Lets's learn about ECG. Please correct if something uncorrect

1. BASIC OF ECG
By: SRI NINING,S.Kep.,Ns
Dipresentasikan pada In HouseTrainning RS MEGA BUANA
PALOPO

2. PRETEST
JAWABLAH SEMAMPU ANDA

3. MATERI
• PENGENALAN EKG
• TEKNIK PEREKAMAN EKG
• PENGENALAN KERTAS EKG
• ELEKTROFISIOLOGI JANTUNG DAN GELOMBANG EKG

4. Apa itu EKG
Adalah alat elektronik medis yang mampu menangkap sinyal listrik pada
jantung yang kemudian dapat membantu tenaga medis untuk
menginterpretasikan keadaan jantung.

5. THE HISTORY OF ECG MACHINE
1903
A Dutch doctor and physiologist.
He invented the first
practical electrocardiogram and
received the Nobel Prize in
Medicine in 1924 for it
Willem Einthoven
NOW
Modern ECG machine
has evolved into compact electronic
systems that often include
computerized interpretation of the
electrocardiogram.

6. EKG DENGAN 10
ELECTRODA
EKG DENGAN 5
ELECTRODA

8. PEREKAMAN JANTUNG
• POSISI PASIEN
• Dimana letak elektroda ?
• Apa yang perlu diperhatikan setelah merekam ekg?

9. 1. Place the patient in a supine or
semi-Fowler's position. If the
patient cannot tolerate being flat,
you can do the ECG in a more
upright position.
2. Instruct the patient to place their
arms down by their side and to
relax their shoulders.
3. Make sure the patient's legs are
uncrossed.
4. Remove any electrical devices,
such as cell phones, away from
the patient as they may interfere
with the machine.
5. Shave hairs around the
placement, using alcohol to dry
the location from sweet or oil.
HOWTO DO ELECTROCARDIOGRAPHY
An ECG with artifacts.
Patient, supine position

10. PRINSIP PEREKAMAN
• PASIENTIDAK GOYANG
• TIDAK ADA SINYAL LISTRIK PENGGANGGU SEKITAR PASIEN
• ELECTRODA MENEMPEL DAN MENGANTAR LISTRIK DENGAN BAIK
• PENEMPATANYANGTEPAT

11. The limb electrodes
RA - On the right arm, avoiding thick muscle
LA – On the left arm this time.
RL - On the right leg, lateral calf muscle
LL- On the left leg this time.
The 6 chest electrodes
V1 - Fourth intercostal space, right sternal
border.
V2 - Fourth intercostal space, left sternal
border.
V3 - Midway betweenV2 andV4.
V4 - Fifth intercostal space, left midclavicular
line.
V5 - Level withV4, left anterior axillary line.
V6 - Level withV4, left mid axillary line.
Placement of electrodes
AHA/ACC/HRS : Recomendation S Of Standardization And Interpretation OfThe Electrocardiogram.
Part I : Electrocardiogram And AitsTechnology. 2007;4(3):394-412

12. The arm electrodes (A and B) are placed on the mid-arm, on the lateral aspect of the biceps,
immediately below the V4 horizontal line.
Gabriel M Khan Open Heart 2015;2:e000226
©2015 by British Cardiovascular Society

13. Figure 6. Frank vectorcardiographic lead configuration.
Barbara J. Drew et al. Circulation. 2004;110:2721-2746
Copyright © American Heart Association, Inc. All rights reserved.

16. PERMASALAHANYANG SERING DIDAPATI
• ARTEFACT
• WRONG POSITION

17. EKG Leads
The standard EKG has 12 leads:
3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads

18. IIIII
LEADS I, II, III
THEY ARE FORMED BYVOLTAGE
TRACINGS BETWEENTHE LIMB
ELECTRODES (RA, LA, RL AND LL).
THESEARETHE ONLY BIPOLAR
LEADS.ALLTOGETHERTHEY ARE
CALLEDTHE LIMB LEADS OR
THE EINTHOVEN’S
TRIANGLE RA LA
RL LL
I
INGAT !!!
LEAD I : RA – LA
LEAD II : RA – LL
LEAD III : LA -LL

19. LEADS aVR, aVL, aVF
THEY ARE ALSO DERIVED FROMTHE LIMB
ELECTRODES,THEY MEASURETHE
ELECTRIC POTENTIALAT ONE POINTWITH
RESPECTTO A NULL POINT.THEY ARETHE
AUGMENTED LIMB LEADS
RA LA
RL LL
aVR
aVF
aVL

20. LEADS
V1,V2,V3,V4,V5,V6
THEY ARE PLACED DIRECTLYONTHE
CHEST. BECAUSE OFTHEIR CLOSE
PROXIMITYOFTHE HEART,THEY DO
NOT REQUIREAUGMENTATION.THEY
ARE CALLEDTHE PRECORDIAL
LEADS
RA LA
RL LL
V1
V2
V3
V4
V5
V6

21. Precordial Leads

22. Precordial Leads

23. Right Sided & Posterior Chest Leads
• Lead V7 - sejajar lead
V4-6 di linea axillaris
posterior kiri
• Lead V8 - sejajar lead
V4-6 di bawah tip dari os
scapula
• Lead V9 - sejajar lead
V4-6 di linea paravertebra
kiri

25. SOLUTION : PINDAHKAN ATAUTENANGKAN PASIEN

27. SOLUSI : ATASI PENYEBABNYA , PINDAHKAN KE AREAYANG
AMAN ( MIS: CLAVICULA)

28. SOLUSI : AREA BAHU

32. BASIC PEMBACAAN EKG

33. PENGENALAN KERTAS EKG

34. KERTAS EKG
Kertas EKG merupakan kertas grafik
yang merupakan garis horizontal dan
vertikal dengan jarak 1mm ( kotak
kecil ). Garis yang lebih tebal terdapat
pada setiap 5mm disebut ( kotak
besar ).
•Garis horizontal Menunjukan
waktu, dimana 1mm = 0,04 dtk,
sedangkan 5mm = 0,20 dtk.
•Garis vertical Menggambarkan
voltage, dimana 1mm = 0,1 mv ,
sedangkan setiap 5 mm =0,5 mv.
0,04 sec
0,1 mV
0,2 sec

35. URUTAN CABRERA
V1
V2
V3
V4
V5
V6
aVR
aVL
aVF
I
II
III
II

36. Some ECG machines come with interpretation software. This one says
the patient is fine. DO NOT totally trust this software.

37. 300
the number of BIG SQUARE between R-R interval
Rate =
1500
the number of SMALL SQUARE between R-R interval
OR
Rate =
MENGHITUNG JUMLAH KOTAK ANTARA R-R
HEART RATE
Irama Reguler

38. CALCULATING RATE
300
Rate =
For example:
3
1500
15
Rate =or
Rate = 100 beats per minute

39. The Rule of 300
It may be easiest to memorize the following table:
No of big
boxes
Rate
1 300
2 150
3 100
4 75
5 60
6 50

40. HEART RATE
Irama Irreguler
1. 10 second rule
Menghitung gelombang R yang muncul dalam 10 detik
lalu dikalikan 6
1. 6 second rule
Menghitung gelombang R yang muncul dalam 6 detik
lalu dikalikan 10

41. What is the heart rate?
33 x 6 = 198 bpm

42. 16 x 6 = 98 bpm

44. KONDUKSI JANTUNG DAN
REKAMANNYA

45. 1. SA NODE
2. BACHMAN
3. AV NODA
4. BUNDLE HIS
5. BUNDLE BRANCH
6. LEFT FASCICLE
7. PURKINJE CELL
2
3
1
4
5
6 7
6

46. PACEMAKER
1. SA NODE 60-100 x/mnt
2. ATRIAL CELL 55 - 60
3. AV NODE 45-50 x/mnt
4. Bundle HIS 40 -45
5. Bundle Branch 40 -45
6. SERABUT PURKINJE 20-
40 x/mnt
A V
SP

49. Fill in the Blanks…
•P wave: Created with the depolarization of
the sinoatrial node, which spreads
electrical activity to the atria.This electrical
impulse is spread downwards to the left, in
the direction of the positive pole of lead II.
Because the electrical activity is moving in
a downward deflection away from the
negative pole, the ECG tracing inscribes
the P wave in an upward direction.

50. Between the Lines…
• The PR interval is inscribed
due to a delay of
depolarization at the
atrioventricular node
(allowing time for the
ventricles to fill) and no wave
is produced.

51. On your mark….
•QWave
•The wave of depolarization moves through
the Bundle of His and it’s branches, and then
the interventricular septum is depolarized.
This is the first part of the ventricular
myocardium to become depolarized.This
depolarization occurs from left to right.The
electrical current moves through the thin
layered interventricular septum in a downward
motion, resulting in the Q wave being
inscribed on the ECG. The Q wave is aimed
downward because the current moves toward
the negative pole.

52. Get ready…
 R wave
 From the downward inscription
of the Q wave on the ECG,
depolarization spreads along the
ventricular conduction system
and depolarization occurs in
both ventricles simultaneously.
Because the LeftVentricle has
greater mass than the right
ventricle, most of the electrical
impulse travels in a left and
downward direction.This
electrical activity moving in an
upward deflection towards the
positive pole of Lead II results in
the inscription of the large R
wave.

53. Set…
• S wave
• Electrical impulses move
from the apex to the base
of the heart, continuing
ventricular depolarization.
This results in the ECG
inscription of the S wave.

54. Almost there….
ST interval
After the ventricle is
completely depolarized, few
impulses take place during this
time before repolarization
(also called ventricular
relaxation).This time is
inscribed on the ECG as the ST
interval.
At this time the heart is
susceptible to any electrical
impulse and somewhat
unstable. *This is the point
where defibrillators are placed
during human CPR.

55. Go!
• T wave
• Repolarization.
• Different way with Depolarization
waveform
• This occurs from the epicardium
TOthe endocardium. Because the
left ventricle has more mass than
the right ventricle or atria, electrical
impulses travel downward to the
left.This produces an upwardT wave
in Lead II.
• A period of electrical inactivity
follows repolarization, and is
inscribed as a flat line until the SA
node begins all over again!

56. P wave
• Merupakan depolarisasi atrium
• DURASI = < 3 small boxes or 0,12-
0,20 s
• AMPLITUDO = < 2.5 small boxes
or < 0,3 mV Commonly biphasic in
leadV1
• Best seen in leads II
• Always positive in lead I and II
• Always negative in lead aVR
• INTERPRETASI : melihat adanya
pembesaran atrium

57. Q wave
• Defleksi negatif pertama pada gelombang QRS
• Lebar kurang dari 0,04 detik atau 1 kotak kecil
• Tinggi dan dalamnya kurang dari 1/3 tinggi gel R atau
25 % dari gel R
• Gelombang Q abnormal disebut dengan Q patologis.
• INTERPRETASI : adanya adanya infark

58. Interval PR
• Diukur dari permukaan gel P sampai permulaan gel QRS.
• Nilai normal antara 0,12 - 0,20 detik.
• Merupakan waktu yang dibutuhkan untuk depolarisasi atrium dan jalannya
impuls melalui berkas His sampai permulaan depolarisasi ventrikel.
• INTERPRETASI : mengetahui adanya AV BLOK dan adanya perikarditis

59. Gelombang QRS
• Merupakan gambaran proses depolarisasi ventrikel.
• Lebar 0,06 – 0,11 s atau < 3 boxs kecil
• Tinggi tergantung lead
• INTERPRETASI : Blok pada Bundle Branch, PembesaranVentrikel, dan delay
konduksi interventrikular

60. Gelombang R
• Defleksi positif pertama pada gelombang QRS
• Umumnya positif di lead I, II,V5 danV6. dan di lead AVR,V1 danV2 biasanya
hanya kecil atau tidak ada sama sekali.

61. Gelombang S
• Defleksi negatif sesudah gelombang R
• Di lead AVR danV1 gelombang S terlihat dalam,
• DariV2 keV6 akan terlihat makin lama makin menghilang atau berkurang
dalamnya.

62. GelombangT
• Merupakan gambaran proses repolarisasi ventrikel.
• Dalam dan tingginya tidak lebih dari 6 mm atau 0,6 Mv pada Limbs lead dan
tidak lebih dari 12 mm atau 0,12 mV pada lead precordials.
• Umumnya gelT positif di lead I, II,V3 –V6 dan terbalik di AVR.
• Bentuknya asimetris
• INTERPRETASI : mengetahui adanya iskemia, gangguan elektrolit

63. Gelombang U
• Gelombang yang timbul setelah gelT dan sebelum gel P berikutnya.
• Penyebab timbulnya gel U belum diketahui namun di duga akibat
repolarisasi lambat sistem konduksi intervertikel.

64. Segmen ST
• Diukur dari akhir gel S sampai awal gelT
• Awal ST segment disebut J point
• Segmen ini normalnya isoelektris, tetapi pada lead prekordial dapat
bervariasi dari – 0,5 sampai + 2 mm
• Segmen ST yang naik disebut ST elevasi dan yang turun disebut ST depresi.
• INTERPRETASI : mengetahui adanya infark

65. the J Point

66. POSTTEST
JAWABAH SESUAI KEMAMPUANANDA
NYOTEK = RUGI

69. REFERENCE
1. Practice Standards for Electrocardiographic Monitoring in Hospital Settings An American Heart
Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical
Cardiology, and Cardiovascular Disease in the Young
2. Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for
Implementation
3. Kligfield P, Gettes L, Bailey JJ, et al. Recommendations for the standardization and interpretation of the
electrocardiogram: part II: the electrocardiogram and its technology: a scientific statement from the
American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical
Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. J Am Coll
Cardiol 2007;49:1109–27
4. Gracia, Tomas B, 12 Lead ECG The Art of Interpretation, Copyright 2015