NORMAL ECG

&
ARRHYTHMIA

Dr. Mangiring P.L. Toruan, SpJP

Designations of different QRS patterns
EKG pada Sindroma Koroner Akut
 5 kotak kecil
= 1 kotak sedang
= 0.2 detik Paper speed : 25 mm/second
1 kotak kecil
= 0.04 detik=
40 ms

5 kotak sedang
= 1 kotak besar
= 1 detik
MENGHITUNG LAJU JANTUNG

A. Jarak R R : 300 / jumlah kotak sedang

- 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 ) = heart rate / menit

 Causes of Cardiac Arrhythmias

Disturbed automaticity : this may involved a speeding

up or slowing down of areas of automaticity such as
the sinus node, the atrioventricular (AV) node, or the
myocardium. Abnormal beats (depolarizations) may
arise through this mechanism from the atria, the AV
junction, or the ventricles.
Disturbed conduction : conduction may be either too
rapid (as in Wolff- Parkinson-White syndrome) or too
slow (as in AV block)
Combinations of disturbed automaticity and disturbed
conduction
 HOW TO READ ECG RHYTHM

QRS Complex ? -Asystole

-V F (fine)
(-)
(+)

-Wide ? (Ventricular ? ) (
Wide / Narrow complex
0.12s)
(Consider consult the
expert )

-Narrow ? (Supra
ventricular)
0.10 s
Fast / Slow ? -Takikardia (>
100x/mnt)/
-Bradicardia (< 60
x/mnt
 QRS regular /irregular ? R R distance

P wave ? Normal / abnormal P wave ?

P in front of QRS
P (+) in II, negative in aVR

P wave and QRS complex -1 P followed 1 QRS

Connection ? -Appropriate distance between
P wave and QRS complex
 Sinus Rhythm

60 ms

p p p

QRS lebar/sempit? 160 ms

QRS 1.5 kotak= 60 ms sempit

Reguler atau Irreguler? Reguler HR ? 300/5 : 60

PR interval?
Gel P terlihat? Ya

P=QRS Sinus Rhytm

P > QRS ?
 Differential Diagnosis Takikardia dengan QRS sempit
Narrow QRS tachycardia
(QRS duration < 120 ms

Reguler Tachycardia ?
No
Yes

No Atrial Fibrilation
Visible P waves ? Atrial Tachycardia/flutter with variable AV conduction
No MAT
Yes

P > QRS Rate ? No

No PSVT
Yes

Atrial Flutter or Analyze RP interval

Atrial tachycardia

Short (RP shorter than PR) Long (RP longer than PR)

RP < 70 ms RP > 70 ms

ATRIAL TACHYCARDIA
AVRT ATYPICAL AVNRT
AVNRT AVNRT, ATRIAL TACHYCARDIA
 QRS : 80 ms

Narrow QRS tachycardia

(QRS duration < 120 ms

Reguler Tachycardia ?

Yes

Visible P
No
Waves?
No
SVT
 Atrial Fibrillation

60 ms
Narrow QRS tachycardia
(QRS duration < 120 ms

Reguler Tachycardia ?
No

Atrial Fibrilation
Atrial Tachycardia/flutter with variable AV conduction
MAT
 p p p p p p

60 ms
Narrow QRS tachycardia
(QRS duration < 120 ms

Reguler Tachycardia ?

Yes

Visible P waves?

Yes

P > QRS Rate ?

Yes

Atrial Flutter
 Junctional Rhythm

p p p
80 ms

QRS lebar/sempit? QRS 1.5 kotak= 80 ms sempit

Reguler atau Irreguler? Reguler HR ? 1500/12 : 125x/

Gel P terlihat? P terbalik stlh QRS

P=QRS Junctional Rhythm

P > QRS ?
VES
 VES VES

SR SR
SR SR SR SR

Sinus rhythm with multifocal VES

Sinus rhythm with VES couplet
Sinus rhythm with VES, R on T
 Differential Diagnosis Takikardia dengan QRS lebar
Wide QRS tachycardia
(QRS duration > 120 ms)

Regular or irregular

Irregular
Regular

-- Atrial Fibrillation
1 To 1 AV relationship? - Atrial flutter / AT with
BBBB
No
Yes or Unknown

QRS > P ? P > QRS ?

QRS morphology in
Precordial Lead
VT Atrial Fibrillation

-RBBB pattern -LBBB pattern

Typical RBBB/LBBB -Concordant
- qR or rR di V1 - R in V1 > 30 ms
SVT - No RS pattern
-Axis RAD -R to nadir S in V1 > 60 ms
-Onset R to nadir
VT - qR or qS in V6
> 100 ms VT
VT
 Ventricular tachycardia

Wide QRS tachycardia

(QRS duration > 120 ms)

Regular or irregular

Regular

1 To 1 AV relationship?
-Concordant
- No RS pattern
QRS morphology in -Onset R to nadir
Yes or Unknown Precordial Lead > 100 ms VT
QRS? Lebar, susunan seperti spiral

Torsades de pointes
 QRS?
Halus, frekwensi ?

Kes : VF fine

QRS? 2, lebar, kemudian tidak ada

Kes :

ASISTOLE
 AV Block
1st degree 2nd degree 2nd degree 3rd degree
Type I Type II
PR Interval Normal Irregular

P : QRS 1:1 4:3 5 :3 Irregular

R to R Slight Slight Regular than Regular

irregular irregular irregular
 First-degree AV block

p p p

60 ms

QRS lebar/sempit? QRS 1.5 kotak= 60 ms sempit

Reguler atau Irreguler? Reguler HR ? 1500/40 : 37

Gel P terlihat? Ya PR interval 320 ms memanjang

P=QRS 1ST degree AV Block

P > QRS ?
 Second-degree AV block type 1

p p p p

60 ms
QRS lebar/sempit? QRS 1.5 kotak= 60 ms sempit

Reguler atau Irreguler? Reguler - irreguler HR ? 1500/25 : 60

Gel P terlihat? Ya PR interval 320-480 ms memanjang

P > QRS ? P > QRS = 4:3 2nd degree AV block type I

 Second-degree AV block type 2

p p p p p p

Reguler atau Irreguler? Reguler - irreguler

Gel P terlihat? Ya PR interval160 ms normal

P > QRS ? P > QRS = 5:3 Kes: 2nd degree AV block type 2
 Third-degree AV block / Total AV block
QRS QRS QRS

P P P P P P P

Reguler atau Irreguler? Reguler

Gel P terlihat? Ya PR intervalMemendek-memanjang

P > QRS ? P > QRS = 7:3 Kes: 3rd degree AV block

 Kesimpulan
Irama Sinus: RR teratur, setiap P diikuti QRS, gel
P (+) di II,aVF, (-) di aVR, HR 60-100, PR
interval normal
Irama arrest: (VF, VT pulseless Shockable
gambar ekg QRS lebar, sedangkan ,PEA, asistole
Non Shockable
Takikardia: HR > 100x/i, ST, VT stable, SVT, AF,
Atrial Flutter (QRS sempit)
Bradikardia: HR < 60 x/, SB, Junctional Rhytm,
AV block