Presentasi ekg rs agung

L/O/G/O
DASAR
INTERPRESTASI
EKG
Dr Fonda RP Silalahi

www.themegallery.com
DASAR YANG AKAN
DIPELAJARI
• Menilai Ritme
• Mengetahui Frekuensi
• Mengetahui Jenis Irama
• Transisi Zone
• Aksis Jantung
• Morfologi gelombang (silahkan dilihat di
slide “Pengenalan EKG Dasar ”)

MENILAI RITME
Kita lihat regularitasnya dengan menghitung
Interval R-R dan P-P
Penghitungannya kita menggunakan kertas
lalu diberi titik, lalu kita lihat regularitasnya.

CARA MENILAI RITME
Setelah tahu reguler/ireguler kita akan
menghitung frekuensi.

MENGHITUNG FREKUENSI
• Metode I  Menghitung Kotak Kecil
Rumusnya :
• Metode II  Menghitung Kotak Besar
Rumusnya:
Frekuensi = 1500/jumlah kotak kecil
Frekuensi = 300/jumlah kotak besar
Hanya untuk yang REGULER saja

MENGHITUNG FREKUENSI
• Metode IIII  Menghitung 6 detik EKG
Rumusnya :
Frekuensi =
Jumlah komplek QRS dalam 6 detik x 10
BISA UNTUK REGULER MAUPUN
IRREGULER
3 sec 3 sec
3 detik = 15 kotak besar

BELAJAR EKG
TERNYATA
MENYENANGKAN,
SIAP KE LANGKAH
SELANJUTNYA??!

JENIS IRAMA EKG
• Irama EKG akan sangat dipengaruhi oleh
SUMBER KELISTRIKAN JANTUNG.
– jika berasal dari SA node  Irama Sinus,
– jika berasal dari Atrium  Irama Atrial
– jika dari penghubung (AV node ) Irama
Junctional,
– jika dari ventrikel  Irama Ventrikuler
– jika dari pacemaker buatan  Irama Pacing

IRAMA SINUS
• Irama denyut jantung
yang sumber pacu
listriknya dari SA node
• Ciri gel P diikuti
kompplek QRS

IRAMA ATRIAL
• Irama yang pemacu
utamanya adalah
atrium
• Mirip gel P namun
berbeda dengan
gelombang P yang
dari sinus

IRAMA JUNCTIONAL
• Irama yang pacuannya dari AV node
• Ciri:
– Gel P inversi = Junctional letak atas
– Gel P hilang = Junctional letak
tengah
– Gel P retograde (setelah QRS
komplek) = Junctional letak bawah

IRAMA VENTRIKULER
• Irama denyut jantung yang
pemacu dominannya
Ventrikel
• Ciri mirip komplek QRS
namun tidak sempurna

IRAMA PACING
• Irama yang berasal dari alat pacu jantung
(pace maker)
• Irama pacing atrial
• Irama pacing ventrikuler

RHYTHM
Atrial Fibrillation
A-fib is the most common cardiac arrhythmia involving atria.
Rate= ~150bpm, irregularly irregular, baseline irregularity, no visible p waves,
QRS occur irregularly with its length usually < 0.12s

RHYTHM
Atrial Flutter
Atrial Rate=~300bpm, similar to A-fib, but have flutter waves, ECG baseline
adapts ‘saw-toothed’ appearance’. Occurs with atrioventricular block (fixed
degree), eg: 3 flutters to 1 QRS complex:

RHYTHM
Ventricular Fibrillation
A severely abnormal heart rhythm (arrhythmia) that can be life-threatening.
Emergency- requires Basic Life Support
Rate cannot be discerned, rhythm unorganized

RHYTHM
Ventricular tachycardia
fast heart rhythm, that originates in one of the ventricles- potentially life-
threatening arrhythmia because it may lead to ventricular fibrillation, asystole,
and sudden death.
Rate=100-250bpm

RHYTHM
Supraventricular Tachycardia
SVT is any tachycardic rhythm originating above the ventricular
tissue.Atrial and ventricular rate= 150-250bpm
Regular rhythm, p is usually not discernable.
*Types:
•Sinoatrial node reentrant tachycardia (SANRT)
•Ectopic (unifocal) atrial tachycardia (EAT)
•Multifocal atrial tachycardia (MAT)
•A-fib or A flutter with rapid ventricular response. Without rapid ventricular
response both usually not classified as SVT
•AV nodal reentrant tachycardia (AVNRT)
•Permanent (or persistent) junctional reciprocating tachycardia (PJRT)
•AV reentrant tachycardia (AVRT)

RHYTHM
Asystole
a state of no cardiac electrical activity, hence no contractions of the
myocardium and no cardiac output or blood flow.
Rate, rhythm, p and QRS are absent

BELAJAR EKG
SEMAKIN
MENANTANG,
SIAP KE LANGKAH
SELANJUTNYA??!

AKSIS JANTUNG
• Aksis adalah sudut yang dibentuk oleh
vektor listrik terhadap garis horizontal.
• Analisis terhadap aksis dapat membantu
menemukan lokasi kelainan yang terjadi
pada jantung.
– Aksis normal +90o
hingga -30o
– Deviasi Kiri -30o
hingga -90o
– Deviasi Kanan +90o
hingga +180o
– Deviasi Kanan Ekstrem -180o
hingga -90o

AKSIS JANTUNG

MENILAI AKSIS
Lead I Lead aVF Arah Aksis
+ - Deviasi kiri
+ + NORMAL
- + Deviasi kanan
- - Deviasi kanan
ekstrim
(+) artinya gelombang cenderung ke atas
atau panjang gel R > q + S
(-) artinya gelombang cenderung ke
bawah atau panjang gel R < q + S

MENILAI AKSIS
• Bisa juga dengan diagram

Cardiac Axis Causes
Left axis deviation Normal variation in pregnancy, obesity; Ascites,
abdominal distention, tumour; left anterior
hemiblock, left ventricular hypertrophy, Q Wolff-
Parkinson-White syndrome, Inferior MI
Right axis deviation normal finding in children and tall thin adults,
chronic lung disease(COPD), left posterior
hemiblock, Wolff-Parkinson-White syndrome,
anterolateral MI.
North West emphysema, hyperkalaemia. lead transposition,
artificial cardiac pacing, ventricular tachycardia
CARDIAC AXIS

ASAL GELOMBANG EKG
Untuk lebih
jelasnya bisa
dilihat di flash
dunia jantung
di Elisa Blok
4.2

KERTAS EKG
1 kotak kecil horizontal = 0.04 detik
1 kotak kecil vertikal = 0.1 mV
1 kotak besar terdiri atas
• 5 kotak kecil horizontal
• 5 kotak kecil vertikal
Hal ini penting untuk anda
ingat karena dari sini kita bisa
mengetahui apakah ada
kelainan atau tidak pada
sebuah hasil EKG.

GELOMBANG EKG
Normal
Pada gambar
disamping dapat
kita lihat adanya
gelombang (P, Q,
R, S, T dan U),
komplek (QRS),
interval (PR, QT)
serta
sebuah segmen
(ST segmen)

Gelombang P
• Gelombang yang tampak pertama kali
• Bentuk normalnya melengkung kecil ke atas
• Menunjukkan depolarisasi atrium
• Kelainan gelombang P menunjukkan adanya
kelainan di atrium.
• Gelombang P normalnya adalah sebagai
berikut:
• Positif (kecuali di aVR & V1 bisa negatif)
• Letak di depan QRS
• Tinggi < 2,5 kotak kecil
• Lebar < 3 kotak kecil
Yang ditebal harus
kamu hafal

P -WAVE
P pulmonale
Tall peaked P wave. Generally due to enlarged
right atrium- commonly associated with congenital
heart disease, tricuspid valve disease, pulmonary
hypertension and diffuse lung disease.
Biphasic P wave
Its terminal negative deflection more than 40 ms
wide and more than 1 mm deep is an ECG sign of
left atrial enlargement.
P mitrale
Wide P wave, often bifid, may be due to mitral
stenosis or left atrial enlargement.

PR Interval
•Jarak antara gelombang P dan
permulaan komplek QRS
• Untuk mengukur perjalanan
depolarisasi dari atrium ke ventrikel
• Normalnya
Lebar 3-5 kotak
kecil

PR-INTERVAL
First degree heart block
P wave precedes QRS complex but P-R intervals prolong (>5 small
squares) and remain constant from beat to beat

Second degree heart block
1. Mobitz Type I or Wenckenbach
Runs in cycle, first P-R interval is often normal. With successive beat, P-R
interval lengthens until there will be a P wave with no following QRS complex.
The block is at AV node, often transient, maybe asymptomatic
PR-INTERVAL

Second degree heart block
2. Mobitz Type 2
P-R interval is constant, duration is normal/prolonged. Periodically, no
conduction between atria and ventricles- producing a p wave with no
associated QRS complex. (blocked p wave).
The block is most often below AV node, at bundle of His or BB,
May progress to third degree heart block
PR-INTERVAL

Third degree heart block (Complete heart block)
No relationship between P waves and QRS complexes
An accessory pacemaker in the lower chambers will typically activate
the ventricles- escape rhythm.
Atrial rate= 60-100bpm. Ventricular rate based on site of escape
pacemaker. Atrial and ventricular rhythm both are regular.
PR-INTERVAL

QRS Komplek
• Tiga defleksi yang yang mengikuti gelombang
P
• Mengindikasikan depolarisasi (dan kontraksi)
ventrikel
• Gel Q = defleksi negatif pertama setelah P.
Normalnya lebar < 1 kotak kecil, dalamnya < 2
kotak kecil.
• Gel R = defleksi positif pertama setelah P.
Normalnya tinggi < 27 kotak kecil, tidak
bertakik
• Gel S = defleksi negatif pertama setelah R.
Normalnya tidak ditemukan di V6, dalamnya <
7 kotak besar di V1-V2
• Normal QRS
Lebar 1 ½ - 3 kotak kecil

QRS COMPLEX
Left Bundle Branch Block (LBBB)
indirect activation causes left ventricle contracts
later than the right ventricle.
Right bundle branch block (RBBB)
indirect activation causes right ventricle
contracts later than the left ventricle
QS or rS complex in V1 - W-shaped
RsR' wave in V6- M-shaped
Terminal R wave (rSR’) in V1 - M-shaped
Slurred S wave in V6 - W-shaped
Mnemonic: WILLIAM Mnemonic: MARROW

ST Segment
• Jarak antara gelombang S dan
permulaan gelombang T
•Menunjukkan repolarisasi ventrikel
• Normalnya
Terletak pada garis iso
elektris

ST-SEGMENT
Look at ST changes, Q wave in all leads. Grouping
the leads into anatomical location, we have this:
Ischaemic change can be attributed to
different coronary arteries supplying the
area.
Location of
MI
Lead with
ST changes
Affected
coronary
artery
Anterior V1, V2, V3,
V4
LAD
Septum V1, V2 LAD
left lateral I, aVL, V5,
V6
Left
circumflex
inferior II, III, aVF RCA
Right atrium aVR, V1 RCA
*Posterior Posterior
chest leads
RCA
*Right
ventricle
Right sided
leads
RCA
*To help identify MI, right sided and
posterior leads can be applied
Localizing MI
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
(LAD)
(RCA)

Criteria:
ST elevation in > 2 chest leads > 2mm elevation
ST elevation in > 2 limb leads > 1mm elevation
Q wave > 0.04s (1 small square).
*Be careful of LBBB
The diagnosis of acute myocardial infarction should be
made circumspectively in the presence of pre-existing
LBBB. On the other hand, the appearance of new LBBB
should be regarded as sign of acute MI until proven
otherwise
DIAGNOSING MYOCARDIAL INFARCTION (STEMI)
Definition of a pathologic Q wave
Any Q-wave in leads V2–V3 ≥ 0.02 s or QS complex in leads V2 and V3
Q-wave ≥ 0.03 s and > 0.1 mV deep or QS complex in leads I, II, aVL, aVF, or V4–V6 in any two
leads of a contiguous lead grouping (I, aVL,V6; V4–V6; II, III, and aVF)
R-wave ≥ 0.04 s in V1–V2 and R/S ≥ 1 with a concordant positive T-wave in the absence of a
conduction defect.
A little bit troublesome to remember? I usually take pathological Q wave as >1 small square deep
Pathologic Q waves are a sign of previous myocardial infarction.

ST SEGMENT
ST-ELEVATION MI (STEMI)
0 HOUR
1-24H
Day 1-2
Days later
Weeks later
Pronounced T Wave initially
ST elevation (convex type)
Depressed R Wave, and Pronounced T Wave. Pathological Q waves
may appear within hours or may take greater than 24 hr.- indicating full-
thickness MI. Q wave is pathological if it is wider than 40 ms or deeper
than a third of the height of the entire QRS complex
Exaggeration of T Wave continues for 24h.
T Wave inverts as the ST elevation begins to resolve. Persistent ST
elevation is rare except in the presence of a ventricular aneurysm.
ECG returns to normal T wave, but retains pronounced
Q wave. An old infarct may look like this

I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Check again!
>2mm
Yup, It’s acute
anterolateral MI!
Let’s see this
ST elevation in > 2 chest leads > 2mm
Pathological Q wave
Q wave > 0.04s (1 small square).
ST SEGMENT

I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Check again!
Inferior MI!
How about this one?
ST SEGMENT

NSTEMI is also known as subendocardial or non Q-wave MI.
In a pt with Acute Coronary Syndrome (ACS) in which the ECG does not show ST
elevation, NSTEMI (subendocardial MI) is suspected if
ST SEGMENT
NON ST-ELEVATION MI (NSTEMI)
•ST Depression (A)
•T wave inversion with or without ST depression (B)
•Q wave and ST elevation will never happen
To confirm a NSTEMI, do Troponin test:
•If positive - NSTEMI
•If negative – unstable angina pectoris

A ST depression is more suggestive of myocardial ischaemia than infarction
1mm ST-segment depression
Symmetrical, tall T wave
Long QT- interval
MYOCARDIAL ISCHEMIA
ST SEGMENT

QT Interval
• Permulaan QRS hingga akhir T
• Menunjukkan aktivitas ventrikel total
• Normalnya
Lebar < ½ interval R-R atau
Lebar < 2 kotak besar

Gelombang T
• Gelombang lengkungan ke atas yang
mengikuti QRS
• Menunjukkan repolarisasi ventrikel
• Normalnya
Postif (terutama bersama R tinggi)
atau
Inversi di III, aVR, V1

Narrow and tall peaked T wave (A) is an early sign
PR interval becomes longer
P wave loses its amplitude and may disappear
QRS complex widens (B)
When hyperkalemia is very severe, the widened QRS complexes merge with their
corresponding T waves and the resultant ECG looks like a series of sine waves (C).
If untreated, the heart arrests in asystole
T wave becomes flattened together with appearance of a prominent U
wave.
The ST segment may become depressed and the T wave inverted.
these additional changes are not related to the degree of hypokalemia.
HYPERKALAEMIA
HYPOKALAEMIA

SUMMARY
Unsur EKG Tinggi/Dalam Lebar
Gelombang P < 2,5 kotak kecil < 3 kotak kecil
PR Interval - - - 3 – 5 kotak kecil
Gelombang Q < 2 kotak kecil < 1 kotak kecil
Gelombang R < 27 kotak kecil - - - -
Gelombang S < 7 kotak besar di V1-V2 - - - -
QRS Komplek - - - 1 ½ - 3 kotak kecil
QT Interval - - - < ½ interval R- R
< 2 kotak besar
TERNYATA MUDAH DAN MENYENANGKAN
YA BELAJAR EKG 

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