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Interpretasi EKG

ECG interpretation
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
Quality of the ECG
 Patient name
 Date of the ECG
 Is there any interference?
 Is there electrical activity from all 12
leads?

 Calibration:
- speed = 25mm/second
- height = 1cm/mV (10mm/mV)
The ECG Paper
 Horizontally
 One small box - 0.04 s
 One large box - 0.20 s
 Vertically
 One large box - 0.5 mV
The ECG Paper (cont)
3 sec 3 sec

 Every 3 seconds (15 large boxes) is


marked by a vertical line.
 This helps when calculating the heart

rate.
NOTE: the following strips are not
marked but all are 6 seconds long.
Calibration
Calibration
ECG interpretation
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
Rhythm Analysis

 Step 1: Calculate rate.


 Step 2: Determine regularity.
 Step 3: Assess the P waves.
 Step 4: Determine PR interval.
 Step 5: Determine QRS duration.
Step 1: Calculate Rate
3 sec 3 sec

 Option 1
 Count the # of R waves in a 6 second
rhythm strip, then multiply by 10.
 Reminder: all rhythm strips in the Modules
are 6 seconds in length.
Interpretation? 9 x 10 = 90 bpm
Step 1: Calculate Rate

R wave

 Option 2
 Find a R wave that lands on a bold line.
 Count the number of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes -
100, 4 boxes - 75, etc. (cont)
Step 1: Calculate Rate
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0

 Option 2 (cont)
 Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50
(30 – 10 – 5 – 3 – 2)

Interpretation? Approx. 1 box less than


100 = 95 bpm
Rate
 300/number of big squares between R waves
 1500/number of small square between R
waves
 Number of R waves in a 6 second rhythm
strip, then multiply by 10

 Rate is either:
- normal: 60-100/mnt
- bradycardic: <60/mnt
- tachycardic: >100/mnt
Differential Diagnosis of Tachycardia

Tachycardia Narrow Complex Wide Complex


Regular ST ST w/ aberrancy
SVT SVT w/ aberrancy
Atrial flutter VT
Irregular A-fib A-fib w/ aberrancy
A-flutter w/ A-fib w/ WPW
variable conduction VT
MAT
Rate
Step 2: Determine regularity
R R

 Look at the R-R distances (using a caliper or


markings on a pen or paper).
 Regular (are they equidistant apart)?
Occasionally irregular? Regularly irregular?
Irregularly irregular?
Interpretation? Regular
Step 3: Assess the P waves

 Are there P waves?


 Do the P waves all look alike?

 Do the P waves occur at a regular rate?

 Is there one P wave before each QRS?


Normal P waves with 1 P
Interpretation? wave for every QRS
P-Wave: 


1.SA Node “fires”
2. Right and Left
Atria Depolarize
AV
SA Node  3. AV Node
Node
“pauses”
 Questions:
 P waves
present?
LA/RA  Regular

Depol rhythm?
 1/QRS?
Step 4: Determine PR interval

 Normal: 0.12 - 0.20 seconds.


(3 - 5 boxes)

0.12 seconds
Interpretation?
Step 5: QRS duration

 Normal: 0.04 - 0.12 seconds.


(1 - 3 boxes)

0.08 seconds
Interpretation?
Sinus Rythm
 HR: 60 – 100 bpm
 Irama: Reguler
 Gel P: mendahului setiap kompleks QRS & bentuknya
konsisten
 Interval PR: 0,12 – 0,20 dtk
 Kompleks QRS: 0,04 – 0,10 dtk
Normal Sinus Rhythm

Mattu, 2003
Rhythm Summary

 Rate 90-95 bpm


 Regularity regular
 P waves normal
 PR interval 0.12 s
 QRS duration 0.08 s
Interpretation? Normal Sinus Rhythm
Gelombang P
Ada / Normal Tidak Ada

Komplek QRS
Diikuti QRS

Sempit Lebar
PR Interval

Atrial Takikardi/
Normal Memanjang Tidak dapat dihitung Supra ventricular
takikardi Irama

AV Blok Gel P teratur spt mata Gel P tidak teratur


Irama gergaji

Teratur Tidak teratur


Teratur Tidak Teratur Atrial Flutter Atrial Fibrilasi

Ventrikel Ventrikel fibrilasi


takikardi
Frekwensi Sinus Aritmia

< 60 x/mnt 60-100 x/mnt > 100 x/mnt

Sinus Sinus Rhythm Sinus Takikardi


Bradikardi
Jenis-jenis irama listrik jantung
Jenis Pemacu
No Ciri Utama Contoh
Irama dominan
Irama Nodus Adanya P diikuti Normal (NSR), takikardi
sinus sinoatrial QRS (100-150), bradikardi (<60),
1. (NSA) aritmia (R-R ireguler),
arrest/paust (PQRS
menghilang min. 1 siklus)
Irama Sel-sel atrial Gelombang P nya Takikardi (150-250),
2. atrial berbeda dengan P ekstrasistol, flutter (gergaji),
sinus fibrilasi (getaran)
Irama Nodus P hilang/inversi Takikardi (>60), ekstrasistol,
3. junctio atrioventrikuler /mundur junctional
nal
Irama Sel-sel P menghilang, jika Takikardi, ventrikular,
ventrik ventrikuler ada biasanya tidak ekstrasistol, flutter, fibrilasi
4.
uler berhubungan dg
QRS secara konstan
Types of Arryhthmias:
 Sinus Problems: Formed in the
sinus node, but irregular
 Ectopic Problems: Formed
outside of the sinus node
 Conduction Problems: Formed in
the sinus node, but conduction in
error
 Pre-Excitation Problems: “Short
circuits” in normal conduction
Causes of Arrhytmias:
 Hypoxia: Lung disease
 Ischemia: CAD, angina (local hypoxia)
 Sympathetic Stimulation: Nervous,
exercise, CHF, hyperthyroidism
 Drugs: Caffeine, cocaine,
stimulants…many antiarryhtmic drugs…
 Electrolyte Disturbances: K+, Ca++,
Mg++
 Bradycardia: “Escape” rhythms…
 Stretch: CHF, hypertrophy, valve
disease
Sinus bradikardi

Sinus takikardi

NSR with premature atrial contractions/PAC

NSR with premature ventricular contractions/PVC


Atrial fibrillation  No organized atrial
depolarization, chaotic

Atrial flutter  “sawtooth” pattern

Paroxysmal SVT  The heart rate suddenly


speeds up
VT
 Ventrikel flutter
 Ventrikel fibrilasi

 SVT (Narrow complex, regular;


retrograde P waves, rate <220)

 VT
The QRS Axis
 Represents the overall direction of the heart’s activity
 Axis of –30 to +90 degrees is normal
Axis
Axis
The Quadrant Approach
 QRS up in I and up in aVF = Normal
What is the axis?
Normal- QRS up in I and aVF
Axis

Positive in I and
aVF = NORMAL

Positive in I and
negative in aVF =
LAD

Negative in I and
positive in aVF =
RAD
Kondisi-kondisi yang ditandai
perubahan axis
 Gangguan konduksi, mis. Left anterior
hemiblock
 Pembesaran ventrikel, mis. RVH
 Penyakit jantung kongenital, mis. Atrial
septal defect
 Konduksi pre eksitasi
 Embolus pulmoner
ECG interpretation
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
Gelombang P

 Mewakili depolarisasi
otot atrium
 Normal: Kecil,
melengkung
 Tinggi < 2,5 mm,
lebar < 0.11 dtk
P wave
 Are there P waves present?

 Bifid = P mitrale (LA hypertrophy)


 Pointy = P pulmonale (RA hypertrophy)
P mitrale
P pulmonale
Gelombang, Kompleks &
Interval, Cont…
Interval PR
 Diukur dr awal gel P –
awal kompleks QRS
 Mewakili waktu yang
diperlukan untuk impuls
bergerak dr atrium, AV
junction dan sistem
purkinje
 Normal: 0,12 – 0,20 dtk
PR interval
 Start of P wave to start of QRS complex

 Normal = 0.12 - 0.2 seconds (3-5 small


squares)

 Decreased = can indicate an accessory


pathway

 Increased = indicates AV block (1st/2nd/3rd)


1st Degree AV Block  irama sinus normal,
PR>0,2 detik (>5kk)

2nd degree block, type 1  Pemanjangan


progresif interval PR, disusul hilangnya QRS

2nd Degree AV Block, Type II  munculnya


gelombang P tanpa diikuti QRS secara tiba-tiba
3rd Degree AV Block (block total): tidak
terkoneksinya P dan QRS. P & QRS
memiliki pola sendiri-sendiri.
ECG interpretation
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
Gelombang, Kompleks &
Interval, Cont…
Kompleks QRS
 Mewakili depolarisasi
otot ventrikel
 Gel Q: defleksi Θ I,
<0,03 dtk, <25 %
tinggi R
 Gel R: defleksi + I
 Gel S: defleksi Θ
mengikuti R
 Lebar Kompleks QRS:
0,04 – 0,10 dtk
QRS complex
 Normal = <0.12 seconds

 >0.12 seconds = Bundle Branch Block


QRS complex
W I LL ia m = LBBB
Monophasic R wave in I and V6, QRS >
0.12 sec
Loss of R wave in precordial leads
QRS T wave discordance I, V1, V6
Consider cardiac ischemia if a new finding

M a RR o w = RBBB
V1: RSR prime pattern with inverted T
wave
V6: Wide deep slurred S wave
QRS complex
 Is there LVH?

 Sum of the Q or S wave in V1 and the


tallest R wave in V5 or V6
>35mm is suggestive of LVH
Q waves
 Q waves are allowed in V1, aVR & III

 Pathological Q waves can indicate


previous MI
 Q patologis:
 Lebar >1kk
 Dalam >2kk
(>1/3 R)
ECG interpretation
 Quality of ECG?

 Rate
 Rhythm
 Axis

 P wave
 PR interval
 QRS duration
 QRS morphology
 Abnormal Q waves
 ST segment
 T wave
 QT interval
Gelombang, Kompleks &
Interval, Cont…
Segmen ST
 Mewakili waktu yang
diperlukan oleh
ventrikel untuk
depolarisasi
 Mulai dr akhir kompleks
QRS – permulaan gel T
 Segmen ST harus pada
garis isoelektrik
ST segment
 ST depression
- downsloping or horizontal =
ABNORMAL

 ST elevation
- infarction
- pericarditis (widespread)
ST segment
ST segment
ST segment
EKG Distributions
 Anteroseptal: V1, V2, V3, V4
 Anterior: V1–V4
 Anterolateral: V4–V6, I, aVL
 Lateral: I and aVL
 Inferior: II, III, and aVF
 Inferolateral: II, III, aVF,
and V5 and V6
What is the diagnosis?
Acute inferior MI with ST elevation
in leads II, III, aVF
What do you see in this EKG?
ST depression II, III, aVF, V3-V6 = ischemia
Lateral MI

Reciprocal changes
Inferolateral MI

ST elevation II, III, aVF


ST depression in aVL, V1-V3 are reciprocal changes
Anterolateral / Inferior Ischemia

LVH, AV junctional rhythm, bradycardia


Right Ventricular Myocardial Infarction

Found in 1/3 of patients with inferior MI


Increased morbidity and mortality
ST elevation in V4-V6 of Right-sided EKG
Gelombang, Kompleks &
Interval, Cont…
Gelombang T
 Mewakili repolarirasi
otot ventrikel
 Tinggi: < 5 mm pd lead
di ekstremitas
< 10 mm pd
lead di precordial
 Bentuk: melengkung &
sedikit Asismetris
T wave
 Small = hypokalaemia

 Tall = hyperkalaemia

 Inverted/biphasic = ischaemia/previous
infarct
T wave
T wave
T wave
Gelombang, Kompleks &
Interval, Cont…
Gelombang U
 Gelombang kecil
melengkung, kadang2
mengikuti gel T
 Sering dijumpai pd lead V2-
V3
 Tinggi: 10 % tinggi gel T
 Merupakan bagian dr
repolarisasi ventrikel dan
menunjukkan repolarisasi
serat purkinje
Gelombang, Kompleks &
Interval, Cont…
Interval QT
 Menunjukkan durasi

aktivasi dan
recovery ventrikel
 Diukur mulai awal

Kompleks QRS –
akhir gel T
QT interval
 Start of QRS to end of T wave

 Needs to be corrected for HR

 Normal QTc = < 400ms

 Long QT can be genetic or iatrogenic


QT interval
Normal Intervals
 PR
 0.20 sec (less than one
large box)
 QRS
 0.08 – 0.10 sec (1-2
small boxes)
 QT
 450 ms in men, 460 ms
in women
 Based on sex / heart rate
 Half the R-R interval with
normal HR
Torsades de Pointes

Notice twisting pattern


Treatment: Magnesium 2 grams IV
Wolff-Parkinson-White Syndrome

Short PR interval <0.12 sec


Prolonged QRS >0.10 sec
Delta wave
Can simulate ventricular hypertrophy, BBB and previous MI
Hyperkalemia

Tall, narrow and symmetric T waves


Hypokalemia

U waves
Can also see PVCs, ST depression, small T waves
Digitalis

Dubin, 4th ed. 1989