Firman, S.

Ked 110 203 011

INTRODUCTION

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INTRODUCTION

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INTRODUCTION

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INTRODUCTION
ACTION

POTENTIAL CARDIAC CELL PROPERTIES CONDUCTION SYSTEM

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ACTION POTENTIAL

Polarization

Intracellular is more negative than extracellular

Intracellular becomes more positive Influx of Na+ Intracellular restores to its resting potential Efflux of K+

Depolarization

Repolarization

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ACTION POTENTIAL

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CARDIAC CELLS PROPERTIES

Automaticity Excitability Conductivity Contractility

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CONDUCTION SYSTEM

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CONDUCTION SYSTEM

Sinoatrial Node (SA Node)

Rhythmic rate : 60 100 bpm Anterior, middle, posterior pathways

Regions : atrionodal (AN), nodal (N), nodal-His (NH) Delays the impulse
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Internodal Pathway

Atrioventricular Node (AV Node)

CONDUCTION SYSTEM

Bundle of His

Rate : 40 60 bpm LBB & RBB LBB : anterior, posterior, septal fascicles Rate : 20 40 bpm

Bundle Branches

Purkinje Fibers

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CONDUCTION SYSTEM

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TUJUAN PEMERIKSAAN EKG

EKG sangat berguna dalam menentukan kelainan seperti berikut :

Kelainan-kelainan irama jantung (Disritmia) Gangguan Otot jantung berupa Iskemia dan infark miokard. Memperkirakan adanya pembesaran jantung ( Hipertrofi Atrium dan Ventrikel ) Efek obat-obatan terutama Digitalis dan Anti-aritmia Peradangan pada dinding jantung seperti miokarditis Gangguan keseimbangan elektrolit khususnya kalium. Dan lain-lain.

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BASIC ELECTROCARDIOGRAPHY
HISTORY OF ECG TYPES OF ECG LEADS ECG BOXES ECG WAVEFORMS ABNORMAL WAVEFORMS

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HISTORY OF ECG
Willem Einthoven (1860-1927) introduced in 1893 the term 'electrocardiogram'. He described in 1895 how he used a galvanometer to visualize the electrical activity of the heart. In 1924 he received the Nobelprize for his work on the ECG
Willem Einthoven

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TYPES OF ECG

Classic ECG

Modern ECG

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LEADS

Standard Limb Leads

Lead I, II, III aVL, aVR, aVF V1, V2, V3, V4, V5, V6 V1R, V2R, V3R, V4R, V5R, V6R V7, V8, V9

Augmented Limb Leads

Precordial Leads

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LEADS
The extremity leads are: I from the right to the left arm II from the right arm to the left leg III from the left arm to the left leg Augmented Limb leads are: AVL points to the left arm AVR points to the right arm AVF points to the feet

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LEADS

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LEADS
PRECORDIAL LEADS
- Lead V1 is placed in the fourth intercostal space to the right of the sternum. - Lead V2 is placed in the fourth intercostal space to the left of the sternum. - Lead V3 is placed directly between leads V2 and V4. - Lead V4 is placed in the fifth intercostal space in the midclavicular line (even if the apex beat is displaced). - Lead V5 is placed horizontally with V4 in the anterior axillary line - Lead V6 is placed horizontally with V4 and V5 in the midaxillary line.

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LEADS
PRECORDIAL LEADS

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LEADS

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LEADS
LEADS I, aVL VIEW OF HEART Lateral

II, III, aVF

V1, V2 V3, V4 V5, V6 I, aVL, V5, V6 V1-V6

Inferior
Antero-Septal Antero-Apical Antero-Lateral High Lateral Whole Anterior

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ECG BOXES

BOX OF ECG

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ECG WAVEFORMS

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ECG WAVEFORMS

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ECG WAVEFORMS

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ECG WAVEFORMS

P wave

No more than 2.5 mm in height No more than 0.11 sec in duration Positive : I,II,aVF,V2-6 May be positive, negative, or biphasic : III,aVL,V1

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ECG WAVEFORMS

PR interval

0.12 0.20 sec in adult, may be shorter in children and longer in elders

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ECG WAVEFORMS

QRS Complex

0.06 0.10 sec Q : 1st negative deflection after P R : 1st positive deflection after P S : negative deflection after R

Types Of QRS Complex

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ECG WAVEFORMS

ST Segment

Isoelectric (flat)

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ECG WAVEFORMS

T wave

Limb lead : no more than 5 mm (height) Precordial lead : no more than 10 mm (height)

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ECG WAVEFORMS

Normal ECG Waveforms in all the Leads

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ABNORMAL WAVEFORMS

P : tall, notched PR interval : prolonged, shortened Q : pathologic Q (>0.04 sec, 25% of the R wave) QRS complex : widened (>0.10 sec) ST segment : depression (>1 mm), elevation (>1 mm in limb leads or >2mm in precordial leads) T : peaked/tall, inverted, flattened QT interval : prolonged, shortened

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ABNORMAL WAVEFORMS

ST segment : Depression (>1 mm), Elevation (>1 mm in limb leads or >2mm in precordial leads)
Elevation Depression

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ABNORMAL WAVEFORMS

T wave : peaked/tall, inverted, flattened

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ABNORMAL WAVEFORMS

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ECG INTERPRETATION
RHYTHM RATE AXIS HYPERTROPHIC

SIGNS MYOCARDIAL INFARCTION ARRHYTHMIA

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RHYTHM
Sinus rhythm characteristics : Rate 60-100 bpm Constant R R interval Negative P wave in aVR and positive in II P wave is always followed by QRS complex

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NORMAL RHYTME

Normal ECG Waveforms in all the Leads

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RATE MEASUREMENT

Large Boxes 300/R-R interval Small Boxes 1500/R-R interval Six-Second Method count the number of complete QRS complexes in 6 seconds multiply by 10 for irreguler rhythm

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HEART AXIS
NORMO AXIS AXIS DEVIATION

RAD

LAD

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AXIS DEVIATION

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ATRIAL ENLARGEMENT

Left Atrial Enlargement Notched P wave

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ATRIAL ENLARGEMENT

Right Atrial Enlargement Peaked P wave

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ATRIAL ENLARGEMENT

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VENTRICULAR HYPERTROPHY

Left Ventricular Hypertrophy

S wave in V1/V2 + R wave in V5/V6 35 mm (mV) R wave in aVL 12 mm (mV) Strain pattern in V5 and V6 May be accompanied by LAD

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VENTRICULAR HYPERTROPHY

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VENTRICULAR HYPERTROPHY

LVH Strain

Left Ventricular Hypertrophy

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VENTRICULAR HYPERTROPHY

Right Ventricular Hypertrophy

RAD Reversed R-wave progression (taller R waves and smaller S waves in V1 & V2; deeper S waves & small R waves in V5 & V6

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VENTRICULAR HYPERTROPHY

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VENTRICULAR HYPERTROPHY

Right Ventricular Hypertrophy

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MYOCARDIAL INFARCTION

Ischemia Injury Necrosis

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MYOCARDIAL INFARCTION
Evolution of the ECG during a myocardial infarct
Time Minutes See Figure A B C Change Normal S-T Elevation S-T elevation with Negative T Waves

Hours
Day

D
E

Negative T Waves with Pathologic Q Waves

Pathologic Q Waves

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MYOCARDIAL INFARCTION

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MYOCARDIAL INFARCTION
Localization of a Myocardial Infarction
LOCALIZED S-T ELEVATION CORONARY ARTERY

Anterior MI
Septal MI Lateral MI Inferior MI Posterior MI

V1-V6
V1-V4 I, aVL, V5, V6 II, III, aVF V7, V8, V9

LAD
LAD RCX or MO RCA (80%) RCX (20%) RCX
Vascularization of the Heart

KET : LAD Left Anterior Descending Artery RCX Ramus Circumflexa LM Left Main Artery RCA Right Coronary Artery

Left Coronary Artery

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ANTERIOR INFARCTION

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INFERIOR INFARCTION

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POSTEROLATERAL INFARCTION

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MYOCARDIAL INFARCTION
Acute inferior myocardial infarction

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MYOCARDIAL INFARCTION
Septal wall myocardial infarction

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MYOCARDIAL INFARCTION
Extensive (whole) anterior myocardial infarction

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DYSRHYTHMIAS
Caused : Enhanced Automaticity Reentry Escape Beats Conduction Disturbances

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SUPRAVENTRICULAR ARRHYTHMIAS

Supraventricular Tachycardia Rate : 150-250 bpm Rhythm : regular P waves : frequently buried in preceding T waves PR interval : usually not possible to measure QRS : normal

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SUPRAVENTRICULAR ARRHYTHMIAS

Atrial Flutter Rate : atrial : 250 350 bpm; ventricular : slow/fast Rhythm : usually regular P waves : saw teeth appearance PR interval : variable QRS : usually normal, may be widened Conduction ratio : 2:1, 4:1, 6:1

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SUPRAVENTRICULAR ARRHYTHMIAS

Atrial Fibrillation (AF) Rate : atrial : > 350 bpm; ventricular : slow/fast Rhythm : irregular P waves : no true P waves; chaotic atrial activity PR interval : none QRS : normal

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VENTRICULAR ARRHYTHMIAS

Ventricular Tachycardia

Rate : 100 250 bpm Rhythm : regular P waves : none or not associated with QRS PR interval : none QRS : wide (>0.10 sec), bizarre appearance

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VENTRICULAR ARRHYTHMIAS

Ventricular Fibrillation

Rate : indeterminate Rhythm : chaotic P waves : none PR interval : none QRS : none

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VENTRICULAR ARRHYTHMIAS

Torsades de Pointes

Rate : 200 250 bpm Rhythm : irregular P waves : none PR interval : none QRS : wide (>0.10 sec), bizarre appearance

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EXTRASYSTOLE

Atrial Extrasystole (AES) / Premature Atrial Contraction (PAC) Rhythm : irregular due to the premature beat Rate : depends on its basic rhythm P wave : unusual compare to basic rhythm PR interval : normal, maybe shorten QRS : normal

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EXTRASYSTOLE

Ventricular Extrasystole (VES) / Premature Ventricular Contraction (PVC)

Rhythm Rate P wave PR interval QRS

: irregular due to the premature beat : depends on its basic rhythm : none : none : > 0.12 sec

Threatening VES : R on T VES VES > 6 times/min Bigemini VES Multifocal VES Consecutive VES

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EXTRASYSTOLE

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BLOCKS

1st Degree AV Block Rate : normal Rhythm : regular P waves : normal PR interval : prolonged (>0.20 sec) but constant QRS : usually 0.10 sec or less

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BLOCKS

2nd Degree AV Block Type I/Mobitz Type I/Wenckebach Rate : atrial > ventricular Rhythm : atrial regular; ventricular irregular P wave : normal PR interval : lengthen with each cycle until P wave appears without a QRS complex QRS : usually 0.10 sec or less

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BLOCKS

2nd Degree AV Block Type II/Mobitz Type II Rate : atrial > ventricular Rhythm : atrial regular; ventricular irregular P wave : normal PR interval : normal or slightly prolonged but constant for the conducted beats; there maybe some shortening of the PR interval that follows a non-conducted P wave QRS : usually 0.10 sec or less Conduction ratio 2:1, 3:1, 4:1

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BLOCKS

3rd Degree AV Block/Complete AV Block/Total Heart Block Rate : atrial > ventricular. Rhythm : atrial regular; ventricular regular (AV dissociation) P wave : normal PR interval : none; the atria and ventricles beat independently QRS : narrow or wide

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BLOCKS

Left Bundle Branch Block (LBBB)

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BLOCKS

Right Bundle Branch Block (RBBB)

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THANKS FOR THE ATTENTION

GOODLUCK!