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5 and V6) and its position on a 12-lead ECG is usually standardized to make pattern recognition easier. Each limb lead looks at the heart from the side (the coronal plane) The six chest leads (V1V6) look at the heart in a horizontal plane from the front and around the side of the chest

How to Measure Waves on the EKG

EKG Paper

The EKG is recorded on special standardized paper that scrolls out of the machine at a specific and controlled speed. Each large box is 5mm wide and represents 0.20 seconds. Each large box is equivalent to 5 smaller 1-mm boxes, each representing 0.04 seconds.

The Baseline

The baseline on a 12lead EKG is an imaginary line that connects the end of the T wave to the beginning of the P wave. All measurements of other waves are made relative to the baseline.

How to Measure Waves on the EKG

Each little box is 1 mm tall (vertically). A wave that goes upward from the baseline is said to be positive. A wave that goes downward from the baseline is said to be negative. Measuring the distance of a positive waves peak from the baseline gives the amplitude (height) of the wave in milli meters. Measuring the distance of a negative waves lowest point from the baseline gives the amplitude (depth) of the wave in millimeters.

Standardization/Calibration

How do I record an ECG?

To record a clear, noise-free ECG, begin by asking the patient to lie down and relax to reduce electrical interference from skeletal muscle. Before attaching the electrodes, prepare the skin underneath with a spirit wipe and remove excess hair to ensure good electrical contact. Attach the limb and chest electrodes in their correct positions.

How do I record an ECG?

The right-leg electrode is not used for the measurement but serves as an electrical ground.

created by combining the six limb leads

How do I record an ECG?

Position of the six chest electrodes for standard 12 lead electrocardiography. V1: right sternal edge, 4th intercostal space; V2: left sternal edge, 4th intercostal space; V3: between V2 and V4; V4: mid-clavicular line, 5thspace; V5: anterior axillary line, horizontally in line with V4; V6: mid-axillary line, horizontally in line with V4

1.

2.

3. 4.

5.

6.

leads II, III, and aVF view the inferior surface of the heart; leads V1 to V4 view the anterior surface; leads I, aVL, V5, and V6 view the lateral surface; leads V1 and aVR look through the right atrium directly into the cavity of the left ventricle.

The heart muscle is arranged in three muscle masses: the intraventricular septum, a large left ventricular muscle mass, and a small right ventricular muscle mass. The magnitude or amplitude of the deflections recorded is influenced by the size of the muscle mass depolarized and the distance from the recording electrode

Conventional Sequence Regarding Interpretation

Rate Rhythm Electrical axis P wave morphology PR interval QRS interval, QRS complex morphology ST segment T wave U wave, and QT duration

Rate
Normal heart rate 60-100 beats/minutes The standard ECG paper speed is 25 mm/sec. Therefore, or more simply,

Rhythm

1. 2. 3. 4.

To assess the cardiac rhythm accurately, a prolonged recording from one lead is used to provide a rhythm strip. Lead II, which usually gives a good view of the P wave. The normal cardiac rhythm, initiated by depolarization of the sinus node, is known as sinus rhythm and is present if: The P wave is upright in leads I and II Each P wave is usually followed by a QRS complex The heart rate is 60-99 beats/min The PR interval is 0.12-0.20 s

Cardiac axis

The cardiac axis refers to the mean direction of the wave of ventricular depolarisation in the vertical plane, measured from a zero reference point. The flow of electrical current through the heart is fairly uniform, as it normally passes along a well-defined pathway In simple terms, the cardiac axis is an indicator of the general direction that the wave of depolarization takes as it flows through the heart.

Cardiac axis
Conditions for which determination of the axis is helpful in diagnosis 1. Conduction defectsfor example, left anterior hemiblock 2. Ventricular enlargementfor example, right ventricular hypertrophy 3. Broad complex tachycardiafor example, bizarre axis suggestive of ventricular origin 4. Congenital heart diseasefor example, atrial septal defects 5. Pre-excited conductionfor example,Wolff-Parkinson-White syndrome 6. Pulmonary embolus

Cardiac axis

The simplest method is by inspection of leads I, II, and III.

Cardiac axis

Cardiac axis

A more accurate estimate of the axis can be achieved if all six limb leads are examined. The hexaxial diagram shows each leads view of the heart in the vertical plane. Electrical force is pointing toward the sensor

P wave

1. 2. 3.

4.
5.

6.

The sinoatrial node lies high in the wall of the right atrium and initiates atrial depolarisation, producing the P wave on the electrocardiogram. Characteristics of the P wave Positive in leads I and II Best seen in leads II and V1 Commonly biphasic in lead V1 < 3 small squares in duration < 2.5 small squares in amplitude Inverted in aVR

PR interval

During this time the electrical impulse is conducted through the atrioventricular node, the bundle of His and bundle branches, and the Purkinje fibres. The PR interval is the time between the onset of atrial depolarisation and the onset of ventricular depolarisation The normal duration of the PR interval is three to five small squares (0.12-0.20 s).

QRS complex

The QRS complex represents the electrical forces generated by ventricular depolarisation. The depolarisation wave travels through the interventricular septum via the bundle of His and bundle branches and reaches the ventricular myocardium via the Purkinje fibre network. The left side of the septum depolarises first, and the impulse then spreads towards the right. Nomenclature in QRS complexes Q wave: Any initial negative deflection R wave: Any positive deflection S wave: Any negative deflection after an R wave

QRS complex

The duration of the QRS complex is measured in the lead with the widest complex and should not exceed two and a half small squares (0.10 s). Non-pathological Q waves are less than two small squares deep and less than one small square wide, and should be < 25% of the amplitude of the corresponding R wave. Non-pathological Q waves are often present in leads I, III, aVL, V5, and V6; Normally present in aVR;

ST segment

The QRS complex terminates at the J point or ST junction. The ST segment lies between the J point and the beginning of the T wave, and represents the period between the end of ventricular depolarisation and the beginning Of repolarisation. Isoelectric or <1 mm elevation in limb leads and <1 mm in precordial leads except for normal variant

T wave

The T wave is always upright (positive) in leads I, II and V4 through V6 The T wave is normally upright in lead aVF if the QRS complex is <5 mm tall, but the T wave can be flat or inverted. The T wave is variable in leads III and aVL. There is no clearly defined normal range for T wave height, although, as a general guide, a T wave should be no more than half the size of the preceding QRS complex.

T wave

The T wave is always inverted in aVR The T wave in V1 is inverted in approximately 50% of women and in <33% of men In women with a persistent juvenile pattern, the T wave is inverted in V1 and V2 and sometimes in V3 . This finding is common in AfricanAmerican women.

QT interval

The QT measures the distance from the beginning of the QRS to the end of the T wave. The QT represents the time it takes the ventricles to depolarize and then reset or repolarize for the next cycle. the QT interval should be 0.35-0.45 s

QT interval corrected

Unfortunately, deciding whether or not the QT interval is normal is not entirely straightforward, because the duration varies according to the patients heart rate: the faster the heart rate, the shorter the QT interval. To allow for this, you must calculate the corrected QT interval (QTc) using the following formula:

where QTc is the corrected QT interval, QT is the measured QT interval and RR is the measured RR interval (all measurements in seconds).

U wave

The U wave is a small deflection that follows the T wave. It is generally upright except in the aVR lead and is often most prominent in leads V2 to V4. U waves result from repolarisation of the mid-myocardial cellsthat is, those between the endocardium and the epicardiumand the His-Purkinje system. There is no normal range that you can apply to the height of a U wave. Prominent U waves may be found in athletes and are associated with hypokalaemia and hypercalcaemia.

Artefacts on the ECG

Electrode misplacement

See the unexpected wave inversion.

Incorrect calibration

Incorrect paper speed

Patient movement

Dextrocardia

Dextrocardia is a congenital condition in which the contents of the thorax and abdomen are reversed in placement in a mirror image from normal. The difference is seen in the V leads. In arm lead reversal, the V leads appear normal. In dextrocardia, the V leads are on the opposite side of the chest from the heart. This results in the tell-tale decremental size of the QRS as one moves from lead V1 to lead V6.