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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

 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
- 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?

##  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

Komplek QRS
Diikuti QRS

Sempit Lebar
PR Interval

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

Irama gergaji

## Teratur Tidak teratur

Teratur Tidak Teratur Atrial Flutter Atrial Fibrilasi

## Ventrikel Ventrikel fibrilasi

takikardi
Frekwensi Sinus Aritmia

## Sinus Sinus Rhythm Sinus Takikardi

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++
 Stretch: CHF, hypertrophy, valve
disease

Sinus takikardi

## NSR with premature ventricular contractions/PVC

Atrial fibrillation  No organized atrial
depolarization, chaotic

## Paroxysmal SVT  The heart rate suddenly

speeds up
VT
 Ventrikel flutter
 Ventrikel fibrilasi

##  SVT (Narrow complex, regular;

 VT
The QRS Axis
 Represents the overall direction of the heart’s activity
 Axis of –30 to +90 degrees is normal
Axis
Axis
 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 =

Negative in I and
positive in aVF =
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

squares)

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
garis isoelektrik
ST segment
 ST depression
- downsloping or horizontal =
ABNORMAL

 ST elevation
- infarction
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
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
 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
mengikuti gel T
 Sering dijumpai pd lead V2-
V3
 Tinggi: 10 % tinggi gel T
 Merupakan bagian dr
repolarisasi ventrikel dan
serat purkinje
Gelombang, Kompleks &
Interval, Cont…
Interval QT

aktivasi dan
recovery ventrikel
 Diukur mulai awal

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

##  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

## 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